Prep U: Newborn

Parents tell the nurse they have been told to keep their newborn away from windows. They do not understand why this is necessary. Which rationale will the nurse provide to the parents?

"Newborns cannot shiver to produce heat and need to be kept away from sources of heat loss."

A new mother of a newborn girl calls the clinic in a panic, concerned about the blood-tinged soiled diaper. What is the best response from the nurse?

"This can be from the sudden withdrawal of your hormones. It is not a cause for alarm."

The nurse is caring for the newborn after birth. The nurse has obtained erythromycin ophthalmic ointment and prepares for administration. The parent asks the nurse, "I know all newborns get ointment put in their eyes, but why?" How will the nurse respond?

It is precautionary to prevent gonorrheal and chlamydial conjunctivitis.

The nurse is teaching a prenatal class illustrating the steps that are used to keep families safe. The nurse determines the session is successful when the parents correctly choose which precaution to follow after the birth of their infant?

Check the identification badge of any health care worker before releasing baby from room.

A nursing student is preparing a class for new mothers about adaptations they can expect in their newborns. Which information about newborn vision should the student include in the presentation?

Newborns have the ability to focus only on objects in close proximity.

A nurse is required to obtain the temperature of a healthy newborn who was placed in an open crib. Which is the most appropriate method for measuring a newborn's temperature?

Place electronic temperature probe in the midaxillary area.

A 3-hour old newborn is assessed and is tachypneic with a respiratory rate of 44. Heart rate is 168, temperature is 97.3°F (36.3°C) and blood glucose is 90. What is the first action the nurse should take?

Place the newborn away from drafts and under a blanket.

The nurse is assessing a woman who had a forceps-assisted birth for complications. Which condition would the nurse assess in the fetus?

caput succedaneum

A nurse is assessing the fluid status of a preterm newborn. Which parameter would be most appropriate for the nurse to assess?

fontanels (fontanelles)

While assessing a newborn, the nurse notes that half the body appears red while the other half appears pale. The nurse interprets this finding as:

harlequin sign.

The nurse is explaining to new parents that a potential complication of a cesarean birth is transient tachypnea of the newborn. The nurse explains that this is due to which occurrence?

lack of thoracic compressions during birth

According to Brazelton's Neonatal Behavioral Assessment Scale, a newborn would be in what state if the eyes are open and looking at people nearby, and he/she has minimal activity or body movement?

quiet alert

The nurse is documenting assessment of infant reflexes. She strokes the side of the infant's face, and the baby turns toward the stroke. What reflex has the nurse elicited?

rooting

Which of the following describes a chromosome aberration?

short stature, webbed neck

A nurse is assessing a newborn. Which finding would alert the nurse to the possibility of respiratory distress in a newborn?

sternal retractions

A nurse is teaching a postpartum client and her partner about caring for their newborn's umbilical cord site. Which statement by the parents indicates a need for additional teaching?

"The cord stump should change from brown to yellow."

The nurse is assessing a newborn's vital signs and notes the following: HR 138, RR 42, temperature 98.7oF (37.1oC), and blood pressure 70/40 mm Hg. Which action should the nurse prioritize?

Document normal findings.

The nurse is preparing the nursing care plan for a newborn who was born via a cesarean delivery. Which diagnosis should the nurse prioritize?

Ineffective airway clearance related to mucus and secretions

New parents are getting ready to go home from the hospital and have received information to help them learn how best to care for their new infant. Which statement indicates that they need additional teaching about how to soothe their newborn if he becomes upset?

"We'll hold off on feeding him for a while because he might be too full."

The student nurse is attending her first cesarean delivery and is asked by the mentor what should be carefully assessed in this infant. After responding "Respiratory status" the student is asked "Why?" What would be the best response?

"There is more fluid present in the lungs at birth after a cesarean delivery than after a vaginal delivery."

A nurse is teaching a newborn's caregivers how to change a diaper correctly. Which statement by the caregiver best indicates the nurse's teaching was effective?

"We will fold down the front of her diaper under the umbilical cord until it falls off."

A nurse teaches new parents how to soothe a crying newborn. Which statement by the parents indicates to the nurse the teaching was effective?

"We will turn the mobile on that's hanging on our baby's crib."

A parent asks the nurse how to swaddle the newborn because the parent heard that it helps newborns calm down. Which statement will the nurse include in the teaching?

"Wrapping the newborn too tightly can impair breathing."

A nurse is providing teaching to a new mother about her newborn's nutritional needs. Which suggestions would the nurse include in the teaching? Select all that apply.

-Feed the newborn on demand or at least every 2 to 4 hours during the day. -Use feeding time for promoting closeness. -Burp the newborn frequently throughout each feeding.

A nurse is called into the room of one of the clients where the grandparents are visiting. The grandmother is visibly upset, and says "Just look at my grandson! His head is all soft and swollen here and it shouldn't be. The doctor injured him when he was born." The nurse assesses the newborn and finds an area of swelling about the size of a half-dollar at the center of the upper scalp. The nurse determines this finding is most likely which condition?

Caput succedaneum

The nurse is preparing discharge instructions for the parents of a male newborn who is to be circumcised before discharge. Which instruction should the nurse prioritize?

Cover the glans generously with petroleum jelly.

Which nursing intervention is priority for the nursery nurse to complete on a newborn immediately following a cesarean birth?

Suction the newborn's airway.

A neonate has been administered a prescribed dose of vitamin K. What outcome would most clearly indicate to the nurse that the medication has had the intended effect?

The infant remains free of bleeding.

Which statement is true regarding fetal and newborn senses?

The rooting reflex is an example that the newborn has a sense of touch.

The nurse is preparing to assess the pulse on a newborn who has just arrived to the nursery after being cleaned in the labor and birth suite and swaddled in a blanket. Which action should the nurse prioritize?

Wear clean gloves.

The nurse is teaching a prenatal class and illustrating some of the basic events that will happen right after the birth. The nurse should point out which action will best help the infant maintain an adequate body temperature?

Wrap the infant in a warm, dry blanket.

The nurse is assessing a newborn who was born vaginally. The newborn was in the vertex position. The nurse notes that the newborn has some localized scalp edema primarily over the presenting part of the head. There is some bruising and edema that crosses the suture line. The nurse documents this finding as which of the following?

cephalohematoma

A Black couple are spending time with their newborn after the nurse brings the newborn back from the transition nursery. The parents note that their newborn's buttocks appear bruised and ask what happened. The nurse should explain this is related to which factor?

congenital dermal melanocytosis (slate gray nevi)

The nurse is assessing the skin of a newborn and notes a rash on the newborn's face and chest. The rash consists of small papules and is scattered with no pattern. The nurse interprets this finding as:

erythema toxicum.

A nurse needs to monitor the blood glucose levels of a newborn under observation at a health care facility. When should the nurse check the newborn's initial glucose level?

on admission to the nursery

During an assessment, the nurse suspects a newborn has a chromosomal disorder. What did the nurse most likely assess in the baby?

low-set ears

The nurse is providing teaching to a new mother who is breastfeeding. The mother demonstrates understanding of teaching when she identifies which characteristics as being true of the stool of breastfed newborns? Select all that apply.

-yellowish gold color -stringy to pasty consistency

A nurse is conducting a class for a group of pregnant women who are near term. As part of the class, the nurse is describing the process of attachment and bonding with their soon to be newborn. The nurse determines that the teaching was successful when the group states that bonding typically develops during which time frame after birth?

first 30 to 60 minutes