Chapter 18
The nurse is teaching a new mother about the changes in her newborn's gastrointestinal tract. The nurse determines that additional teaching is needed when the mother makes which statement?
"His stomach can hold approximately 10 ounces."
The mother of a formula-fed newborn asks how she will know if her newborn is receiving enough formula during feedings. Which response by the nurse is correct?
A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight."
Which assessment by the nurse will best monitor the nutrition and fluid balance in the postterm newborn?
Assess for decrease in urinary output.
The nurse is monitoring an infant who was born at 0515 hrs. At 1315 hrs, the same day, the nurse determines the infant is starting to show yellowish staining on the head and face. Which action should the LPN prioritize?
Document and report to RN
After the birth of a newborn, which action would the nurse do first to assist in thermoregulation?
Dry the newborn thoroughly.
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
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
A nurse is assisting with the assessment of a newborn. The neuromuscular and physical characteristics of the newborn are being evaluated to determine gestational age. Which assessment tool is most likely being used?
The New Ballard Score
The student nurse is attending her first cesarean delivery and is asked by the mentor what should be carefully assessed in this infant. After responding "Respiratory status" the student is asked "Why?" What would be the best response?
There is more fluid present in the lungs at birth after a cesarean delivery than after a vaginal delivery."
A new mother of a newborn girl calls the clinic in a panic, concerned about the blood-tinged soiled diaper. What is the best response from the nurse?
This can be from the sudden withdrawal of your hormones. It is not a cause for alarm."
The nurse is describing fetal circulation to new parents and how the circulation changes after birth. The nurse describes a structure that allows the pulmonary circulation to be bypassed, but that shortly after birth this structure should close. Which structure is the nurse describing?
ductus arteriosus
A new mother asks the nurse why her newborn must receive a vitamin K injection after birth. Which is the best response made by the nurse?
will decrease the risk of bleeding immediately after birth
The parents of a newborn become concerned when they notice that their baby seems to stop breathing for a few seconds. After confirming the parents' findings which action should the nurse prioritize?
Assess the newborn for signs of respiratory distress.
A mother asks the nurse about having her son circumcised. The nurse understands that circumcision is contraindicated under which circumstances? Select all that apply.
- there is a family hx of hemophilia - the infant is at 33 weeks gestation
A nurse is caring for a client postpartum who complains of sore nipples. The nurse observes that the client's newborn is unable to suck properly although latched well. What intervention should the nurse perform to assist the baby to suck properly
Check the baby's frenulum.
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?
Explain this is normal.
The parents are bonding with their newborn when the nurse notes the infant's axillary temperature is 97.2oF (36.2oC) an hour after birth. Which intervention should the nurse prioritize for this family?
Help the mother provide skin-to-skin (kangaroo) care.
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?
Hepatitis B vaccination and 1 dose of hepatitis B immunoglobulin within 12 hours of birth
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?
Holding and comforting the newborn will not cause the infant to become spoiled.
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.
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?
Jitteriness and irritability
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
A nurse is explaining to the parents of a newborn how their newborn responds to care giving based on the results of which assessment tool?
Neonatal Behavioral Assessment Scale
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?
Physiologic jaundice.
When a newborn takes its first breath, what physical changes occur in the heart to increase oxygenation of the infant's blood?
The foramen ovale closes, preventing blood exchange from right to left in the heart
The nurse is assessing a male neonate using the Ballard gestational age assessment tool. The neonate has the following characteristics: Deep cracking skin, no vessels Thinning lanugo Creases on the plantar surface Raised areola Formed ear, instant recoil Testes down, good rugae From the above characteristics, which can the nurse determine?
The neonate is a term newborn
Following delivery, a newborn has a large amount of mucus coming out of his mouth and nose. What would be the nurse's first action?
Using a bulb syringe, suction the mouth then the nose.
Which newborn neuromuscular system adaptation would the nurse not expect to find?
an extrusion reflex at 9 months of age
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.
The nurse is assessing a woman who had a forceps-assisted birth for complications. Which condition would the nurse assess in the fetus?
caput succedaneum
On inspecting a newborn's abdomen, which finding would you note as abnormal?
clear drainage at the base of the umbilical cord
A clinical pathway is being used to coordinate care for a postpartum client who had an uncomplicated vaginal delivery of an 8-lb, 2-oz (3,693-g) neonate over an intact perineum 24 hours ago. While planning care for this client, the registered nurse collaborates with the licensed practical nurse to achieve which priority outcome in the next 8 hours?
encouraging the client to demonstrate an ability to breastfeed the neonate
A nurse is conducting a refresher in-service program for a group of neonatal nurses. The nurse determines the session is successful after the participating nurses correctly choose which factor is responsible for the appearance of jaundice in the newborn?
hemolysis of erythrocytes
The nurse explains to the parents of a 2-day-old newborn that decreased life span of neonatal red blood cells has contributed to which complication?
hyperbilirubinemia
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?
notify the charge nurse, because it represents a possible complication, and document the finding.
A 36-hour-old newborn is ready for discharge from the hospital and the nurse notices that the skin looks yellow. What action will the nurse take?
Assess the bilirubin level.
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?
Take no action because these are normal findings in a newborn.
The nurse dries the neonate thoroughly and promptly changes wet linens. The nurse does so to minimize heat loss via which mechanism?
evaporation
A nursing instructor explains to students that, regardless of their gestational age, all newborns experience the same pattern that includes which periods? Select all that apply
first period of reactivity period of decreased responsiveness second period of reactivity
Screening for this most common birth defect is required by law in most states. Each nurse should know the law for his or her state and the requirements for screening. The nurse would expect a newborn to be screened for which defect as the most common?
hearing
When conducting a class for new parents, the nurse explains that newborns demonstrate several predictable responses when interacting with their environment. Which behavioral responses would the nurse integrate into the discussion? Select all that apply.
orientation habituation self-quieting ability
A mother tells the nurse that she has been reading a book that says that newborns need stimulation to develop properly and asks what she can do to help her infant. Which tip would not be helpful to the mother?
Swaddling the infant
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
The nurse observes the stool of a newborn who is being bottle-fed. The newborn is 2 days old. What would the nurse expect to find?
yellowish-green, pasty stool
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?
Assess the infant's blood sugar
The nurse caring for a newborn has to perform assessment at various intervals. When should the nurse complete the second assessment for the newborn?
within the first 2 to 4 hours, when the newborn reaches the nursery
After teaching an in-service program to a group of nurses working in newborn nursery about a neutral thermal environment, the nurse determines that the teaching was successful when the group identifies which process as the newborn's primary method of heat production?
nonshivering thermogenesis
The nurse is teaching new parents the best way to prevent hypothermia. Which mechanism would the nurse include when explaining about the newborn's primary method of heat production?
nonshivering thermogenesis
The nurse is providing teaching to a new mother who is breastfeeding. The mother demonstrates understanding of teaching when she identifies which characteristics as being true of the stool of breastfed newborns? Select all that apply.
yellowish gold color stringy to pasty consistency
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.