CH. 13 Newborn Transition
What is the best way for the nurse to assess the newborn's heartbeat?
auscultating the apical pulse for 60 seconds
A nurse is caring for an infant with an elevated bilirubin level who is under phototherapy. What evaluation data would best indicate that the newborn's jaundice is improving?
Bilirubin level went from 15 to 11.
Neonatal hypoglycemia is a risk of newborns with diabetic mothers. What laboratory value would be classified as neonatal hypoglycemia?
Blood glucose of 50 mg/dL
What is the term for a small collection of blood that forms underneath the skull as a result of birth trauma?
Cephalhematoma *Vernix caseosa is a thick white substance found on a newborn. Erythema toxicum is a newborn rash. Caput succedaneum is molding or edema.
After the birth of a newborn, which action would the nurse do first to assist in thermoregulation?
Dry the newborn thoroughly.
The nurse places a warmed blanket on the scale when weighing a newborn to minimize heat loss via which mechanism?
conduction
At birth, changes from fetal to newborn circulation must occur. What change causes the ductus arteriosus to close?
higher oxygen content of the circulating blood *The first few breaths greatly increase the oxygen content of circulating blood. This chemical change (i.e., higher oxygen content of the blood) contributes to the closing of the ductus arteriosus, which eventually becomes a ligament.
What are the functions of kangaroo care? Select all that apply.
is skin-to-skin contact helps the parents bond with their neonate keeps the neonate warm
The nurse is preparing a teaching plan for new parents about why newborns experience heat loss. Which information about newborns would the nurse include?
limited voluntary muscle activity
A nurse is assessing a newborn. Which finding would alert the nurse to the possibility of respiratory distress in a newborn?
sternal retractions
The nurse is assessing a newborn at 1 minute of life for an APGAR score. The newborn's heart rate is 125, the cry is lusty, the extremities are well flexed, the newborn coughs when a catheter is placed in the nose to remove secretions, and acrocyanosis is present. The nurse gives an APGAR score of ___ for this newborn.
9
A newborn has physiologic jaundice. The parents ask why the baby has a yellowish skin color. The most appropriate nursing response is which of the following?
"I can tell you are worried about your baby. Let's talk about this change in your baby's skin color."
A patient who gave birth 2 hours ago expresses concern about her baby developing jaundice. How should the nurse respond? Choose the best response.
"I understand your concern because as many as 50% of babies can develop jaundice."
You are a graduate LVN/LPN seeing your first cesarean delivery. An infant girl is born and as the nurse assesses the infant she asks you what you would carefully assess in this infant. You respond "Respiratory status." The assessing nurse asks you "Why?" What would be your best response?
"There is more fluid is present in the lungs at birth after a cesarean delivery than after a vaginal delivery."
The nurse institutes measures to maintain thermoregulation based on the understanding that newborns have limited ability to regulate body temperature because they:
are unable to shiver effectively to increase heat production.
A hypoglycemic newborn will have a blood glucose reading of what value on heel stick?
45 mg/dL
Baby boy Alvarez is five minutes old. The nurse performs a quick assessment and determines that the newborn has a heart rate of 110 bpm, a weak cry, and acrocyanosis. His extremities are held in partial flexion, and he grimaces when a catheter is placed in his nose. What Apgar score does the nurse record, and what does this score mean?
5-The newborn is having moderate difficulty transitioning.
A 1-minute-old newborn has a heart rate of 105 bpm, a pink body and blue feet, and a strong cry, along with sneezing and minimal flexion. What should the nurse assign as the 1-minute APGAR score?
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Which statement is true regarding fetal and newborn senses?
The rooting reflex is an example that the newborn has a sense of touch.
You are the senior LVN/LPN in the newborn nursery and you are orienting a new graduate LVN/LPN. One of the subjects you want to cover today is hepatic adaptation of the normal newborn. What would you know to talk about?
AquaMEPHYTON (vit. K)
The nurse is assessing an infant's reflexes. While eliciting a rooting reflex, the infant strongly sucks on the nurse's finger. How does the nurse interpret this finding?
The rooting reflex was tested incorrectly.
What should the nurse expect for a full-term newborn's weight during the first few days of life?
There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns.
You have just received a newborm male into the nursery with the report that he has a hypospadias. What does this mean?
His urinary meatus in located on the under surface of the glans *The term hypospadias refers to the urinary meatus being abnormally located on the ventral (under) surface of the glans.
Which of the following would lead you to suspect that a newborn has developmental hip dysplasia?
Inability of the right hip to abduct *Newborns whose acetabulums are shallow cannot abduct their hip joint.
You are assessing a newborn girl, four hours old, weighing 9 lbs. 2 oz. While doing the initial assessment the RN mentioned that the mothers' history showed her to be morbidly obese. You would know to observe this infant frequently for signs/symptoms of hypoglycemia. What would be early signs of hypoglycemia in this newborn?
Jitteriness and irritability
When teaching a mother to care for her newborn's umbilical cord, which of the following instructions would you include?
Keeping it dry
You are assisting with the admission of a newborn boy to the nursery. The mother's history states that she is of Hispanic descent. You note what appears to be bruising on the left upper outer thigh. How would you document this?
Mongolian spot noted on left upper outer thigh
A nurse is explaining to a group of new parents about the changes that occur in the neonate to sustain extrauterine life, describing the cardiac and respiratory systems as undergoing the most changes. Which information would the nurse integrate into the explanation to support this description?
Pulmonary vascular resistance (PVR) is decreased as lungs begin to function.
Which of the following is true regarding the newborn's fontanelles?
The anterior fontanelle is diamond shaped and measures about 3.5 cm. The posterior fontanelle is triangular shaped and measures about 1 cm. *The anterior fontanel is diamond shaped and is larger than the posterior fontanel, which is triangular in shape.
A nurse is teaching newborn care to students. The nurse correctly identifies which mechanism as the predominant form of heat loss in the newborn?
radiation, convection, and conduction
When explaining how a newborn adapts to extrauterine life, the nurse would describe which body systems as undergoing the most rapid changes?
respiratory and cardiovascular
All the options are signs of respiratory distress in the newborn except:
respiratory rate >50 breaths/minute
What is the primary goal of nursing care immediately after birth?
to maintain the safety of the neonate from intrauterine to extrauterine life
When assessing the newborn's umbilical cord, what should the nurse expect to find?
two smaller arteries and one larger vein
At what point should the nurse expect a healthy newborn to pass meconium?
within 24 hours after birth
