CHAPTER 18
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?
The newborn will experience no bleeding episodes lasting more than 5 minutes. Bleeding episodes should not be occurring at all, and any episodes should be reported to the physician immediately if not responsive to immediate action to stop it. All other outcomes are pertinent to the newborn's care.
A nurse is reviewing the medical records of several newborns who are about to be discharged. The nurse notes the birth weight of each newborn, classifying the newborn with which birth weight as term?
3,500 grams Typically, the term newborn weighs 2,500 to 4,000 g. Birth weights less than 10% or more than 90% on a growth chart are outside the normal range and need further investigation. A newborn weighing less than 1,500 grams is considered very-low-birth-weight. A newborn weighing 1,800 grams or 2,200 grams would be considered low-birth-weight.
A newborn weighing 5 lb (2250 g) needs to eat 3 oz (90 ml) of formula every 3 hours. To meet this goal, how many ounces of formula per day will the parent need to feed the newborn? Record your answer using a whole number.
24 Feeding every 3 hours equates to 8 feedings per day. 3 oz × 8 = 24 oz. This can also be calculated in milliliters and converted back into ounces. 90 ml × 8 = 720 ml.
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?
24 to 72 hours after birth. 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.
A newborn has a heart rate of 90 beats per minute, a regular respiratory rate of 40 breaths per minute, tight flexion of the extremities, a grimace when stimulated, and acrocyanosis. The nurse assigns an Apgar score of:
7. The newborn would receive an Apgar score of 7: 1 point for heart rate (<100 beats/minute), 2 points for respiratory rate (regular respirations at a rate between 30 and 60 breaths/minute), 2 points for muscle tone (tight flexion), 1 point for reflex irritability (grimace), and 1 point for skin color (acrocyanosis).
During a childbirth class, the nurse talks to the parents about how to prevent infant abductions in the hospital by recognizing the profile of an abductor. Which person best fits the profile of a typical infant abductor?
A female in her mid-20s who appears pregnant Typical abductors are women age 12 to 50 who appear pregnant or are overweight. They are usually married or cohabiting with a companion. They are also usually familiar with the area or live there. Often they will dress as health care personnel such as a nurse or nursing assistant. Men are not typically abductors nor are honor students
A newborn is receiving ampicillin and gentamicin every 12 hours. When would this client have his hearing screen performed?
After the newborn has completed the antibiotic therapy It is recommended that all newborns undergo a hearing screening before they are discharged from the hospital. If the newborn is treated with an ototoxic medication such as gentamycin, the hearing screen must be conducted after completion of the antibiotic therapy.
The nurse is educating a client who is breastfeeding her 2-week-old newborn regarding the nutritional requirements of newborns, according to the recommendations of the American Academy of Pediatrics (AAP). Which response by the mother would validate her understanding of the information she received?
"I will give him vitamin D supplements daily for the first 2 months of life." As per the recommendations of AAP, all newborns should receive a daily supplement of vitamin D during the first 2 months of life to prevent rickets and vitamin D deficiency. There is no need to feed the newborn water, as breast milk contains enough water to meet the newborn's needs. Iron supplements need not be given, as the newborn is being breastfed. Infants over 6 months of age are given fluoride supplementation if they are not receiving fluoridated water.
The nurse is checking on a newborn who was circumcised 2 hours ago using a Plastibell. Which intervention would be inappropriate for this client?
Apply petroleum gauze to the penis with each diaper change. 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.
The nurse is caring for an infant. Which nursing action will facilitate psychosocial growth of the infant?
Be consistently attentive to the infant's basic needs. 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 is conducting a preadmission class for a group of parents on the safety features that are utilized to help prevent infant abduction. The nurse should prioritize which factor as most essential to ensure the program's success?
Cooperation by the parents with the hospital policies The most essential piece to an effective infant abduction prevention plan is the cooperation of the parents. If the parents are not willing to participate in the unit policy, the unit is at risk. Using pass codes, placing cameras at each door, and using monitors on the infants will all help, but only if the parents are cooperative.
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?
Evaporative Evaporative heat loss occurs with the evaporation of fluid from the infant.
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?
General questions about different aspects of newborn care 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.
What measures can a nurse take to reduce the risk of hypoglycemia in a newborn? Select all that apply.
Initiate early and frequent breastfeeding. Dry the newborn off immediately after birth to prevent chilling. Begin skin-to-skin (kangaroo) care for the newborn. 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.
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?
Instill 0.5% ophthalmic erythromycin. 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.
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.
It is thinner and more fragile than an adult's. Substances are easily absorbed. 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.
The head nurse of the newborn nursery is teaching new employees ways to reduce the transmission of infection in the nursery. What information would be included in this session?
Keep all of the newborn's belongings together in the bassinet. By keeping all the newborn's belongings in the bassinet and not sharing items, the risk of cross-contamination is greatly reduced. Rooming-in, not staying in the nursery, also reduces the likelihood of cross-contamination. Artificial nails are shown to increase infection transmission and should not be worn.
A nurse is aware that the newborn's neuromuscular maturity assessment is typically completed within 24 hours after birth. Which assessment would the nurse be least likely to complete to determine the newborn's degree of maturity?
Moro reflex There are six activities or maneuvers that are evaluated to determine the newborn's degree of neuromuscular maturity: posture, square window, arm recoil, popliteal angle, scarf sign, heel-to-ear. The Moro reflex is an indication of the newborn's neurologic status.
A nurse removes and discards a newborn's diaper before placing the newborn on the scales for a daily weight. The nurse realizes there are no clean diapers at the scale. The supply closet is located down the hallway. What will the nurse do?
Place newborn in the bassinet and cover with blanket while obtaining diapers. The nurse will cover the newborn to maintain temperature and place the infant in the bassinet while obtaining more diapers. The nurse would not leave to newborn on the scales and walk away, because the newborn could fall off the scale. Current policy prevents the nurse from carrying the newborn while going to the supply closet to obtain more diapers because this is a fall risk or safety issue. Infection control measures dictate that there is no sharing of supplies between newborns.
Which newborn neuromuscular system adaptation would the nurse not expect to find?
an extrusion reflex at 9 months of age An extrusion reflex usually disappears around 4 months of age. A positive Babinski reflex can be seen until 3 months of age. The plantar grasp disappears around 8 to 9 months of age. The Moro reflex disappears around 4 to 5 months of age.
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?
blood pressure 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.
In an effort to decrease complications for the infant right after birth, the nurse would expect to administer which medication for prophylaxis of potential eye conditions?
erythromycin ophthalmic ointment Erythromycin ophthalmic ointment is the only drug approved by the U.S. Food and Drug Administration (FDA) for the prophylaxis of gonococcal neonatorum in the United States. Silver nitrate solution was once used for eye prophylaxis, but it is no longer used because it has little efficacy in preventing chlamydial eye disease. Vitamin K is used to promote blood clotting in the newborn. Gentamicin is not used for newborn eye prophylaxis.
A nurse is teaching new parents how to bathe their newborn once they bring the baby home. Place the body areas listed below in the order that the parents clean the newborn's body. Use all options.
eyes face hair extremities diaper area The parents should wash the newborn, progressing from the cleanest to the dirtiest areas: eyes, rest of face, hair, extremities, trunk, and back. The diaper area is washed last.
The nurse is completing an assessment of a newborn. When auscultating the newborn's heart, the nurse would place the stethoscope at which area to auscultate the point of maximal impulse (PMI)?
lateral to the midclavicular line at the fourth intercostal space The point of maximal impulse in a newborn is lateral to the midclavicular line at the fourth intercostal space. A displaced PMI may indicate a tension pneumothorax or cardiomegaly.
The nurse is teaching the parents of a newborn baby girl the basic discharge instructions. The nurse determines the session is successful after the couple articulate they will contact the primary care provider if their infant shows which sign of diarrhea?
more than two episodes of diarrhea in one day Diarrhea is defined as frequent stools with high water content. Because newborns dehydrate quickly, it is important for parents to notify the care provider if the newborn has more than two episodes of diarrhea in one day.
A nurse is preparing to administer erythromycin ointment to a 1-hour-old newborn. What will the nurse do first?
Review the health care provider's order. 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.
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?
24 hours after the newborn's first protein feedin 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.
The nurse orienting a student to the nursery determines that teaching has been effective when the student states that the signs of neonate respiratory distress include which findings? Select all that apply.
Nasal flaring Respiratory rate of 64 breaths per minute Chest retractions Signs of respiratory distress in the newborn include tachypnea (respirations greater than 60 breaths/min), tachycardia (heart rate greater than 160/beats/min), nasal flaring, chest retractions, and generalized cyanosis. Blue hands and feet, referred to as acrocyanosis, is caused by poor peripheral circulation not respiratory distress.
The nurse is teaching discharge instructions to the young parents of a healthy newborn boy whose vital signs are stable and whose circumcision appears clean and intact. The nurse should encourage the parents to call the health care provider if which situation is discovered?
Redness at the base of the umbilical cord The cord should dry and fall off in the 7 to 10 days after birth. If the cord base changes color or develops drainage, the health care provider needs to be notified as these could be signs of infection. A yellowish crusty substance on the circumcision site indicates normal healing. Crying for 2 hours or more each day and straining during bowel movements are normal in a newborn.
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?
Before feedings 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.
The nurse is conducting a safety class for a group of new parents in the hospital. What tips would the nurse provide for these parents? Select all that apply.
Question anyone who is not wearing proper identification even if they are dressed in hospital attire. Know when the newborn is scheduled for any tests and how long the procedure will last. Do not remove the identification bands until the newborn is discharged from the hospital. To ensure the safety of their newborn, parents must understand how to keep their infant safe. They are to never leave their newborn unattended at any time, be sure to ask to see identification of anyone who comes into the room to remove the infant, don't remove the newborn's identification bands until leaving the hospital at discharge, and know when any test or procedures are scheduled for their newborn. Parents are instructed to question anyone who does not have proper identification or acts suspiciously.
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 Infection control is a priority nursing intervention. Gloves need to be worn when in contact with the infant who has not been bathed after birth. All options are valid options; however, a three-minute surgical scrub is generally only required at the beginning of a shift. The nurse should always wash the hands before putting on gloves to care for an infant and after taking gloves off. Standard precautions are used with every client.
The mother of a newborn asks the nurse, "What are these small red marks on the back of my baby's neck and between the eyes? They seem to more visible when my baby is crying." The nurse would describe this finding as which skin variation?
salmon patches Stork bites or salmon patches are superficial vascular areas found on the nape of the neck, on the eyelids, and between the eyes and upper lip. They are caused by a concentration of immature blood vessels and are most visible when the newborn is crying. Milia are multiple pearly-white or pale yellow unopened sebaceous glands frequently found on a newborn's nose. They may also appear on the chin and forehead. Vernix caseosa is a thick white substance that protects the skin of the fetus. It is formed by secretions from the fetus's oil glands and is found during the first 2 or 3 days after birth in body creases and the hair. Nevus flammeus, also called a port-wine stain, commonly appears on the newborn's face or other body areas. It is a capillary angioma located directly below the dermis. It is flat with sharp demarcations and is purple-red.
