CHAPTER 23 Nursing MGMT of newborn
As you are examining the newborn female, you notice a small pinkish discharge from the vaginal area. What should you suspect? a) Pseudomenstruation, a normal finding b) Impending hemorrhage from a congenital defect c) Infection d) Evidence of birth trauma
Pseudomenstruation, a normal finding Correct Explanation: Pseudomenstruation is seen when a newborn female has a small amount of pinkish discharge. It comes from the withdrawal of maternal hormones and is a normal finding.
When counseling a patient about the advantages of circumcision, which should NOT be included in the nurse's teaching? a) "Circumcision decreases rates of penile cancer." b) "Circumcision decreases risks of skin dehiscence, adhesions, and urethral fistulas." c) "Males who are circumcised have lower rates of sexually transmitted infection." d) "Circumcision decreases rates of urinary tract infection."
"Circumcision decreases risks of skin dehiscence, adhesions, and urethral fistulas." Correct Explanation: Newborn males who are circumcised have higher rates of skin dehiscence, adhesions, and urethral fistulas.
When instructing a new mom on providing skin care to her newborn, which of the following should NOT be included in the teaching? a) "Change diapers frequently." b) "Give the newborn sponge baths until the umbilical cord falls off." c) "Use talc powders to prevent diaper rash." d) "Daily tub baths are not necessary."
"Use talc powders to prevent diaper rash." Correct Explanation: Talc powders can be a respiratory hazard and should not be used with a newborn.
A woman comes to the nursery and states "Mrs. Smith is ready for her baby. I will be glad to take the baby to her." The woman is dressed in hospital scrub attire but has no name badge showing. What is the best response by the nurse caring for the baby? a) "Leave immediately! I'm calling security." b) "May I see your identification, please?" c) "I don't know you. Are you trying to take a baby?" d) "You must be Mrs. Smith's sister. She said her sister is a nurse."
"May I see your identification, please?" Correct Explanation: Each member of the hospital staff should have an identification badge clearly displayed. The nurse in the nursery is appropriate in asking to see the identification of the woman who is offering to take Mrs. Smith's baby to her. Education and watchful vigilance are the keys to preventing infant abductions. Each facility that cares for newborns should have specific policies and procedures in place that address this problem. Review these policies and know the protocols for the facility in which you will be working.
How should the nurse counsel the postpartum patient about sleep and her newborn? a) "In the first few days at home, you can expect your newborn to sleep 22 hours in a 24-hour period." b) "Using a fan in the baby's room or opening a window may reduce the incidence of sudden infant death syndrome (SIDS)." c) "Always put the baby on his back or side to sleep until he is able to hold his neck up." d) "Introducing solid foods early will help the baby sleep at night."
"Using a fan in the baby's room or opening a window may reduce the incidence of sudden infant death syndrome (SIDS)." Correct Explanation: Introducing solid foods early will not help the baby sleep better at night. A normal newborn sleeps a lot, but less than 22 hours a day in the first week of life. The American Academy of Pediatrics recommends always putting a baby on his back to sleep. Oxygen-rich air from a fan or a window has been shown to decrease SIDS.
To indicate that the infant is making a successful transition immediately after birth, the nurse checks the heart rate for 6 seconds. What should the count minimally be? a) 9 b) 10 c) 11 d) 12
11 Explanation: The normal infant heart rate should be greater than 100 bpm. Therefore, options A and B are incorrect. Option D is an acceptable heart rate in an infant but is not the minimal accepted heart rate
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? a) 24 hours after the newborn's first protein feeding. b) When the infant is 48 hours old. c) Just before discharge home.. d) 36 hours before the infant is discharged home with its parents.
24 hours after the newborn's first protein feeding. Correct Explanation: 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.
Baby Eliza is 7 minutes old. Her heart rate is 92, her cry is weak, her muscles are limp and flaccid, she makes a face when she is stimulated, and her body and extremities are pink. What would the nurse assign as her Apgar score? a) 3 b) 4 c) 6 d) 5
5 Correct Explanation: The infant is not demonstrating a good transition to extra uterine life; the APGAR score ranges from 0 to 10 with a score of 0, 1, or 2 points for each: respiratory effort, heart rate, tone, grimace, and color. A score of 5 indicates the infant need support. Options A, B, and D are incorrect Apgar scores based on the scenario provided.
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: a) 7 b) 6 c) 5 d) 8
7 Correct Explanation: 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).
You record a newborn's Apgar score at birth. A normal 1-minute Apgar score is a) 5 to 9. b) 1 to 2. c) 12 to 15. d) 7 to 10.
7 to 10. Correct Explanation: An Apgar score of 7 to 10 implies the infant is breathing well and cardiovascular adaptation is occurring.
On examination, the hands and feet of a 12-hour-old infant are cyanotic without other signs of distress. The nurse should document as: a) Cold stress. b) Acrocyanosis. c) Potential for respiratory distress. d) Poor oxygenation.
Acrocyanosis. Correct Explanation: Acrocyanosis is a blue tint to the hands and feet of newborns during the first few days of life. Acrocyanosis is a normal finding and is not indicative of a potential for respiratory distress, poor oxygenation, nor cold stress.
What is the best thing the nurse can do to manage pain in a neonate? a) Teach the infant's caregivers ways to soothe and comfort the child during any episode of pain. b) Adhere carefully to the plan for administration of any analgesics to the child. c) Advocate to the physician to use effective treatment methods that cause no pain or less pain. d) Provide a soothing environment, swaddling, and holding to the newborn experiencing pain.
Advocate to the physician to use effective treatment methods that cause no pain or less pain. Correct Explanation: It is the ethical responsibility of the nurse to prevent and treat pain. The nurse should advocate to the provider to provide pain treatment. All answer options are correct; however, the best answer is to advocate for effective treatment methods that cause no pain, or less pain. Therefore, options A, B, and D are incorrect.
A newborn is discharged from the hospital before undergoing metabolic screening. A community health nurse scheduling a follow-up home visit knows that the most appropriate time to perform the heel stick is: a) Before the baby has received 8 feeds of breast milk or formula. b) Within 24 hours of birth. c) At least 36 hours after birth. d) At least 24 hours after birth.
At least 24 hours after birth. Correct Explanation: This screening needs to be done on an infant 24 hours to 7 days after birth. The timing of the screening test is determined by the age of the infant, not the number of feedings.
Which vital sign is not routinely assessed in a term, healthy newborn with 9/9 AGPARs? a) Pain b) Pulse c) Respirations d) Temperature e) Blood pressure
Blood pressure Correct Explanation: Because the readings can be inaccurate, blood pressure is not routinely assessed in term, normal healthy newborns with normal AGPARs. 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.
What is the most important thing the nurse can teach the family of a newborn to prevent abduction while the baby is in the hospital? a) Check the identification badge of any health care worker before he or she takes the baby from the room. b) Check the number on the baby's identification bracelet. c) Check the name on the baby's identification bracelet. d) Learn to recognize the baby's cry.
Check the identification badge of any health care worker before he or she takes the baby from the room. Correct Explanation: Infant abduction is a concern, all personal should wear identification badges and introduce themselves to the parents before they enter the room or take the infant. If at any time the mother is suspicious, she has the right to not allow an individual to take the infant. Learning to recognize the baby's cry would be ineffective in the prevention of an infant abduction from the hospital, the baby may not be crying as it is carried out of the unit. Checking the name and number on the baby's identification bracelet would tell the family it is their baby, not if it is being abducted by someone who is not employed by the hospital.
How can the nurse be instrumental in preventing hypoglycemia in the newborn? Choose the best answer. a) Assessing the newborn's blood pressure within 1 hour of delivery b) Encouraging skin to skin for the first few minutes after birth c) Administering vitamin K within 1 hour of birth d) Encouraging early and frequent feedings
Encouraging early and frequent feedings Correct Explanation: The best way listed above to prevent hypoglycemia in the newborn is encouraging early and frequent feedings with the breast or a bottle. Skin to skin will aid in keeping the newborn warm and preventing hypothermia, which in time will also help to prevent hypoglycemia. However, a few minutes is not enough to prevent low glucose levels. It would need to be done as often as possible. Vitamin K is given to prevent hemorrhage. Blood pressure is not routinely checked in healthy, term newborns.
What are small unopened or plugged sebaceous glands that occur in a newborn's mouth and gums? a) Epstein's pearls b) Milia c) Stork bites d) Mongolian spots
Epstein's pearls Correct Explanation: Unopened sebaceous glands are generally called milia. When they are in the mouth and gums, they are called Epstein's pearls.
It is common for a newborn to have one or two erupted teeth (natal teeth) at birth. a) False b) True
False Correct Explanation: It is highly unusual for a newborn to have erupted teeth (natal teeth) at birth.
On examining a newborn's eyes, which of the following would you expect to assess? a) Follows a light to the midline b) Has a white rather than a red reflex c) Follows your finger a full 180 degrees d) Produces tears when he cries
Follows a light to the midline Correct Explanation: Newborns do not usually follow past the midline until 3 months of age. They do not tear.
Which of the following nursing diagnosis would be highest in priority for a newborn? a) Ineffective thermoregulation related to heat loss to the environment. b) Altered nutrition less than body requirement related to limited formula intake. c) Altered urinary elimination related to post-circumcision status. d) Ineffective airway clearance related to mucous obstruction.
Ineffective airway clearance related to mucous obstruction. Correct Explanation: Any airway clearance or obstruction issue is the highest priority for nursing interventions. Options A, B, and C are valid nursing diagnoses for some newborns; however, they would not take precedence over an airway problem.
The nurse measures a newborn's temperature immediately after birth and finds it to be 99°F. An hour later, it has dropped several degrees. The nurse understands that this heat loss can be explained in part by which of the following in the newborn? a) Continual crying b) Continual kicking c) Constriction of blood vessels d) Lack of subcutaneous fat
Lack of subcutaneous fat Correct Explanation: Insulation, an efficient means of conserving heat in adults, is not as effective in newborns because they have little subcutaneous fat to provide insulation. Newborns can conserve heat by constricting blood vessels and moving blood away from the skin. Brown fat, a special tissue found in mature newborns, apparently helps to conserve or produce body heat by increasing metabolism as well as regulating body temperature similar to that of a hibernating animal. Other ways newborns are able to increase their metabolic rate and produce more heat include kicking and crying.
When auscultating the newborn's heart, the nurse would place the stethoscope at which area to auscultate the point of maximal impulse? a) Lateral to the midclavicular line at the fourth intercostal space b) At the fifth intercostal space at the right midclavicular line c) At the third intercostal space adjacent to the midclavicular line d) At the midsternum, just below the suprasternal notch
Lateral to the midclavicular line at the fourth intercostal space Correct Explanation: 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 observes tiny white pinpoint papules on a newborn's nose. The nurse documents this finding as: a) Lanugo b) Milia c) Harlequin sign d) Vernix caseosa
Milia Correct Explanation: Milia are the tiny white pinpoint papules of unopened sebaceous glands frequently found on the newborn's nose. Lanugo is the fine downy hair that covers the newborn's shoulders, back, and upper arms. Vernix caseosa is the thick white substance that provides a protective covering of the skin of the fetus. The harlequin sign refers to a transient phenomenon in which a newborn appears red on the dependent side of the body and pale on the upper side when lying on his or her side
An African American baby has discoloring which appears similar to bruising on his buttock after a normal vaginal delivery. This assessment should be documented as: a) Lanugo. b) Bruising. c) Vascular nevi. d) Mongolian spots.
Mongolian spots. Correct Explanation: This is a Mongolian spot and occurs in ethnicities with darker colored skin. This is a normal finding, but does require documentation. Lanugo is the fine hair on the baby's body when it is born. Mongolian spots are not vascular nevi and they are not bruising.
To prevent misidentification of a newborn identification bands are placed on the newborn and on the parents before the newborn is separated from the parents. What information is on all the bands? a) Father's name and date and time of birth b) Hospital number, attending physician, and father's name c) Newborn's sex and date and time of birth d) Mother's name and date and time of her birth
Newborn's sex and date and time of birth Explanation: Information included on the bands is the mother's name, hospital number, and physician, newborn's sex, and date and time of birth.
A father is asking questions about the circumcision of his son. He is asking the nurse if there are any disadvantages to the procedure. How should the nurse respond? a) Lower rate of urinary tract infections b) Fewer complications than if done later in life c) Reduced risk of penile cancer d) Pain administration may not be effective during the procedure
Pain administration may not be effective during the procedure Correct Explanation: The anesthetic block is not always effective. Not all providers use anesthetics prior to the procedure and the infant can feel the pain of the circumcision. A lower rate of urinary tract infections, a reduced risk of penile cancer, and fewer complications than if circumcised later in life are not disadvantages to the procedure; they are advantages.
You are assisting with the circumcision of a 16-hour-old male infant. Immediately after the procedure, what kind of dressing would you apply to the surgical area? a) Sterile 2×2s and paper tape b) Petrolatum gauze dressing c) Steri strips d) Small pressure dressing
Petrolatum gauze dressing Correct Explanation: Immediately after the procedure, place a petrolatum gauze dressing, as ordered by the physician.
The infant's temperature is 97.2F axillary an hour after birth. Which intervention is the appropriate for the nurse? a) Administer a warm bath with temperature slightly higher than usual b) Place a second stockinette on the baby's head c) Place the infant under a radiant warmer or in a heated isolette. d) Take the infant to the mother for bonding.
Place the infant under a radiant warmer or in a heated isolette. Correct Explanation: If the infant has a low temperature of 97.2F, the nurse should place the infant in a radiant warmer or in an isolette. Once the infant has a core temperature of greater than 97.7F, the nurse will double bundle and re-check the temperature in 30 minutes. If an infant has a temperature that is considered low you would not take the infant to its mother for bonding nor administer a warm bath. You would initiate interventions to stabilize the infant's temperature within normal range
A father asks the nurse what medication is in the baby's eyes and why it is needed. Which of the following is the appropriate explanation? a) Destroy an infectious exudate of the vaginal canal. b) Prevent infection of the baby's eyes by bacteria which may have been in the vaginal canal. c) Prevent potentially harmful virus from invading the tear ducts. d) Prevent the baby's eyelids from sticking together to help see.
Prevent infection of the baby's eyes by bacteria which may have been in the vaginal canal. Correct Explanation: Antibiotic ointment is used in the infant's eyes at delivery to prevent ophthalmia neonatorum, an infection which can lead to blindness. Option A is incorrect as it gives misinformation to the father. Antibiotic ointment is not used for a potentially harmful virus; therefore option C is incorrect. Option D is incorrect as it also gives misinformation to the father of the infant.
Baby Tarik has been circumcised, his temperature is stable, his breathing and heart rate are healthy, and he is ready to be discharged from the hospital. What can the nurse tell his parents to be on the lookout for that might indicate that Tarik needs medical attention? a) Straining when he is passing stools b) Redness at the base of the umbilical cord c) A yellowish crusty substance on the circumcision site d) Crying for 2 hours or more each day
Redness at the base of the umbilical cord Explanation: The cord should dry and fall off in the 7 to 10 days after delivery. 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 two hours or more each day and straining at stools are normal in a newborn.
Which of the following would the nurse do first after the birth of a newborn? a) Obtain footprints. b) Administer vitamin K. c) Apply identification bracelet. d) Suction the mouth and nose.
Suction the mouth and nose. Correct Explanation: The first priority is to ensure a patent airway by suctioning the newborn's mouth and nose. Before leaving the birthing area, newborn identification procedures are completed, including applying the identification bracelet and possibly footprinting, depending on the agency's policy. Vitamin K is administered soon after birth but it does not take priority over ensuring a patent airway.
The nurse is providing discharge education on newborn care at home. The nurse provides instructions that infants need to be placed on their back to sleep. What is the nurse reducing the risk for with this education? a) Sudden infant death syndrome b) Gastroesophageal reflux c) Apnea episodes d) Waking at night
Sudden infant death syndrome Correct Explanation: The "back to sleep" campaign is a national campaign used to educate the public concerning the fact that the proper position for sleep of infants is on their back to help decrease the risk of SIDS. Placing the infant on their back to sleep does not reduce the risk for gastroesophageal reflux, apnea episodes, nor waking at night.
All of the following are characteristics of an infant abductor EXCEPT a) Married and/or lives with a male partner b) Lives near the hospital c) Targets a specific infant d) A woman of childbearing age
Targets a specific infant Correct Explanation: Most infant abductors do not target specific infants.
Which is the best place to perform a heel stick on a newborn? a) The front of the heel (the outer arch) b) The vascularized flat surface of the foot c) The fat pads on the lateral aspects of the foot d) The calcaneus
The fat pads on the lateral aspects of the foot Correct Explanation: The calcaneus is the bone of the heel. A heel stick should not be done on the flat part of the foot or heel, but instead on the lateral aspect of the foot, where the fat pads are.
The nurse is providing discharge education to a first time mother and father on their newborn female infant. The father notes the infant has a yellow skin color. How should the nurse explain what the father is noting? a) Yellow is the normal color for a newborn b) The tint is yellow from jaundice c) The infant needs to be in the sunlight to clear the skin d) This might be a sign of a bleeding problem
The tint is yellow from jaundice Correct Explanation: Newborns often have a yellow tint to the skin if the newborn develops jaundice. Any newborn developing jaundice needs to be assessed by the health care provider. Yellow is not the normal color for a newborn. Placing the infant in sunlight may help to clear the skin of the yellow color; however, unless instructed by the physician, this is not information provided in discharge teaching. Jaundice is not a sign of a bleeding problem.
Which of the following findings would the nurse identify as normal when assessing a newborn? Select all that apply. a) Chest circumference of 35 cm b) Length of 54 cm c) Temperature of 37 degrees C d) Weight of 3,300 grams e) Head circumference of 30 cm f) Apical pulse rate of 100 beats/minute
• Length of 54 cm • Temperature of 37 degrees C • Weight of 3,300 grams Correct Explanation: Typical newborn findings include length of 45 to 55 cm, weight of 2,700 to 4,000 grams, head circumference of 33 to 35 cm, chest circumference of 30 to 33 cm, temperature of 36.5 to 37.5 degrees C, and apical pulse rate of 120 to 160 beats/minute.
When performing Ortolani's maneuver, which of the following should occur? Select all that apply. a) Attempt to abduct the hips 180 degrees while applying upward pressure. b) The newborn should be in a supine position. c) A click should be heard when the legs are abducted. d) Attempt to abduct the hips 90 degrees while applying upward pressure. e) The newborn should be in a prone position.
• Attempt to abduct the hips 180 degrees while applying upward pressure. • The newborn should be in a supine position. Correct Explanation: The newborn should be in the supine position. The nurse will flex the hips and knees to 90 degrees at the hip, then will attempt to abduct the hips 180 degrees while applying upward pressure. A "click" or a "cluck" should not be heard when the legs are abducted.
A 25-year-old P3023 spontaneously ruptured clear fluid at home and has had a normal labor progression. The nurse and the midwife do not anticipate any complications. What should the nurse do to prepare for the birth? Select all that apply. a) Document events as they are happening. b) Check the functionality of the oxygen source and equipment. c) Open the newborn crash cart or box to ensure easy access to all supplies. d) Move the newborn warmer to the delivery area and turn it on. e) Connect the meconium aspirator to the wall suction and turn it on.
• Document events as they are happening. • Check the functionality of the oxygen source and equipment. • Move the newborn warmer to the delivery area and turn it on. Correct Explanation: To prepare for the birth of a normal newborn in an uncomplicated labor, the nurse should ensure that there is an adequately warm area to receive the newborn. She needs to ensure that oxygen and suction equipment is readily available and functional and must ensure that all equipment for resuscitation is available (not necessarily opened). The nurse should also make a record of the development of the labor as it progresses. A meconium aspirator is necessary only when meconium is present.
When assessing a newborn's gestational age, the nurse evaluates which of the following parameters to indicate physical maturity? Select all that apply. a) Posture b) Lanugo c) Arm recoil d) Scarf sign e) Genitals
• Lanugo • Genitals Correct Explanation: Physical maturity indicators include skin, lanugo, plantar surface, breast, eye-ear, and genitals. Arm recoil, posture, and the scarf sign are used to evaluate neuromuscular maturity.
You are doing discharge teaching with a group of new parents before they are discharged home with their infant. One set of parents inquire as to why they need to place their new baby on its back to sleep. What is your best response?
"Research has shown that placing an infant on its' back to sleep reduces the risk for SIDS." Correct Explanation: Newborns should always be placed on their backs to sleep to reduce the risk for SIDS.
The parents of a newborn baby boy ask you about circumcising their son. They are undecided as to what to do. Which response by the nurse is best? a) "If you do not circumcise your baby, he will always have difficulty maintaining adequate hygiene." b) "It is best not to circumcise your baby because the procedure is very painful." c) "There are pros and cons to circumcision. Let me ask the pediatrician to come and talk to you about the procedure." d) "Circumcision is best in order to protect the baby from diseases like cancer."
"There are pros and cons to circumcision. Let me ask the pediatrician to come and talk to you about the procedure." Correct Explanation: If the parents decide to have their male newborn circumcised, informed consent is necessary. It is the physician's responsibility to obtain informed consent, although you may be responsible for witnessing the parents' signatures to a written documentation of that consent. If the parents have unanswered questions, notify the physician before the procedure is done.
Which of the following statements by the parents of a newborn indicate that they understand how to soothe their newborn if he becomes upset? a) "We'll place him on his belly on a blanket on the floor." b) "We'll turn the mobile on that's hanging above his head in his crib." c) "We'll vigorously rub his back as we play some music." d) "We'll hold off on feeding him for a while because he might be too full."
"We'll turn the mobile on that's hanging above his head in his crib." Correct Explanation: Turning on a mobile above the newborn's head is helpful in calming the newborn. The movement is distracting and the music is comforting. The newborn's back should be rubbed lightly while the parents speak softly to him. Swaddling the newborn rather than having him lie on a blanket on the floor provides security and comfort. Feeding or burping can be helpful in relieving air or stomach gas.
The nurse has completed the initial assessment and vital signs for an infant born at 12 noon. The assessment and vital signs were completed at 1:30pm. What time will the nurse plan to complete the next set of vital signs? a) 1:45pm b) 2:00pm c) 2:30pm d) 3:30pm
2:00pm Correct Explanation: The nurse needs to complete vital signs every half hour for the first 2 hours of life. This makes options A, C, and D incorrect.
What is the expected range for respirations in a newborn? a) 20-40 breaths per minute b) 40-80 breaths per minute c) 10-30 breaths per minute d) 30-60 breaths per minute
30-60 breaths per minute Correct Explanation: Although episodic breathing is normal and short periods of apnea can occur, the normal respiratory rate for a newborn is 30-60 breaths per minute. For adults, it is typically 8-20 breaths per minute.
A nurse is performing Apgar scoring on a newborn. The newborn demonstrates the following: a heart rate of 110; a good, strong cry; muscles of the extremities well flexed; a grimace in response to a slap to the sole of the foot; and normal pigment in most of the body, with blue at the extremities. Which of the following would be the total Apgar score for this newborn? a) 7 b) 6 c) 8 d) 9
8 Explanation: The heart rate of 110, the strong cry, and the muscles of the extremities being well flexed each indicate a score of 2 in the heart rate, respiratory effort, and muscle tone areas, respectively. The grimace in response to a slap to the sole of the foot and the blue at the extremities each indicate a score of 1 for the reflex irritability and color areas, respectively. Thus, the total Apgar score for this infant is 8.
The infant has APGAR scores of 7 at one minute and 9 at five minutes. What is the indication of this assessment finding?
Adjusting to extrauterine life. Correct Explanation: The infant is tolerating the adjustment to extrauterine life, the APGAR scores are within normal limits for appropriate transition. Severe distress and absolute need for resuscitation is an APGAR score of 0 to 3; moderate difficulty is indicated by a score of 4 to 7. An APGAR of 8 to 10 at five minutes indicates a fair neurologic future outcome.
You are admitting a 10-pound newborn to the nursery. You know that it will be important to monitor what during the transition period? a) Temperature b) Heart rate c) Apgar score d) Blood sugar
Blood sugar Correct Explanation: Most facilities have protocols to guide nursing care in the treatment of hypoglycemia. Many pediatricians have preprinted orders that can be initiated if the glucose level falls below a predetermined level (usually 40-50 mg/dL).
Ophthalmia neonatorum is contracted when a mother has which sexually transmitted infection(s)? a) Chlamydia b) Gonorrhea c) Trichomonas d) Both A and B e) Both B and C
Both A and B Correct Explanation: Colonization of chlamydia and gonorrhea in the vaginal tract can lead to ophthalmia neonatorum in the newborn.
On inspecting a newborn's abdomen, which finding would you note as abnormal? a) Clear drainage at the base of the umbilical cord b) Bowel sounds present at two to three per minute c) Liver palpable 2 cm under the right costal margin d) Abdomen slightly protuberant (rounded)
Clear drainage at the base of the umbilical cord Correct Explanation: Clear drainage at the base of the umbilical cord suggests the child may have a patent urachus or a fistula to the bladder.
A newborn male is circumcised. Which of the following instructions would you include in the discharge teaching plan for his parents? a) Cleanse the glans daily with alcohol. b) Cover the glans generously with Vaseline. c) Notify her physician if it appears red and sore. d) Soak the penis daily in warm water.
Cover the glans generously with Vaseline. Correct Explanation: Covering the surgical site with an ointment such as petroleum jelly (Vaseline) prevents it from adhering to the diaper and being continually irritated. Normal appearance is red and raw. Soaking the penis daily in warm water is not recommended. Washing the penis with warm water, dribbled gently from a washcloth at each diaper change, is the recommended way of keeping the penis clean. You would not tell the parents to use alcohol on the glans.
The nurse notices while holding him upright that a day-old newborn has a significantly indented anterior fontanelle. She immediately brings it to the attention of the physician. What does this finding most likely indicate? a) Cyanosis b) Vernix caseosa c) Dehydration d) Increased intracranial pressure
Dehydration Correct Explanation: The anterior fontanelle can be felt as a soft spot. It should not appear indented (a sign of dehydration) or bulging (a sign of increased intracranial pressure) when the infant is held upright. Vernix caseosa is the white, cream cheese-like substance that serves as a skin lubricant in utero. Some of it is invariably noticeable on a term newborn's skin, at least in the skin folds, at birth. Cyanosis is a condition of decreased oxygenation that results in the skin having a blue hue.
A new mother asks the nurse why her baby's back and groin have a red and raised rash. Which of the following does the nurse correctly identify as the name of this condition? a) Acrocyanosis. b) Erythema toxicum. c) Mumps. d) Yeast infection.
Erythema toxicum. Correct Explanation: Erythema toxicum is a rash of unknown cause, with pink papules and superimposed vesicles. It appears within 24 to 48 hours after birth and resolves spontaneously in a few days. Acrocyanosis is a blue color of the hands and feet appearing in most infants at birth. Acrocyanosis may persist for 7 to 10 days. Yeast is a fungal infection caused by Candida albicans; it usually manifests in the groin. The rash of C. albicans is excoriated and does not disappear without treatment. The presentation described in this scenario is not consistent with that of mumps.
Which of the following would the nurse expect to administer for eye prophylaxis in the newborn? a) Erythromycin ophthalmic ointment b) Vitamin K c) Silver nitrate solution d) Gentamicin ophthalmic ointment
Erythromycin ophthalmic ointment Correct Explanation: Erythromycin or tetracycline ophthalmic ointment is the agent of choice for newborn eye prophylaxis. 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.
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? a) Radiating b) Conductive c) Convective d) Evaporative
Evaporative Correct Explanation: Evaporative heat loss occurs with the evaporation of fluid from the infant.
The AGPAR score is based on which 5 parameters? a) Heart rate, respiratory effort, temperature, tone, and color b) Heart rate, breaths per minute, irritability, reflexes, and color c) Heart rate, muscle tone, reflex irritability, respiratory effort, and color d) Hear rate, breaths per minute, irritability, tone, and color
Heart rate, muscle tone, reflex irritability, respiratory effort, and color Correct Explanation: A newborn can receive an APGAR score ranging from 0 to 10. The score is based on 5 factors, each of which is assigned a 0, 1, or 2. Heart rate (should be above 100), muscle tone (should be able to maintain a flexion position), reflex irritability (newborn should cry or sneeze when stimulated), and respiratory effort are evaluted by the presence of a strong cry and by color. Color is evaluated by noting the color of the body and hands and feet.
Infants receive vitamin K within the first hour after delivery. What is the rationale for administering the vitamin? a) Administered to give the infant better eye sight. b) Is a routine vitamin needed by the infant. c) Helps in formation of clotting factors, to prevent bleeding. d) Used to help infant fight infections.
Helps in formation of clotting factors, to prevent bleeding. Correct Explanation: Vitamin K is necessary in the formation of certain clotting factors. The newborn is lacking in vitamin K and the only method for the infant to receive it is to administer the vitamin IM. Vitamin K is manufactured by normal flora in the gut. Since the newborn has not yet eaten, there is no normal flora in the gut so the infant cannot manufacture vitamin K. Vitamin K is not administered to give the infant better eye sight nor is it to help fight infections.
The standard of care and recommendation by the Centers for Disease Control is to administer an immunization to all newborns. Which immunization is recommended to be administered prior to discharge? a) Prevnar b) DTaP c) HiB d) Hep B
Hep B Correct Explanation: Hep B is the vaccination again Hepatitis B recommended by the CDC. All the other immunizations are recommended to be started at 2 months of age. Therefore options A, C, and D are incorrect.
You are doing discharge teaching with the parents of a newborn baby girl. You know that it is important to teach them about diarrhea and dehydration. When should the parents notify the physician about diarrhea in the newborn.? a) If the infant has more than three episodes of diarrhea in one day b) If the infant has more than four episodes of diarrhea in one day c) If the infant has more than two episodes of diarrhea in one day d) If the infant has more than one episode of diarrhea in one day
If the infant has more than two episodes of diarrhea in one day Explanation: Diarrhea is defined as frequent stools with high water content. Because newborns dehydrate quickly, it is important for parents to notify the physician if the newborn has more than two episodes of diarrhea in one day.
While examining a 2-day old newborn, a nurse notices that the skin and sclera of the eyes appear yellow. The nurse recognizes this condition as which of the following? a) Jaundice b) Pallor c) Harlequin sign d) Cyanosis
Jaundice Correct Explanation: Hyperbilirubinemia is caused by the accumulation of excess bilirubin in blood serum. In the average newborn, the skin and sclera of the eyes begin to appear noticeably yellow on the second or third day of life as a result of a breakdown of fetal red blood cells (called physiologic jaundice), happening because, as the high red blood cell count built up in utero is being reduced, heme and globin are released. Cyanosis is a condition of decreased oxygenation that results in the skin having a blue hue. Pallor, or a pale appearance to skin, occurs as a result of anemia, or lack of red blood cells due to low iron stores, blood loss, poor circulation, or internal bleeding. The harlequin sign is when one side of the body appears red and the other pale, due to immature blood circulation.
Shortly after the birth of a newborn, the mother notices a gray patch across the baby's buttocks. She is immediately concerned that the baby has been bruised during the birth and asks the nurse about this. The nurse recognizes patch as a birth mark and explains this to the mother. Which type of birth mark is this most likely to be? a) Cavernous hemangioma b) Nevus flammeus c) Strawberry hemangioma d) Mongolian spot
Mongolian spot Correct Explanation: Mongolian spots are collections of pigment cells (melanocytes) that appear as slate-gray patches across the sacrum or buttocks and possibly on the arms and legs of newborns. They tend to occur most often in children of Asian, Southern European, or African ethnicity and disappear by school age without treatment. Be sure to inform parents that although these marks look like bruises, they are not. Otherwise, they may worry their baby sustained a birth injury from improper handling. A nevus flammeus is a macular purple or dark-red lesion (sometimes called a port-wine stain because its color is the same as that of red wine). These lesions are present at birth and typically appear either on the face or a thigh. Strawberry hemangiomas are elevated areas formed by a combination of immature capillaries and endothelial cells. Cavernous hemangiomas are raised and irregular in shape ans so resemble a strawberry hemangioma in appearance but do not disappear with time.
A nurse is observing respiratory effort in a newborn as part of Apgar scoring. Which of the following methods should he use to do this? a) Observing resistance to any effort to extend the newborn's extremities b) Observing and counting the pulsations of the umbilical cord c) Observing chest movement d) Observing response to a suction catheter in the nostrils
Observing chest movement Correct Explanation: Respirations are counted by observing chest movement. Reflex irritability may be evaluated by observing response to a suction catheter in the nostrils or response to having the soles of the feet slapped. Heart rate is typically determined by auscultation with a stethoscope but may also be obtained by observing and counting the pulsations of the umbilical cord at the abdomen, if the cord is still uncut. Muscle tone is evaluated by observing resistance to any effort to extend the newborn's extremities.
Newborn Ming has secretions in his mouth and nose. What are the first steps the nurse should take to clear his airways? a) Position Ming on his side with his head slightly below his body; use a bulb syringe to clear his mouth. b) Position Ming on his side with his head slightly below his body; use a bulb syringe to clear his nose. c) Position Ming on his side and guide his caregivers in suctioning his mouth with a bulb syringe. d) Position Ming on his side with his head slightly below his body; use a small suction catheter to clear his nose.
Position Ming on his side with his head slightly below his body; use a bulb syringe to clear his mouth. Correct Explanation: The infant needs to have bulb suction used to remove the secretions, the head should be held slightly lower than the body to facilitate use of gravity. Right after birth is not the time for the parents of the newborn to be instructed in how to suction their infant. A bulb syringe, not a small suction catheter, is used to suction the mouth and nose of a newborn. Option D is incorrect as it does not clear the infant's mouth of secretions.
When evaluating neurologic maturity to determine gestational age, which of the following is not part of the assessment? a) Rooting b) Popliteal angle c) Square window d) Posture
Rooting Correct Explanation: The six activities the newborn performs when being evaluated for gestational age based on neurologic maturity are as follows: posture, square window, arm recoil, popliteal angel, scar sign, and heel to ear
All of the following are ways the nurse can encourage bonding between the parents and the newborn EXCEPT a) Asking the parents' permission to pick up the newborn b) Encouraging parents to provide care while you are there to observe them c) Telling the mother that the best way to bond with her baby is to breastfeed d) Talking to the newborn in front of the parents
Telling the mother that the best way to bond with her baby is to breastfeed Correct Explanation: Modeling behavior such as talking to the newborn will aid in bonding. Being able to observe parents as they provide care to their newborn will give new parents confidence. Asking their permission to pick up the newborn will give them a sense of ownership. Although breastfeeding is an excellent way for a mother to bond with her baby, it is not the only way and it is not necessarily the best way.
With an HBV-positive mother, what should the newborn receive? a) The HBV vaccination and 2 doses of hepatitis B immunoglobulin within 24 hours of birth b) The HBV vaccination and 1 dose of hepatitis B immunoglobulin within 24 hours of birth c) The HBV vaccination and 1 dose of hepatitis B immunoglobulin within 12 hours of birth d) Two doses of the hepatitis B immunoglobulin within 24 hours of birth
The HBV vaccination and 1 dose of hepatitis B immunoglobulin within 12 hours of birth Correct Explanation: If a mother has HBV or is suspected of having HBV, the newborn should be bathed and then should receive 1 dose of the hepatitis B vaccine and 1 dose of the hepatitis B immuoglobulin within 12 hours of birth.
The American Academy of Pediatrics and the American Dietetic Association recommend breastfeeding exclusively for how long? a) The first 28 days b) The first 3 months c) The first 4 months d) The first 6 months
The first 6 months Correct Explanation: Both the AAP and the ADA recommend breastfeeding exclusively for the first 6 months of life. After 6 months, breastfeeding does not need to be exclusive, but it should be continued until 12 months.
Which of the following is FALSE regarding bathing the newborn? a) Mild soap should be used on the body and hair, but not on the face. b) While bathing the newborn, the nurse should wear gloves. c) Bathing should not be done until the newborn is thermally stable. d) To reduce the risk of heat loss, the bath should performed by the nurse, not the parents, within 2-4 hours of birth.
To reduce the risk of heat loss, the bath should performed by the nurse, not the parents, within 2-4 hours of birth. Correct Explanation: Bathing the newborn is not necessary for thermal stability. It can be postponed until the parents are able to do it.
A 23-year-old P1011 has just delivered a term infant who is not crying and has decreased tone. Place the nursing actions in the order they should be carried out. Clear the airway. Check the heart rate. Dry the newborn. Transfer the newborn to a preheated radiant warmer. Stimulate the newborn by rubbing the back.
Transfer the newborn to a preheated radiant warmer. Dry the newborn. Clear the airway. Stimulate the newborn by rubbing the back. Check the heart rate. Correct Explanation: Commonly the first step in a nursing intervention cascade is assessment. However, the nurse already has assessed that the newborn is term, is not crying, and has decreased tone that would require intervention. The first step is to warm the newborn and then to decrease any further loss of heat through evaporation by drying the newborn. The airway should be cleared before the newborn is stimulated to avoid aspiration. The nurse would then check the heart rate to see if further resuscitation efforts are necessary.
Babies of mothers with human immunodeficiency virus (HIV) infection should have a thorough bath immediately after birth to decrease the possibility of HIV transmission. a) False b) True
True
Following birth, a newborn is placed on the mother's abdomen for a period of skin-to-skin contact. a) False b) True
True Correct Explanation: Following birth, a newborn is placed on the mother's abdomen for a period of skin-to-skin contact, to allow the mother to begin breastfeeding if she wishes and to allow time for parents to enjoy and get acquainted with their newborn. It's important not to interrupt this time as newborns are alert (first period of activity) and respond well to the parents' first tentative touches or interactions with them during this time. (less)
Newborn Isaac has been taken to the nursery after delivery. He has been cleaned in the labor and delivery suite and swaddled in a blanket. The nurse is going to check his pulse. What must the nurse do? a) Perform a 3-minute surgical type scrub before touching him. b) Use infection transmission precautions. c) Clean his or her hands with a betadine scrub. d) Wear gloves.
Wear gloves. Correct Explanation: Infection control is a priority nursing intervention. Gloves need to be worn when in contact with the infant who has not been bathed after delivery. All options are valid options. However, a three-minute surgical scrub is generally only required at the beginning of a shift. You should always wash your hands before putting on gloves to care for an infant and after taking your gloves off. Standard precautions are used with every patient.
Discharge teaching is an important part of the labor and delivery room nurse's position. New parents need to know the basics of baby care, like how to monitor fluid volume and when to call the physician. What are the parameters for calling the physician in regards to an infants' temperature? a) less than 96.7 °F or greater than 99.5 °F. b) less than 96 °F or greater than 101 °F c) less than 97 °F or greater than 100.5 °F. d) Less than 97.7 °F or greater than 100 °F.
Less than 97.7 °F or greater than 100 °F. Correct Explanation: Temperatures of less than 97.7 °F or greater than 100 °F should be reported to the physician.
How should the nurse counsel the postpartum patient about sleep and her newborn? a) "Introducing solid foods early will help the baby sleep at night." b) "Always put the baby on his back or side to sleep until he is able to hold his neck up." c) "In the first few days at home, you can expect your newborn to sleep 22 hours in a 24-hour period." d) "Using a fan in the baby's room or opening a window may reduce the incidence of sudden infant death syndrome (SIDS)."
"Using a fan in the baby's room or opening a window may reduce the incidence of sudden infant death syndrome (SIDS)." Explanation: Introducing solid foods early will not help the baby sleep better at night. A normal newborn sleeps a lot, but less than 22 hours a day in the first week of life. The American Academy of Pediatrics recommends always putting a baby on his back to sleep. Oxygen-rich air from a fan or a window has been shown to decrease SIDS.
A patient expresses concern to the nurse that her baby is dehydrated and is not getting enough milk from breastfeeding. What is the best response from the nurse? a) "You can tell that your baby is adequately hydrated because he is making 8 wet diapers a day." b) "We will give him some water through a bottle in the nursery tonight while you rest." c) "Does he pass urine that is a light amber color right after eating?" d) "You should supplement with formula because your baby is 24 hours old and has not passed meconium yet."
"You can tell that your baby is adequately hydrated because he is making 8 wet diapers a day." Correct Explanation: The nurse will know that a newborn is adequately hydrated if he has 6 to 12 wet diapers a day. It is still within normal limits if the newborn has not passed meconium by 24 hours of age. Although urinating after feeding is common, it is not essential to ensure adequate hydration.
A nurse tests a newborn's nervous functioning by stroking the sole of the baby's foot in an inverted "J" curve from the heel upward. The baby responds by fanning his toes. Which reflex has just been demonstrated? a) Extrusion b) Moro c) Babinski reflex d) Rooting reflex
Babinski reflex Correct Explanation: The Babinski reflex is demonstrated when the sole of a newborn's foot is stroked in an inverted "J" curve from the heel upward and the newborn fans the toes in response (positive Babinski sign). The rooting reflex is demonstrated when, in response to the newborn's cheek being stroked, the infant turns her head in that direction. This reflex serves to help a newborn find food: when a mother holds the child and allows her breast to brush the newborn's cheek, the reflex causes the baby to turn toward the breast. The extrusion reflex is demonstrated when a newborn extrudes any substance that is placed on the anterior portion of the tongue; this reflex prevents the swallowing of inedible substances. The Moro reflex is demonstrated when, in response to a sudden backward head movement, the newborn abducts and extends arms and legs, then swings the arms into an embrace position and pulls up the legs against the abdomen.
When educating patients in a maternal-newborn unit about prevention of infant abduction, what is essential in the effectiveness of prevention of abduction? a) Use of monitor attached to babies b) Policy posted about security c) Cooperation by the parents with the hospital policies d) Staff awareness of infant abduction profiles
Cooperation by the parents with the hospital policies Correct Explanation: 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. Posting security policies, placing monitors on the babies, and educating the staff about infant abduction profiles are not the most essential elements of an effective abduction prevention plan.
A very healthy mother delivered a newborn with an immediate Apgar score of 10. The newborn was cradled in a kangaroo hold by both her mother and her father for 45 minutes. The parents feel ready to get cleaned up and let the newborn be taken care of by the health care personnel for a little while. What eye care action will the nurse now take? a) Instill 1 percent erythromycin eye drops b) Instill antibiotic 0.5 percent erythromycin c) Instill 0.5 percent silver nitrate eye drops d) Wait to see if the eyes show signs of irritation before any eye care treatment is completed
Instill antibiotic 0.5 percent erythromycin Correct Explanation: The standard eye care to prevent ophthalmia neonatorum is 0.5 percent erythromycin or 1 percent tetracycline eye drops. Although 1% silver nitrate drops where once used, it has not been shown to prevent chlamydial eye disease. One percent erythromycin and 0.5 percent silver nitrate are incorrect concentrations of these medications and should not be instilled into the eyes of the newborn. The nurse would not wait to see if the eyes show signs of irritation before completing eye care treatment on the newborn.
The New Ballard scoring system evaluates newborns on which 2 factors? a) Physical maturity and neuromuscular maturity b) Body maturity and cranial nerve maturity c) Skin maturity and reflex maturity d) Tone maturity and extremities maturity
Physical maturity and neuromuscular maturity Correct Explanation: When determining a newborn's gestational age using the New Ballard scale, physical signs and neurologic characteristics are assessed.
The nurse is preparing to apply a thermistor probe to a newborn to monitor the newborn's temperature. At which location would the nurse most likely apply the probe? a) Upper left arm b) Right upper abdominal quadrant c) Lower back d) Right great toe
Right upper abdominal quadrant Correct Explanation: A thermistor probe is taped to the newborn's abdomen, usually in the right upper quadrant. This allows for position changes without having to readjust the probe.
When caring for a newborn who is jittery and irritable 30 minutes after birth, what should the nurse do? a) Take blood, using a heel stick, to check for hypoglycemia. b) Place the child beneath a radiant warmer. c) Assess the baby's temperature with a thermal skin probe. d) Rule out hypoglycemia by checking the mother's chart for diabetes or other risk factors.
Take blood, using a heel stick, to check for hypoglycemia. Correct Explanation: One of the primary signs/symptoms of hypoglycemia in newborn infants is jitteryness and irritability. Anytime an infant is suspected of having hypoglycemia, the nurse needs to check the blood glucose level with a heel stick. The infant described in the scenario does not need to be placed under a radiant warmer or have its temperature assessed with a thermal skin probe. You do not rule out hypoglycemia in an infant by checking the mother's chart to see if she is diabetic or has other risk factors.
A nurse is discussing breastfeeding with a new mother and demonstrates that when she strokes the baby's cheek, the baby turns his head in that direction. This reflex is known as which of the following? a) Moro reflex b) Babinski reflex c) Extrusion reflex d) Rooting reflex
Rooting reflex Correct Explanation: The rooting reflex is demonstrated when, in response to the newborn's cheek being stroked, the infant turns her head in that direction. This reflex serves to help a newborn find food: when a mother holds the child and allows her breast to brush the newborn's cheek, the reflex causes the baby to turn toward the breast. The extrusion reflex is demonstrated when a newborn extrudes any substance that is placed on the anterior portion of the tongue; this reflex prevents the swallowing of inedible substances. The Moro reflex is demonstrated when, in response to a sudden backward head movement, the newborn abducts and extends arms and legs, then swings the arms into an embrace position and pulls up the legs against the abdomen. The Babinski reflex is demonstrated when the sole of a newborn's foot is stroked in an inverted "J" curve from the heel upward and the newborn fans the toes in response (positive Babinski sign).
On an Apgar evaluation, reflex irritability is tested by which of the following? a) Dorsiflexing a foot against pressure resistance b) Raising the infant's head and letting it fall back c) Tightly flexing the infant's trunk and then releasing it d) Slapping the soles of the feet and observing the response
Slapping the soles of the feet and observing the response Correct Explanation: Reflex irritability means the ability to respond to stimuli. It can be tested by slapping the foot or evaluating the response to a catheter passed into the nose.
When assessing the umbilical cord of a newborn, which of the following would the nurse expect to find? a) Three arteries and no veins b) Two arteries and two veins c) One artery and two veins d) Two arteries and one vein
Two arteries and one vein Correct Explanation: The normal umbilical cord contains three vessels: two arteries and one vein.
Which of the following interventions would a nurse implement to best prevent heat loss in a 1 day of age newborn? a) Bathe and wash the newborn when temperature is 36.4 C (97.5F) b) Warm all surfaces and objects that come in contact with the newborn. c) Keep the newborn under the radiant heater when not with mom. d) Cover the newborn with several blankets while under the warmer.
Warm all surfaces and objects that come in contact with the newborn. Explanation: The infant will have regulated the body temperature at this point in life. Interventions to prevent heat loss are the best way to prevent heat loss for this newborn. Keeping the newborn under a radiant heater and covering the newborn with several blankets while under the warmer could lead to hyperthermia which can be just as detrimental to the newborn as hypothermia. Infants are bathed when their temperatures are stable.