Maternity and Women's Health Nursing - Newborn

While inspecting her newborn a mother asks the nurse whether her baby has flat feet. How should the nurse respond?

"Infants' feet appear flat because the arch is covered with a fat pad."

How should the nurse assess a newborn's grasp reflex?

By pressing the examining fingers against the palms of the newborn's hands

Shortly after birth the nurse instills erythromycin ophthalmic ointment in the newborn's eyes. The father asks why an antibiotic is needed because the mother does not have an infection. The nurse explains that it protects the newborn from:

Chlamydia and gonorrhea

During the second reactive period a newborn becomes more alert and responsive and there is an increase in mucus production and gagging. What should the nurse do first?

Remove secretions from the pharynx

What is the most important parameter for the nurse to monitor during the first 24 hours after the birth of an infant at 36 weeks' gestation?

Respiratory distress

When a preterm newborn requires oxygen, the nurse in the neonatal intensive care unit monitors and adjusts the oxygen concentration. What complication do these adjustments attempt to prevent?

Retinopathy of prematurity

What is the nurse's initial action immediately after assisting with a precipitous birth in the triage area of the emergency department?

Warming the newborn

During labor a client states that she does not want eyedrops or ointment placed in her baby's eyes immediately after birth. How should the nurse respond?

"Let's talk about why you don't want the medicine to be put into your baby's eyes."

The mother of a newborn son tells the nurse that she is concerned about circumcision because of the pain involved. What is the nurse's best response?

"The health care provider will tell you how your baby's pain will be controlled."

While a mother is inspecting her newborn she expresses concern that her baby's eyes are crossed. How should the nurse respond?

"This is expected. Your baby is trying to focus."

Vitamin K 0.5 mg is prescribed for a newborn. The vial on hand is labeled "1 mL = 2 mg." How many milliliters should the nurse administer? Include a leading zero if applicable. Record your answer using two decimal places. _____ mL

0.25

One minute after birth a nurse assesses a newborn and auscultates a heart rate of 90 beats/min. The newborn has a strong, loud cry; moves all extremities well; and has acrocyanosis but is otherwise pink. What is this neonate's Apgar score?

8

A nurse decides on a teaching plan for a new mother and her infant. What should the plan include?

A demonstration and explanation of infant care

What does an Apgar score recorded 5 minutes after birth help the nurse evaluate?

Adequacy of the transition to extrauterine life

A newborn male is being discharged 4 hours after having had a circumcision. What should the nurse instruct the mother to do?

Apply the diaper loosely for several days

A nurse is caring for a newborn with a myelomeningocele. What should immediate nursing care for this infant include?

Applying sterile, moist nonadherent dressings to the sac

An infant born at 40 weeks' gestation weighs 6 lb 13 oz (3090 g). What category describes this neonate?

Appropriate for gestational age (AGA) and term

An infant is born with a bilateral cleft palate. Plans are made to begin reconstruction immediately. What nursing intervention should be included to promote parent-infant attachment?

Demonstrating positive acceptance of the infant

A nurse determines that a 1-day-old newborn has a heart rate of 138 beats/min. What is the best nursing action at this time?

Documenting the heart rate

After a spontaneous vaginal delivery the client expresses concern because the newborn has a red rash with small papules on the face, chest, and back. What condition does the nurse recognize?

Erythema toxicum

Hydramnios is diagnosed in a primigravida at 35 weeks' gestation. What condition of the newborn is associated with hydramnios?

Esophageal atresia

What does the nurse conclude is related directly to an infant's survival in the neonatal period?

Gestational age and birth weight

A 15-year-old emancipated minor gave birth to a boy 36 hours ago and has requested a circumcision. What is the nurse's priority?

Getting an informed consent signed by the mother of the baby

A client gives birth to a full-term male with an 8/9 Apgar score. What should the immediate nursing care of this newborn include?

Identifying the infant, assessing respirations, and keeping him warm

Since giving birth six months ago, a woman has breastfed her infant. The woman becomes hysterical after learning that her husband has been seriously injured in an automobile accident. Culturally this woman believes that emotional stress while breastfeeding can "sour the milk," and she indicates that she must wean her infant immediately. What should the nurse do?

Instruct the mother about formula feeding

A nurse who is caring for a 32-week appropriate-for-gestational-age (AGA) neonate develops a plan of potential interventions for the neonate. What is the priority intervention?

Maintaining respirations

What does the nursing care for an infant with necrotizing enterocolitis (NEC) include?

Measuring abdominal girth every 2 hours

When calculating an Apgar score for a newborn, what is given a score in addition to the heart rate?

Muscle tone

The nurse is reassessing a newborn who had an axillary temperature of 97° F (36° C) and was placed skin to skin with the mother. The newborn's axillary temperature is still 97° F (36° C) after 1 hour of skin-to-skin contact. Which intervention should the nurse implement next?

Placing the newborn under a radiant warmer in the nursery

During a vertex vaginal birth the nurse notes meconium-stained amniotic fluid. What is the priority nursing intervention for the newborn?

Suctioning the airway

On the second day of life, minutes after drinking 2½ ounces of formula, a newborn regurgitates about half an ounce. The mother remarks, "My baby spits up after every feeding." What should the nurse do next?

Suggest that she hold her baby upright for 30 minutes after feeding

A newborn's total body response to noise or movement is often distressing to the parents. What should the nurse explain about this response?

This reflexive response is an expected part of development.

The mother of a neonate with Down syndrome visits the clinic 1 week after delivery. She explains to the nurse that she is having problems feeding her baby. What is the probable cause of these feeding difficulties?

Tongue thrust

After her baby's birth a client wishes to begin breastfeeding. How can the nurse assist the client at this time?

Touching the infant's cheek adjacent to the nipple to elicit the rooting reflex

The nurse is caring for a couple after the birth of their first child. What should the nurse tell the family to do when their infant is exhibiting the behavior demonstrated in the picture?

"This is the time when the baby is likely to be most responsive to you."

A newborn with a severe bilateral cleft lip and palate is shown to the father first. The father says, "How could this happen to us? What's my wife going to do? It would've been better if she'd never gotten pregnant." How should the nurse respond?

"This must be very hard on you. I can go with you when your wife sees the baby."

The parents of a newborn tell the nurse that they do not want their infant's eyes treated with a prophylactic agent. How should the nurse respond?

"You'll have to sign an informed consent to refuse the treatment."

A 7-lb, 4-oz (3290-g) boy is admitted to the nursery and placed in a warm crib. The neonate begins to choke on mucus. How should the nurse suction him with a bulb syringe?

By suctioning the mouth before the nostrils

The nurse visualizes and palpates a generalized, soft, edematous area of the scalp on the occiput of a newborn. What does the nurse suspect?

Caput succedaneum

A nurse in the clinic determines that a 4-day-old neonate who was born at home has a purulent discharge from the eyes. What condition does the nurse suspect?

Chlamydia trachomatis infection

A nurse teaches a new mother about neonatal weight loss in the first 3 days of life. What does the nurse explain is the cause of this weight loss?

Excretion of accumulated excess fluids

An infant born with hydrocephalus is to be discharged after insertion of a ventriculoperitoneal shunt. Which common complication should the nurse instruct the parents to report if it occurs at home?

Fever accompanied by decreased responsiveness

Absence or weakness of which of the following reflexes during the newborn assessment should the nurse report to the health care provider?

Gag

A neonate has phenylketonuria (PKU). What information should the nurse include in a discussion with the parents when explaining what caused their infant's problem?

Inborn error of metabolism

The nurse administers the prescribed vitamin K intramuscularly to a newborn immediately after birth to:

Promote the synthesis of prothrombin

A client's membranes rupture during the transition phase of labor, and the amniotic fluid appears pale green. What priority intervention for the infant can the nurse anticipate implementing upon delivery?

Providing for suctioning of the oropharynx as the head emerges

A newborn has congenital cataracts, microcephaly, deafness, and cardiac anomalies. Which infection does the nurse suspect that the newborn's mother contracted during her pregnancy?

Rubella

What should the nurse tell a new mother will be delayed until her newborn is 36 to 48 hours old?

Screening for phenylketonuria