Chapter 18: Nursing Management of the Newborn 1-4
Evaporative
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? Conductive Convective Evaporative Radiating
Changing a diaper Performing a heel stick Accucheck Providing the first bath
Under which circumstances should gloves be worn in the newborn nursery? Select all that apply. Feeding the newborn a bottle Changing a diaper Performing a heel stick Accucheck Taking the newborn's crib to the mother's room Providing the first bath
Epstein pearls
What are small unopened or plugged sebaceous glands that occur in a newborn's mouth and gums? milia stork bites Epstein pearls congenital dermal melanocytosis
30 to 60 breaths per minute
What is the expected range for respirations in a newborn? 10 to 30 breaths per minute 20 to 40 breaths per minute 30 to 60 breaths per minute 40 to 80 breaths per minute
vastus lateralis
A nurse is preparing to administer vitamin K to a newborn who was just birthed vaginally. Which site would be appropriate for the nurse to select? deltoid ventrogluteal vastus lateralis dorsogluteal
hearing disorders epilepsy cerebral palsy
Assessment of a newborn reveals microcephaly. The nurse develops a teaching plan for the parents about the need for follow-up care based on the understanding that the newborn is at risk for developing which complication(s)? Select all that apply. hearing disorders hydrocephalus epilepsy cerebral palsy achondroplasia
bright red, raised bumpy area noted above the right eye
As a part of the newborn assessment, the nurse examines the infant's skin. Which nursing observation would warrant further investigation? fine red rash noted over the chest and back small pink or red patches on the newborn's eyelids and back of the neck blue or purplish splotches on buttocks bright red, raised bumpy area noted above the right eye
respirations head circumference
Assessment of a newborn reveals the following findings: Length, 48 cm; weight, 2900 g; apical pulse, 150 beats/min; respirations, 24 breaths/min; head circumference, 31cm; chest circumference, 32 cm; temperature 97.9°F (36.6°C). After reviewing these findings, the nurse would notify the provider about which one(s)? Select all that apply. length weight apical pulse respirations head circumference chest circumference temperature
heart rate, muscle tone, reflex irritability, respiratory effort, and color
The Apgar score is based on which 5 parameters? heart rate, respiratory effort, temperature, tone, and color heart rate, muscle tone, reflex irritability, respiratory effort, and color heart rate, breaths per minute, irritability, reflexes, and color heart rate, breaths per minute, irritability, tone, and color
"A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight."
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? "Your newborn should finish a bottle in less than 15 minutes." "A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight." "If your newborn is wetting three to four diapers and producing several stools a day, enough formula is likely being consumed." "Your newborn should be taking about 2 oz of formula for every pound of body weight during each feeding."
blood sugar
The nurse is admitting a 10-pound (4.5-kg) newborn to the nursery. What is important for the nurse to monitor during the transition period? Apgar score blood sugar heart rate temperature
Bathe the newborn thoroughly
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? Bathe the newborn thoroughly Assist the mother to breastfeed Test the newborn for HIV Administer zidovudine
Check blood glucose.
A 30-minute-old newborn starts crying in a high-pitched manner and cannot be consoled by the mother. Which action should the nurse prioritize if jitteriness is also noted and the infant is unable to breastfeed? Place child in a radiant warmer. Assess the baby's temperature. Assess for pain source. Check blood glucose.
blood pressure
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 pulse temperature respirations pain
short, creased neck swollen genitals congenital dermal melanocytosis (slate gray nevi)
A nurse is performing a detailed assessment of a female newborn. Which observation(s) indicates a normal finding? Select all that apply. short, creased neck swollen genitals enlarged fontanels (fontanelles) low-set ears congenital dermal melanocytosis (slate gray nevi)
Neworn D: 48-hour-old newborn with bilirubin level of 14 mg/dl (239.46 µmol/l)
A nurse is providing care to four breastfed newborns who are being monitored for hyperbilirubinemia. When assessing each newborn's indirect bilirubin level, the nurse would notify the health care provider about which newborn? Newborn A: 1-day-old newborn with bilirubin level of 2 mg/dl (34.32 µmol/l) Newborn B: 2-day-old newborn with bilirubin level of 6 mg/dl (102.62 µmol/l) Newborn C: 36-hour-old newborn with a bilirubin level of 10 mg/dl (171.04 µmol/l) Neworn D: 48-hour-old newborn with bilirubin level of 14 mg/dl (239.46 µmol/l)
rooting
The nurse is documenting assessment of infant reflexes. She strokes the side of the infant's face, and the baby turns toward the stroke. What reflex has the nurse elicited? rooting sucking tonic neck Moro
Expose the newborn's bottom to air several times a day.
The mother of a newborn observes a diaper rash on her newborn's skin. Which intervention should the nurse instruct the parent to implement to treat the diaper rash? Expose the newborn's bottom to air several times a day. Use only baby wipes to cleanse the perianal area. Use products such as talcum powder with each diaper change. Place the newborn's buttocks in warm water after each void or stool.
Hep B
The nurse is explaining to new parents the various vaccinations their newborn will receive before being discharged home. Which immunization should the nurse teach the parents about that will help decrease the incidence of hepatic disease later in life? Vitamin K Hep B HBV immunoglobin HiB
6 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.
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? 3 4 5 6
7 to 10.
The nurse records a newborn's Apgar score at birth. A normal 1-minute Apgar score is: 1 to 2. 12 to 15. 5 to 9. 7 to 10.
Document this as a normal finding.
When assessing the head of a newborn, the nurse notes that when pressing the skull, an indentation is made and then the area returns to normal after removing the pressure. What would the nurse do next? Document this as a normal finding. Measure the head circumference. Notify the health care provider. Assess the newborn's hearing.
lanugo.
When conducting an assessment, the nurse observes fine, downy hair covering the newborn's shoulders and back. The nurse documents this finding as: milia. lanugo. vernix caseosa. harlequin sign.
rooting
When evaluating neurologic maturity to determine gestational age, the nurse understands that which activity is not part of the assessment? rooting square window popliteal angle posture
congenital dermal melanocytosis (slate gray nevi)
A Black couple are spending time with their newborn after the nurse brings the newborn back from the transition nursery. The parents note that their newborn's buttocks appear bruised and ask what happened. The nurse should explain this is related to which factor? lanugo vascular nevi bruising congenital dermal melanocytosis (slate gray nevi)
Look at the woman's hospital identification badge.
A woman wearing hospital scrubs comes to the nursery and states "Mrs. Smith is ready for her baby. I will be glad to take the baby to her." What will the nursery nurse do next? Determine which hospital unit the woman works on. Inform the woman she cannot transport the baby. Look at the woman's hospital identification badge. Ask if the client actually sent the woman.
It is a normal skin finding in a newborn.
A woman who is about to be discharged after a vaginal birth notices a flea-like rash on her newborn's chest. The rash has tiny red lesions all across the nipple line. What does this rash indicate? It is a normal skin finding in a newborn. It is a sign of a group B streptococcus (GBS) skin infection. It is an indication that the woman has mistreated her newborn. It is a self-limiting virus that does not require treatment.
Report the finding to the pediatrician.
The nursery nurse notes that one of the newborn infants has white patches on his tongue that look like milk curds. What action would be appropriate for the nurse to take? Report the finding to the pediatrician. Rinse the tongue off with sterile water and a cotton swab. Since it looks like a milk curd, no action is needed. Wipe the tongue off vigorously to remove the white patches.
"I can use talc powders to prevent diaper rash."
When instructing a new mom on providing skin care to her newborn, which statement, made by the mother, indicates additional teaching is needed? " I will change my baby's diapers frequently." "I will give sponge baths until the umbilical cord falls off." "I can use talc powders to prevent diaper rash." "It is not necessary to give my baby a bath daily."
Use the sealed and chilled milk within 24 hours.
A first-time mother informs the nurse that she is unable to breastfeed her newborn through the day as she is usually away at work. She adds that she wants to express her breast milk and store it for her newborn to have later. What instruction would be correct to offer the mother to ensure the safety of the stored expressed breast milk? Use the sealed and chilled milk within 24 hours. Use microwave ovens to warm the chilled milk. Use any frozen milk within 6 months of obtaining it. Refreeze any unused milk for later use if it has not been out more that 2 hours.
The infant is experiencing moderate difficulty in adjusting to extrauterine life.
A nurse determines that a newborn has a 1-minute Apgar score of 5 points. What conclusion would the nurse make from this finding? The infant requires immediate and aggressive interventions for survival. The infant is experiencing moderate difficulty in adjusting to extrauterine life. The infant is adjusting well to extrauterine life. The infant probably has either a congenital heart defect or an immature respiratory system.
"We will turn the mobile on that's hanging on our baby's crib."
A nurse teaches new parents how to soothe a crying newborn. Which statement by the parents indicates to the nurse the teaching was effective? "We will turn the mobile on that's hanging on our baby's crib." "We will hold feedings until our baby stops crying." "We will vigorously rub our baby's back as we play some music." "We will place our baby on the belly on a blanket on the floor."
Toes fan out when sole of foot is stroked.
The newborn should have the neurologic status evaluated to determine its maturity and to identify any potential problems. The nurse tests the newborn's Babinski sign. Which response would the nurse interpret as normal for the newborn? Newborn throws arms outward and flexes knees. Newborn makes stepping motion. Toes fan out when sole of foot is stroked. Newborn's toes curl over the nurse's finger.
Instill 0.5% ophthalmic erythromycin.
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 silver nitrate. Instill 0.5% ophthalmic tetracycline. Instill 0.5% ophthalmic erythromycin. Watch for signs of eye irritation.
Cover the glans generously with petroleum jelly.
The nurse is preparing discharge instructions for the parents of a male newborn who is to be circumcised before discharge. Which instruction should the nurse prioritize? Soak the penis daily in warm water. Cover the glans generously with petroleum jelly. Cleanse the glans daily with alcohol. Notify the primary care provider if it appears red and sore.
Warmer bed Suction equipment Identification bands
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. Warmer bed Glucose water Suction equipment Identification bands Ophthalmoscope
"We will fold down the front of her diaper under the umbilical cord until it falls off."
A nurse is teaching a newborn's caregivers how to change a diaper correctly. Which statement by the caregiver best indicates the nurse's teaching was effective? "We will apply a moisture barrier cream with every diaper change to prevent diaper rash." "We should clean the skin with soap and water after each bowel movement." "We will fold down the front of her diaper under the umbilical cord until it falls off." "It is best practice to change the diaper every 2 to 4 hours, even during the night."
Caregivers can demonstrate competency in caring for the infant and ask questions.
The nurse explains the hospital's home visitation program for new families after discharge from the hospital. Which information will the nurse include regarding this program? Caregivers use this time to rest or complete errands while the visiting nurse takes care of the infant. The nurse can discuss parenting conflicts with the caregivers to determine which style is best. Caregivers can demonstrate competency in caring for the infant and ask questions. The nurse will complete any procedures the infant was not able to have performed while in the hospital.
"The opening of his urethra in located on the under surface of the tip of the penis."
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."
Epstein pearls.
The nurse is inspecting the mouth of a newborn and finds small, white cysts on the gums and hard palate. The nurse documents this finding as: oral candidiasis (thrush). Epstein pearls. milia. vernix caseosa.
The newborn will experience no bleeding episodes lasting more than 5 minutes.
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's body temperature will stabilize between 97.8ºF and 99.5ºF (36.6ºC and 37.5ºC). The newborn's blood glucose will remain above 50 mg/dl The newborn will experience no bleeding episodes lasting more than 5 minutes. The newborn will be correctly identified prior to separation from the parents.
0.5 to 1.0 mg
The nurse is preparing to administer an intramuscular injection of vitamin K to a newborn. The nurse will ensure the amount per injection is within which range? no more than 0.25 mg 0.5 to 1.0 mg 1.25 to 1.75 mg 2.0 to 2.5 mg
Check the identification badge of any health care worker before releasing baby from room.
The nurse is teaching a prenatal class illustrating the steps that are used to keep families safe. The nurse determines the session is successful when the parents correctly choose which precaution to follow after the birth of their infant? Send a family member to accompany the infant when leaving the room. Check the name on the baby's identification bracelet. Provide a list of approved visitors who came spend time with the infant. Check the identification badge of any health care worker before releasing baby from room.
Moro magnet trunk incurvation crossed extension
The nurse is testing the reflexes of a newborn. The nurse correlates a positive response to which reflex test(s) with spinal cord integrity? Select all that apply. Moro magnet trunk incurvation crossed extension Landau
Call the Labor and Delivery nurse who cared for the newborn to inquire about why the medication was not documented.
The nurse notices that there is no vitamin K administration recorded on a newborn's medical record upon arrival to the newborn nursery. What would be the nurse's first action? Administer an oral dose of vitamin K to the newborn. Assume that the parents refused this medication for their infant. Call the Labor and Delivery nurse who cared for the newborn to inquire about why the medication was not documented. Give the IM dose of vitamin K to prevent the possibility of hemorrhage in the newborn.
Place the infant on the back when sleeping.
The parents of a 2-day-old newborn are preparing for discharge from the hospital. Which teaching is most important for the nurse to include regarding sleep? The infant may sleep through the night around 2 months of age. Caregivers need to sleep while the baby is sleeping. Newborns usually sleep for 16 or more hours each day. Place the infant on the back when sleeping.
Anesthetic may not be effective during the procedure
The parents of a newborn male are questioning the nurse concerning the pros and cons of a circumcision. Which disadvantage should the nurse point out to these parents? Lower rate of urinary tract infections Reduced risk of penile cancer Fewer complications than if done later in life Anesthetic may not be effective during the procedure
Retracting the foreskin over the glans to assess for secretions
Which action will the nurse avoid when performing basic care for a newborn male? Palpating if testes are descended into the scrotal sac Determining the location of the urethral opening Inspecting the genital area for irritated skin Retracting the foreskin over the glans to assess for secretions
weight = 3500 g, length = 20 inches (51 cm), head circumference = 34 cm, and chest circumference = 32 cm
Which measurements were most likely obtained from a normal newborn born at 38 weeks to a healthy mother with no maternal complications? weight = 2000 g, length = 17 inches (43 cm), head circumference = 32 cm, and chest circumference = 30 weight = 2500 g, length = 18 inches (46 cm), head circumference = 32 cm, and chest circumference = 50 cm weight = 3500 g, length = 20 inches (51 cm), head circumference = 34 cm, and chest circumference = 32 cm weight = 4500 g, length = 22 inches (56 cm), head circumference = 36 cm, and chest circumference = 34 cm
The bath should be performed by the nurse, not the parents, within 2 to 4 hours of birth.
Which statement is false regarding bathing the newborn? The bath should be performed by the nurse, not the parents, within 2 to 4 hours of birth. While bathing the newborn, the nurse should wear gloves. Bathing should not be done until the newborn is thermally stable. Mild soap should be used on the body and hair but not on the face.
harlequin sign. Harlequin sign refers to the dilation of blood vessels on only one side of the body
While assessing a newborn, the nurse notes that half the body appears red while the other half appears pale. The nurse interprets this finding as: stork bites. harlequin sign. congenital dermal melanocytosis (slate gray nevi). erythema toxic.
Feeding the infant more formula whenever she begins to fuss
A new mother calls her pediatrician's office concerned about her 2-week-old infant "crying all the time." When the nurse explores further, the mother reports that the infant cries at least 2 hours each day, usually in the afternoons. What recommendation would the nurse not make to this mother? Rocking and talking to the infant Swaddling the infant before returning to the crib Feeding the infant more formula whenever she begins to fuss Gently patting or stroking the infant's back
temperature of 38.3° C (101° F) or higher refuse feeding abdominal distention
A nurse is teaching new parents about keeping follow-up appointments and calling their health care provider if they notice signs of illness in their newborn. The nurse determines that the teaching was successful when the parents identify which signs as needing to be reported? Select all that apply. temperature of 38.3° C (101° F) or higher general fussiness approximately eight wet diapers a day refuse feeding abdominal distention
It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanel (fontanelle).
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 (fontanelle) feels full, then this is normal. This finding is normal if the pulsation can also be palpated in the posterior fontanel (fontanelle). It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanel (fontanelle).
