Ch.18
A newborn is 7 minutes old. The heart rate is 92 beats/min, the cry is weak, the muscles are limp and flaccid, the newborn responds promptly when stimulated, and the body and extremities are pink. What would the nurse assign as the Apgar score? A. 6 B. 3 C. 5 D. 4
A. 6 Rationale: The newborn is not demonstrating a good transition to extrauterine life; the Apgar score for this newborn is appearance/color = 2; pulse = 1; grimace/reflex irritability = 2; respiration/cry = 1; activity/muscle tone = 0. This newborn's Apgar score = 6.
Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress? A. short periods of apnea (less than 15 seconds) B. acrocyanosis C. asymmetrical chest movement D. respiratory rate of 50 breaths/minute
C. asymmetrical chest movement Rationale: Chest movements should be symmetrical. Typical newborn respirations range from 30 to 60 breaths per minute. Acrocyanosis is a common finding in newborns and does not indicate respiratory distress. Periods of apnea of less than 15 seconds are considered normal in a newborn. However, if these periods last more than 15 seconds and are accompanied by cyanosis and heart rate changes, additional evaluation is needed.
Which statement is false regarding bathing the newborn?
To reduce the risk of heat loss, the bath should be performed by thee nurse, not the parents, within 2-4 hrs of birth. Rationale: Bathing is not necessary for thermal stability. It can be postponed until the parents are able to do it.
The nurse is looking over a newborn's plan of care regarding expected outcomes. Which outcome would not be appropriate according to a newborn's nursing care? A. The newborn will experience no bleeding episodes lasting more than 5 minutes. B. The newborn will be correctly identified prior to separation from the parents. C. The newborn's body temperature will stabilize between 97.8ºF and 99.5ºF (36.6ºC and 37.5ºC). D. The newborn's blood glucose will remain above 50 mg/dl
A. The newborn will experience no bleeding episodes lasting more than 5 minutes.
Which is the best place to perform a heel stick on a newborn? A. the fat pads on the lateral aspects of the foot B. the calcaneus C. the vascularized flat surface of the foot D. the front of the heel (the outer arch)
A. the fat pads on the lateral aspects of the foot Rationale: The calcaneus is the bone of the heel. A heel stick should not be done on the flat part of the foot or heel, but instead on the lateral aspect of the foot, where the fat pads are.
A nurse is preparing to weigh a newborn just admitted to the nursery. Place the steps listed below in the order that the nurse would complete them. Use all options. 1. Cover the scale with a warmed cloth 2. Place the unclothed newborn in the center of the scale 3. Balance the scale 4. Recalibrate the scale to zero
You Selected: Balance the scale. Cover the scale with a warmed cloth. Recalibrate the scale to zero. Place the unclothed newborn in the center of the scale.
The nurse is conducting a newborn assessment and notes the head circumference is 35 cm. What is the largest measurement that the nurse will predict for the chest circumference in this newborn?
33 Rationale: The chest circumference in a term newborn is usually 2 to 3 cm smaller than the head circumference. 35 cm - 3 cm = 32 cm 35 cm - 2 cm = 33 cm Thus, the larger chest circumference is 33 cm.
A new mother is changing the diaper of her 12-hour-old newborn and asks why the stool is black and sticky. Which response by the nurse would be most appropriate? A. "This is meconium stool and is normal for a newborn." B. "I'll take a sample and check it for possible bleeding." C. "You probably took iron during your pregnancy and that is what causes this type of stool." D. "This is unusual, and I need to report this to your pediatrician. "
A. "This is meconium stool and is normal for a newborn." Rationale: Meconium is greenish-black and tarry and usually passed within 12 to 24 hours of birth. This is a normal finding. Iron can cause stool to turn black, but this would not be the case here. The stool is a normal occurrence and does not need to be checked for blood or reported.
The nurse is caring for an infant. Which nursing action will facilitate psychosocial growth of the infant? A. Be consistently attentive to the infant's basic needs. B. Allow the infant opportunities to self-soothe. C. Ensure the caregivers bring blankets and toys from home. D. Follow the nap and feeding schedule used at home.
A. Be consistently attentive to the infant's basic needs. Rationale: To help the infant develop a sense of trust, the nurse will consistently meet the infant's needs through feedings, holding the infant, and keeping the infant dry. Following the same schedule as at home or allowing security items (blankets, favorite stuffed animal) may help provide comfort, but will not facilitate building trust. Self-soothing at this age is discouraged because the infant needs to feel that someone is always there and attentive to his/her needs.
The nurse has completed an assessment on a 1-day-old newborn. Which finding should the nurse prioritize? A. Blood sugar 42 mg/dL B. Temperature of 97.8°F C. Respiratory rate 42 D. Heart rate 158
A. Blood sugar 42 mg/dL 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.
A nurse does an initial assessment on a newborn and notes a pulsation over the anterior fontanel (fontanelle) that corresponds with the newborn's heart rate. How would the nurse interpret this finding? A. It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanel. B. This finding is normal if the pulsation can also be palpated in the posterior fontanel. C. This is an abnormal finding and needs to be reported immediately. D. If the fontanel feels full, then this is normal.
A. It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanel. Rationale: Feeling a pulsation over the fontanel (fontanelle) correlating to the newborn's heart rate is normal. The pulsation should not be felt in the posterior fontanel. The fontanel should not be bulging under any circumstance in a newborn.
The nurse is checking on a newborn who was circumcised 2 hours ago using a Plastibell. Which intervention would be inappropriate for this client? A. Monitor the amount of bleeding and chart it. B. Apply petroleum gauze to the penis with each diaper change. C. Administer analgesics for pain on a scheduled basis. D. Position the infant on his side for comfort.
B. Apply petroleum gauze to the penis with each diaper change. Rationale: When a newborn is circumcised using a Plastibell, petroleum gauze is not used since the Plastibell protects the glans of the penis until it is healed. All other interventions are appropriate.
An infant born at 35 weeks' gestation is being screened for hypoglycemia. During the first 24 hours of life, when will the nurse screen this infant? A. Every 8 hours B. Before feedings C. After feedings D. Only if the infant is jittery
B. Before feedings Rationale: To screen for hypoglycemia, a glucose level is obtained prior to the first feeding and then prior to feedings for 24 to 48 hours. Infants are screened even in the absence of symptoms; this is done before feeding to obtain a preprandial measure.
When a newborn takes its first breath, what physical changes occur in the heart to increase oxygenation of the infant's blood? A. The umbilical vein that carried oxygenated blood in utero becomes the ascending aorta entering the right atrium. B. The ductus arteriosus expands to allow more blood to enter the lungs. C. The foramen ovale closes, preventing blood exchange from right to left in the heart. D. The ductus venous shunts oxygenated aortic blood to the lungs.
C. The foramen ovale closes, preventing blood exchange from right to left in the heart. Rationale: As the infant takes its first breath, the pressure gradient in the heart reverses from the intrauterine state. The higher pressure switches to the left side of the heart, which closes the foramen ovale, sending blood to the lungs instead of across the opening. The ductus venosus and the ductus arteriosus both close and become ligaments and the umbilical vein atrophies after the cord is cut.
A newborn is placed in an open crib in the newborn nursery, which is located near the doorway to the hall. What type of heat loss would this infant experience? A. Evaporative B. Conductive C. Convective D. Radiant
C. Convective Rationale: Convective heat loss occurs when air currents blow across the infant's body, causing it to chill. By placing the infant near a doorway, the infant will be exposed to drafts. Conductive heat loss occurs with direct contact with a cold surface. Evaporative heat loss occurs with moisture evaporating from the body. Radiant heat loss occurs with being close to a cold object but not touching it.
The nurse notes the following on a newborn's assessment: poor muscle tone, jitteriness, and temperature 97.0oF (36.1oC), HR 120 bpm, RR 26 breathes per minute, and blood pressure 60/40 mm Hg. Which nursing action should the nurse prioritize? A. Check the infant's temperature again. B. Complete an entire set of vital signs. C. Check oxygen saturation of the blood. D. Assess the infant's blood sugar.
D. Assess the infant's blood sugar. Rationale: The poor muscle tone, low temperature, and jitteriness are signs and symptoms indicative of hypoglycemia. The nurse should assess the blood glucose first. Assessing the vital signs and oxygen saturation would be assessed again at the appropriate time. The main concern at the moment is assessing for hypoglycemia to prevent further complications.
A nurse is conducting a refresher program for a group of nurses returning to work in the newborn clinic. The nurse is reviewing the protocols for assessing vital signs in healthy newborns and infants. The nurse determines that additional education is needed when the group identifies which parameter as being included in the assessment? A. pulse B. respirations C. temperature D. pain E. blood pressure
E. blood pressure Rationale: Because the readings can be inaccurate, blood pressure is not routinely assessed in term, normal healthy newborns with normal Apgar scores. It is assessed if there is a clinical indication such as suspected blood loss or low Apgar scores. Pain is assessed by objective signs of pain such as grimacing and crying in response to certain stimuli.
A nurse is preparing to administer erythromycin ointment to a 1-hour-old newborn. What will the nurse do first? A. Apply gloves and obtain the medication. B. Review the health care provider's order. C. Explain the procedure to the caregivers. D. Administer the medication in each eye.
B. Review the health care provider's order. Rationale: Prior to administering the erythromycin ointment, the nurse will review the order. The nurse would then explain the procedure to the caregivers, apply gloves, and administer the medication in both eyes.
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? A. The infant remains free of bleeding B. The infant's jaundice resolves C. The infant's hemoglobin level increases D. The infant remains free of infection
A. The infant remains free of bleeding Rationale: Vitamin K injections are given to ensure that neonates do not hemorrhage while their immature liver increases production of clotting factors.
The nurse is preparing to administer the ordered injections to a newborn. After noting the mother tested positive for HbsAG, which nursing intervention should the nurse prioritize for the infant? A. Two doses of the hepatitis B immunoglobulin within 24 hours of birth B. Hepatitis B vaccination and 1 dose of hepatitis B immunoglobulin within 24 hours of birth C. Hepatitis B vaccination and 1 dose of hepatitis B immunoglobulin within 12 hours of birth D. Hepatitis B vaccination and 2 doses of hepatitis B immunoglobulin within 24 hours of birth
C. Hepatitis B vaccination and 1 dose of hepatitis B immunoglobulin within 12 hours of birth Rationale: If a mother has hepatitis B (HbsAG) or is suspected of having hepatitis B, the newborn should be bathed and then should receive 1 dose of the hepatitis B vaccine and 1 dose of the hepatitis B immunoglobulin within 12 hours of birth. The other choices are the wrong dosages and/or times.
The nurse is caring for a newborn of a mother with human immunodeficiency virus (HIV). What is the priority for the nurse to complete following delivery? A. Administer zidovudine B. Assist the mother to breastfeed C. Test the newborn for HIV D. Bathe the newborn thoroughly
D. Bathe the newborn thoroughly Rationale: The newborn should have a thorough bath immediately after birth to decrease the possibility of HIV transmission. It is recommended the newborn be tested for HIV at 14 to 21 days after birth, at 1-2 months and again at 4-6 months. Zidovudine should be administered within 6-12 hours post-delivery to help prevent transmission of HIV from the mother to the newborn.
New parents report to the nurse that their newborn has "crying jags" in the afternoon each day. They are worried that if they hold the newborn every time she cries, she will become spoiled. What advice would the nurse give these parents? A. Rocking the newborn may soothe her but the time needs to be limited to 30 minutes per session. B. Crying indicates that the newborn has a need, so changing the diaper and feeding the infant should help. C. Try walking with the newborn around the house then place her back in the crib to let her cry for a while. D. Holding and comforting the newborn will not cause the infant to become spoiled.
D. Holding and comforting the newborn will not cause the infant to become spoiled. Rationale: Newborns often have periods of crying; the parents should first check for a physical reason for crying such as hunger or a soiled diaper. If this is not the cause, then the parents need to try to soothe the newborn by holding, walking, rocking the newborn or even taking the infant for a ride in the car. Reassure the parents that they will not spoil the newborn by meeting its needs.
A nurse is assessing a newborn's gestational age. Which parameter would the nurse evaluate to assess physical maturity? Select all that apply. A. scarf sign B. posture C. arm recoil D. lanugo E. genitals
D. lanugo E. genitals Rationale: Physical maturity indicators include skin, lanugo, plantar surface, breast, eye-ear, and genitals. Arm recoil, posture, and the scarf sign are used to evaluate neuromuscular maturity.
A neonate born by cesarean birth required oxygen after the birth. The mother expresses concern because this was not a factor with her previous vaginal birth. What response by the nurse is most appropriate? A. "Neonates born by cesarean do not benefit from the squeezing of the contractions, which helps to clear the lungs." B. "Neonates born by cesarean tend to need oxygen supplementation due to the rapid change in fetal circulation when the uterus was cut during the birth." C. "Normally, neonates born by cesarean do better after delivery since it is a much gentler birth." D. "This is likely just coincidence." E. "You are older now and that can impact how your neonate adapts to the birth process."
A. "Neonates born by cesarean do not benefit from the squeezing of the contractions, which helps to clear the lungs." Rationale: During labor and delivery, the contractions provide pressure on the fetus. These forces "squeeze" the fetus's thoracic cavity. This aids the fetus in forcing the amniotic fluid from the lungs. The neonate born by cesarean does not have this experience, which may result in some initial periods of tachypnea and a need for oxygen supplementation. Maternal age and the uterine incision do not impact this phenomenon.
When the nurse performs the Ortolani maneuver, which action would be appropriate? Select all that apply. A. Attempt to abduct the hips 180 degrees while applying upward pressure. B. Place the newborn in a supine position. C. Listen for a click when the legs are abducted. D. Attempt to abduct the hips 90 degrees while applying upward pressure. E. Position the newborn prone with the head face down.
A. Attempt to abduct the hips 180 degrees while applying upward pressure. B. Place the newborn in a supine position. Rationale: The newborn should be in the supine position. The nurse will flex the hips and knees to 90 degrees at the hip, then will attempt to abduct the hips 180 degrees while applying upward pressure. A "click" or a "cluck" should not be heard when the legs are abducted.
What measures can a nurse take to reduce the risk of hypoglycemia in a newborn? Select all that apply. A. Begin skin-to-skin (kangaroo) care for the newborn. B. Initiate early and frequent breastfeeding. C. Feed the newborn formula every 4 hours, starting 8 hours after birth. D. Dry the newborn off immediately after birth to prevent chilling. E. Feed only glucose water for the first 24 hours following birth.
A. Begin skin-to-skin (kangaroo) care for the newborn. B. Initiate early and frequent breastfeeding. D. Dry the newborn off immediately after birth to prevent chilling. Rationale: By preventing hypothermia in a newborn, the chance of hypoglycemia is lessened since cold stress causes a newborn to burn more calories. Feedings should also begin early, with either breast milk or formula. Glucose water does not provide enough glucose for the newborn. Skin-to-skin (kangaroo) care keeps the newborn in a thermoneutral environment.
A new mother is learning how to change the diaper on her newborn and becomes concerned after observing a rash on the trunk of the infant. Which response should the nurse prioritize? A. Explain this is normal. B. Check all of the baby's vital signs before calling the doctor. C. Immediately call the RN or health care provider. D. Change and bathe the infant.
A. Explain this is normal. Rationale: Erythema toxicum is otherwise known as normal newborn rash. The rash will resolve without intervention. There is no need to call the RN or health care provider, change and bathe the infant, or check the vital signs.
Parents are taking home their second child. They also have a 2-year-old at home. The nurse would anticipate which behavior by these parents? A. General questions about different aspects of newborn care B. Only questions specific to breastfeeding C. Confidence since they have another child already D. No questions of the nurse
A. General questions about different aspects of newborn care Rationale: Just because parents have had a previous child does not mean that they will not have questions about their newborn infant. Each newborn is different and parents my not feel comfortable this time caring for the newborn.
The parents of a newborn are upset that their newborn needs treatment for ophthalmia neonatorum. The nurse should explain this is related to which maternal infection? Select all that apply. A. Gonorrhea B. Chlamydia C. Trichomonas D. Candidiasis E. Syphilis
A. Gonorrhea B. Chlamydia Rationale: Colonization of chlamydia and gonorrhea in the vaginal tract can lead to ophthalmia neonatorum in the newborn, which infants contract at birth. The treatment is the use of an antibiotic ophthalmic ointment that is usually applied within the first hour. Trichomonas, syphilis, and candidiasis do not cause ophthalmia neonatorum.
A nurse is conducting a parenting class on infant skin care. What information should the nurse include when preparing materials on the characteristics of the skin of infants? Select all that apply. A. It is thinner and more fragile than an adult's B. Sweat glands are fully functioning at birth. C. Skin is less susceptible to the sun. D. The epidermis is thicker than in adults. E. Substances are easily absorbed.
A. It is thinner and more fragile than an adult's E. Substances are easily absorbed. Rationale: An infant's skin is more fragile than that of adult's and is more susceptible to breakdown as well as the effects of the sun. The epidermis of an infant's skin is much thinner than an adult's and does not reach the thickness of adult skin until late adolescence. Sweat glands are immature at birth, contributing to the difficulty infants have in regulating temperature. Sweat glands do mature as the infant grows.
During which state of Brazelton's Neonatal Behavioral Assessment Scale would be the best time for new parents to interact with their newborn? A. Quiet alert state B. Light drowsy state C. Active alert state D. Drowsy state
A. Quiet alert state Rationale: In the quiet alert state, the newborn's eyes are open and the infant is attentive to people and things occurring in close proximity to them. This is an ideal time for parents to interact with the infant.
A mother asks the nurse about having her son circumcised. The nurse understands that circumcision is contraindicated under which circumstances? Select all that apply. A. There is a family history of hemophilia. B. The newborn was febrile at birth but temperature is now normal. C. The father is uncircumcised. D. The penis is small. E. The infant is at 33 weeks' gestation.
A. There is a family history of hemophilia. E. The infant is at 33 weeks' gestation. Rationale: Circumcision is contraindicated for several reasons including prematurity, family history of a bleeding disorder, and illness. A fever at birth is not a problem as long as it comes back down to normal shortly after birth. A small penis or a father who was never circumcised are not reasons to delay circumcision.
A nurse is conducting a prenatal class for some clients who are in their third trimester with the topic being preventing misidentification. The nurse determines the session is successful after the participants correctly choose which items will be on matching identification bracelets? A. newborn's sex and date and time of birth B. mother's name, infant's blood type, and date and time of birth C. blood type and date and time of birth D. hospital number, attending care provider, and father's name
A. newborn's sex and date and time of birth Answer: Information included on the bands is the mother's name, hospital number, care provider's name, newborn's sex, and date and time of birth. The father's name and infant's blood type would not be included on these bracelets, which are put on at the time of birth.
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? A. "Newborns weighing below 8 lb (3630 g) lack enough brown fat to produce heat." B. "Newborns cannot shiver to produce heat and need to be kept away from sources of heat loss." C. "Windows can be drafty and placing the newborn by one can result in evaporative heat loss." D. "Covering the newborn with heavy blankets is the best way to keep your newborn warm."
B. "Newborns cannot shiver to produce heat and need to be kept away from sources of heat loss." Rationale: Thermoregulation is difficult for newborns due to their inability to produce heat through muscle movement or shivering. They must rely on metabolizing brown fat. Placing a hat on the newborn can assist with thermoregulation. Newborns less than 8 lb (3630 g) still have brown fat. Windows can be problematic due to the potential for convective heat loss. Covering the newborn with heavy blankets is not recommended, because this can place the newborn at risk for sudden infant death syndrome (SIDS).
The nurse is explaining to the parents about the various laboratory tests which will be conducted on their newborn. The nurse should point out that testing for phenylketonuria will be conducted in which time frame? A. 4 weeks after solid food is first eaten. B. 24 to 72 hours after birth. C. within 24 hours after birth. D. within 1 hour after birth.
B. 24 to 72 hours after birth. Rationale: PKU is an inherited disease involving a specific enzyme necessary in the production of amino acids. Without this enzyme, phenylalanine builds up in the blood and can lead to serious consequences, such as brain damage. Phenylketonuria testing measures the amount of phenylalanine present in the blood. The infant must have taken breast milk or formula for an abnormal amount to be present. The blood sample is obtained via a heel stick and is best conducted 2 to 3 days after birth, allowing time for the infant to eat. The main treatment for this condition is life-long dietary restrictions, so it needs to be identified quickly so appropriate care can be started.
The nurse is concerned that the nares of a newborn are not patent bilaterally. What can the nurse do to address this concern? A. Pass an NG tube down both sides of the nostrils to assess patency. B. Occlude the nares one at a time by applying pressure to each side to see if the newborn can breath comfortably. C. Use a swab to explore the nares bilaterally for occlusions. D. Look for nasal flaring to indicate that the newborn is breathing out of both sides of the nostrils.
B. Occlude the nares one at a time by applying pressure to each side to see if the newborn can breath comfortably. Rationale: If a nurse is concerned that the nostrils are patent in a newborn, the nurse will occlude the nares one at a time to see if the newborn can breath easily. The nurse would never place something like a swab into the nares to check patency due to potential trauma. Nasal flaring is an abnormal finding and indicates respiratory distress, not ease of breathing. Passing an NG tube is traumatic to the newborn and is not needed in most cases.
Within three days of birth, a newborn has developed a yellowish tinge that extends from face to mid-chest, is lethargic, and has to be awoken to feed. Which condition does the nurse suspect this infant is manifesting? A. Breastfeeding jaundice. B. Physiologic jaundice. C. Bile duct blockage. D. Pathologic jaundice.
B. Physiologic jaundice. Rationale: Physiologic jaundice occurs 48 hours or more after birth. Pathologic jaundice occurs within the first 24 hours of life and is often related to blood incompatibility. Breastfeeding jaundice occurs later within the first week of life. Evidence of bile duct blockage would be more severe and noted at an earlier age.
A female 1-day-old newborn's temperature is 97.1℉ (36.2℃) in an open crib and the newborn has been in the mother's room for several hours. What action should the nurse take? Select all that apply. A. Ask the mother if she fed the newborn while the infant was in the room with her. B. Place a cap on the newborn and wrap her up in a blanket. C. Place the newborn's crib in the middle of the room away from the door. D. Turn the nursery temperature up to 80°F (26.7°C). E. Determine the mother's room temperature during the visit.
B. Place a cap on the newborn and wrap her up in a blanket. C. Place the newborn's crib in the middle of the room away from the door. E. Determine the mother's room temperature during the visit. Rationale: The newborn's temperature is low and she needs to be warmed up. Placing a cap on her head and wrapping her in a blanket helps the newborn conserve body heat. Determining the maternal room temperature is important to ensure that the newborn was not chilled while out with the mother, and helps determine the cause of the hypothermia. Lastly, placing the crib away from walls and drafts will help prevent heat loss and maintain a thermoneutral environment. Increasing the nursery temperature is not a good idea since this may overheat this newborn as well as other babies in the nursery.
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? A. Place a pillow under the newborn to raise the head of the bed. B. Place the newborn away from drafts and under a blanket. C. Feed the newborn to provide more glucose. D. Begin the newborn on oxygen with BNC at 2L.
B. Place the newborn away from drafts and under a blanket. Rationale: When a newborn becomes cold stressed, they often develop respiratory distress. The newborn's temperature is low, so the first nursing action is to place the newborn in a warmer environment and cover with a blanket to warm the newborn up. The serum glucose is normal so the newborn does not need additional nutrition. The newborn does not have documented hypoxia, so oxygen is not appropriate. Pillows are never used in newborn's beds due to the risk of suffocation.
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? A. The rooting reflex shows a strong sucking response. B. The rooting reflex was tested incorrectly. C. The infant displays a normal rooting reflex. D. The infant does not have a normal rooting reflex.
B. The rooting reflex was tested incorrectly. Rationale: Gently stroking the newborn's cheek brings out the rooting reflex. The newborn would demonstrate this reflex by turning toward the touch with an open mouth. This infant demonstrates a positive suck reflex but does not display the rooting reflex because the test was performed incorrectly.
What supplies would the nursery nurse collect in preparation for bathing a newborn infant? Select all that apply. A. Talc powder B. Thermometer C. Hexachlorophene soap D. A washcloth E. Warm tub of water
B. Thermometer D. A washcloth E. Warm tub of water Rationale: The initial bath for a newborn is done using warm water, a mild soap (not hexachlorophene, which can be absorbed through the skin), and a thermometer to check the newborn's temperature following the bath. Talc powder is not recommended because of the risk for aspiration.
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? A. "This can be related to cleaning her perineal area; be more careful." B. "The baby may have a problem; let's schedule an appointment." C. "This can be from the sudden withdrawal of your hormones. It is not a cause for alarm." D. "If this continues, call us back; for now, just watch her."
C. "This can be from the sudden withdrawal of your hormones. It is not a cause for alarm." Rationale: The mother is describing pseudomenstruation and is usually the result of the infant no longer having the mother's hormones in the body. This is not a cause for alarm. It is always appropriate to offer to schedule an appointment if the mother continues to be upset. The nurse should know that the infant's "bleeding" is not indicative of a pathologic process and should be careful to not upset the mother further. The statement of it being related to the way the mother is cleaning the perineum is incorrect for it places the blame on the mother for the infant's problem. The instruction to call back if it continues does not meet the mother's need to know why this is happening to her baby, and it negates her concern for her infant.
Neonatal screening is done before the infant leaves the hospital. Blood is drawn through a heel stick and tested for several disorders that can cause lifelong disabilities. When is the ideal time to collect this specimen? A. When the infant is 48 hours old B. 36 hours before the infant is discharged home with its parents C. 24 hours after the newborn's first protein feeding D. Just before discharge home
C. 24 hours after the newborn's first protein feeding Rationale: The laws in most states require this initial screening, which is done within 72 hours of birth. The ideal time to collect the specimen is after the newborn is 36 hours old and 24 hours after he has his first protein 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? A. Harlequin sign B. Molding C. Caput succedaneum D. Increased intracranial pressure
C. Caput succedaneum Rationale: Caput succedaneum is swelling of the soft tissue of the scalp caused by pressure of the presenting part on a partially dilated cervix or trauma from a vacuum-assisted delivery. This finding is often of concern for the families. Reassure them that the caput will decrease in a few days without treatment. Increased intracranial pressure would involve the entire scalp and not just a small portion. There would also be other neurologic signs accompanying it. Molding is an elongated head shape caused by overlapping of the cranial bones as the fetus moves through the birth canal. This will also resolve in a few days without treatment. The Harlequin sign is characterized by a clown-suit-like appearance of the newborn where the skin is dark red on one side of the body and the other side is pale. This is a harmless condition which occurs most frequently with vigorous crying or with the infant lying on his or her side.
The nursing instructor is conducting a class exploring the care of the neonate right after birth. The instructor determines the class is successful when the students correctly choose the best reason to prevent cold stress? A. Evaporative heat loss happens when the neonate is not bundled and does not have a hat on. B. The neonate will stabilize its temperature by 8 hours after birth if kept warm and dry. C. If the neonate becomes cold stressed, it will eventually develop respiratory distress. D. It takes energy to keep warm, so the neonate has to remain in an extended position.
C. If the neonate becomes cold stressed, it will eventually develop respiratory distress. Rationale: If cold stressed, the infant eventually will develop respiratory distress- O2 requirements rise, even before noting a change in temperature, glucose use increases, acids are released into the bloodstream and surfactant production decreases bringing on metabolic acidosis. Bundling and using a hat will help prevent heat loss by evaporation which can lead to cold stress. It is better if the neonate remains in a flexed position as it will assist with keeping warm. The neonate should stabilize its temperature by 8 hours as long as proper measures are followed.
The LPN is assessing a 1-day-old newborn and notices a large amount of white drainage and redness at the base of the umbilical cord. What is the best response by the nurse? A. Show the mother how to clean the area with soap and water, and document the intervention. B. Call the doctor immediately to ask for intravenous antibiotics and document finding. C. Notify the charge nurse, because it represents a possible complication, and document the finding. D. Carefully clean the area with a damp washcloth and cover it with an absorbent dressing and document finding and intervention.
C. Notify the charge nurse, because it represents a possible complication, and document the finding. Rationale: The base of the cord should be dry without redness or drainage, and the umbilical clamp should be fastened securely. The white drainage and redness are potential signs of an infection and would need to be reported immediately to the RN by the LPN. Antibiotics may or may not be necessary, however.
The nurse notes in a newborn's chart that the newborn has been diagnosed with physiologic jaundice. The nurse recognizes that physiologic jaundice is determined by what criteria? A. The jaundice occurred within the first 24 hours after birth. B. The conjugated bilirubin is higher than the unconjugated bilirubin. C. The bilirubin peaked between days 3 and 5 after birth. D. The bilirubin level rose 6 mg/dl to 13 mg/dl over the last 24 hour
C. The bilirubin peaked between days 3 and 5 after birth. Rationale: Physiologic jaundice involves the liver's inability to break down the bilirubin as fast as it is being produced due to the immaturity of the liver. The criteria for physiologic jaundice is that the jaundice occurs after 24 hours of age, it peaks between days 3 and 5 and does not rise more than 5 mg/dl per day Conjugated bilirubin is the water-soluble version of bilirubin and is excreted in feces; it should always be lower than the unconjugated bilirubin.
A nurse is analyzing a journal article that explains the changes at birth from fetal to newborn circulation. The nurse can point out the closure of the ductus arteriosus is related to which event after completing the article? A. higher oxygen levels at the respiratory centers of the brain B. precipitous drop in blood pressure C. higher oxygen content of the circulating blood D. drop in pressure in the neonate's chest
C. higher oxygen content of the circulating blood Rationale: 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. A drop in the pressure results in a reversal of pressures in the right and left atria, causing the foramen ovale to close, which redirects blood to the lungs. A drop in blood pressure and higher oxygen levels at the respiratory centers of the brain do not result in the closure of the foramen ovale.
The nurse is preparing the delivery room before the birth occurs. What supplies would the nurse have available to care for the newborn? Select all that apply. A. Glucose water B. Ophthalmoscope C.Suction equipment D. Identification bands E. Warmer bed
C.Suction equipment D. Identification bands E. Warmer bed Rationale: In preparing the delivery room, the nurse should preheat a warmer bed, have suction equipment at bedside, and have the identification bands ready for both the mother and newborn. Glucose water and an ophthalmoscope are not needed immediately after delivery to stabilize the newborn.
