Prep U 18

A nurse is teaching new parents about keeping follow-up appointments and calling their health care provider if they notice signs of illness in their newborn. The nurse determines that the teaching was successful when the parents identify which signs as needing to be reported? Select all that apply. A. temperature of 38.3° C (101° F) or higher B. approximately eight wet diapers a day C. general fussiness D. abdominal distention E. refuse feeding

A, E, D Rationale: Parents should call their health care provider if they note any of the following warning signs: temperature of 38.3° C (101° F) or higher; forceful, persistent vomiting; refusal to take feedings; two or more green, watery diarrheal stools; infrequent wet diapers and change in bowel movements from normal pattern; lethargy or excessive sleepiness; inconsolable crying and extreme fussiness; abdominal distention; or difficult or labored breathing.

The AGPAR score is based on which 5 parameters? A. heart rate, respiratory effort, temperature, tone, and color B. heart rate, muscle tone, reflex irritability, respiratory effort, and color C. heart rate, breaths per minute, irritability, reflexes, and color D. heart rate, breaths per minute, irritability, tone, and color

B. Rationale: A newborn can receive an APGAR score ranging from 0 to 10. The score is based on 5 factors, each of which is assigned a 0, 1, or 2. Heart rate (should be above 100), muscle tone (should be able to maintain a flexion position), reflex irritability (newborn should cry or sneeze when stimulated), and respiratory effort are evaluted by the presence of a strong cry and by color. Color is evaluated by noting the color of the body and hands and feet.

A newborn develops physiologic jaundice, and the mother asks the nurse why this happened. Which response by the nurse would be most accurate? A. "We really don't know why jaundice develops in some babies and not in others. We just know how to treat it." B. "Your baby must have a blocked duct near his liver that's preventing the bilirubin from being excreted." C. "Because his liver is a bit immature, the baby can't break down the bilirubin as fast as needed." D. "There is some type of blood incompatibility between you and your baby that's causing the problem."

C. Rationale: The newborn has physiologic jaundice, which is related to decreased bilirubin conjugation. Newborns have relatively immature livers and cannot conjugate (break down) bilirubin as fast as needed. Bilirubin overproduction is responsible for causing jaundice associated with a blood incompatibility. Impaired bilirubin excretion, such as from an obstruction in the biliary tree, also can lead to jaundice. The causes of newborn jaundice are known; jaundice usually results from one of these three mechanisms.

What is the expected range for respirations in a newborn? A. 10 to 30 breaths per minute B. 40 to 80 breaths per minute C. 20 to 40 breaths per minute D. 30 to 60 breaths per minute

D.

The nurse documents that a newborn has a normal head-to-body proportion. What did the nurse document in the baby's medical record? A. Head one eighth of total length B. Head one sixth of total length C. Head one half of total length D. Head one fourth of total length

D. Rationale: A newborn's head usually appears disproportionately large because it is about one fourth of the total body length. The newborn's head is not one half, one sixth, or one eighth of the total body length.

The nurse is caring for a newborn after the parents have spent time bonding. As the nurse performs the assessment and evidence-based care, which eye care will the nurse prioritize? A. Instill 0.5% ophthalmic erythromycin. B. Instill 0.5% ophthalmic tetracycline. C, Instill 0.5% ophthalmic silver nitrate. D. Watch for signs of eye irritation.

A. Rationale: The standard eye care to prevent ophthalmia neonatorum is 0.5% erythromycin ointment or 1% tetracycline eye drops. Although 1% silver nitrate drops were once used, it has been discontinued due to its ineffectiveness. The nurse would not wait to see if the eyes show signs of irritation before administering the medication. Delaying could lead to preventable blindness.

The nurse has completed an assessment on a 1-day-old newborn. Which finding should the nurse prioritize? A. Temperature of 97.6°F B. Blood sugar 42 mg/dL C. Respiratory rate 42 D. Heart rate 158

B. Rationale: Any blood sugar lower than 50 mg/dL is considered hypoglycemic and should be further assessed. In the scenario described, the infant's temperature, heart rate, and respiratory rate are all considered within normal limits.

The newborn has been placed in skin-to-skin contact with his mother. A blanket covers all of his body except his head. His hair is still wet with amniotic fluid, etc. What is the most likely type of heat loss this baby may experience? A. Convective B. Evaporative C. Radiating D. Conductive

B. Evaporative Rationale:Evaporative heat loss occurs with the evaporation of fluid from the infant.

A nurse is teaching a new mother about what to expect for bowel elimination in her newborn. Because the mother is breastfeeding, what should the nurse tell her about the newborn's stools? A. Stools should be yellow-gold, loose, and stringy to pasty. B. Stools should be brown and loose. C. Stools should be yellow-green and loose. D. Stools should be greenish and formed in consistency.

A. Rationale: The stools of a breast-fed newborn are yellow-gold, loose, and stringy to pasty in consistency. The stools of the formula-fed newborn vary depending on the type of formula ingested. They may be yellow, yellow-green, or greenish and loose, pasty, or formed in consistency, and they have an unpleasant odor.

Which measurements were most likely obtained from a normal newborn born at 38 weeks to a healthy mother with no maternal complications? A. weight = 2000 g, length = 17 inches (43 cm), head circumference = 32 cm, and chest circumference = 30 B. weight = 2500 g, length = 18 inches (46 cm), head circumference = 32 cm, and chest circumference = 30 cm C. weight = 3500 g, length = 20 inches (51 cm), head circumference = 34 cm, and chest circumference = 32 cm D. weight = 4500 g, length = 22 inches (56 cm), head circumference = 36 cm, and chest circumference = 34 cm

C. Rationale: weight = 3500 g, length = 20 inches (51 cm), head circumference = 34 cm, and chest circumference = 32 cm

A nurse is preparing to administer vitamin K to a newborn. The nurse would administer the drug by which route? A. Intramuscularly in the thigh B. Topically to the eyelid C. Intravenously through a scalp vein D. Orally via a dropper

C. Rationale: The American Academy of Pediatrics recommends that vitamin K be administered to all newborns soon after birth in a single intramuscular dose of 0.5 to 1 mg. An oral vitamin K preparation is also being given to newborns outside the United States, but at least three doses are needed over a one month period. It is not given intravenously or topically. Erythromycin or tetracycline is used for eye prophylaxis.

Which statement is false regarding bathing the newborn? A. Bathing should not be done until the newborn is thermally stable. B. Mild soap should be used on the body and hair but not on the face. C. While bathing the newborn, the nurse should wear gloves. D. To reduce the risk of heat loss, the bath should be performed by the nurse, not the parents, within 2 to 4 hours of birth.

D. Rationale: Bathing the newborn is not necessary for thermal stability. It can be postponed until the parents are able to do it.

The nurse is conducting a prenatal class explaining the various activities which will occur within the first 4 hours after birth. The nurse determines the session is successful when the couples correctly choose which reason for the use of an antibiotic ointment? A. Prevent infection of the umbilical cord B. Prevent infection of the eyes from vaginal bacteria C. Protect tear ducts from vaginal bacteria D. Protect the urethra from fecal material

B. Rationale: Antibiotic ointment is used in the infant's eyes at birth to prevent ophthalmia neonatorum, an infection which can lead to blindness. It is not an acceptable practice to apply antibiotic ointment to the tear ducts, the umbilical cord, or the perineum and urethra.

The mother of a formula-fed newborn asks how she will know if her newborn is receiving enough formula during feedings. Which response by the nurse is correct? A. "If your newborn is wetting three to four diapers and producing several stools a day, enough formula is likely being consumed." B. "Your newborn should finish a bottle in less than 15 minutes." C. "A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight." D. "Your newborn should be taking about 2 oz of formula for every pound of body weight during each feeding."

C. Rationale: A sign of adequate formula intake is when the newborn seems satisfied and is gaining weight regularly. The formula fed newborn should take 30 minutes or less to finish a bottle, not less than 15 minutes. The newborn does normally produce several stools per day, but should wet 6 to 10 diapers rather than 3 to 4 per day. The newborn should consume approximately 2 oz of formula per pound of body weight per day, not per feeding.

A newborn is passing greenish-black stool of tarry consistency. The nursing student correctly identifies this type of stool as: A. Stool of a formula-fed newborn. B. Transitional stool. C. Stool of a breastfed newborn. D. Meconium stool.

D. Rationale: Meconium is a newborn's first stool. It is composed of amniotic fluid, shed mucosal cells, intestinal secretions, and blood. Breastfed newborns will pass stools that are yellow-gold, loose, and stringy to pasty in consistency. A formula-fed newborn will have stools that are yellow, yellow-greeen, or greenish and loose, pasty, or formed in consistency based upon the type of formula.

The mother of a newborn observes a diaper rash on her newborn's skin. Which intervention should the nurse instruct the parent to implement to treat the diaper rash? A. Use only baby wipes to cleanse the perianal area. B. Place the newborn's buttocks in warm water after each void or stool. C. Use products such as talcum powder with each diaper change. D. Expose the newborn's bottom to air several times a day.

D. Rationale: The nurse should instruct the parent to expose the newborn's bottom to air several times per day to treat and prevent diaper rashes. Use of baby wipes and products such as powder should be avoided. The parent should be instructed to place the newborn's buttocks in warm water after having had a diaper on all night but not with every diaper change.

While examining a newborn, a nurse observes salmon patches on the nape of the neck and on the eyelids. Which is the most likely cause of these skin abnormalities? A. An immature autoregulation of blood flow B. An allergic reaction to the soap used for the first bath C. Bruising from the birth process D. Concentration of immature blood vessels

D. Rationale: A concentration of immature blood vessels causes salmon patches. Bruising does not look like salmon patches but would be more bluish-purple in appearance. Harlequin sign is a result of immature autoregulation of blood flow and is commonly seen in low birth weight newborns. An allergic reaction would be more generalized and would not be salmon colored.