Chapter 13: Nursing Care During Newborn Transition

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? "We will be readmitting your child to the hospital. She has a condition known as jaundice." "There is nothing to worry about. Jaundice is very common." "I can tell you are worried about your baby. Let's talk about this change in your baby's skin color." "You let us worry about your baby. This is a pretty critical time for her."

"I can tell you are worried about your baby. Let's talk about this change in your baby's skin color."

A newborn is born and, at 1 minute of life, is acrocyanotic, HR is 110, is floppy with some flexion, has a weak cry and grimaces. What Apgar score would the nurse assign this infant? 6 7 8 9

6

Which findings by a nurse would be considered abnormal when examining the eyes of a newborn? Select all that apply. Absent red reflex Swollen eyelids Positive "doll's eye" reflex Blue-tinged sclera Sub-conjunctival hemorrhages

Absent red reflex Blue-tinged sclera

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? Reticulocyte count is 6%. Hematocrit is 38. Skin looks less jaundiced. Bilirubin level went from 15 to 11.

Bilirubin level went from 15 to 11.

A newborn's vital signs are documented by the nurse and are as follows: HR 144, RR- 36, BP- 128/78, and T- 98.6℉ (37℃). Which finding would be concerning to the nurse? Heart Rate Respiratory Rate Blood Pressure Temperature

Blood Pressure

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? Increased intracranial pressure Caput succedaneum Molding Harlequin sign

Caput succedaneum

The nurse is assessing a newborn who appears healthy and at term. Which assessment finding of the feet does the nurse predict to observe to confirm the status of at-term birth? Creases covering one fourth of the foot Longitudinal but no horizontal creases Creases on two-thirds of the foot Heel but no anterior creases

Creases on two-thirds of the foot

After the birth of a newborn, which action would the nurse do first to assist in thermoregulation? Dry the newborn thoroughly. Put a hat on the newborn's head. Check the newborn's temperature. Wrap the newborn in a blanket.

Dry the newborn thoroughly.

The nurse is assessing reflexes in a newborn infant. What can the nurse do to elicit the rooting reflex? Place a gloved finger in the newborn's mouth. Startle the newborn by letting the head drop back slightly. Turn the head to one side without moving the rest of the body. Gently stroke the newborn's cheek.

Gently stroke the newborn's cheek.

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? Rocking the newborn may soothe her but the time needs to be limited to 30 minutes per session. Crying indicates that the newborn has a need, so changing the diaper and feeding the infant should help. Holding and comforting the newborn will not cause the infant to become spoiled. Try walking with the newborn around the house then place her back in the crib to let her cry for a while.

Holding and comforting the newborn will not cause the infant to become spoiled.

Which of the following would lead you to suspect that a newborn has developmental hip dysplasia? Inability of the right hip to abduct Crying on straightening of the right leg Continual drawing of his legs under him while prone Inward rotation of his right foot

Inability of the right hip to abduct

A nurse is explaining the Apgar scoring to new mother and her partner. What should the nurse point out about this scoring method? Select all that apply. It is done at 1 and 5 minutes after birth. The baby is considered vigorous if the 5-minute score is above 7. Each factor receives a score of 0 or 2. The Apgar score is used to guide newborn resuscitation. The Apgar score is an immediate assessment of newborn cardiopulmonary adaptation.

It is done at 1 and 5 minutes after birth. The baby is considered vigorous if the 5-minute score is above 7. The Apgar score is an immediate assessment of newborn cardiopulmonary adaptation.

Upon examination of the skin, which assessment findings would the nurse recognize as normal findings for a full-term newborn at 3 hours of age? Select all that apply. Lanugo on the back Vernix caseosa over the abdomen and lower extremities Milia Acrocyanosis Jaundice

Lanugo on the back Milia Acrocyanosis

The nurse enters the room and notes the infant is in its bed sleeping, close to the outside window. Which action should the nurse prioritize? Place another blanket on the infant. Check the infant's vital signs. Move the infant away from the window. Observe infant's status.

Move the infant away from the window.

On a newborn's initial assessment, it is noted that the newborn's head is misshapen and elongated with swelling of the soft tissue of the skull. What nursing intervention is needed? No interventions are needed. This will resolve on its own over the next several days. An ice pack should be placed on the edematous scalp. Have the mother massage the scalp twice daily to reduce the swelling. Place a snug cap on the newborn's head to compress the swelling.

No interventions are needed. This will resolve on its own over the next several days.

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? Feed the newborn to provide more glucose. Place the newborn away from drafts and under a blanket. Begin the newborn on oxygen with BNC at 2L. Place a pillow under the newborn to raise the head of the bed.

Place the newborn away from drafts and under a blanket

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? The cardiac murmur heard at birth disappears by 48 hours of age. Pulmonary vascular resistance (PVR) is decreased as lungs begin to function. Heart rate remains elevated after the first few moments of birth. Breath sounds will have rhonchi for at least the first day of life as fluid is absorbed.

Pulmonary vascular resistance (PVR) is decreased as lungs begin to function.

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 the newborn has minimal activity or body movement? Drowsy Quiet alert Active alert Active attentive

Quiet alert

During which state of Brazelton's Neonatal Behavioral Assessment Scale would be the best time for new parents to interact with their newborn? Drowsy state Active alert state Light drowsy state Quiet alert state

Quiet alert state

A nurse is doing an admission assessment on a female infant born to a primipara. Which findings would warrant notification of the physician? Select all that apply. Heart rate of 150 Scaphoid abdomen Episodic breathing Head circumference of 38 cm Overlapping cranial sutures

Scaphoid abdomen Head circumference of 38 cm

The nurse is assessing a 2-hour-old newborn and notes that the infant has irregular patterns of breathing rate, depth, and rhythm. Which is the best action made by the nurse? Calling the provider immediately and report the findings. Reassess the newborn in 2 hours. Take no action because these are normal findings in a newborn. Begin supplemental oxygen with a nasal cannula immediately.

Take no action because these are normal findings in a newborn.

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? The jaundice occurred within the first 24 hours after birth. The bilirubin peaked between days 3 and 5 after birth. The bilirubin level rose 6 mg/dl to 13 mg/dl over the last 24 hours. The conjugated bilirubin is higher than the unconjugated bilirubin.

The bilirubin peaked between days 3 and 5 after birth.

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 The infant's jaundice resolves The infant's hemoglobin level increases The infant remains free of infection

The infant remains free of bleeding

What should the nurse expect for a full-term newborn's weight during the first few days of life? There is an increase in 3% to 5% of birth weight by day 3 in formula-fed babies. A formula-fed newborn should gain 3% to 5% of the initial birth weight in the first 48 hours, but a breastfed newborn may lose up to 3%. There is a loss of 5% to 10% of the birth weight in the first few days in breastfed infants only. There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns.

There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns.

The nurse is examining a newborn and notes that there is bruising and swelling on the newborn's head, limited to the right side of the scalp and does not cross the suture lines. How will the nurse interpret this finding? This is concerning because the swelling does not cross the newborn's suture lines. This is a cephalohematoma that typically spontaneously resolves without interventions. This newborn has a subarachnoid hemorrhage requiring surgical intervention. The newborn has caput succedaneum that will go away within the first week of life.

This is a cephalohematoma that typically spontaneously resolves without interventions.

When teaching new parents about the sensory capabilities of their newborn, which sense would the nurse identify as being the least mature? hearing touch taste vision

Vision

A newborn has a 5-minute Apgar score of 9. What intervention should the nurse take for this client? Actively stimulate the infant to cry. Offer blow-by oxygen. Wrap the infant in a blanket and hand to the mother for bonding. Place the infant in a warmer bed and heat the newborn up.

Wrap the infant in a blanket and hand to the mother for bonding.

The nurse notices that a newborn has a white discharge from his breasts. The nurse would explain to his parents that this is: caused by his mother's hormones. a suggestion he may need chromosomal studies. a sign that he has a pituitary tumor. caused by exposure to cool air.

caused by his mother's hormones.

The nurse places a warmed blanket on the scale when weighing a newborn to minimize heat loss via which mechanism? evaporation conduction convection radiation

conduction

Eliminating drafts in the birth room and in the nursery will help to prevent heat loss in a newborn through which mechanism? evaporation convection conduction radiation

convection

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? drop in pressure in the neonate's chest higher oxygen content of the circulating blood higher oxygen levels at the respiratory centers of the brain precipitous drop in blood pressure

higher oxygen content of the circulating blood

The nurse is preparing a teaching plan for new parents about why newborns experience heat loss. Which information about newborns would the nurse include? thick skin with deep lying blood vessels enhanced shivering ability expanded stores of glucose and glycogen limited voluntary muscle activity

limited voluntary muscle activity

On inspection, the nurse notes that a newborn has a normal newborn head/body proportion. This proportion for the head is: one-half his total length. one-fourth his total length. one-sixth his total length. one-eighth his total length.

one-fourth his total length.

A nurse is teaching newborn care to students. The nurse correctly identifies which mechanism as the predominant form of heat loss in the newborn? nonshivering thermogenesis lack of brown adipose tissue sweating and peripheral vasoconstriction radiation, convection, and conduction

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? gastrointestinal and hepatic urinary and hematologic respiratory and cardiovascular neurological and integumentary

respiratory and cardiovascular

At what point should the nurse expect a healthy newborn to pass meconium? before birth within 1 to 2 hours of birth by 12 to 18 hours of life within 24 hours after birth

within 24 hours after birth

A woman who is about to be discharged after a vaginal birth notices a flea-like rash on her newborn's chest that consists of tiny red lesions all across the nipple line. What is the best response from the nurse when explaining this to the woman? "It is a normal skin finding in a newborn." "It is a sign of a group B streptococcus skin infection. " "It is an indication that the woman has mistreated her newborn." "It is a self-limiting virus that does not require treatment."

"It is a normal skin finding in a newborn."

Which action will the nurse avoid when performing basic care for a newborn male? Inspecting the genital area for irritated skin Palpating if testes are descended into the scrotal sac Determining the location of the urethral opening Retracting the foreskin over the glans to assess for secretions

Retracting the foreskin over the glans to assess for secretions

Upon assessing the newborn's respirations, which finding would cause the nurse to notify the primary care provider? coughing and sneezing in the newborn short periods of apnea that last 10 seconds in a pink newborn a respiratory rate of 15 breaths per minute with nasal flaring a respiratory rate of 45 breaths per minute with acrocyanosis

a respiratory rate of 15 breaths per minute with nasal flaring

Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress? respiratory rate of 50 breaths/minute acrocyanosis asymmetrical chest movement short periods of apnea (less than 15 seconds)

asymmetrical chest movement

What is the term for a small collection of blood that forms underneath the skull as a result of birth trauma? cephalohematoma caput succedaneum erythema toxicum vernix caseosa

cephalohematoma

When assessing the newborn's umbilical cord, what should the nurse expect to find? two smaller arteries and one larger vein two smaller veins and one larger artery one smaller vein and two larger arteries one smaller artery and two larger veins

two smaller arteries and one larger vein

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 don't need to worry about your baby developing jaundice because you are both A+." "If you are concerned about your baby developing jaundice, don't breastfeed your baby until you get home." "We will monitor the baby now, and your baby will not develop jaundice after the first 24 hours of life."

"I understand your concern because as many as 50% of babies can develop jaundice."

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? "This is likely just coincidence." "Neonates born by cesarean do not benefit from the squeezing of the contractions, which helps to clear the lungs." "Normally, neonates born by cesarean do better after delivery since it is a much gentler birth." "You are older now and that can impact how your neonate adapts to the birth process." "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."

"Neonates born by cesarean do not benefit from the squeezing of the contractions, which helps to clear the lungs."

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 weighing below 8 lb (3630 g) lack enough brown fat to produce heat." "Windows can be drafty and placing the newborn by one can result in evaporative heat loss." "Newborns cannot shiver to produce heat and need to be kept away from sources of heat loss." "Covering the newborn with heavy blankets is the best way to keep your newborn warm."

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

The nurse is assessing a male neonate in the presence of the parents and notes that the neonate has hypospadias. How should the nurse respond when questioned by the parents as to what this means? "He has normal male genitalia." "His testicles have not descended into the scrotal sac." "The opening of his urethra in located on the under surface of the tip of the penis." "He has fluid in the scrotal sac."

"The opening of his urethra in located on the under surface of the tip of the penis."

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." "Surfactant may be missing from the lungs depending on the newborn's gestational age." "The respiratory centers in the brain have not been stimulated when a newborn is delivered by a cesarean delivery." "A newborn delivered by cesarean has less sensory stimulation to breathe."

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

The mother of a 1-day-old newborn calls the nurse alarmed and asks the nurse to hurry to her room because there is something wrong with her baby. The nurse arrives to find the newborn lying on his crib on his side, awake and crying with one side of his body a dark red color and the other side of his body is pale. What would the nurse tell this mother? "Your newborn needs to go back to the nursery so the doctor can examine him for a possible cardiac problem." "I need to give him some oxygen to help him raise his blood oxygen level." "This is a harlequin sign and is a normal finding in newborns. It usually occurs when the infant is crying or when he is lying on his side." "I have never seen anything like this but he is crying and active, so I'm sure he is OK."

"This is a harlequin sign and is a normal finding in newborns. It usually occurs when the infant is crying or when he is lying on his side."

A hypoglycemic newborn will have a blood glucose reading of what value on a heel stick? 45 mg/dl 60 mg/dl 80 mg/dl 90 mg/dl

45 mg/dl

The nurse institutes measures to maintain thermoregulation based on the understanding that newborns have limited ability to regulate body temperature because they: have a smaller body surface compared to body mass. lose more body heat when they sweat than adults. have an abundant amount of subcutaneous fat all over. are unable to shiver effectively to increase heat production.

Are unable to shiver effectively to increase heat production

A nurse is conducting the initial assessment for a 3-hour-old neonate and notes the following: RR 30 breaths/min, BP 60/40 mm Hg, HR 155 beats/min, axillary temperature 98.2°F (36.8°C), and the neonate is in a state of quiet alert. What action should the nurse take? Inform the charge nurse. Call the primary care provider. Document the data. Stimulate the neonate.

Document the data.

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? This is an abnormal finding and needs to be reported immediately. If the fontanel feels full, then this is normal. This finding is normal if the pulsation can also be palpated in the posterior fontanel. It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanel.

It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanel.

The nurse is assessing a newborn, 4 hours old, weighing 9 lbs, 2 oz (4088 g). While doing the initial assessment the RN mentioned that the mother's history reveals gestational hypertension. Which assessment findings should the nurse prioritize as the newborn is continued to be monitored? Low temperature and hypertonia Jitteriness and irritability Hypotonia and fever Frequent activity and jitteriness

Jitteriness and irritability

The nurse is assisting with the admission of a newborn to the nursery. The nurse notes what appears to be bruising on the left upper outer thigh of this dark-skinned newborn. Which documentation should the nurse provide? Mongolian spot noted on left upper outer thigh. Harlequin sign noted on left upper outer thigh. Mottling noted on left upper outer thigh. Birth trauma noted on left upper outer thigh.

Mongolian spot noted on left upper outer thigh.

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? Call the doctor immediately to ask for intravenous antibiotics and document finding. Carefully clean the area with a damp washcloth and cover it with an absorbent dressing and document finding and intervention. Notify the charge nurse, because it represents a possible complication, and document the finding. Show the mother how to clean the area with soap and water, and document the intervention.

Notify the charge nurse, because it represents a possible complication, and document the finding.

The nurse is concerned that the nares of a newborn are not patent bilaterally. What can the nurse do to address this concern? Occlude the nares one at a time by applying pressure to each side to see if the newborn can breath comfortably. Pass an NG tube down both sides of the nostrils to assess patency. Look for nasal flaring to indicate that the newborn is breathing out of both sides of the nostrils. Use a swab to explore the nares bilaterally for occlusions

Occlude the nares one at a time by applying pressure to each side to see if the newborn can breath comfortably.

A 1-day-old newborn is being examined by the nurse practitioner, who makes the following notation: face and sclera appear mildly jaundiced. What causes this finding? The breakdown of RBCs release bilirubin, which the liver cannot excrete. The GI tract is immature, so the bilirubin remains in the intestines. The newborn's Vitamin K levels are low. Feedings are not adequate to eliminate the build-up of bilirubin.

The breakdown of RBCs release bilirubin, which the liver cannot excrete.

When a newborn takes its first breath, what physical changes occur in the heart to increase oxygenation of the infant's blood? The ductus arteriosus expands to allow more blood to enter the lungs. The foramen ovale closes, preventing blood exchange from right to left in the heart. The ductus venous shunts oxygenated aortic blood to the lungs. The umbilical vein that carried oxygenated blood in utero becomes the ascending aorta entering the right atrium.

The foramen ovale closes, preventing blood exchange from right to left in the heart.

Which statement is true regarding fetal and newborn senses? A newborn cannot experience pain. A newborn cannot see until several hours after birth. A newborn does not have the ability to discriminate between tastes. The rooting reflex is an example that the newborn has a sense of touch. A fetus is unable to hear in utero.

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

Which measurements were most likely obtained from a normal newborn delivered at 38 weeks to a healthy mother with no maternal complications? Weight = 2000 g, length = 17 inches, head circumference = 32 cm, and chest circumference = 30 Weight = 2500 g, length = 18 inches, head circumference = 32 cm, and chest circumference = 30 cm Weight = 3500 g, length = 20 inches, head circumference = 34 cm, and chest circumference = 32 cm Weight = 4500 g, length = 22 inches, head circumference = 36 cm, and chest circumference = 34 cm

Weight = 3500 g, length = 20 inches, head circumference = 34 cm, and chest circumference = 32 cm

In which newborn should the nurse suspect hypoglycemia? a jittery, irritable newborn with a high-pitched cry a newborn with a heart rate of 60 bpm after a prolonged deceleration in utero a newborn who weighs 3500 grams and is falling asleep at the breast a newborn who did not do skin-to-skin (kangaroo) care with his mother

a jittery, irritable newborn with a high-pitched cry

The nursing instructor is conducting a class explaining the various causes of jaundice in a newborn infant. The instructor determines additional education is warranted after the class chooses which factor as being responsible for newborn jaundice? bilirubin overproduction decreased bilirubin conversion impaired bilirubin excretion bilirubin hyperexcretion

bilirubin hyperexcretion

A nurse is developing a plan of care for a newborn to minimize the risk for heat loss. The nurse prioritizes potential interventions based on which mechanism is responsible. Place the interventions listed below in the order the nurse would address them based on the mechanism accounting for the greatest to least amount of heat loss. Use all options. drying the newborn after giving the newborn a bath placing the newborn under a radiant warmer during a procedure encouraging skin-to-skin contact with the mother using a warmed isolette to transfer a newborn to the nursery

placing the newborn under a radiant warmer during a procedure using a warmed isolette to transfer a newborn to the nursery drying the newborn after giving the newborn a bath encouraging skin-to-skin contact with the mother

A nurse is assessing a newborn. Which finding would alert the nurse to the possibility of respiratory distress in a newborn? symmetrical chest movements periodic breathing respirations of 40 breaths/minute sternal retractions

sternal retractions