Chapter 18: Nursing Management of the Newborn 5-8

milia.

Assessment of a newborn reveals tiny white pinpoint papules on a newborn's nose. The nurse documents this finding as: vernix caseosa. lanugo. harlequin sign. milia.

two or three times per week

After completing a class for new parents, the nurse notes the session is successful when the class recognizes the newborn should be bathed how often? once a week once a day two or three times per week every other day

Before feedings

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? Only if the infant is jittery Every 8 hours Before feedings After feedings

erythromycin ophthalmic ointment

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 silver nitrate solution gentamicin ophthalmic ointment vitamin K

24 hours after the newborn's first protein feeding

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? When the infant is 48 hours old 24 hours after the newborn's first protein feeding Just before discharge home 36 hours before the infant is discharged home with its parents

flicking the soles of the feet and observing the response

On an Apgar evaluation, how is reflex irritability tested? raising the infant's head and letting it fall back flicking the soles of the feet and observing the response dorsiflexing a foot against pressure resistance tightly flexing the infant's trunk and then releasing it

General questions about different aspects of newborn care

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 No questions of the nurse Only questions specific to breastfeeding Confidence since they have another child already

salmon patches

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? milia salmon patches vernix nevus flammeus

Help the mother provide skin-to-skin (kangaroo) care.

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? Administer a warm bath with temperature slightly higher than usual. Place a second stockinette on the baby's head. Help the mother provide skin-to-skin (kangaroo) care. Place the infant under a radiant warmer.

Provide oxygen supplementation. Ensure the newborn's warmth. Observe respiratory status frequently.

A nurse is caring for a newborn with transient tachypnea. What nursing interventions should the nurse perform while providing supportive care to the newborn? Select all that apply. Provide warm water to drink. Provide oxygen supplementation. Massage the newborn's back. Ensure the newborn's warmth. Observe respiratory status frequently.

There is a family history of hemophilia. The infant is at 33 weeks' gestation.

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 history of hemophilia. The infant is at 33 weeks' gestation. The newborn was febrile at birth but temperature is now normal. The penis is small. The father is uncircumcised.

It is thinner and more fragile than an adult's Substances are easily absorbed.

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. Skin is less susceptible to the sun. The epidermis is thicker than in adults. Sweat glands are fully functioning at birth.

temperature of 98.6° F (37° C) length of 54 cm weight of 3,300 grams

A nurse is conducting a physical examination of a newborn. The nurse documents which finding as within normal parameters? Select all that apply. temperature of 98.6° F (37° C) length of 54 cm weight of 3,300 grams head circumference of 30 cm chest circumference of 35 cm apical pulse rate of 100 beats/minute

Hold the newborn upright with the newborn's head on the mother's shoulder.

A nurse is educating the mother of a newborn about feeding and burping. Which strategy should the nurse offer to the mother regarding burping? Lay the newborn on its back on its mother's lap. Hold the newborn upright with the newborn's head on the mother's shoulder. Gently rub the newborn's abdomen while the newborn is in a sitting position. Lay the newborn on its abdomen in the mother's lap, and gently pat the buttocks.

labored breathing generalized cyanosis flaccid body posture

During an initial newborn assessment, the nurse recognizes certain signs need to be reported to the primary care provider as they indicate potential problems. Which finding(s) would the nurse report? Select all that apply. labored breathing tachycardia, greater than 140 beats per minute tachypnea, greater than 50 breaths per minute generalized cyanosis flaccid body posture

Suction the mouth and then the nose with a suction catheter.

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? Suction the mouth and then the nose with a suction catheter. Place the newborn on its stomach with the head down and gently pat its back. Suction the nose first and then the mouth with a bulb syringe. Using a bulb syringe, suction the mouth then the nose.

within the first 2 to 4 hours, when the newborn reaches the nursery

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 30 minutes after birth, in the birthing area within the first 2 to 4 hours, when the newborn reaches the nursery prior to the newborn being discharged 24 hours after the newborn's birth

two arteries and one vein

The nurse is assessing the abdomen of the neonate. When inspecting the umbilical cord area of a newborn, the nurse would expect which finding? two arteries and two veins one artery and two veins two arteries and one vein three arteries and no veins

Cooperation by the parents with the hospital policies

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? Use of pass codes onto the unit Use of monitor attached to babies Use of cameras at all doors Cooperation by the parents with the hospital policies

less than 97.7° F (36.5° C) or greater than 100° F (37.8° C)

The nurse is preparing discharge teaching for a young couple and their infant. Which axillary temperatures should the nurse point out should be reported to the primary care provider? less than 96.7° F (35.9° C) or greater than 99.5° F (37.4° C) less than 97° F (36.1° C) or greater than 100.5° F (38.1° C) less than 96° F (35.6° C) or greater than 101° F (38.3° C) less than 97.7° F (36.5° C) or greater than 100° F (37.8° C)

Injecting the medication into the vastus lateralis

The nurse is preparing to administer the vitamin K injection to a newborn. Which action would be correct for this client? Injecting at a 45-degree angle Injecting the medication into the vastus lateralis Injecting 1cc of medication Using a 21-gauge needle

Wear clean gloves.

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? Perform a 3-minute surgical-type scrub. Wear clean gloves. Use infection transmission precautions. Clean hands with a betadine scrub.

Begin skin-to-skin (kangaroo) care for the newborn. Dry the newborn off immediately after birth to prevent chilling. Initiate early and frequent breastfeeding.

What measures can a nurse take to reduce the risk of hypoglycemia in a newborn? Select all that apply. Feed only glucose water for the first 24 hours following birth. Begin skin-to-skin (kangaroo) care for the newborn. Feed the newborn formula every 4 hours, starting 8 hours after birth. Dry the newborn off immediately after birth to prevent chilling. Initiate early and frequent breastfeeding.

A washcloth Warm tub of water Thermometer

What supplies would the nursery nurse collect in preparation for bathing a newborn infant? Select all that apply. A washcloth Hexachlorophene soap Warm tub of water Thermometer Talc powder

Swaddling the infant

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? Rocking and singing to her infant. Holding and cuddling the infant Use of mobiles above the crib. Swaddling the infant

33 cm

A nurse is assessing a newborn and obtains the newborn's head circumference. The head circumference is 35 cm. The nurse then measures the newborn's chest circumference. Which chest circumference measurement would the nurse document as expected and within normal parameters? 28 cm 30 cm 33 cm 37 cm

pulse rate 100 bpm A pulse rate between 110 and 160 bpm is considered within acceptable parameters.

A nurse is assessing a newborn's vital signs 2 hours after birth. The newborn had low Apgar scores at birth. Which finding would lead the nurse to notify the health care provider? temperature 99°F (37.2°C) pulse rate 100 bpm respirations 40 breaths/min blood pressure 60/40 mm Hg

Moro reflex

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? square window popliteal angle Moro reflex scarf sign

hearing

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 vision genetic-linked skeletal malformations

24 to 72 hours after birth.

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? within 1 hour after birth. within 24 hours after birth. 24 to 72 hours after birth. 4 weeks after solid food is first eaten.

24

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. 18 20 22 24

an extrusion reflex at 9 months of age

Which newborn neuromuscular system adaptation would the nurse not expect to find? a Moro reflex at 3 months of age an extrusion reflex at 9 months of age a positive Babinski sign at 2 months of age a plantar grasp reflex at 7 months of age

"Breastfed babies need supplements of glucose water to help lower bilirubin levels."

Which statement made by a new nurse indicates additional teaching is needed on the topic of hyperbilirubinemia (physiologic jaundice) in newborns? "Physiologic jaundice usually begins in the first week after birth." "Placing the infant in direct sunlight for short periods helps in eliminating the bilirubin." "Breastfed babies need supplements of glucose water to help lower bilirubin levels." "The problem is a result of the shortened lifespan of the newborn's red blood cells (RBCs)."

"Newborns lack the intestinal flora needed to produce vitamin K, so it is given to prevent bleeding episodes."

A new mother asks the nurse why newborns receive an injection of vitamin K after delivery. What will be the best response from the nurse? "Newborns are given vitamin K to help with the digestion to help them absorb fat-soluble vitamins." "Newborns lack the intestinal flora needed to produce vitamin K, so it is given to prevent bleeding episodes." "Newborns are given vitamin K and erythromycin ointment to help prevent ophthalmia neonatorum." This vitamin substitutes for vitamin C for newborns to strengthen their immune systems."

concentration of immature blood vessels

While examining a newborn, a nurse observes salmon patches on the nape of the neck and on the eyelids. Which is the most likely cause of these skin abnormalities? bruising from the birth process an immature autoregulation of blood flow an allergic reaction to the soap used for the first bath concentration of immature blood vessels

Place newborn in the bassinet and cover with blanket while obtaining diapers.

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? Go get another pack of diapers from the supply closet to place at the scales. Wrap the newborn in a blanket and carry the newborn to get another diaper. Place newborn in the bassinet and cover with blanket while obtaining diapers. Take a diaper from the newborn next in line to be weighed.

lateral to the midclavicular line at the fourth intercostal space

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)? at the third intercostal space adjacent to the midclavicular line at the midsternum, just below the suprasternal notch lateral to the midclavicular line at the fourth intercostal space at the fifth intercostal space at the right midclavicular line

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.

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. Don't leave the newborn unattended unless the mother is going to the bathroom. 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. It is ok to release your newborn to hospital personnel when they come into your room to transport the newborn back to the nursery.

Assess the newborn for signs of respiratory distress.

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? Notify the health care provider immediately. Reassure the parents that this is an expected pattern. Tell the parents not to worry since his color is fine. Assess the newborn for signs of respiratory distress.