Intrapartum/Newborn

Which are considered normal findings in a newborn less than 12 hours old? Select all that apply.

2. Presence of vernix caseosa 4. Anterior fontanelle measuring 5.0 cm 5. Bluish discoloration of hands and feet

The nurse checks the respirations of a newborn who was just delivered. The respiratory rate is 40 breaths/minute. Which intervention is most appropriate related to this finding?

Document the findings in the electronic health record

The nurse has provided instructions about measures to clean the penis to a mother of a male newborn who is not circumcised. Which statement, if made by the mother, indicates an understanding of how to clean the newborn's penis?

"I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions."

A client who is positive for human immunodeficiency virus (HIV) delivers a newborn infant. The nurse provides instructions to help the client with care of her infant. Which client statement indicates the need for further instruction?

"I need to breast-feed, especially for the first 6 weeks postpartum."

The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings should alert the nurse to the possibility of this syndrome? Select all that apply.

1. Cyanosis 2. Tachypnea 4. Retractions 5. Audible grunts

A new mother reports that her niece was diagnosed as an infant with gastroesophageal reflux (GER). The newborn's mother asks the nurse if her newborn also has this diagnosis. Which findings should the nurse identify as potential indicators of GER? Select all that apply.

1. Irritability 2. Failure to thrive 3. Choking with feeding 5. Spitting up and regurgitation

The nursery room nurse is assessing a newborn infant who was born to a mother who abuses alcohol. Which assessment finding should the nurse expect to note? Select all that apply.

1. Tremors 3. Irritability 4. Poor feeding

The nurse is monitoring a newborn born to a client who abuses alcohol. Which findings should the nurse expect to note when assessing this newborn? (Select all that apply.)

2. Irritability 3. Minimal response to stimuli

The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which findings should the nurse expect to note during the assessment of this newborn? Select all that apply.

3. Irritability 4. Constant crying 5. Difficult to comfort

The home care nurse is visiting a mother 1 week after she gave birth to an infant who is at risk for developing neonatal congenital syphilis. After teaching the mother about the signs and symptoms of this disorder, the nurse instructs the mother to monitor the infant for which findings? Select all that apply

4. A copper-colored skin rash 5. Mucopurulent nasal drainage (snuffles)

Which newborn is most at risk for a brachial plexus injury?

A large for gestational age infant with a history of shoulder dystocia at delivery

An initial assessment of a large for gestational age (LGA) newborn infant is being done. Which physical assessment technique should the nurse assist in performing to assess for evidence of birth trauma?

Palpate the clavicles for a fracture.

The nurse is caring for a post-term, small for gestational age (SGA) newborn infant immediately after admission to the nursery. What should the nurse monitor as the priority?

Blood glucose levels

The nurse assisted with the birth of a newborn. Which nursing action is most effective in preventing heat loss by evaporation?

Drying the infant with a warm blanket

The nurse is reviewing the record of a newborn infant in the nursery and notes that the health care provider (HCP) has documented the presence of a cephalohematoma. Based on this documentation, what should the nurse expect to note on assessment of the infant?

Edema resulting from bleeding below the periosteum of the cranium

The nurse is providing instructions to the mother of a breast-fed newborn who has hyperbilirubinemia. Which instruction should the nurse provide to the mother?

Increase the frequency of the breast-feeding.

The nurse in the labor room is performing an initial assessment on a newborn infant. On assessment of the head, the nurse notes that the ears are low set. Which nursing action would be appropriate?

Notify the health care provider (HCP).

The nurse is performing an admission assessment on a newborn infant with the diagnosis of subdural hematoma after a difficult vaginal delivery. Which assessment technique assists to support the newborn's diagnosis?

Stimulating for reflex responses in the extremities

The nurse is planning to administer an intramuscular injection of vitamin K to a newborn. To administer the injection, which site should the nurse select?

The lateral aspect of the middle third of the vastus lateralis muscle

The nurse in the delivery room is performing an assessment on a newborn to determine the Apgar score. The nurse notes a heart rate of 92, a weak cry, some flexion of extremities, grimacing with stimulation, and pink body with blue extremities. On the basis of this score, what should the nurse determine?

The newborn requires some resuscitative interventions.