Maternity- Care of the Newborn

The nurse is reinforcing measures regarding the care of the newborn with a mother. To bathe the newborn, the mother should be taught which intervention? 1. begin with the eyes and face 2. start with the dirtiest area first 3. begin with the feet and work upward 4. only wash the diaper area, because this is the only part of the baby that gets soiled

1 Rationale: bathing should start at the eyes and face, which are usually the cleanest areas. next, the external of the ears and behind the ears are cleansed. the newborns neck should be washed, because formula, breast milk, or lint will often accumulate in the folds of the neck. the hands and arms are then washed. the babys legs are washed, with the diaper area being washed last

The nurse should monitor for which signs associated with respiratory distress syndrome in a preterm newborn? 1. tachypnea and retractions 2. acrocyanosis and grunting 3. hypotension and bradycardia 4. the presence of a barrel chest with acrocyanosis

1 Rationale: the newborn infant with RDS may present with clinical signs of cyanosis, tachypnea, apnea, nasal flaring, chest wall retractions, or audible grunts. acrocyanosis is a bluish discoloration of the skin and feet that is associated with immature peripheral circulation, and is not uncommon in the first few hours of life

The nurse notes hypotonia, irratibility, and a poor sucking reflex in a full term newborn after admission to the nursery. The nurse suspects fetal alcohol syndrome (FAS) and is aware that which additional sign consistent with FAS? 1. a length of 19 inches 2. abnormal palmar creases 3. a birth weight of 6 pounds and 14 ounces 4. a head circumference that is appropriate for gestational age

2 Rationale: features of newborn infants who are diagnosed with FAS include craniofacial abnormalities, intrauterine growth restriction, cardiac abnormalities, abnormal palmar creases, and resp distress

The nurse is reinforcing instructions to a new mother about cord care and how to monitor for infection. The nurse should tell the mother that which is a sign of infection? 1. a darkened drying stump 2. a moist cord with discharge 3. a purple stump that shows pinkness around the base 4. a purple stump that shows some moistness at the base

2 Rationale: signs of infection of the umbilical cord are moistness, oozing, discharge, and a reddened base. if signs of infection occur, the HCP is notified. antibiotic treatment may be necessary

A newborn has just been circumcised. Which describes how the nurse should expect the surgical site to appear? 1. pink, without drainage 2. reddened, with a small amount of bloody drainage 3. reddened, with a small amount of yellow exudate on the glans 4. reddened, with a large amount of bloody drainage that requires a dressing change every 30 mins

2 Rationale: the glans penis is normally dark red. after circumcision, a small amount of bloody drainage is expected. during the normal healing process, the glans becomes covered with a yellow exudate. if excessive bleeding is noted from the circumsicion, the nurse applies gentle pressure to the site of bleeding with a sterile gauze pad. if the bleeding is not controlled, the HCP is notified because a blood vessel may need to be ligated

The nurse in the newborn nursery receives a telephone call to prepare for the admission of a neonate born at 43 weeks gestation with Apgar scores of 1 and 4. When planing for the admission of this infant which is the nurses highest priority? 1. turning on the apnea and cardiorespiratory monitor 2. connecting the resuscitation bag to the oxygen outlet 3. setting up the IV line with 5% dextrose in water 4. setting the radiant warmer control temp at 97.6 degrees

2 Rationale: the highest priority during the admission to the nursery of a newborn with low apgar scores is airway support, which would involve preparing respiratory resuscitation equipment. the remaining options are also important, although they are of lower initial priority.

After birth the nurse prevents hypothermia as a result of evaporation by performing which action? 1. warming the crib pad 2. closing the doors of the room 3. drying the baby with a warm blanket 4. turning on the overhead radiant warmer

3 Rationale: evaporation occurs when moisture from the newborns wet body surface dissipates heat along with moisture. by keeping the newborn dry, evaporation is prevented. conduction occurs when the newborn is on a cold surface, such as a cold pad or mattress. convection occurs as air moves across the newborns skin from an open door and heat is transferred to the air. radiation occurs when heat from the newborn radiates to a colder surface

A client asks the nurse why her newborn baby needs an injection of vitamin k. The nurse should make which statement to the client? 1. your newborn needs vitamin k to develop immunity 2. the vitamin k will protect your newborn from becoming jaundiced 3. newborns are deficient in vitamin k. this injection prevents your baby from abnormal bleeding 4. newborns have sterile bowels. the vitamin k will colonize the bowel with necessary bacteria

3 Rationale: vitamin k is necessary for the body to synthesize coagulation factors, and it is administered to the newborn infant to prevent abnormal bleeding. it promotes the livers formation of the clotting factors II, VI, IX, and X. newborn infants are deficient in vitamin k because the bowel does not have the bacteria necessary for synthesizing this fat soluble vitamin. the normal flora in the intestinal tract produces vitamin k, but the newborns bowel does not support the normal production of vitamin k until bacter have adequately colonized it. the bowel becomes colonized by bacteria as food is ingested. vitamin k does not promote the development of immunity or prevent the infant from becoming jaundiced

The nurse administers erythromycin ointment (0.5%) to the newborns eyes, and the mother asks the nurse why this is done. The nurse should give which response to the client? 1. prevents cataracts in the neonate born to a woman who is susceptible to rubella 2. protects the neonates eyes from possible infections acquired while hospitalized 3. minimizes the spread of microorganisms to the neonate from invasive procedures during labor 4. prevents opthalmia neonatorum from occuring after delivery to a neonate born to a woman with an untreated gonococcal infection

4 Rationale: erythromycin opthalmic ointment 0.5% is used as a prpphylactic treatment for opthalmia neonatorum, which is caused by the bacteria neisseria gonorrhoeae.

A pregnant woman has a positive history of genital herpes, but she has had lesions during her pregnancy. The nurse plans to provide which information to the client? 1. you will be isolated from your newborn after delivery 2. there is little risk to your baby during your pregnancy, birth, and after delivery 3. vaginal deliveries can reduce neonatal infection risks, even if you have an active lesion at birth 4. you will be evaluated at the time of delivery for herpetic genital tract lesions. if they are present, a c section delivery will be needed

4 Rationale: if herpetic genital lesions are present at the time of delivery, a c section delivery will be necessary to reduce the risk of infecting the neonate. in the absence of herpetic genital lesions, a vaginal delivery may be indicated, unless there are other reasons for performing a c section. maternal isolation is not necessary, but potentially exposed neonates should be cultured on the day of delivery

The nurse is assisting in caring for a postterm neonate immediately after admission to the nursery. The priority nursing action should be to monitor which? 1. urinary output 2. blood glucose levels 3. total bilirubin levels 4. hemoglobin and hematocrit levels

2 Rationale: the most common metabolic complication in the postterm newborn is hypoglycemia, which can produce central nervous system abnormalities and mental retardation if it is not correct immediately. urinary output, although important, is not the highest priority action. the polycythemia contributes to increased bilirubin levels, usually beginning on the second day after delivery. hemoglobin and hematocrit levels are monitored, because the postterm neonate may exhibit polycythemia

The nurse is assigned to assist with caring for a neonate born to a mother who is human immunodeficiency virus (HIV) positive. The nurse understands that which should be included in the plan of care? 1. monitoring the neonates vital signs routinely 2. maintaining standard precautions at all times while caring for the neonate 3. instructing breastfeeding mothers regarding the treatment of their nipples with an antifungal cream 4. initiating a referral to evaluate for blindness, deafness, learning, or behavioral problems in the neonate

2 Rationale: the neonate born to a mother who is HIV positive must be cared for with strict attention to standard precautions. This prevents the transmission of the infection from the neonate, if he or she is infected, to others, and it prevents the transmission of other infectious agents to the possibly immunocompromised neonate. the mother should not breastfeed, unless the HCP has specific recommendations about doing so.

The nurse is planning to reinforce instructions about cord care to a new mother. The nurse should plan to tell the mother which about cord care? 1. alcohol is the only agent used to clean the cord 2. it takes 21 days for the cord to dry up and fall off 3. cord care is done only at birth to control bleeding 4. the process of keeping the cord clean and dry will decrease bacterial growth

4 Rationale: the cord should be kept clean and dry to decrease bacterial growth; this includes keeping the diaper folder below the cord to keep urine away from the cord. the cord should be cleansed two to three times a day. it usually falls off within 7 to 14 days. agents other than alcohol may be prescribed to clean the cord

A pregnant human immunodeficiency virus (HIV) positive woman delivers a baby. The nurse provides guidance to help the client make decisions regarding newborn care. Which statement by the woman indicates that additional guidance is needed? 1. i will be sure to wash my hands before feeding the newborn 2. i will breastfeed, especially for the first 6 weeks postpartum 3. i will be sure to wash my hands after bathroom use 4. i will administer the prescribed antiviral medication to the newborn for the first 6 weeks after delivery

2 Rationale: the mode of perinatal transmission of HIV to the fetus or neonate of an HIV positive woman can occur during the antenatal, intrapartal, or postpartum periods. HIV transmission can occur during breastfeeding; thus HIV positive clients need to bottle feed their neonates. Antiviral medications will be prescribed for the neonate for the first 6 weeks of life. the principles related to hand washing need to be taught to the mother

The nurse is preparing to care for a newborn who is receiving phototherapy. Which measures should be implemented? SATA 1. avoid stimulation 2. decrease fluid intake 3. expose all of the newborns skin 4. monitor the skin temp closely 5. reposition the newborn every 2 hours 6. cover the newborns eyes with shields or patches

4, 5, 6 Rationale: phototherapy is the use of intense fluorescent lights to reduce serum bilirubin levels in the newborn. injury from treatment (eye damage, dehydration, sensory deprivation) can occur. interventions include exposing as must of the newborns skin as possible; however, the genital area is covered. the newborns eyes are also covered with shields or patches to ensure that the eyelids are closed. the shield or patches are removed at least once per shift to inspect the eyes for infection or irritation and to allow for eye contact. the nurse measures the quantity of light every 8 hours, monitors the skin temp closely, and increases fluids to compensate for water loss. the newborn will have loose green stools and green colored urine. the newborns skin color is monitored with the fluorescent light turned off every 4 to 8 hours, and he or she is monitored for bronze baby syndrome., which is a grayish brown discoloration of the skin. the newborn is repositioned every 2 hours, and stimulation is provided. after treatment, the newborn is monitored for signs of hyperbilirubinemia, because rebound elevations are normal after therapy is discontinued