Newborn

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. rationale: Circumcision is contraindicated for several reasons including prematurity, family history of a bleeding disorder, and illness. A fever at birth is not a problem as long as it comes back down to normal shortly after birth. A small penis or a father who was never circumcised are not reasons to delay circumcision. ricci, ch. 18, p. 613-614

Which maternal factors should the nurse consider contributory to a newborn being large for gestational age? Select all that apply.

- diabetes - postdates gestation - prepregnancy obesity rationale: Diabetes, postdates gestation, and prepregnancy obesity are the maternal factors the nurse should consider that could lead to a newborn being large for gestational age. Renal condition and maternal alcohol use are not factors associated with a newborn being large for gestational age. ricci, ch. 23, p. 840

The nurse is providing teaching to a new mother who is breastfeeding. The mother demonstrates understanding of teaching when she identifies which characteristics as being true of the stool of breastfed newborns? Select all that apply.

- yellowish gold color - stringy to pasty consistency rationale: The stools of a breastfed newborn are yellowish gold in color. They are not firm in shape or solid. The smell is usually sour. A formula-fed infant's stools are formed in consistency, whereas a breastfed infant's stools are stringy to pasty in consistency. ricci, ch. 17, p. 577

How long is the neonatal period for a newborn?

28 Rationale: neonatal period is the first 28 days of life Ricci: chapter 17, p. 564

When teaching a class of new parents about the needs of their newborn, the nurse explains that the newborn's voiding is a good indicator that he or she is getting enough fluids. The nurse determines that the teaching was successful when the parents state which number of voidings per day is a good indicator of adequate fluids?

6 to 8 rationale: From birth to about 3 months of age, the newborn's kidneys are unable to concentrate urine and they will urinate frequently. Approximately 6 to 8 voidings per day is average and indicates adequate fluid intake. ricci, ch. 17, p. 578

The nursing instructor is teaching a class on the physiologic prosperities involved with the birthing process. The instructor determines the session is successful when the students correctly match surfactant with which function?

It keeps alveoli from collapsing with breaths. rationale: The role of surfactant is to act on surface tension and assist in keeping the alveoli open in the lungs so the lungs do not collapse with the respiratory effort of the newborn. Surfactant does not expand the lungs, remove fluid from the lungs, or allow oxygen to move in the lungs. ricci, ch. 17, p. 568

The nurse is assessing a newborn, 4 hours old, weighing 9 lbs, 2 oz (4088 g). While doing the initial assessment the RN mentioned that the mother's history showed her to be morbidly obese. Which assessment findings should the nurse prioritize as the newborn is continued to be monitored?

Jitteriness and irritability rationale: Infants born to women who are morbidly obese are at a greater risk for developing hypoglycemia. Early signs of hypoglycemia in the newborn include jitteriness, poor feeding, listlessness (not frequent activity), irritability, low temperature (not fever), weak or high-pitched cry, and hypotonia (not hypertonia). ricci, ch. 17, p. 622-623

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?

Moro reflex rationale: There are six activities or maneuvers that are evaluated to determine the newborn's degree of neuromuscular maturity: posture, square window, arm recoil, popliteal angle, scarf sign, heel-to-ear. The Moro reflex is an indication of the newborn's neurologic status. ricci, ch. 18, p. 589

a client is worried that her newborn's stools are greenish, with an unpleasant odor. the newborn is being formula-fed. what instruction should the nurse give the client?

No action is need; this is normal. rationale: The nurse should tell the client not to worry because it is perfectly normal for the stools of a formula-fed newborn to be greenish, loose, pasty, or formed in consistency, with an unpleasant odor. There is no need to change the formula, increase the newborn's fluid intake, or switch from formula to breast milk. ricci, ch. 17, p. 577

The LPN is assessing a 1-day-old newborn and notices a large amount of white drainage and redness at the base of the umbilical cord. What is the best response by the nurse?

Notify the charge nurse, because it represents a possible complication, and document the finding. ricci, ch. 17, p. 604-605

The nurse is assessing a 3-day-old infant. The infant's sclerae have a yellow tinge as does the infant's forehead and nose. What would the nurse do next?

Obtain a transcutaneous bilirubin level. rationale: Following visual identification of jaundice, the blood level of circulating bilirubin needs to be measured either by a transcutaneous bilirubin meter or a blood draw for a bilirubin level. Until the level of bilirubin in the blood is known to be elevated, neither phototherapy nor an exchange transfusion would be implemented. A metabolic panel is not useful in determining the level of neonatal jaundice. ricci, ch. 18

A client gives birth to a baby at a local health care facility. The nurse observes that the infant is fussy and begins to move her hands to her mouth and suck on her hand and fingers. How should the nurse interpret these findings? a. the infant is entering habituation state b. the infant is in a state of hyperactivity c. the infant is displaying a state of alertness d. the infant is attempting self-consoling maneuvers

d. the infant is attempting self-consoling maneuvers rationale: the hand-to-mouth movement of the baby indicates the self-quieting and consoling ability of a newborn. the other options are states of behavior of a newborn but are not applicable to this situation ricci, chapter 17, p. 581

The nurse is assessing the stools of a 36-hour-old neonate who is being breastfed. The nurse determines that the stools are within normal parameters based on which finding?

yellowy mustard color with seedy appearance rationale: The evolution of a stool pattern begins with a newborn's first stool, which is meconium. Meconium is composed of amniotic fluid, shed mucosal cells, intestinal secretions, and blood. It is greenish black, has a tarry consistency, and is usually passed within 12 to 24 hours of birth. The first meconium stool passed is semi-sterile, but this changes rapidly with ingestion of bacteria through feedings. After feedings are initiated, a transitional stool develops, which is greenish brown to yellowish brown, thinner in consistency, and seedy in appearance. If breastfed, the stools will resemble light mustard with seed-like particles. If formula-fed, the stools will be tan or yellow in color and firmer. The neonate's stool should not appear brownish-black and mucous-like. ricci, ch. 17, p. 577

A 36-week neonate born weighing 1,800 g has microcephaly and microphthalmia. Based on these findings, which risk factor might be expected in the maternal history?

use of alcohol rationale: The most common sign of the effects of alcohol on fetal development is restricted growth in weight, length, and head circumference. Intrauterine growth restriction is not characteristic of marijuana use. Gestational diabetes usually produces large-for-gestational-age neonates. Positive group B streptococcus is not a relevant risk factor. ricci, ch. 24, p. 898

A client gives birth to a newborn baby at term. The nurse records the weight of the baby as 1,200 g, interpreting this to indicate that the newborn is of:

very low birth weight. rationale: A birth weight of 1,200 g would be classified as very-low-birth-weight. A normal birth weight at term ranges between 2,500 g and 4,000 g. Typically it is between 3,000 g and 4,000 g. A birth weight below 2,500 g is termed a low-birth-weight. A birth weight between 1,000 g and 1,500 g is termed a very-low-birth-weight. A birth weight less than 1,000 g is termed an extremely-low-birth-weight. ricci, ch. 23, p. 834

Which statement is false regarding bathing the newborn?

To reduce the risk of heat loss, the bath should be performed by the nurse, not the parents, within 2 to 4 hours of birth. rationale: Bathing the newborn is not necessary for thermal stability. It can be postponed until the parents are able to do it. ricci, ch. 18, p. 610

Which newborn neuromuscular system adaptation would the nurse not expect to find?

an extrusion reflex at 9 months of age rationale: An extrusion reflex usually disappears around 4 months of age. A positive Babinski reflex can be seen until 3 months of age. The plantar grasp disappears around 8 to 9 months of age. The Moro reflex disappears around 4 to 5 months of age. ricci, ch. 18, p. 607

A preterm infant is experiencing cold stress after birth. For which symptom should the nurse assess to best validate the problem?

apnea rationale: Preterm newborns are at a greater risk for cold stress than term or postterm newborns. Cold stress can cause hypoglycemia, increased respiratory distress and apnea, and metabolic acidosis. Preterm infants lack the ability to shiver in response to cold stress. ricci, ch. 17, p. 573

What action by the nurse provides the neonate with sensory stimulation of a human face?

assisting the mother to position the infant in an en face position rationale: To allow the infant to see a human face, assist the mother to assume an en face position with the infant. Mother and child need to be in the same plane and about 6 to 10 inches (15 to 25 cm) apart. Looking through the isolette dome or porthole distorts the image. Infants need to see objects within 12 inches (30 cm) to focus clearly. ricci, ch. 23, p. 852

A 12-hour-old infant is receiving IV fluids for polycythemia. For which complication should a nurse monitor this client? a. tachycardia b. fluid overload c. decreased level of consciousness d. hypotension

b. fluid overload rationale: the possibility of fluid overload is increased and must be considered by a nurse when administering IV therapy to a newborn. IV therapy does not significantly increase heart rate or change blood pressure, as well as the level of consciousness, unless fluid overload occurs. ricci, chapter 17, p. 577

A nursing student is aware that fetal gas exchange takes place in which area? a. bronchioles b. placenta c. uterus d. lungs

b. placenta rationale: many different changes occur for the newborn to survive outside the uterus. one such change is that gas exchange that once took place in the placenta now will take place in the lungs. ricci: chapter 17, p. 564

Which statement is true regarding fetal and newborn senses? a. a newborn cannot see until several hours after birth b. rooting reflex is an example that the newborn has a sense of touch c. newborn does not have the ability to discriminate between tastes d. fetus is unable to hear in utero e. newborn cannot experience pain

b. rooting reflex is an example that the newborn has a sense of touch rationale: the rooting reflex is an example of a newborn's sense of touch. newborns experience pain, have vision, and can discriminate between tastes. the fetus can hear in utero. ricci, chapter 17, p. 579

The nursing instructor is conducting a class explaining the various causes of jaundice in a newborn infant. The instructor determines additional education is warranted after the class chooses which factor as being responsible for newborn jaundice?

bilirubin hyperexcretion rationale: Overexcretion of bilirubin would not cause jaundice. Bilirubin overproduction, decreased bilirubin conjugation or conversion, and impaired bilirubin excretion would cause hyperbilirubinemia, which leads to jaundice. ricci, ch. 17, p. 575

The nurse suspects a preterm newborn receiving enteral feedings of having necrotizing enterocolitis (NEC). What assessment finding best correlates with this diagnosis?

bloody stools rationale: NEC assessment includes assessing the newborn's health history and physical examination as well as laboratory and diagnostic testing. The onset of NEC is demonstrated by the development of feeding intolerance, abdominal distention, and bloody stools in a preterm infant receiving enteral feedings. As the disease worsens, the infant develops signs and symptoms of septic shock with RDS, temperature instability, lethargy, hypotension, and oliguria. ricci, ch. 24, p. 883

A nurse is assessing a neonate during the first 24 hours after birth. Which finding would the nurse recognize as normal?

body temperature of 97.9° to 99.7° F (36.5° to 37.5° C) rationale: On average, a neonate's temperature ranges from 97.9° to 99.7° F (36.5° to 37.5° C). Although female neonates labia often appear swollen, the discharge is white (physiologic leukorrhea). A positive Ortolani sign is noted if the hip is dislocated. The abdomen should be soft, round, and nondistended. ricci, ch. 17, p. 570

When examining a newborn's eyes, the nurse would expect which assessment?

follows a light to the midline Newborns do not usually follow past the midline until 3 months of age. They do not tear. ricci, ch. 18, p. 603

One of the nurse's responsibilities is to educate new parents on the best method to prevent infections in the newborn environment. Which method would the nurse identify as best to control infection?

handwashing ricci, ch 18, p. 617

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 rationale: Hearing loss is the most common birth defect in the United States: one in 1,000 newborns are profoundly deaf, and 3 in 1,000 have some degree of hearing impairment. Newborn hearing screening is required by law in most states. Vision, genetic-linked, and skeletal malformations are other forms of birth defects that can occur. ricci, ch. 18, p. 603

What is a consequence of hypothermia in a newborn?

holds breath 25 seconds rationale: Apnea is the cessation of breathing for a specific amount of time, and in newborns it usually occurs when the breath is held for 15 seconds. Apnea, cyanosis, respiratory distress, and increased oxygen demand are all consequences of hypothermia. ricci, ch. 23, p. 850

A nurse is assigned to care for a high-risk newborn with a periventricular-intraventricular hemorrhage (PVH-IVH) in the home environment after discharge. For which condition should the nurse monitor the infant?

hydrocephalus rationale: A significant number of newborns with PVH-INH will incur brain injury, leading to complications that may include hydrocephalus. The nurse should monitor for the incidence of hydrocephalus in this high-risk newborn. Urinary tract infection is not condition that persists after discharge. Spina bifida is most often noted at birth and would not to need to be assessed for by the nurse. Formula intolerance is not specific to high-risk newborns. ricci, ch. 24, p. 882

A preterm newborn is noted to have hypotonia, apnea, bradycardia, a bulging fontanel (fontanelle), cyanosis, and increased head circumference. These signs indicate the newborn has which complication?

intraventricular hemorrhage (IVH) rationale: Signs that may accompany IVH include hypotonia, apnea, bradycardia, a full (or bulging) fontanel, cyanosis, and increased head circumference. ricci, ch. 24,

When caring for a neonate of a mother with diabetes, which physiologic finding is most indicative of a hypoglycemic episode?

jitteriness rationale: Hypoglycemia in a neonate is expressed as jitteriness, lethargy, diaphoresis, and a serum glucose level below 40 mg/dl. A hyperalert state in a neonate is more suggestive of neuralgic irritability and has no correlation to blood glucose levels. Excessive crying isn't found in hypoglycemia. A serum glucose level of 60 mg/dl is a normal level. ricci, ch. 24, p. 887

A nurse is assessing a preterm newborn. The nurse determines that the newborn is comfortable and without pain based on which finding?

lack of body posturing rationale: The newborn may be in pain if the following are exhibited: sudden high-pitched cry; facial grimace with furrowing of brown and quivering chin; increased muscle tone; oxygen desaturation; body posturing, such as squirming, kicking, and arching; limb withdrawal and thrashing movements; increase in heart rate, blood pressure, pulse, and respirations; fussiness and irritability. ricci, ch. 23, p. 853

The nurse measures a newborn's temperature immediately after birth and finds it to be 99°F (37.2°C). An hour later, it has dropped several degrees. The nurse understands that this heat loss can be explained in part by which factor in the newborn?

lack of subcutaneous fat rationale: 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. ricci, ch. 18, p 594

When conducting an assessment, the nurse observes fine, downy hair covering the newborn's shoulders and back. The nurse documents this finding as:

lanugo rationale: Lanugo is the fine downy hair that covers the newborn's shoulders, back, and upper arms. Milia are the tiny white pinpoint papules of unopened sebaceous glands frequently found on the newborn's nose. Vernix caseosa is the thick white substance that provides a protective covering of the skin of the fetus. 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. ricci, ch. 18, p. 598

It would be best to place an infant with a myelomeningocele in which position prior to surgery?

on the stomach (prone) rationale: Placing the infant prone prevents direct trauma to the lesion and reduces the chance that feces will contaminate the lesion. ricci, ch. 24, p. 916

A nurse is preparing to place a skin temperature probe on a neonate who is lying on his back. To ensure an accurate reading, which location would be most appropriate to use for placement?

over the liver rationale: A skin temperature probe should not be placed over a bony area or one with brown fat (such as between the scapulae, at the nape of the neck or above the kidneys) because it does not give an accurate assessment of the whole body temperature. To ensure the best accuracy, most temperature probes are placed over the liver when the newborn is supine or side-lying. ricci, ch. 17, p. 573

The Ballard scoring system evaluates newborns on which two factors?

physical maturity and neuromuscular maturity rationale: When determining a newborn's gestational age using the Ballard scale, the nurse assesses physical signs and neurologic characteristics. ricci, ch. 18, p. 589

The nurse is assessing a small-for-gestational age (SGA) newborn, 12 hours of age, and notes the newborn is lethargic with cyanosis of the extremities, jittery with handling, and a jaundiced, ruddy skin color. The nurse expects which diagnosis as a result of the findings?

polycythemia rationale: Newborns born small for gestational age (SGA) are at risk for polycythemia. They should therefore undergo screening at 2, 12, and 24 hours of age. Observe for clinical signs of polycythemia (respiratory distress, cyanosis, jitteriness, jaundice, ruddy skin color, and lethargy). ricci, ch. 23, p. 836

Which assessment finding would best validate a problem in a small-for-gestational age newborn secondary to meconium in the amniotic fluid?

respiratory rate of 60 to 70 bpm rationale: The nurse should identify respiratory complications such as tachypnea as a symptom of meconium aspiration in the newborn that results from presence of meconium in the amniotic fluid. Tachycardia, elevated bilirubin levels, and polycythemia are some of the common problems faced by an SGA newborn, but these are not related to meconium in the amniotic fluid. ricci, ch. 23, p. 837

Which is the best place to perform a heel stick on a newborn?

the fat pads on the lateral aspects of the foot rationale: 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. ricci, ch. 18, p. 620

The nurse is teaching nursing students about the risks that late preterm infants may experience. The nurse feels confident learning has taken place when the students make which statement?

"A late preterm newborn may have more clinical problems compared with full-term newborns." rationale: The most common complications for late preterm infants are cold stress, respiratory distress, hypoglycemia, sepsis, cognitive delays, hyperbilirubinemia, and feeding difficulties. These are similar to those facing the preterm newborn and require similar management. Late preterm newborns have more clinical problems, longer lengths of stay, higher costs when compared with full-term newborns, and increased mortalities. ricci, ch. 23, p. 857

The mother of a formula-fed newborn asks how she will know if her newborn is receiving enough formula during feedings. Which response by the nurse is correct?

"A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight." ricci, ch. 18, p. 624

When instructing a new mom on providing skin care to her newborn, which statement, made by the mother, indicates additional teaching is needed?

"I can use talc powders to prevent diaper rash." rationale: Talc powders can be a respiratory hazard and should not be used with a newborn. All other statements are correct. ricci, ch. 18, p. 610

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 lack the intestinal flora needed to produce vitamin K, so it is given to prevent bleeding episodes." rationale: Vitamin K is needed in newborns to prevent bleeding episodes. It is especially important for male newborns who are being circumcised. The newborn's intestine is sterile and has no symbiotic bacteria in it to produce vitamin K, so the newborn receives a supplement through the vitamin K injection. Vitamin K does not assist in absorbing fat-soluble vitamins, prevent ophthalmia neonatorum, or strengthen the immune system. ricci, ch. 18, p. 592-593

A nursing student observes that the babies in the nursery are wrapped up warmly and are wearing knit caps. Which explanation by the nursery staff would be correct?

"Newborns lose body heat easily and need to be kept warm until their body temperature stabilizes." rationale: Nurses provide an appropriate environment to help newborns maintain thermal stability. Newborns lose body heat easily and need to kept warm until their temperature stabilizes. The other answers are not adequate and do not address the correct rationale. Practice is based upon evidence-based practice. ricci, ch. 17, p. 573

A nurse is giving discharge education to a group of new parents before they are discharged home with their infants. What information will the nurse include in the teaching?

"Place the newborn on the back to sleep and stomach to play." rationale: Newborns should always be placed on their backs to sleep to reduce the risk for SIDS and on their stomach a few times a day to develop neck muscles. Caregivers should change the newborn's diaper when it is soiled, not at timed intervals. Newborns should never be left unattended on high surfaces to prevent injury from falls. Bathing a newborn daily is not recommended as it may dry the skin. ricci, ch. 18, p. 617

A nursing mother calls the nurse and is upset. She states that her newborn son just bit her when he was nursing. Upon examining the newborn's mouth, two precocious teeth are noted on the lower central portion of the gums. What would be the nurse's best response?

"Precocious teeth can occur at birth but we may need to remove them to prevent aspiration." rationale: Precocious or natal teeth occur infrequently but need to be addressed when they are present. They may cause the mother discomfort when nursing and pumping may be needed initially until the mother can condition the newborn not to bite. Precocious teeth are often loose and need to be removed to prevent aspiration. Even if they are not loose, they are often removed due to them causing ulcerations on the newborn's tongue from irritation. They will not just fall out and are not the newborn's actual baby teeth that are just coming in early. ricci, ch. 18, p. 603

A nursing instructor is teaching about changes the newborn must make to survive outside of the uterus. The instructor realizes that further teaching is needed when a student makes which statement?

"The baby takes the first breath when ready to leave the uterus." rationale: When the baby's umbilical cord is clamped, the baby takes the first breath and the lungs begin to function. The breath usually occurs when the baby is stimulated by a slight slap. The baby takes the first breath within 10 seconds post birth, not when ready to leave the uterus. ricci, ch 17, o. 565

The nurse is assessing a male neonate in the presence of the parents and notes that the neonate has hypospadias. How should the nurse respond when questioned by the parents as to what this means?

"The opening of his urethra in located on the under surface of the tip of the penis." rationale: The term "hypospadias" refers to the urinary meatus (external opening of the urethra) being abnormally located on the ventral (under) surface of the glans (the rounded head or tip of the penis). There are no special terms to indicate normal genitalia. Cryptorchidism refers to undescended testes. Hydrocele refers to the collection of fluid in the scrotal sac. ricci, ch. 18, p. 605

A nurse teaches new parents how to soothe a crying newborn. Which statement, by the parents, indicates to the nurse the teaching was effective?

"We will turn the mobile on that's hanging on our baby's crib." rationale: 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 or play calming music or white noise. Swaddling the newborn rather placing on a blanket on the floor provides security and comfort. Feeding or burping can be helpful in relieving air or stomach gas. ricci, ch. 18, p. 617

To indicate that the infant is making a successful transition immediately after birth, the nurse checks the heart rate. The newborn is 4 hours old. Which rate would the nurse identify as a cause for concern?

108 beats/minute rationale: The heart rate of a fetus in utero averages between 110 and 160 beats/minute. Immediately after birth, as the newborn struggles to initiate respirations, the heart rate may be as rapid as 180 beats/minute. Within 1 hour after birth, as the newborn settles down to sleep, the heart rate stabilizes to an average of 120 to 140 beats/minute. Therefore, a heart rate of 108 beats/minute would be a cause for concern. ricci, ch. 18, p. 589

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?

24 to 72 hours after birth. rationale: PKU is an inherited disease involving a specific enzyme necessary in the production of amino acids. Without this enzyme, phenylalanine builds up in the blood and can lead to serious consequences, such as brain damage. Phenylketonuria testing measures the amount of phenylalanine present in the blood. The infant must have taken breast milk or formula for an abnormal amount to be present. The blood sample is obtained via a heel stick and is best conducted 2 to 3 days after birth, allowing time for the infant to eat. The main treatment for this condition is life-long dietary restrictions, so it needs to be identified quickly so appropriate care can be started. ricci, ch. 18, p. 618-619

A nurse is reviewing the medical records of several newborns who are about to be discharged. The nurse notes the birth weight of each newborn, classifying the newborn with which birth weight as term?

3,500 grams rationale: Typically, the term newborn weighs 2,500 to 4,000 g. Birth weights less than 10% or more than 90% on a growth chart are outside the normal range and need further investigation. A newborn weighing less than 1,500 grams is considered very low birth weight. A newborn weighing 1,800 grams or 2,200 grams would be considered low birth weight. ricci, ch. 18, p. 588

The nurse has completed assessing the blood glucose levels of several infants who are 24 hours old. Which result should the nurse prioritize for intervention?

30 mg/dl (1.67 mmol/L) rationale: Blood glucose levels less than 40 mg/dl (2.22 mmol/L) or 50 mg/dl (2.77 mmol/L), depending on the source of information, is indicative of hypoglycemia in a newborn infant and should be further evaluated and/or treated depending on the individual situation. ricci, ch. 18, p. 622-623

A nurse is assessing a term newborn and finds the blood glucose level is 23 mg/dl (1.28 mmol/L). The newborn has a weak cry, is irritable, and exhibits bradycardia. Which intervention is most appropriate?

Administer dextrose intravenously. rationale: The infant is demonstrating signs and symptoms of significant hypoglycemia. IV dextrose should be administered to the term newborn intravenously when the blood glucose level is less than 40 mg/dL (2.22 mmol/L), and the newborn is symptomatic for hypoglycemia. Administration of IV glucose assists in stabilizing blood glucose levels. Providing oral glucose feedings or placing the infant on a radiant warmer will not help maintain the glucose level. Monitoring the infant's hematocrit level is not a priority and not related to the problem at hand. ricci, ch. 23, p. 840

The nurse is assisting parents who have just experienced the death of their twin infants. What would be the most appropriate action for the nurse?

Allow the parents to be present at medical rounds and the resuscitation. rationale: In times of impending death and loss initiate spiritual comfort by calling the hospital clergy only if appropriate; offer to pray with the family only if appropriate. Have the parents participate in early and repeated care conferencing to reduce family stress. Allow the family to be present at both medical rounds and resuscitation; provide explanations of all procedures. Encourage the father to cry and grieve with his partner. ricci, ch. 23, p. 861

A 36-hour-old newborn is ready for discharge from the hospital and the nurse notices that the skin looks yellow. What action will the nurse take?

Assess the bilirubin level. rationale: If a nurse notices that a newborn appears jaundiced, the nurse will assess the newborn's bilirubin level. Current guidelines recommend newborns be screened for jaundice and high bilirubin levels prior to discharge from the hospital. The nurse will then notify the health care provider based on the results. The nurse may assist the mother to feed in newborn if needed, as this may facilitate decreasing jaundice. The newborn should not be discharged at this time. ricci, ch. 18, p. 621-622

which intervention would be the best way for the nurse to prevent heat loss in a newborn while bathing?

Bathe the baby under a radiant warmer. rationale: Bathing a newborn under a radiant warmer helps to prevent heat loss. To minimize the effects of cold stress during the bath, the nurse should also prewarm blankets, dry the child completely to prevent heat loss from evaporation, encourage skin-to-skin contact with the mother, promote early breastfeeding, used heated and humidified oxygen, and defer bathing until the newborn is medically stable. Limiting the length of time spent bathing the baby is secondary to maintaining the baby's body temperature. Having warm water is also important but is irrelevant if the baby is not kept warm under a warmer. ricci, ch. 17, p. 571

The nurse is caring for an infant. Which nursing action will facilitate psychosocial growth of the infant?

Be consistently attentive to the infant's basic needs. rationale: To help the infant develop a sense of trust, the nurse will consistently meet the infant's needs through feedings, holding the infant, and keeping the infant dry. Following the same schedule as at home or allowing security items (blankets, favorite stuffed animal) may help provide comfort, but will not facilitate building trust. Self-soothing at this age is discouraged because the infant needs to feel that someone is always there and attentive to his/her needs. ricci, ch. 18, p. 611-612, 616-617, 623-624

The newborn nursery nurse has admitted a large-for-gestational age infant, one hour old for observation. The initial blood glucose level is 44 mg/dl (2.44 mmol). What is the nurse's priority action?

Begin supervised feedings for the newborn. rationale: Hypoglycemia in a neonate is defined as blood glucose value below 40 mg/dL. Supervised breastfeeding or formula feeding may be initial treatment options in asymptomatic hypoglycemia. Hypoglycemia has been linked to poor neurodevelopmental outcome, and hence aggressive screening and treatment is recommended. Monitor blood glucose levels within 30 minutes of birth, and repeat the screening every hour. Recheck levels before feedings and also immediately in any infant suspected of having or showing clinical signs of hypoglycemia. ricci, ch. 23, p. 840

When performing an assessment on a neonate, which assessment finding is suggestive of hypothermia?

Bradycardia rationale: Bradycardia is an indicator that the neonate is hypothermic. A cold infant may develop acidosis as a result of metabolism of brown fat. Newborns do not shiver when cold. Hyperglycemia and metabolic alkalosis are not signs or consequences of hypothermia. ricci, ch. 18, p. 870

The nurse notices that there is no vitamin K administration recorded on a newborn's medical record upon arrival to the newborn nursery. What would be the nurse's first action?

Call the Labor and Delivery nurse who cared for the newborn to inquire about why the medication was not documented. ricci, ch. 18, p. 592-593

A 30-minute-old newborn starts crying in a high-pitched manner and cannot be consoled by the mother. Which action should the nurse prioritize if jitteriness is also noted and the infant is unable to breastfeed?

Check blood glucose. rationale: One of the primary signs/symptoms of hypoglycemia in newborn infants is jitteriness and irritability. Anytime an infant is suspected of having hypoglycemia, the nurse needs to check the blood glucose level. Cold stress and pain are potential considerations to rule out if hypoglycemia is not the cause; however, jitteriness is not a recognized sign of these. ricci, ch. 18, p. 622

The nurse is preparing discharge instructions for the parents of a male newborn who is to be circumcised before discharge. Which instruction should the nurse prioritize?

Cover the glans generously with petroleum jelly. rationale: Covering the surgical site with an ointment such as petroleum jelly 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. The nurse would not tell the parents to use alcohol on the glans. ricci, ch. 18, p. 613

What is the correct sequence of events in a neonatal resuscitation?

Dry the infant, establish an airway, expand the lungs, and initiate ventilation. rationale: The infant is dried to prevent brown fat metabolism and acidosis. An airway is established to allow interventions to expand the lungs. Then ventilation is initiated. ricci, ch. 23, p. 870

Which action would be priority for the nurse to complete immediately after the delivery of a 40-week gestation newborn?

Dry the newborn and place it skin-to-skin on mother. rationale: Thermoregulation is priority immediately following delivery and is best achieved by keeping the newborn warm and dry. This can be accomplished by drying the newborn and placing it skin-to-skin with the mother. The newborn should be dried before being swaddled and placed in the bassinet. A complete assessment needs to be done within 2 hours of delivery and glucose isn't routinely assessed. ricci, ch. 18, p. 594

A new mother calls her pediatrician's office concerned about her 2-week-old infant "crying all the time." When the nurse explores further, the mother reports that the infant cries at least 2 hours each day, usually in the afternoons. What recommendation would the nurse not make to this mother?

Feeding the infant more formula whenever she begins to fuss rationale: Crying by a young infant is frustrating for parents, so it is suggested that the parents first be sure that the infant's physical needs are met, then soothing measures are implemented. Feeding the infant every time he cries is not needed nor suggested. Swaddling, a soothing touch, and gentle pats on the back all help calm a fussy infant. ricci, ch. 18, p. 617-618

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?

Help the mother provide kangaroo care. rationale: The nurse should encourage bonding to continue. One way to help the infant get warm is to help the parents provide kangaroo care, which involves skin-to-skin contact and parent/baby coverage with blankets. Once the infant is taken for the initial assessment, placement under the radiant heater would then be appropriate. Placing a second stockinette is a potential option; however, it would not be as effective as the skin-to-skin contact. The bath would not be undertaken until the infant's temperature is stabilized within the normal range. ricci, ch. 18, p. 594

The nurse explains to the parents of a 2-day-old newborn that decreased life span of neonatal red blood cells has contributed to which complication?

Hyperbilirubinemia rationale: Neonatal red blood cells have a life span of 80 to 100 days and normally have a higher count at birth. This combination leads to an increased hemolysis. Complications of this process include hyperbilirubinemia. ricci, ch. 17, p. 568

The nurse is preparing the nursing care plan for a newborn who was born via a cesarean delivery. Which diagnosis should the nurse prioritize?

Ineffective airway clearance related to mucus and secretions rationale: Any airway clearance or obstruction issue is the highest priority for nursing interventions, whether the infant is born via vaginal or cesarean delivery. The other options are valid nursing diagnoses for some newborns; however, they would not take precedence over an airway problem. ricci, ch. 18, p. 591

The nurse in a newborn nursery is observing for developmentally appropriate care. Which is an example of self-regulation?

Infant has hand in mouth. rationale: Self-regulation is a form of self-soothing for an infant, such as sucking on hands or putting hand to mouth. ricci, ch. 23, p. 856

The nurse is preparing to administer the vitamin K injection to a newborn. Which action would be correct for this client?

Injecting the medication into the vastus lateralis rationale: Use of the vastus lateralis is the preferred site for administration of the medication. The nurse would use a 22- to 25-gauge needle and inject 0.5 cc of medication at a 90-degree angle. ricci, ch. 18, p. 593-594

A newborn's cord begins to bleed 1 day following birth. What measures would the nurse take to address this problem?

Inspect the clamp to insure that it is tightly closed and applied correctly. rationale: Cord clamps can become loosened in such cases as a newborn with a large amount of Wharton jelly in the cord when the jelly begins to disintegrate. Also, cord clamps can be defective. The nurse must inspect the cord to determine what the problem is and why the cord is bleeding. Washing the cord does not address the problem and the nurse should not remove the clamp because the bleeding will get worse. However, the doctor does not need to be contacted at this point. The nurse should inspect the clamp, ensuring that it is tight and apply a new clamp closer to the skin level if needed. ricci, ch. 18, p. 613

A woman who is about to be discharged after a vaginal birth notices a flea-like rash on her newborn's chest. The rash has tiny red lesions all across the nipple line. What does this rash indicate?

It is a normal skin finding in a newborn. ricci, ch. 18, p. 598

A nurse does an initial assessment on a newborn and notes a pulsation over the anterior fontanel (fontanelle) that corresponds with the newborn's heart rate. How would the nurse interpret this finding?

It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanel. rationale: Feeling a pulsation over the fontanel (fontanelle) correlating to the newborn's heart rate is normal. The pulsation should not be felt in the posterior fontanel. The fontanel should not be bulging under any circumstance in a newborn. ricci, ch. 19, p. 600-601

The parents of a 2-day-old newborn are preparing for discharge from the hospital. Which teaching is most important for the nurse to include regarding sleep?

Place the infant on the back when sleeping. rationale: It is most important to educate caregivers on how to place the newborn while sleeping to ensure safety and reduce the risk of SIDS. The other information is good to include, but not priority. ricci, ch. 18, p. 616-617

A nurse is caring for a newborn client who is diagnosed with myelomeningocele. Which nursing intervention would protect the newborn from injury?

Place the newborn in a prone or lateral position. rationale: The nurse should place the newborn in a prone or lateral position to keep pressure off the spinal sac and avoid newborn injury. Parents should be allowed to hold the stable infant with assistance. The spinal sac should be kept covered and moist until surgery to avoid rupture. Collecting urine decreases the risk of urine stasis, which is sometimes common in spinal defects. ricci, ch. 24, p. 916

A preterm infant will be hospitalized for an extended time. Assuming the infant's condition is improving, which environment would the nurse feel is most suitable for the child?

Provide a mobile the child can see no matter how he or she is turned. rationale: Preterm infants are able to focus at short distances before they can see well at long distances. A mobile offers short-distance stimulation. ricci, ch. 23, p. 891

A nurse is assessing a newborn's vital signs 2 hours after delivery. The newborn had low Apgar scores at birth. Which finding would lead the nurse to notify the health care provider?

Pulse rate 100 bpm rationale: A pulse rate between 110 and 160 bpm is considered within acceptable parameters. Therefore, a pulse rate of 100 bpm would be a cause for concern. Temperature typically ranges from 97.7°F to 99.5°F (36.5°C to 37.5°C); respirations typically range from 30 to 60 breaths/min; and blood pressure ranges from 50 to 75 mm Hg systolic and 30 to 45 mm Hg diastolic. ricci, ch. 18, p. 589

The nursery nurse notes that one of the newborn infants has white patches on his tongue that look like milk curds. What action would be appropriate for the nurse to take?

Report the finding to the pediatrician. rationale: Although the finding looks like a milk curd, if the white patch remains after feeding, the pediatrician needs to be notified. The likely cause of the white patch on the tongue is a fungal infection called Candida albicans, which the newborn probably contracted while passing through the birth canal. The nurse should not try to remove the patches. ricci, ch. 18, p. 603

The nurse is caring for a neonate with an exstrophy of the bladder. When the nurse is planning care, which client goal is the priority?

The client will be free from infection. rationale: The highest priority goal is that the client will be free from infection. This client has open mucosa of the bladder and a developed tract that leads to the bladder and then the kidney. Nursing intervention must include frequent vital signs; inspection of the site; observation for drainage, color and clarity of urine in diaper; and frequent urinalysis as ordered until surgical correction. Bonding is always a goal when caring for a newborn and family. Having an adequate urine output is an appropriate goal. Due to the sensitive nature of the mucosa, it is important for the neonate to not experience discomfort, particularly when the area is being cleansed. ricci, ch. 24, p. 927

A nurse determines that a newborn has a 1-minute Apgar score of 5 points. What conclusion would the nurse make from this finding?

The infant is experiencing moderate difficulty in adjusting to extrauterine life. rationale: The nurse should conclude that the newborn is facing moderate difficulty in adjusting to extrauterine life. The nurse should not conclude that the infant is in severe distress requiring immediate interventions for survival or has a congenital heart or respiratory disorder. If the Apgar score is 8 points or higher, it indicates that the condition of the newborn is better. An Apgar score of 0 to 3 points represents severe distress in adjusting to extrauterine life. ricci, ch. 18, p. 587

A nurse is caring for a newborn with a repaired cleft lip. What intervention can the nurse provide to facilitate drainage of mucus and secretions to prevent aspiration?

Position the child on the side. rationale: To facilitate drainage of mucus and secretions, the nurse should position the infant on the side, never on the abdomen, after a cleft lip repair. ricci, ch. 24, p. 921

Which nursing action is required when caring for the post-term infant?

Serial blood glucose levels rationale: Of the options provided, the one that is required is serial blood glucose levels. The newborn may require IV glucose infusion to stabilize glucose level. The rest of the options are on an as-needed basis. ricci, ch. 24, p. 841-842

The nurse is developing a plan of care for a neonate experiencing symptoms of drug withdrawal. What should be included in this plan?

Swaddle the infant between feedings. rationale: Supportive interventions to promote comfort include swaddling, low lighting, gentle handling, quiet environment with minimal stimulation, use of soft voices, pacifiers to promote "self-soothing," frequent small feedings, and vertical rocking, which will soothe the newborn's neurological system. ricci, ch. 24, p. 901

The nurse is looking over a newborn's plan of care regarding expected outcomes. Which outcome would not be appropriate according to a newborn's nursing care?

The newborn will experience no bleeding episodes lasting more than 5 minutes. rationale: Bleeding episodes should not be occurring at all, and any episodes should be reported to the physician immediately if not responsive to immediate action to stop it. All other outcomes are pertinent to the newborn's care. ricci, ch. 18, p. 593

The nurse is explaining the care the newborn will be receiving right after birth to the parents. The nurse should point out the infant will receive an ophthalmic antibiotic ointment by approximately which time?

Within one hour rationale: Within the first hour after birth, an antibiotic ointment must be placed in the newborn's eyes to prevent ophthalmia neonatorum, a severe eye infection contracted in the birth canal of a woman with gonorrhea or chlamydia. ricci, ch. 18, p. 593-594

A nursing student is preparing a class for new mothers about adaptations they can expect in their newborns. Which information about newborn vision should the student include in the presentation? a. newborns cannot focus on any objects b. newborns have the ability to focus only on objects in close proximity c. newborns have the ability to focus on objects in midline d. newborns have the ability to focus only on objects far away

b. newborns have the ability to focus only on objects in close proximity rationale: in regards to vision the newborn has the ability to focus on objects in close proximity (8 to 30 cm away) and tracks objects in midline or beyond. vision is the leas mature sense of birth. ricci: chapter 17, p. 579

At what point should the nurse expect a healthy newborn to pass meconium? a. within 1 to 2 hours of birth b. within 24 hours after birth c. before birth d. by 12 to 18 hours of life

b. within 24 hours after birth rationale: the healthy newborn should pass meconium within 24 hours of life ricci, chapter 17, p. 570

The nurse is admitting a 10-pound (4.5-kg) newborn to the nursery. What is important for the nurse to monitor during the transition period?

blood sugar rationale: 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). ricci, ch. 18, p. 622

As a part of the newborn assessment, the nurse examines the infant's skin. Which nursing observation would warrant further investigation?

bright red, raised bumpy area noted above the right eye rationale: A red bumpy area noted above the right eye is a hemangioma and needs further investigation to determine whether the hemangioma could interfere with the infant's vision. They may grow larger during the first year then fade and usually disappear by age 9. Stork bites or salmon patches and blue or purple splotches on buttocks (Mongolian spots) are common skin variations and are not concerning. Erythema toxicum, seen as a fine red rash over the chest and back, is also a normal skin variant that will disappear within a few days. ricci, ch. 18, p. 598

A newborn's primary method of heat production is through nonshivering thermogenesis. This process oxidizes which substance in response to cold exposure?

brown fat rationale: The newborn's primary method of heat production is through nonshivering thermogenesis, a process in which brown fat (adipose tissue) is oxidized in response to cold exposure. The brown color is derived from the fat's rich supply of blood vessels and nerve endings. ricci, ch. 17, p. 573

A primiparous mother gave birth to an 8 lb 12 oz (3970 g) infant daughter yesterday. She is being bottle fed, is Rh positive, has a cephalohematoma, and received her hepatitis A vaccine last evening. Which factor places the newborn at risk for the development of jaundice?

cephalohematoma rationale: Risk factors for the development of jaundice include bruising as seen in a cephalohematoma, male gender, and being breastfed. Blood type incompatibility is only an issue if the infant's blood type differs from the mother and the maternal blood type is not stated. Administering hepatitis A vaccine does not increase the risk of jaundice. ricci, ch. 17, p. 575

What is the term for a small collection of blood that forms underneath the skull as a result of birth trauma?

cephalohematoma rationale: Vernix caseosa is a thick white substance found on a newborn. Erythema toxicum is a newborn rash. Caput succedaneum is molding or edema. ricci, ch. 24, p. 893

A newborn does not breathe spontaneously at birth. The nurse administers oxygen by bag and mask. If oxygen is entering the lungs, the nurse should notice that the:

chest rises with each bag compression. rationale: If air is entering the lungs of a newborn, his or her chest muscles are so elastic that the chest can be seen rising and falling with bag compression. ricci, ch. 23, p. 848

A nurse in the newborn nursery has noticed that an infant is frothing and appears to have excessive drooling. Further assessment reveals that the baby has episodes of respiratory distress with choking and cyanosis. What disorder should the nurse suspect based on these findings?

esophageal atresia rationale: Any swallowed mucus or fluid enters the blind pouch of the esophagus when a newborn suffers from esophageal atresia. The newborn with this disorder will have frothing, excessive drooling, and periods of respiratory distress with choking and cyanosis. If this happens, no feedings should be given until the newborn has been examined. ricci, ch. 24, p. 922

A common symptom that would alert the nurse that a preterm infant is developing respiratory distress syndrome is:

expiratory grunting. rationale: Expiratory grunting is a physiologic measure to ensure alveoli do not fully close on expiration (so they require less energy expenditure to reopen). ricci, ch. 23, p. 845

The nurse assesses a post-term newborn. What finding corresponds with this gestational age diagnosis?

meconium-stained skin and fingernails rationale: Postterm newborns typically exhibit the following characteristics: dry, cracked, peeling, wrinkled skin; vernix caseosa and lanugo are absent; long, thin extremities; creases that cover the entire soles of the feet; abundant hair on scalp; thin umbilical cord; long fingernails; limited vernix and lanugo; and meconium-stained skin and fingernails. ricci, ch. 23, p. 840

Which facial change is characteristic in a neonate with fetal alcohol spectrum disorder?

microcephaly rationale: Infants with fetal alcohol spectrum disorder are usually born with microcephaly. Their facial features include short, palpebral fissures and a thin upper lip. ricci, ch. 24, p. 898

When attempting to interact with a neonate experiencing drug withdrawal, which behavior would indicate that the neonate is willing to interact?

quiet, alert state rationale: When caring for neonates experiencing drug withdrawal, the nurse must be alert for distress signals from the neonate. Stimuli should be introduced one at a time when the neonate is in a quiet, alert state. Gaze aversion, yawning, sneezing, hiccups, and body arching are distress signals that the neonate can't handle stimuli at that time. ricci, ch. 24, p. 902

a nurse is teaching newborn care to students. the nurse correctly identifies which mechanism as the predominant form of heat loss in the newborn?

radiation, convection, and conduction rationale: Heat loss in the newborn occurs primarily through radiation, convection, and conduction because of the newborn's large ratio of body surface to weight and because of the marked difference between core and skin temperatures. Nonshivering thermogenesis is a mechanism of heat production in the newborn. Lack of brown adipose tissue contributes to heat loss, particularly in premature infants, but it is not the predominant form of heat loss. Peripheral vasoconstriction is a method to increase heat production. ricci, ch. 17, p. 570

The nurse is teaching the caregivers of an infant diagnosed with hypospadias how to properly care for the infant. The nurse determines the session is successful when the caregivers make which statement?

"Being able to most likely correct this in one stage rather than several is reassuring." rationale: Surgical repair is often accomplished in one stage and is often done as outpatient surgery. Surgical repair is desirable between the ages of 6 and 18 months, before body image and castration anxiety become problems. Urination is not affected, but the boy cannot void while standing in the normal male fashion. These newborns should not be circumcised because the foreskin is used in the repair. ricci, ch. 24, p. 926

A late preterm newborn is being prepared for discharge to home after being in the neonatal intensive care unit for 4 days. The nurse instructs the parents about the care of their newborn and emphasizes warning signs that should be reported to the pediatrician immediately. The nurse determines that additional teaching is needed based on which parental statement?

"If our newborn's skin turns yellow, it is from the treatments and our newborn is okay." rationale: The parents of a preterm newborn need teaching about when to notify their pediatrician or nurse practitioner. These include: displaying a yellow color to the skin (jaundice); having difficulty breathing or turning blue (call for emergency services in this case); having a temperature below 97°F (36.1°C) or above 100.4°F (38°C); and failing to void for 12 hours. ricci, ch. 23

A nurse is teaching a newborn's caregivers how to change a diaper correctly. Which statement by the caregiver best indicates the nurse's teaching was effective?

"We will fold down the front of her diaper under the umbilical cord until it falls off." rationale: In order to prevent the cord from becoming irritated and help dry it out, the diaper is rolled down in the front. A newborn's diaper needs to be changed frequently; however, the baby does not need to be awoken during the night. Warm water or wipes are sufficient to clean the perineal area at diaper changes. Barrier creams may be used as needed, but should not be applied after every diaper change. ricci, ch. 18, p. 611

New parents are getting ready to go home and have received information to help them learn how best to care for the new infant. Which statement indicates that they need ad ditional teaching about how to soothe their newborn if he becomes upset?

"We'll hold off on feeding him for a while because he might be too full." rationale: The parents need more teaching that feeding or burping can be helpful in relieving air or stomach gas. 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 provides security and comfort. ricci, ch. 18, p. 617

The heart rate of the newborn in the first few minutes after birth will be in which range?

110 to 160 bpm rationale: During the first few minutes after birth, the newborn's heart rate is approximately 110 to 160 bpm. Thereafter, it begins to decrease to an average of 120 to 130 bpm. ricci, ch. 17, p. 565

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.

24 rationale: Feeding every 3 hours equates to 8 feedings per day. 3 oz × 8 = 24 oz. This can also be calculated in milliliters and converted back into ounces. 90 ml × 8 = 720 ml. ricci, ch. 18

The nurse is concerned that a newborn is hypoglycemic. Which blood glucose level would support the nurse's intervention?

30 mg/dl (1.67 mmol/l) rationale: Hypoglycemia in a neonate is defined as blood glucose value typically below 35 to 45 mg/dl (1.94 to 2.50 mmol/l). The American Academy of Pediatrics recommends intervening for a blood glucose less than 40 mg/dl (2.25 mmol/l) in the first 4 hours of life, and less than 45 mg/dl (mmol/l) at ages 4 hours to 24 hours. ricci, ch. 23, p. 840

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?

33 cm rationale: The average chest circumference is 30 to 36 cm (12 to 14 in). It is generally equal to or about 2 to 3 cm less than the head circumference. ricci, ch. 18, p. 597

A nurse is assessing a newborn's temperature. Which reading would the nurse document as normal?

37.0° C (98.6° F) rationale: On average a newborn's temperature ranges from 36.5° C to 37.5° C (97.9° F to 99.7° F). ricci, ch. 17, p. 570

Hypoglycemia in a mature infant is defined as a blood glucose level below which amount?

40 mg/100 ml whole blood rationale: Because newborns do not manifest symptoms of a reduced glucose level until it decreases well below adult levels, a finding below 40 mg/100 ml whole blood is considered hypoglycemia. ricci, ch. 23, p. 837

A woman in scrubs enters a mother's room while the nurse is completing an assessment. The woman states the doctor is in the nursery and has requested the infant be brought back for an examination. What will the nurse do?

Ask to see the woman' hospital identification badge. rationale: The nurse will not release an infant to anyone who does not have a hospital photo ID that matches the security color or code for the hospital, indicating that they are authorized to transport infants. Asking the woman to bring the newborn back, calling the nursery, or determining how long the newborn will be gone do not address the security issue. ricci, ch. 18, p. 592

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?

Cooperation by the parents with the hospital policies rationale: 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. Using pass codes, placing cameras at each door, and using monitors on the infants will all help, but only if the parents are cooperative. ricci, ch. 18, p. 592

A nurse is conducting the initial assessment for a 3-hour-old neonate and notes the following: RR 30 breaths/min, BP 60/40 mm Hg, HR 155 beats/min, axillary temperature 98.2°F (36.8°C), and the neonate is in a state of quiet alert. What action should the nurse take?

Document the data. rationale: The nurse should document the findings as this neonate's assessment is within the normal range. The normal respiratory rate is 30 to 60 breaths/min and should be counted for a full minute when the neonate is quiet. A neonate starts with a low blood pressure (60/40 mm Hg) and a high pulse (120 to 160 beats/min). Normal temperature range is between 97.7°F (36.5°C) and 99.5°F (37.5°C). ricci, ch. 17, p. 569

A preterm infant has an umbilical vessel catheter inserted so that blood can be drawn readily. Which would be most important to implement during this procedure?

Ensure that the infant is kept warm. rationale: Preterm infants must be protected from chilling during all procedures, because maintaining warmth is a major concern because of immaturity. ricci, ch. 23, p. 850-851

The mother of a newborn observes a diaper rash on her newborn's skin. Which intervention should the nurse instruct the parent to implement to treat the diaper rash?

Expose the newborn's bottom to air several times a day. rationale: The nurse should instruct the parent to expose the newborn's bottom to air several times per day to treat and prevent diaper rashes. Use of baby wipes and products such as powder should be avoided. The parent should be instructed to place the newborn's buttocks in warm water after having had a diaper on all night but not with every diaper change. ricci, ch 18, p. 611

A nurse is explaining the benefits of breastfeeding to a client who has just given birth. Which statement correctly explains the benefits of breastfeeding to this mother?

Immunoglobulin IgA in breast milk boosts a newborn's immune system. rationale: Breast milk is a major source of IgA, so breastfeeding is believed to have significant immunologic advantages over formula feeding. Breastfeeding does not provide more iron or calcium to the infant, maternal breast size does not increase, and most breastfed infants gain weight faster the first 2 months and then weight gain slows down. ricci, ch. 17, p. 577

A nurse is caring for a preterm newborn born at 29 weeks' gestation. Which nursing diagnosis would have the highest priority?

Ineffective thermoregulation related to decreased amount of subcutaneous fat rationale: In the condition of hypothermia, newborns typically metabolize brown fat. This requires the newborn to use glucose and oxygen. A premature infant is at risk for respiratory distress and hypoglycemia. The hypoglycemia can increase the infant's need for glucose and oxygen, which, in turn, could cause more severe disease or further complications. The other diagnoses are appropriate but not the highest priority. ricci, ch. 24, p. 870

The nurse is assisting with the admission of a newborn to the nursery. The nurse notes what appears to be bruising on the left upper outer thigh of this dark-skinned newborn. Which documentation should the nurse provide?

Mongolian spot noted on left upper outer thigh. rationale: A Mongolian spot is bluish-black areas of discoloration on the back and buttocks or extremities of dark-skinned newborns. The Harlequin sign refers to the dilation of blood vessels on only one side of the body, giving the newborn the appearance of wearing a clown suit. Mottling occurs when the lips, hands, and feet appear blue from immature peripheral circulation. Birth trauma is a possibility; however, there would be notations of an incident and possibly other injuries would be noted. ricci, ch. 18, p. 598-599

When assessing infant reflexes, the nurse documents a startled response and extension of the arms and legs as which reflex?

Moro rationale: The Moro reflex is also known as the startle reflex. When the infant is startled they extend their arms and legs away from the body. The fencing reflex is also called the tonic neck reflex and is a total body assessment. The rooting reflex assesses the infant's ability to "look" for food. ricci, ch. 18, p. 607

When providing care to the newborn withdrawing from a drug such as cocaine or heroin, which drug is given to ease the symptoms and prevent complications?

Morphine rationale: Care of the newborn experiencing substance withdrawal focuses on providing physical and emotional support and also medication administration to ease withdrawal symptoms. Morphine, an opioid narcotic, is given to the client to ease the withdrawal symptoms and also gradually remove narcotics from the system. The other options do not ease withdrawal symptoms. ricci, ch. 24, p. 902

A laboring mother requests that she be allowed to participate in "kangaroo care" following the birth. The nurse understands that this involves what action?

Placing the diapered newborn skin-to-skin with the mother and covering them both with a blanket. rationale: Skin-to-skin (kangaroo) care involves placing the newborn skin-to-skin with the mother and covering the newborn and mother with a light blanket. It is recommended that the newborn be placed in a diaper prior to being placed on the mother's chest for bonding. ricci, ch. 18, p. 593=594

A nurse is teaching a new mother about what to expect for bowel elimination in her newborn. Because the mother is breastfeeding, what should the nurse tell her about the newborn's stools?

Stools should be yellow-gold, loose, and stringy to pasty. rationale: The stools of a breast-fed newborn are yellow-gold, loose, and stringy to pasty in consistency. The stools of the formula-fed newborn vary depending on the type of formula ingested. They may be yellow, yellow-green, or greenish and loose, pasty, or formed in consistency, and they have an unpleasant odor. ricci, ch. 17, p. 577

A woman has just given birth vaginally to a newborn. Which action will the nurse do first?

Suction the mouth and nose. rationale: 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. An apical heart rate and temperature are checked soon after birth, but do not take priority over ensuring a patent airway. ricci, ch. 18, p. 591

A 20-year-old client gave birth to a baby boy at 43 weeks' gestation. What might the nurse observe in the newborn during routine assessment?

The newborn may look wrinkled and old at birth. rationale: Postterm babies are those born past 42 weeks' gestation. These babies often appear wrinkled and old at birth. They often have long fingernails and hair, dry parched skin, and no vernix caseosa. Both the quantity of lanugo and the amount of vernix decrease with gestational age. Undescended testes are usually not seen in postterm newborns; however, they are highly prevalent in preterm infants. ricci, ch. 23, p. 858

The nurse is preparing new parents and their infant for discharge by answering questions and presenting basic discharge instruction. Which explanation should the nurse provide when questioned about the infant's yellow hue?

The tint is due to jaundice. rationale: 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. Jaundice in the first 24 hours is pathologic and must be reported immediately to the health care provider. Jaundice after 2 days is considered physiologic and is due to the liver's inability to adequately process bilirubin which seeps into the tissues, giving the skin a yellowish color. It is not considered normal and does require assessment and intervention. Phototherapy is the recommended treatment of choice, not putting the child in sunlight. It is not a reaction to the vitamin K injection. ricci, ch. 18, p. 621

what should the nurse expect for a full-term newborn's weight during the first few days of life?

There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns. rationale: The nurse should expect the newborn who is breastfed or formula-fed to lose 5% to 10% of birth weight in the first few days of life. ricci, ch. 17, p. 576

A first-time mother informs the nurse that she is unable to breastfeed her newborn through the day as she is usually away at work. She adds that she wants to express her breast milk and store it for her newborn to have later. What instruction would be correct to offer the mother to ensure the safety of the stored expressed breast milk?

Use the sealed and chilled milk within 24 hours. rationale: The nurse should instruct the woman to use the sealed and chilled milk within 24 hours. The nurse should not instruct the woman to use frozen milk within 6 months of obtaining it, to use microwave ovens to warm chilled milk, or to refreeze the used milk and reuse it. Instead, the nurse should instruct the woman to use frozen milk within 3 months of obtaining it, to avoid using microwave ovens to warm chilled milk, and to discard any used milk and never refreeze it. ricci, ch. 18, p. 632

A woman who has given birth to a postterm newborn asks the nurse why her baby looks so thin with so little muscle. The nurse integrates understanding about which concept when responding to the mother?

With postterm birth, the fetus uses stored nutrients to stay alive, and wasting occurs. rationale: After 42 weeks' gestation, the placenta loses its ability to provide adequate oxygen and nutrients to the fetus, causing the fetus to use stored nutrients to stay alive. This leads to wasting. Meconium aspiration can occur with postterm newborns, but this is not the reason for the baby's wasted appearance. Hyperbilirubinemia occurs with the increased breakdown of red blood cells, but this too would not account for the wasted appearance. Exposure to an intrauterine infection is unrelated to the wasted appearance. ricci, ch. 23, p. 858

The nurse is teaching a prenatal class and illustrating some of the basic events that will happen right after the birth. The nurse should point out which action will best help the infant maintain an adequate body temperature?

Wrap the infant in a warm, dry blanket. rationale: Evaporation is one of the four ways a newborn can lose heat. As moisture evaporates from the body surface of the infant, the newborn loses heat. Wrapping the infant in a warm, dry blanket will allow the moisture to be absorbed, limiting heat loss from evaporation. Bathing the infant will only add to the evaporative heat loss. The newborn's skin is wet, so placing him on the mother' abdomen will not prevent evaporation and heat loss. Increasing the ambient temperature in the birth room does not address the evaporation problem. ricci, ch. 17, p. 571

A nurse is assessing a newborn's temperature. Which reading would the nurse document as normal? a. 37.0° C (98.6° F) b. 38.0° C (100.4° F) c. 35.0° C (95.0° F) d. 36.0° C (96.8° F)

a. 37.0° C (98.6° F) rationale: on average a newborn's temperature ranges from 36.5° C to 37.5° C (97.9° F to 99.7° F) ricci, chapter 17, p. 570

Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress?

asymmetrical chest movement rationale: Chest movements should be symmetrical. Typical newborn respirations range from 30 to 60 breaths per minute. Acrocyanosis is a common finding in newborns and does not indicate respiratory distress. Periods of apnea of less than 15 seconds are considered normal in a newborn. However, if these periods last more than 15 seconds and are accompanied by cyanosis and heart rate changes, additional evaluation is needed. ricci, ch. 17, p. 569

The nurse suspects a preterm newborn receiving enteral feedings of having necrotizing enterocolitis (NEC). What assessment finding best correlates with this diagnosis?

bloody stools rationale: NEC assessment includes assessing the newborn's health history and physical examination as well as laboratory and diagnostic testing. The onset of NEC is demonstrated by the development of feeding intolerance, abdominal distention, and bloody stools in a preterm infant receiving enteral feedings. As the disease worsens, the infant develops signs and symptoms of septic shock with RDS, temperature instability, lethargy, hypotension, and oliguria. ricci, ch. 24, p. 883

A mother is upset because her newborn has lost 6 ounces since birth 2 days ago. The nurse informs the mother that it is normal for a newborn to lose which percentage of their birth weight within the first week of life? a. 15% to 18% of their birth weight b. 20% of their birth weight c. 5% to 10% of their birth weight d. 10% to 15% of their birth weight

c. 5% to 10% of their birth weight rationale: adequate digestion and absorption are essential for newborn growth and development. normally, therm newborns lose 5% to 10% of their birth weight as a result of insufficient caloric intake within the first week after birth ricci: chapter 17, p. 576

A nurse is teaching a new mother about what to expect for bowel elimination in her newborn. Because the mother is breastfeeding, what should the nurse tell her about the newborn's stools? a. stools should be greenish and formed in consistency b. stools should be yellow-green and loose c. stools should be yellow-gold, and stringy to pasty d. stools should be brown and loose

c. stools should be yellow-gold, and stringy to pasty rationale: the stools of a breast-fed newborn are yellow-gold, loose, and stringy to pasty in consistency. the stools of the formula-fed newborn vary depending on the type of formula ingested. they may be yellow, yellow-green, or greenish and loose, pasty, or formed in consistency, and they have an unpleasant odor. ricci: chapter 17, p. 577

When providing postpartum teaching to a couple, the nurse correctly identifies what time as when pathologic jaundice may be found in the newborn?

during the first 24 hours of life rationale: Pathologic jaundice occurs within the first 24 hours of life and is often related to blood incompatibility. Conversely, physiologic jaundice occurs 48 hours or more after birth, peaks at the 5th to 7th day, and disappears between the 7th and 10th day postpartum. Physiologic jaundice is caused by the normal reduction of red blood cells and occurs in both breastfed and bottle-fed babies. ricci, ch. 24, p. 888

The nurse observes a newborn experiencing coughing, choking, and unexplained cyanosis during feeding. These are classic signs of what condition?

esophageal atresia rationale: In esophageal atresia, the esophagus ends in a blind pouch. As the pouch fills during a feeding, the infant begins to cough, choke, and become cyanotic. These characteristics are not present with an intestinal obstruction, cystic fibrosis, or ankyloglossia. ricci, ch. 24, p. 922

On an Apgar evaluation, how is reflex irritability tested?

flicking the soles of the feet and observing the response rationale: Reflex irritability means the ability to respond to stimuli. It can be tested by flicking the foot or evaluating the response to a catheter passed into the nose. ricci, ch18, p. 588

A nurse is assessing the fluid status of a preterm newborn. Which parameter would be most appropriate for the nurse to assess?

fontanels (fontanelles) rationale: When assessing the fluid status of a preterm newborn, the nurse palpates the fontanels (fontanelles). Sunken fontanels suggest dehydration; bulging fontanels suggest overhydration. ricci, ch. 23, p. 851

The nurse is assessing a neonate as he transitions to extrauterine life. The nurse integrates understanding that which structure closes as a result of the neonate's first breath?

foramen ovale rationale: Before birth, the foramen ovale allowed most of the oxygenated blood entering the right atrium from the inferior vena cava to pass into the left atrium of the heart. With the neonate's first breath, air pushes into the lungs, triggering an increase in pulmonary blood flow and pulmonary venous return to the left side of the heart. As a result, the pressure in the left atrium becomes higher than in the right atrium. The increased left atrial pressure causes the foramen ovale to close, thus allowing the output from the right ventricle to flow entirely to the lungs. The closure of the ductus arteriosus depends on the high oxygen concentration of the aortic blood that results from aeration of the lungs at birth. Closure of the ductus venosus occurs because shunting from the left umbilical vein to the inferior vena cava is no longer needed. The umbilical arteries and vein begin to constrict at birth because with placental expulsion blood flow ceases. ricci, ch. 17, p. 565

Following anastomosis repair of a tracheoesophageal fistula, the nurse assesses the infant for which potential complication?

gastroesophageal reflux rationale: Gastroesophageal reflux may also occur after a repair, especially if the esophagus is left shorter than usual; this can lead to recurrent fistula formation and irritation from the presence of stomach acid in the esophagus. Aspiration is a risk prior to the surgical repair. Esophageal rupture and pyloric stenosis are not complications related to the surgical repair. ricci, ch. 24, p. 922-923

While assessing a newborn, the nurse notes that half the body appears red while the other half appears pale. The nurse interprets this finding as:

harlequin sign. rationale: Harlequin sign refers to the dilation of blood vessels on only one side of the body. It gives a distinct midline demarcation, which is pale on one side and red on the opposite. Stork bites are superficial vascular areas found on the nape of the neck, eyelids, between the eyes and upper lip. Mongolian spots are blue or purple splotches that appear on the lower back and buttocks. Erythema toxicum is a benign, idiopathic, generalized, transient rash that resembles flea bites. ricci, ch. 18, p. 599

A nurse is analyzing a journal article that explains the changes at birth from fetal to newborn circulation. The nurse can point out the closure of the ductus arteriosus is related to which event after completing the article?

higher oxygen content of the circulating blood rationale: The first few breaths greatly increase the oxygen content of circulating blood. This chemical change (i.e., higher oxygen content of the blood) contributes to the closing of the ductus arteriosus, which eventually becomes a ligament. A drop in the pressure results in a reversal of pressures in the right and left atria, causing the foramen ovale to close, which redirects blood to the lungs. A drop in blood pressure and higher oxygen levels at the respiratory centers of the brain do not result in the closure of the foramen ovale. ricci, ch. 17, p. 565

The nurse begins frequent oral feedings for a small-for-gestational-age newborn to prevent which occurrence?

hypoglycemia rationale: Intermittent oral feedings are initiated to prevent hypoglycemia as the newborn now must assume control of glucose homeostasis. Hydration and frequent monitoring of hematocrit are important to prevent polycythemia. Resuscitation and suctioning are used to manage meconium aspiration. Immediate resuscitation is used to manage asphyxia. ricci, ch. 23, p. 836

An obese woman with diabetes has just given birth to a term, large-for-gestational-age (LGA) newborn. Which condition should the nurse most expect to find in this infant?

hypoglycemia rationale: LGA infants also need to be carefully assessed for hypoglycemia in the early hours of life because large infants require large amounts of nutritional stores to sustain their weight. If the mother had diabetes that was poorly controlled (the cause of the large size), the infant would have had an increased blood glucose level in utero to match the mother's; this caused the infant to produce elevated levels of insulin. After birth, these increased insulin levels will continue for up to 24 hours of life, possibly causing rebound hypoglycemia. ricci, ch. 23, p. 840

A nurse caring for a client in premature labor knows that the best indicator of fetal lung maturity is which data?

lecithin to sphingomyelin ratio of more than 2:1 rationale: Lecithin and sphingomyelin are phospholipids that help compose surfactant in the lungs; lecithin peaks at 36 weeks, and sphingomyelin concentrations remain stable. Meconium is released due to fetal stress before delivery, but it's chronic fetal stress that matures lungs. Glucocorticoids must be given at least 48 hours before delivery. The presence of phosphatidylglycerol indicates lung maturity. ricci, ch. 24, p. 887

A 2-month-old infant is admitted to a local health care facility with an axillary temperature of 96.8° F (36° C). Which observed manifestation would confirm the occurrence of cold stress in this client?

lethargy and hypotonia rationale: The nurse should look for signs of lethargy and hypotonia in the newborn in order to confirm the occurrence of cold stress. Cold stress leads to a decrease, not increase, in the newborn's body temperature, blood glucose, and appetite. ricci, ch. 17, p. 573

The nurse assesses a post-term newborn. What finding corresponds with this gestational age diagnosis?

meconium-stained skin and fingernails rationale: Postterm newborns typically exhibit the following characteristics: dry, cracked, peeling, wrinkled skin; vernix caseosa and lanugo are absent; long, thin extremities; creases that cover the entire soles of the feet; abundant hair on scalp; thin umbilical cord; long fingernails; limited vernix and lanugo; and meconium-stained skin and fingernails. ricci, ch. 24, p. 840

The nurse is admitting a term, large-for-gestational-age neonate weighing 4,610 g (10 lb, 2 oz), born vaginally with a mid-forceps assist, to a 15-year-old primipara. What would the nurse anticipate as a result of the birth?

midclavicular fracture rationale: Trauma to the newborn may result from the use of mechanical forces, such as forceps during birth. Primarily injuries are found in large babies and babies with shoulder dystocia. Associated traumatic injuries include fracture of the clavicle or humerus or subluxations of the shoulder or cervical spine. ricci, ch. 24, p. 892

The nurse is teaching new parents the best way to prevent hypothermia. Which mechanism would the nurse include when explaining about the newborn's primary method of heat production?

nonshivering thermogenesis rationale: The newborn's primary method of heat production is through nonshivering thermogenesis, a process in which brown fat (adipose tissue) is oxidized in response to cold exposure. When the newborn is in a cold environment, the blood flow is increased through the brown fat, which warms the blood and in turn helps warm the infant. ricci, ch. 17, p. 573

A nurse needs to monitor the blood glucose levels of a newborn under observation at a health care facility. When should the nurse check the newborn's initial glucose level?

on admission to the nursery rationale: Typically, a newborn's blood glucose levels are assessed with use of a heel stick sample of blood on admission to the nursery, not 4 or 24 hours after admission to the nursery. It is also not necessary or even reasonable to check the glucose level only after the newborn has been fed. ricci, ch. 17, p. 575

A client has just given birth at 42 weeks' gestation. What would the nurse expect to find during her assessment of the neonate?

peeling and wrinkling of the neonate's epidermis rationale: Postdate neonates lose the vernix caseosa, and the epidermis may become peeled and wrinkled. A neonate at 42 weeks' gestation is usually very alert and missing lanugo. ricci, ch. 23, p. 858

At birth, the infant has dry, cracked skin, absence of vernix, lack of subcutaneous fat, fingernail extending beyond the fingertips, and poor skin turgor. Based on these findings, how would the nurse would classify this neonate?

postterm rationale: These characteristics are consistent with a postterm infant. An SGA infant has some of these same characteristics but does not exhibit long fingernails. A preterm infant has translucent skin, and an LGA infant has excessive subcutaneous fat. ricci, ch. 23, p. 841

A nurse is assessing a newborn with the parents. The nurse explains that which aspect of newborn behavior is an important indication of neurologic development and function?

reflex rationale: The presence and strength of a reflex is an important indication of neurologic development and function. It is built into the nervous system and does not need the intervention of conscious thought to take effect. These reflexes end at different levels of the spine and brain stem, reflecting the function of the cranial nerves and motor system. ricci, ch. 17, p. 579

a nurse is assessing a newborn with the parents. the nurse explains which aspect of newborn behavior is an important indication of neurological development and function?

reflex rationale: The presence and strength of a reflex is an important indication of neurologic development and function. It is built into the nervous system and does not need the intervention of conscious thought to take effect. These reflexes end at different levels of the spine and brain stem, reflecting the function of the cranial nerves and motor system. ricci, ch. 17, p. 579

A nursing student correctly chooses which stage of behavioral adaptation in the infant to reinforce teaching about feeding, positioning for feeding, and diaper-changing techniques?

second period of reactivity rationale: The second period of reactivity is the best time to teach about feeding, positioning for feeding, and diaper-changing techniques. It is also a good time for the parents to interact with the infant as well as examine the infant and ask questions. ricci, ch. 17, p. 580

a nursing student observing newborns in the nursery is amazed that a crying infant put her fingers in her mouth, instantly stops crying, and then falls asleep. this behavior can best be explained as:

self-quieting ability. rationale: Self-quieting ability refers to newborns' ability to quiet and comfort themselves. Assisting parents to identify consoling behaviors also helps. The sleep state is noted as an infant becoming drowsy and less attentive to the parents and his surroundings. Social behaviors are things such as cuddling and snuggling into the arms of the parents when the newborn is held. Motor maturity refers to posture, tone, coordination, and movements of the newborn. ricci, ch. 17. p. 580

An infant born via a cesarean delivery appears to be transitioning well; however, the nurse predicts that she will note which common assessment finding in this infant?

tachypnea rationale: The infant born from a cesarean birth has not had the opportunity to exit the birth canal and experience the squeezing of fluid from the lungs. The lungs have more amniotic fluid than the lungs of a baby from a vaginal birth and are at greater risk for respiratory complications, such as tachypnea. An infant born by cesarean birth is not at increased risk for hyperthermia, hypoglycemia, or a cardiac murmur. ricci, ch. 17, p. 568

Which sign appears early in a neonate with respiratory distress syndrome?

tachypnea more than 60 breaths/minute rationale: Tachypnea and expiratory grunting occur early in respiratory distress syndrome to help improve oxygenation. Poor capillary filling time, a later manifestation, occurs if signs and symptoms aren't treated. Crackles occur as the respiratory distress progressively worsens. A pale gray skin color obscures earlier cyanosis as respiratory distress symptoms persist and worsen. ricci, ch. 24, p. 873

Which newborn would the nurse suspect to be most at risk for intellectual disability due to the mother's actions during pregnancy?

the child of a client who admits to drinking a liter of alcohol daily during the pregnancy rationale: Fetal alcohol spectrum disorder is one of the most common known causes of intellectual disability. The newborn is also at risk for fetal alcohol spectrum disorder and other alcohol-related birth defects. The other illicit drugs are not linked to intellectual disability but have many other teratogenic effects on the fetus/newborn. Marijuana has not shown to have teratogenic effects on the fetus. ricci, ch. 24, p. 898

The American Academy of Pediatrics and the American Dietetic Association recommend breastfeeding exclusively for how long?

the first 6 months ricci, ch. 18, p. 625

The nurse is teaching a new mother about the changes in her newborn's gastrointestinal tract. The nurse determines that additional teaching is needed when the mother makes which statement?

"His stomach can hold approximately 10 ounces." rationale: A newborn's stomach capacity is approximately 30 to 90 mL or 1 to 3 ounces. The gut is sterile at birth but changes rapidly depending on what feeding is received. Colonization of the gut is dependent on oral intake; oral intake is required for the production of vitamin K. The cardiac sphincter that leads into the stomach and nervous control of the stomach are immature. ricci, ch. 17, p. 576

A nurse is caring for a large-for-gestational-age newborn. Which signs would lead the nurse to suspect that the newborn is experiencing hypoglycemia? Select all that apply.

- Lethargy and stupor - Respiratory difficulty - Appearance of central cyanosis rationale: The features indicating hypoglycemia in large-for-gestational-age (LGA) infants include lethargy, stupor, fretfulness, respiratory difficulty, and central cyanosis. The other features include poor feeding in a previously well-feeding infant and weak, whimpering cry. A high-pitched, shrill cry along with bulging fontanels (fontanelles) are seen in increased intracranial pressure following head trauma in LGA infants. ricci, ch. 23, p. 837

The nurse is providing teaching to a new mother who is breastfeeding. The mother demonstrates understanding of teaching when she identifies which characteristics as being true of the stool of breastfed newborns? Select all that apply.

- yellowish gold color - stringy to pasty consistency rationale: The stools of a breastfed newborn are yellowish gold in color. They are not firm in shape or solid. The smell is usually sour. A formula-fed infant's stools are formed in consistency, whereas a breastfed infant's stools are stringy to pasty in consistency. ricci, ch. 17, p .577

A nurse is caring for an infant with an elevated bilirubin level who is under phototherapy. What evaluation data would best indicate that the newborn's jaundice is improving?

Bilirubin level went from 15 to 11. The newborn has physiologic jaundice, which is related to decreased bilirubin conjugation. Newborns have relatively immature livers and cannot conjugate (break down) bilirubin as fast as needed. Bilirubin overproduction is responsible for causing jaundice. A serum bilirubin is the best way to determine whether the jaundice is improving. The other listed methods will not address the needed information. ricci, ch. 17, p. 575

A newborn's vital signs are documented by the nurse and are as follows: HR 144, RR- 36, BP- 128/78, and T- 98.6℉ (37℃). Which finding would be concerning to the nurse?

Blood Pressure rationale: The blood pressure of a newborn should be quite low—around 60-70 over 35 to 50. The heart rate and respiratory rate are both high, which are normal findings. The temperature falls within a normal range of 97.7℉ to 99.5℉ (36.5℃ to 37.5℃). ricci, ch. 17, p. 588-589

The nurse is assessing a newborn who appears healthy and at term. Which assessment finding of the feet does the nurse predict to observe to confirm the status of at-term birth?

Creases on two-thirds of the foot rationale: As an infant matures in utero, sole creases become prominent to a greater amount. The term infant should have at least two-thirds of the foot covered by creases. These creases should be horizontal and not longitudinal, They should be in the ball of the foot before moving to the heel. ricci, ch. 17, p. 588-589

A nurse is assessing a newborn and observes the newborn bringing his hand up to his mouth. The nurse interprets this finding as which behavioral response?

motor maturity rationale: Motor maturity depends on gestational age and involves evaluation of posture, tone, coordination, and movements. These activities enable newborns to control and coordinate movement. When stimulated, newborns with good motor organization demonstrate movements that are rhythmic and spontaneous. Bringing the hand up to the mouth is an example of good motor organization. The response of newborns to stimuli is called orientation. They become more alert when they sense a new stimulus in their environment. Habituation is the newborn's ability to process and respond to visual and auditory stimuli. It is a measure of how well and appropriately an infant responds to the environment. Self-quieting ability (also called self-soothing) refers to newborns' ability to quiet and comfort themselves. ricci, ch. 17. p. 581

A client who gave birth 2 hours ago expresses concern about her baby developing jaundice. Which response from the nurse would be best?

"I understand your concern because as many as 50% of babies can develop jaundice." rationale: As many as 50% of term newborns will develop physiologic jaundice. Physiologic jaundice occurs after the first 24 hours of life and is not pathologic. Pathologic jaundice will develop within the first 24 hours of life. ricci, ch. 24, p. 904

The parents of a 2-day-old newborn are getting ready to go home with their baby. The mother is breastfeeding the newborn. In preparation for discharge, the nurse obtains the newborn's weight. The newborn weighs 7 lb (3180 g) this morning. The parents voice concern, saying, "Our newborn lost weight since being born. Our newborn was 7 lb 8 oz (3404 g) and now our newborn is less. What is going on?" Which response by the nurse would be most appropriate?

"I understand your concern. It is normal for this to happen but your newborn will gain it back quickly." rationale: Newborns can lose up to 10% of their initial birth weight by 3 to 4 days of age secondary to loss of meconium, extracellular fluid, and limited food intake. This weight loss is usually regained by the 10th day of life. The weight loss is a normal finding. There is no need to talk to the health care provider, increase the number of breastfeeding sessions, or switch to formula. ricci, ch. 18

A nurse is explaining to the parents the preoperative care for their infant born with bladder exstrophy. The parents ask, "What will happen to the bladder while waiting for the surgery?" What is the nurse's best response?

"The bladder will covered in a sterile plastic bag to keep it moist." rationale: In the preoperative period, the infant care is focused on protecting the exstrophied bladder and preventing infection. The infant is kept in a supine position, and the bladder is kept moist and covered with a sterile plastic bag. Change soiled diapers immediately to prevent contamination of the bladder with feces. Sponge-bathe the infant only rather than immersing him or her in water to prevent pathogens in the bath water from entering the bladder. Consult the ostomy nurse if necessary. ricci, ch. 24, p. 927

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 oxygen supplementation - ensure the newborn's warmth - observe respiratory status frequently rationale: The nurse should give the newborn oxygen, ensure the newborn's warmth, and observe the newborn's respiratory status frequently. The nurse need not give the newborn warm water to drink or massage the newborn's back. ricci, ch. 18., p. 621

The nurse needs to conduct a procedure on a preterm newborn. Which measures would be most effective in reducing pain? Select all that apply.

- swaddling the newborn closely - offering a pacifier prior to a procedure - encouraging kangaroo care during procedures rationale: Interventions to reduce pain in the preterm newborn include swaddling the newborn closely to establish physical boundaries; using gentle handling, rocking, caressing, and cuddling; encouraging kangaroo care during procedures; and offering a pacifier for nonnutritive sucking prior to a procedure. Tape should be used minimally and should be removed gently to prevent skin tearing. Environmental stimuli need to be reduced, such as by turning down the volumes on alarms. Warm rather than cool blankets facilitate relaxation. ricci, ch. 23, p. 854

The nurse is preparing the delivery room before the birth occurs. What supplies would the nurse have available to care for the newborn? Select all that apply.

- warmer bed - suction equipment - identification bands rationale: In preparing the delivery room, the nurse should preheat a warmer bed, have suction equipment at bedside, and have the identification bands ready for both the mother and newborn. Glucose water and an ophthalmoscope are not needed immediately after delivery to stabilize the newborn. ricci, ch. 18, p. 591, 592, 594

A newborn is 7 minutes old. The heart rate is 92 beats/min, the cry is weak, the muscles are limp and flaccid, the newborn responds promptly when stimulated, and the body and extremities are pink. What would the nurse assign as the Apgar score?

6 rationale: The newborn is not demonstrating a good transition to extrauterine life; the Apgar score for this newborn is appearance/color = 2; pulse = 1; grimace/reflex irritability = 2; respiration/cry = 1; activity/muscle tone = 0. This newborn's Apgar score = 6. ricci, ch. 18, p. 588

The nurse records a newborn's Apgar score at birth. A normal 1-minute Apgar score is:

7 to 10. rationale: An Apgar score of 7 to 10 implies the infant is breathing well and cardiovascular adaptation is occurring. ricci, ch. 18, p. 587

The parents of a newborn male are questioning the nurse concerning the pros and cons of a circumcision. Which disadvantage should the nurse point out to these parents?

Anesthetic may not be effective during the procedure rationale: The anesthetic block is not always effective when used and not all providers will even use anesthetics prior to the procedure, thus 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 advantages to the procedure. ricci, ch. 18, p. 613

A newborn with high serum bilirubin is receiving phototherapy. Which is the most appropriate nursing intervention for this client?

Application of eye dressings to the infant rationale: Continuous exposure to bright lights by phototherapy may be harmful to a newborn's retina, so the infant's eyes must always be covered while under bilirubin lights. Eye dressings or cotton balls can be firmly secured in place by an infant mask. The lights are placed 12 to 30 inches above the newborn's bassinet or incubator. Bilirubin is removed from the body by being incorporated into feces. Therefore, the sooner bowel elimination begins, the sooner bilirubin removal begins. Early feeding (either breast milk or formula), therefore, stimulates bowel peristalsis and helps to accomplish this. Gently shaking the infant is a method of stimulating breathing in an infant experiencing apnea. ricci, ch. 23, p. 839

The nurse is assessing the plantar creases on the newborns for documentation on the Ballard Scale. Which documentation is interpreted as evidence of a full-term infant?

Creases covering two-thirds of the anterior foot rationale: On the Ballard Scale, an assessment and documentation of a crease covering two-thirds of the anterior foot is interpreted as characteristic of a full-term newborn. The creases are assessed on the foot, not the hand or brow. No creases are indicative of a preterm newborn. ricci, ch. 24, p. 844

The nurse is assessing a newborn's vital signs and notes the following: HR 138, RR 42, temperature 98.7° F (37.1° C), and blood pressure 70/40 mm Hg. Which action should the nurse prioritize?

Document normal findings. rationale: These vital signs are within normal limits and should be documented. The heart rate should be 110 to 160 bpm; RR should be 30 to 60 breaths per minute. The axillary temperature can range from 97.7°F to 99.6&%176;F (36.5°C to 37.5°C). Blood pressure should be 60 to 80/40 to 45 mm Hg. There is no need to contact the health care provider, recheck the blood pressure in 15 minutes, or place a blanket on the infant. ricci, ch. 17, p. 569

The nurse is assessing reflexes in a newborn infant. What can the nurse do to elicit the rooting reflex?

Gently stroke the newborn's cheek. rationale: Stroking the newborn's cheek and observing for the newborn to turn toward the touch with the mouth open elicit the rooting reflex. Placing a gloved finger in the newborn's mouth elicits the suck reflex. Startling the newborn elicits the Moro reflex. Turning the newborn's head to one side elicits the tonic neck reflex. ricci, ch. 17, p. 579

A nurse is preparing to administer phytonadione to a newborn. After confirming the order, what will the nurse do next?

Identify the newborn. rationale: The nurse will identify the correct newborn before administering phytonadione (vitamin K). The newborn's weight is not needed to calculate the dosage as all newborns receive 0.5 mg IM within one hour of birth. Phytonadione is given to decrease the risk of hemorrhage. ricci, ch. 18, p. 592

What is the best rationale for trying to decrease the incidence of cold stress in the neonate?

If the neonate becomes cold stressed, it will eventually develop respiratory distress. rationale: If cold stressed the infant eventually will develop respiratory distress; oxygen requirements rise, even before noting a change in temperature, glucose use increases, acids are released into the bloodstream and surfactant production decreases bringing on metabolic acidosis. A flexed position, not an extended position keeps the neonate warm. ricci, ch. 17, p. 573

A nurse does an initial assessment on a newborn and notes a pulsation over the anterior fontanel (fontanelle) that corresponds with the newborn's heart rate. How would the nurse interpret this finding?

It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanel. rationale: Feeling a pulsation over the fontanel (fontanelle) correlating to the newborn's heart rate is normal. The pulsation should not be felt in the posterior fontanel. The fontanel should not be bulging under any circumstance in a newborn. ricci, ch. 18, p. 600-601

A woman wearing hospital scrubs comes to the nursery and states "Mrs. Smith is ready for her baby. I will be glad to take the baby to her." What will the nursery nurse do next?

Look at the woman's hospital identification badge. rationale: Each member of the hospital staff should have an identification badge clearly displayed. The nursery nurse should look at the badge of the woman who is offering to take Mrs. Smith's baby to her as this is the only way to ensure the nurse is allowing an appropriate person to transport the baby. 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. The nurse should review these policies and know the protocols for the facility in which the nurse will be working. ricci, ch. 18, p. 615

A premature infant in the neonatal intensive care unit exhibits worsening respiratory distress and is noted to have abdominal distention, absent bowel sounds, and frequent diarrhea stools that are positive for hemoccult. What diagnosis would be most likely to correlate with the symptoms?

Necrotizing enterocolitis rationale: Observations for the development of NEC in the premature newborn may include feeding intolerance with abdominal distention tenderness and bloody or hemoccult-positive stools. Diarrhea is present with NEC and worsening of respiratory distress. Decreased or absent bowel sounds are noted. Rotavirus causes inflammation of a child's stomach and digestive tract, usually triggering vomiting, diarrhea, and fever and not seen in a preterm infant. Garamycin-resistant bacteria is usually seen in older adults. ricci, ch. 24, p. 883

A nurse is assessing the temperature of a newborn using a skin temperature probe. Which point should the nurse keep in mind while taking the newborn's temperature?

Place the temperature probe over the liver. rationale: The nurse should place the temperature probe over the newborn's liver. Skin temperature probes should not be placed over a bony area like the forehead or used in an open bassinet with no heat source. The newborn should be in a supine or side-lying position. ricci, ch. 17, p. 573

A client at 6 weeks' gestation asks the nurse what foods she should eat to help prevent neural tube disorders in her growing baby. The nurse would recommend which foods?

Spinach, oranges, and beans rationale: Folic acid assists in preventing the incidence of neural tube disorders. These foods include green, leafy vegetables; citrus fruits, beans, and fortified breads; cereals, rice, and pasta. Milk, yogurt, and cheese are high in calcium. Bananas, avocados, and coconut are high in potassium. Pork, beans, and poultry are high in iron. ricci, ch. 24, p. 911

A nurse is concerned that a 1-day-old newborn is becoming ill and may be septic. What sign of distress would validate the nurse's concerns?

Temperature instability rationale: Temperature instability is one of several signs of possible sepsis in a newborn. Other signs include poor feeding, lethargy, irritability, and hypoglycemia. Late signs of sepsis include apnea and jaundice. A heart rate of 152 beats/min, a respiratory rate of 40 breaths/min, and erythema toxicum are all normal findings. ricci, ch. 24, p. 908

Which assessment finding within the first 24 hours of birth requires immediate health care provider notification?

The skin is jaundiced. rationale: Pathologic jaundice occurs within the first 24 hours of life and is often related to blood incompatibility. Conversely, physiologic jaundice occurs 48 hours or more after birth, peaks at the 5th to 7th day, and disappears between the 7th and 10th day postpartum. This neonate exhibits pathologic jaundice, which needs to be reported immediately. Milia is common on the newborn. It is appropriate for the newborn to sleep for most of the day and eat a couple ounces of formula. ricci, ch. 24, p. 906

Which newborn would be a priority for the nurse to monitor for thermal regulation difficulties?

a preterm newborn with cyanotic hands, feet, and tongue, feeding poorly. ricci, ch. 23, p. 850

The nurse is explaining to new parents that a potential complication of a cesarean birth is transient tachypnea. The nurse explains that this is due to which occurrence? a. loss of blood volume due to hemorrhage b. inadequate suctioning of the mouth and nose of the newborn c. lack of thoracic compressions during birth d. prolonged unsuccessful vaginal birth

c. lack of thoracic compressions during birth rationale: a baby born by cesarean birth does not have the same benefits of the birth canal squeeze as does the newborn born by vaginal birth. this may result in the fluid in the lungs being removed too slowly or incompletely. research findings support the need for thoracic compression to assist with the removal of the fluid and facilitate adequate breathing in the newborn. ricci, chapter 17, p. 568

The nurse enters the room and notes the infant is in its bed sleeping, close to the outside window. Which action should the nurse prioritize? a. check the infant's vital signs b. observe infant's status c. move the infant away from the window d. place another blanket on the infant

c. move the infant away from the window rationale: the nurse should move the infant away from the window to prevent heat loss via radiation. when the nurse moves the newborn away from a cold window, it prevents heat loss from a cold object near the newborn, which is an example of radiation. the other options of placing a blanket,checking vital signs, and observing the infant's status would be accomplished if indicated; however, the priority is to relocate the infant first to a warmer area of the room. ricci, chapter 17, p. 571-572

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?

concentration of immature blood vessels rationale: A concentration of immature blood vessels causes salmon patches. Bruising does not look like salmon patches but would be more bluish-purple in appearance. Harlequin sign is a result of immature autoregulation of blood flow and is commonly seen in low birth weight newborns. An allergic reaction would be more generalized and would not be salmon colored. ricci, ch. 17, p. 598

A nurse is providing care to a 3-hour-old neonate. The nurse ensures that her hands are warm prior to touching the neonate to prevent heat loss by which mechanism?

conduction rationale: Heat loss by conduction can occur when the nurse touches the newborn with cold hands. Conduction involves the transfer of heat from one object to another when the two objects are in direct contact with one another. Convection involves the flow of heat from the body surface to cooler surrounding air or to air circulating over a body surface. Radiation involves the loss of body heat to cooler, solid surfaces that are in proximity but not direct contact with the newborn. Evaporation involves the loss of heat when a liquid is converted to a vapor. ricci, ch. 17, p. 571

Eliminating drafts in the birth room and in the nursery will help to prevent heat loss in a newborn through which mechanism?

convection rationale: Convection involves the flow of heat from the body surface to cooler surrounding air or to air circulating over a body surface. An example of convection-related heat loss would be a cool breeze that flows over the newborn. To prevent heat loss by this mechanism, keep the newborn out of direct cool drafts (open doors, windows, fans, air conditioners) in the environment. Radiation involves the loss of body heat to cooler, solid surfaces that are in proximity but not in direct contact with the newborn. To reduce heat loss by radiation, keep cribs and isolettes away from outside walls, cold windows, and air conditioners. Evaporation involves the loss of heat when a liquid is converted to a vapor. Evaporative loss may be insensible (such as from skin and respiration) or sensible (such as from sweating). Drying newborns immediately after birth with warmed blankets and placing a cap on their head will help to prevent heat loss through evaporation. In addition, drying the newborn after bathing will help prevent heat loss through evaporation. Promptly changing wet linens, clothes, or diapers will also reduce heat loss and prevent chilling. Conduction involves the transfer of heat from one object to another when the two objects are in direct contact with each other. Using a warmed cloth diaper or blanket to cover any cold surface touching a newborn directly helps to prevent heat loss through conduction. Placing the newborn skin-to-skin with the mother also helps prevent heat loss through conduction. ricci, ch. 17, p. 571

The nurse is preparing a teaching plan for new parents about why newborns experience heat loss. Which information about newborns would the nurse include? a. thick skin with deep lying blood vessels b. enhanced shivering ability c. expanded stores of glucose and glycogen d. limited voluntary muscle activity

d. limited voluntary muscle activity rationale: newborns have limited voluntary muscle activity or movement to produce heat. they have thin skin with blood vessels close to the surface. they cannot shiver to generate heat. they have limited stores of metabolic substances such as glucose and glycogen Ricci: Chapter 17, p. 570

The Apgar score is based on which 5 parameters?

heart rate, muscle tone, reflex irritability, respiratory effort, and color rationale: 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 evaluated by the presence of a strong cry and by color. Color is evaluated by noting the color of the body and hands and feet. ricci, ch. 18, p. 587

A nursing student will pick which value as a correct laboratory value for a newborn?

hemoglobin (Hbg) 17 g/dL (170 g/L) rationale: The normal laboratory values for a newborn include Hgb 16 to 18 g/dL (160 to 180 g/L), Hct 46% to 68% (0.46 to 0.68), platelet count 4,500,000/µL to 7,000,000/µL, (4,500 to 7,000 ×109/L) and WBC count 10 to 30,000/mm³ (0,1 to 30 ×109/L). From the values noted, only Hbg of 17 g/dL (170 g/L) is within normal range. ricci, ch. 17, p. 569

Which symptom would most accurately indicate that a newborn has experienced meconium aspiration during the birth process?

meconium stained fluids followed by tachypnea rationale: Meconium stained cord and skin indicates a potential of meconium aspiration, and the nurse should inform the primary care provider. But if the infant actually experiences respiratory distress following a birth with meconium stained fluids, the likelihood of meconium aspiration is greatly increased. Listlessness or lethargy by themselves does not indicate meconium aspiration. Bluish skin discoloration is normal in infants shortly after birth until the infant's respiratory system clears out all the amniotic fluid. ricci, ch. 23, p. 837

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?

two or three times per week rationale: Bathing two or three times weekly is sufficient for the first year; more frequent bathing may dry the skin. ricci, ch. 18, p. 610

at what point should the nurse expect a healthy newborn to pass meconium?

within 24 hours after birth rationale: The healthy newborn should pass meconium within 24 hours of life. ricci, ch. 17, p. 570

A nurse is assigned to care for a newborn with an elevated bilirubin level. Which symptom would the nurse expect to find during the infant's physical assessment?

yellow sclera rationale: The nurse should monitor for yellow skin or sclera in a newborn at risk for developing jaundice due to a high bilirubin. A heart rate of 130 bpm is normal for a newborn, as is a respiratory rate of 24 breaths/minute. Abdominal distension is not a consequence of an elevated bilirubin. ricci, ch. 17, p. 575

The nurse is teaching a prenatal class illustrating the steps that are used to keep families safe. The nurse determines the session is successful when the parents correctly choose which precaution to follow after the birth of their infant?

Check the identification badge of any health care worker before releasing baby from room. ricci, ch. 18, p. 615

A nurse is assigned to care for a newborn with hyperbilirubinemia. The newborn is relatively large in size and shows signs of listlessness. What most likely occurred?

The infant's mother probably had diabetes. rationale: The nurse should know that the infant's mother more than likely had/has diabetes. The large size of the infant born to a mother with diabetes is secondary to exposure to high levels of maternal glucose crossing the placenta into the fetal circulation. Common problems among infants of mothers with diabetes include macrosomia, respiratory distress syndrome, birth trauma, hypoglycemia, hypocalcemia and hypomagnesemia, polycythemia, hyperbilirubinemia, and congenital anomalies. Listlessness is also a common symptom noted in these infants. Infants born to clients who use alcohol during pregnancy, infants who have experienced birth traumas, or infants whose mothers have had long labors are not known to exhibit these particular characteristics, although these conditions do not produce very positive pregnancy outcomes. Infants with fetal alcohol spectrum disorder or alcohol exposure during pregnancy do not usually have hypoglycemia problems. ricci, ch. 24, p. 903

The nurse should carefully monitor which neonate for hyperbilirubinemia?

neonate with ABO incompatibility rationale: The mother's blood type, which is different from the neonate's, has an impact on the neonate's bilirubin level due to the antigen antibody reaction. Neonates of African descent tend to have lower mean levels of bilirubin. Chinese, Japanese, Korean, and Greek neonates tend to have higher incidences of hyperbilirubinemia. Neonates of Rh-negative, not Rh-positive, mothers tend to have hyperbilirubinemia. Low Apgar scores may indicate a risk for hyperbilirubinemia; 9 and 10 are high scores ricci, ch. 24, p. 905

A newborn's parents ask the nurse how to prevent the newborn from becoming ill. What is the best response by the nurse?

"Always wash your hands before you pick up or provide care to your newborn." rationale: Handwashing is the best way to prevent infections in newborn infants. Even the nursery personnel are required to perform a hand scrub before beginning their work in most nurseries. Vaccinations reduce the risk of infections but good handwashing is priority. Keeping the umbilical cord dry and clean helps prevent an infection at the site. It is not appropriate to restrict visitors who are healthy. ricci, ch. 18, p. 617

At a prenatal class the nurse describes the various birth weight terms that may be used to describe a newborn at birth. The nurse feels confident learning has occurred when a participant makes which statement?

"Newborns who are appropriate for gestational age at birth have lower chance of complications than others." rationale: Birth weight variations include appropriate for gestational age (AGA), which describes a newborn with a weight that falls within the 10th to 90th percentile for that particular gestational age. This describes approximately 80% of all newborns. Infants who are appropriate for gestational age have lower morbidity and mortality than other groups. ricci, ch. 23, p. 834

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 the first 2 to 4 hours, when the newborn reaches the nursery rationale: The nurse should complete the second assessment for the newborn within the first 2 to 4 hours, when the newborn is in the nursery. The nurse should complete the initial newborn assessment in the birthing area and the third assessment before the newborn is discharged, whenever that may be. ricci, ch. 18. p. 587

A premature infant is admitted to the neonatal intensive care unit with respiratory distress syndrome and requires assisted ventilation. The parents asks the nurse, "Why won't our baby breath on its own?" What is the nurse's best response?

"Your infant cannot sustain respirations yet due to the lack of assistance from surfactant." rationale: Preterm infants lacks surfactant to lower the surface tension in the alveoli and stabilize them to prevent their collapse. Even if preterm newborns can initiate respirations, they have a limited ability to retain air due to insufficient surfactant. Preterm newborns develop atelectasis quickly without alveoli stabilization. Fetal circulation patterns persist. ricci, ch. 23, p. 845

Which physical findings would the nurse observe in a newborn that would indicate that the newborn is full-term? Select all that apply.

- Creases on the feet cover 2/3 of the bottom of the feet. - Pinnae are flexible with rapid recoil. - Fingernails are present and extend to the end of the fingers. rationale: Full-term infants will have fingernails, a pinna with cartilage with rapid recoil when bent down, and creases over the upper 2/3 of the sole of the foot. The labia majora will be more prominent in full-term infants and their posture is flexed. ricci, ch. 17, p. 588-589, 603-604

A nurse is reviewing the history and physical examination findings of a postpartum woman and her female neonate. The neonate was healthy at birth but is now exhibiting signs of jaundice. Which factor(s) would the nurse assess to help identify the neonate suffers from jaundice? Select all that apply.

- use of oxytocin during labor - maternal gestational diabetes - maternal TORCH infection rationale: Common risk factors for the development of jaundice include fetal-maternal blood group incompatibility, prematurity, asphyxia at birth, an insufficient intake of milk during breastfeeding, drugs (such as diazepam, oxytocin, sulfisoxazole/erythromycin, and chloramphenicol), maternal gestational diabetes, infrequent feedings, male gender, trauma during birth resulting in cephalohematoma, cutaneous bruising from birth trauma, polycythemia, previous sibling with hyperbilirubinemia, and intrauterine infections such as TORCH (toxoplasmosis, rubella, cytomegalovirus, herpes simplex, and other organisms). ricci, ch. 17

A nurse is administering prescribed enteral feedings to assist in preparing the gut of a preterm newborn. Which type of solution would the nurse most likely administer for the feeding?

breast milk rationale: Currently, minimal enteral feeding is used to prepare the preterm newborn's gut to overcome the many feeding difficulties associated with gastrointestinal immaturity. It involves the introduction of small amounts of breast milk or enteral feeding to induce surges in gut hormones that enhance maturation of the intestine. This minute amount of breast milk or formula given via gavage (tube) feeding prepares the gut to absorb future introduction of nutrients. It builds mucosal bulk, stimulates development of enzymes, enhances pancreatic function, stimulates maturation of gastrointestinal hormones, reduces gastrointestinal distention and malabsorption, and enhances transition to oral feedings. All of the expert committees recommend the use of human milk, which reduces the risk of necrotizing enterocolitis, a serious disease of preterm infants in the neonatal period. Saline or sterile water are not used. ricci, ch. 23, p. 842

A 2-month-old infant is admitted to a local health care facility with an axillary temperature of 96.8° F (36° C). Which observed manifestation would confirm the occurrence of cold stress in this client? a. hyperglycemia b. increased appetite c. lethargy and hypotonia d. increase in the body temperature

c. lethargy and hypotonia rationale: the nurse should look for signs of lethargy and hypotonia in the newborn in order to confirm the occurrence of cold stress. cold stress leads to a decrease, not increase, in the newborn's body temperature, blood glucose, and appetite. ricci, chapter 17, p. 573

The nurse is assessing a newborn by auscultating the heart and lungs. Which natural phenomenon will the nurse explain to the parents is happening in the cardiovascular system? a. fluid is removed from alveoli and replaced with air b. the oxygen in the blood decreases c. pressure changes occur and result in closure of ductus arteriosus d. oxygen is exchanged in the lungs

c. pressure changes occur and result in closure of ductus arteriosus rationale: the ductus arteriosus is one of the openings through which there was fetal circulation. at birth, or within the first few days, this closes and the heart becomes the source of movement of blood to and from the lungs. the exchange of oxygen in the lungs and increasing oxygen content in the blood are respiratory functions. the removal from the alveoli occurs mainly during the birthing process and is completed by the lungs after birth. ricci, chapter 17, p. 564

The nurse assesses an infant. Which finding may indicate heart failure?

diminished peripheral pulses rationale: After birth, the nurse should carefully assess the newborn's cardiovascular and respiratory systems, looking for signs and symptoms of respiratory distress, cyanosis, or congestive heart failure that might indicate a cardiac anomaly. Assess rate, rhythm, and heart sounds, reporting any abnormalities immediately. Note any signs of heart failure, including edema, diminished peripheral pulses, hepatomegaly, tachycardia, diaphoresis, respiratory distress with tachypnea, peripheral pallor, and irritability. Capillary refill time and the color of the infant's hands and feet are important to note, but do not indicate possible heart failure and neither does the blood glucose level. ricci, ch. 24, p. 912

A 35-year-old client has just given birth to a healthy newborn during her 43rd week of gestation. What should the nurse expect when assessing the condition of the newborn?

meconium aspiration in utero or at birth rationale: Infants born after 42 weeks of pregnancy are postterm. These infants are at a higher risk of swallowing or aspirating meconium in utero or after birth. As soon as the infant is born, the nurse usually suctions out the secretions and fluids in the newborn's mouth and throat before the first breath to avoid aspiration of meconium and amniotic fluid into the lungs. Seizures, respiratory distress, cyanosis, and shrill cry are signs and symptoms of infants with intracranial hemorrhage. Intracranial hemorrhage can be a dangerous birth injury that is primarily a problem for preterm newborns, not postterm neonates. Yellow appearance of the newborn's skin is usually seen in infants with jaundice. Tremors, irritability, high-pitched or weak cry, and eye rolling are seen in infants with hypoglycemia. ricci, ch. 23, p. 858

An infant born 10 minutes prior was brought into the nursery for an examination. The nurse notices the infant's lip and palate are malformed. The parent comes up to door and asks if the infant seems okay. What is the appropriate response by the nurse?

"Come on over and I will explain your infant's exam and findings." rationale: The nurse should include the parents and notify them of any visible anomalies right away. An in-depth discussion can take place later when the diagnosis is more definitive. Although the family may be in shock or denial, the nurse should give a realistic appraisal of the condition of their infant. Keeping communication lines open will lessen the family's feelings of helplessness and support their parental role. ricci, ch. 23, p. 856

A nurse is observing the interaction between a new mother and her neonate. The nurse notes that the neonate moves his head and eyes to focus on the mother's voice and smile. The nurse interprets this as which behavioral response? a. motor maturity b. self-quieting behavior c. orientation d. habituation

c. orientation rationale: the neonate is demonstrating orientation, the neonate's ability to respond to auditory and visual stimuli, as demonstrated by the movement of head and eyes to focus on the stimuli. habituation is the newborn's ability to process and respond to visual and auditory stimuli. habituation is the ability to block out external stimuli after the newborn has become accustomed to the activity. motor maturity depends on gestational age and involves evaluation of posture, tone, coordination, and movements. these activities enable newborns to control and coordinate movement. when stimulated, newborns with good motor organization demonstrate movements that are rhythmic and spontaneous. self-quieting ability (also called self-soothing) refers to newborn's ability to quiet and comfort themselves. ricci, chapter 17, p. 580

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. - 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. rationale: To ensure the safety of their newborn, parents must understand how to keep their infant safe. They are to never leave their newborn unattended at any time, be sure to ask to see identification of anyone who comes into the room to remove the infant, don't remove the newborn's identification bands until leaving the hospital at discharge, and know when any test or procedures are scheduled for their newborn. Parents are instructed to question anyone who does not have proper identification or acts suspiciously. ricci, ch. 18, p. 592

A nurse is teaching new parents about keeping follow-up appointments and calling their health care provider if they notice signs of illness in their newborn. The nurse determines that the teaching was successful when the parents identify which signs as needing to be reported? Select all that apply.

- temperature of 38.3° C (101° F) or higher - refuse feeding - abdominal distention rationale: Parents should call their health care provider if they note any of the following warning signs: temperature of 38.3° C (101° F) or higher; forceful, persistent vomiting; refusal to take feedings; two or more green, watery diarrheal stools; infrequent wet diapers and change in bowel movements from normal pattern; lethargy or excessive sleepiness; inconsolable crying and extreme fussiness; abdominal distention; or difficult or labored breathing. ricci, ch. 18, p. 636

The nursing instructor is teaching a session on techniques that the nursing students can use to properly address concerns of parents with children who are born with a congenital disorder. The instructor determines the session is successful when the students correctly choose which nursing intervention as being the most effective in these situations?

use reflective listening and offer nonjudgmental support. rationale: Families are naturally apprehensive and find it difficult not to overprotect a child who is ill. They often increase the child's anxiety and cause fear in the child about participating in normal activities. Children are rather sensible about finding their own limitations and usually limit their activities to their capacity if they are not made unduly apprehensive. Some families can adjust well and provide guidance and security for the sick child. Others may become confused and frightened and show hostility, disinterest, or neglect; these families need guidance and counseling. The nurse has a great responsibility to support the family. The nurse's primary goal is to reduce anxiety in the child and family. This goal may be accomplished through open communication and ongoing contact. ricci, ch. 24, p. 889

Which statement made by a new nurse indicates additional teaching is needed on the topic of hyperbilirubinemia (physiologic jaundice) in newborns?

"Breastfed babies need supplements of glucose water to help lower bilirubin levels." rationale: Physiologic jaundice (hyperbilirubinemia) is characterized by a yellowish skin, mucous membranes, and sclera that occurs within the first 3 days of life. Physiologic jaundice is caused by accelerated destruction of fetal RBCs that have a shortened life span (80 days compared with the adult 120 days). Normally the liver removes bilirubin (the by-product of RBC destruction) from the blood and changes it into a form that can be excreted. As the red blood cell breakdown continues at a fast pace, the newborn's liver cannot keep up with bilirubin removal. Thus, bilirubin accumulates in the blood, causing the characteristic signs of physiologic jaundice. Expose the newborn to natural sunlight for short periods of time throughout the day to help oxidize the bilirubin deposits on the skin. Glucose water supplementation should be avoided since it hinders elimination. ricci, ch. 18, p. 621

A woman who is about to be discharged after a vaginal birth notices a flea-like rash on her newborn's chest that consists of tiny red lesions all across the nipple line. What is the best response from the nurse when explaining this to the woman?

"It is a normal skin finding in a newborn." rationale: This most likely is erythema toxicum, also known as newborn rash, and is a common finding that will gradually disappear and not need any treatment. This is often mistaken for staphylococcal pustules. This is not a sign of mistreatment by the woman, nor is it caused by a virus or group B streptococcal (GBS) infection. ricci, ch. 18, p. 598

A neonate born by cesarean birth required oxygen after the birth. The mother expresses concern because this was not a factor with her previous vaginal birth. What response by the nurse is most appropriate?

"Neonates born by cesarean do not benefit from the squeezing of the contractions, which helps to clear the lungs." rationale: During labor and delivery, the contractions provide pressure on the fetus. These forces "squeeze" the fetus's thoracic cavity. This aids the fetus in forcing the amniotic fluid from the lungs. The neonate born by cesarean does not have this experience, which may result in some initial periods of tachypnea and a need for oxygen supplementation. Maternal age and the uterine incision do not impact this phenomenon. ricci, ch. 17, p. 569

Parents tell the nurse they have been told to keep their newborn away from windows. They do not understand why this is necessary. Which rationale will the nurse provide to the parents?

"Newborns cannot shiver to produce heat and need to be kept away from sources of heat loss." rationale: Thermoregulation is difficult for newborns due to their inability to produce heat through muscle movement or shivering. They must rely on metabolizing brown fat. Placing a hat on the newborn can assist with thermoregulation. Newborns less than 8 lb (3630 g) still have brown fat. Windows can be problematic due to the potential for convective heat loss. Covering the newborn with heavy blankets is not recommended, because this can place the newborn at risk for sudden infant death syndrome (SIDS). ricci, ch. 17, p. 573-574

The student nurse is attending her first cesarean delivery and is asked by the mentor what should be carefully assessed in this infant. After responding "Respiratory status" the student is asked "Why?" What would be the best response?

"There is more fluid present in the lungs at birth after a cesarean delivery than after a vaginal delivery." rationale: The process of labor stimulates surfactant production, and much of the fetal lung fluid is squeezed out as the fetus moves down the birth canal. This so-called vaginal squeeze is an important way nature helps to clear the airway in preparation for the first breath. The vaginal squeeze also plays a role in stimulating lung expansion. The pressure of the birth canal on the fetal chest releases immediately when the infant is born. The lowered pressure from chest expansion draws air into the lungs. ricci, ch. 17, p. 568-569

New parents are getting ready to go home and have received information to help them learn how best to care for the new infant. Which statement indicates that they need additional teaching about how to soothe their newborn if he becomes upset?

"We'll hold off on feeding him for a while because he might be too full." rationale: The parents need more teaching that feeding or burping can be helpful in relieving air or stomach gas. 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 provides security and comfort. ricci, ch. 18, p. 617

A new parent is talking with the nurse about feeding the newborn. The parent has chosen to use formula. The parent asks, "How can I make sure that my baby is getting what is needed?" Which response(s) by the nurse would be appropriate? Select all that apply.

- "Make sure to use an iron-fortified formula until your baby is about 1 year old." - "Your baby gets enough fluid with formula, so you do not need to give extra water." - "It is important to give your baby vitamin D each day." rationale: Fluid requirements for the newborn and infant range from 100 to 150 mL/kg daily. This requirement can be met through breastfeeding or bottle feeding. Additional water supplementation is not necessary. Adequate carbohydrates, fats, protein, and vitamins are achieved through consumption of breast milk or formula. Iron-fortified formula is recommended for all infants who are not breastfed from birth to 1 year of age. The breastfed infant draws on iron reserves for the first 6 months and then needs iron-rich foods or supplementation added at 6 months of age. All infants (breastfed and bottle fed) should receive a daily supplement of 400 International Units of vitamin D starting within the first few days of life to prevent rickets and vitamin D deficiency. It is also recommended that fluoride supplementation be given to infants not receiving fluoridated water after the age of 6 months. ricci, ch. 18

The nurse in the NICU is caring for preterm newborns. Which guidelines are recommended for care of these newborns? Select all that apply.

- Supply oxygen for the newborn, if necessary. - Dress the newborn in ways to preserve warmth. - Take the newborn's temperature often. rationale: Controlling the temperature of preterm newborns is often difficult; therefore, special care should be taken to keep these babies warm. Nurses should dress them in a stockinette cap, take their temperature often, and supply oxygen, if necessary. To conserve the energy of small newborns, the nurse should handle them as little as possible. Usually, they will not give them a bath immediately. Parents should be encouraged to bond with their infants. ricci, ch. 23, p. 850

A newborn's ears are lined up below a line from the inner to outer canthus of the eye, extending past the ear. What other possible findings should the nurse be aware of in this client? Select all that apply.

- cognitive impairment - internal organ defects rationale: A newborn noted to have low-set ears often has associated cognitive impairments or internal organ defects. Numerous genetic disorders have low-set ears as one of the characteristics of the syndrome. Deafness, cleft palate and hydrocephalus are not associated with low-set ears. ricci, ch. 17, p. 603-604

A nursing instructor explains to students that, regardless of their gestational age, all newborns experience the same pattern that includes which periods? Select all that apply.

- first period of reactivity - period of decreased responsiveness - second period of reactivity ricci, ch. 17, p. 579

A nurse is caring for a newborn with hypoglycemia. For which symptoms of hypoglycemia should the nurse monitor the newborn? Select all that apply.

- lethargy - cyanosis - jitteriness rationale: The nurse should monitor the newborn for lethargy, cyanosis, and jitteriness. Low-pitched crying or rashes on the infant's skin are not signs generally associated with hypoglycemia. ch. 18, p. 622

Which factors could increase the risk of overheating in a newborn? Select all that apply.

- limited ability of diaphoresis - isolette that is too warm rationale: Limited sweating ability, a crib that is too warm or one that is placed too close to a sunny window, and limited insulation are factors that predispose a newborn to overheating. The immaturity of the newborn's central nervous system makes it difficult to create and maintain balance between heat production, heat gain, and heat loss. Underdeveloped lungs do not increase the risk of overheating. Lack of brown fat will make the infant feel cold because the infant will not have enough fat stores to burn in response to cold; it does not, however, increase the risk of overheating. ricci, ch. 17, p. 573

A nurse is preparing to administer erythromycin ointment to a 30-minute-old newborn. What will the nurse do first?

Review the health care provider's order. rationale: Prior to administering the erythromycin ointment, the nurse will review the order. The nurse would then explain the procedure to the caregivers, apply gloves, and administer the medication in both eyes. ricci, ch. 18, p. 593

A nurse is called into the room of one of the clients where the grandparents are visiting. The grandmother is visibly upset, and says "Just look at my grandson! His head is all soft and swollen here and it shouldn't be. The doctor injured him when he was born." The nurse assesses the newborn and finds an area of swelling about the size of a half-dollar at the center of the upper scalp. The nurse determines this finding is most likely which condition?

Caput succedaneum rationale: Caput succedaneum is swelling of the soft tissue of the scalp caused by pressure of the presenting part on a partially dilated cervix or trauma from a vacuum-assisted delivery. This finding is often of concern for the families. Reassure them that the caput will decrease in a few days without treatment. Increased intracranial pressure would involve the entire scalp and not just a small portion. There would also be other neurologic signs accompanying it. Molding is an elongated head shape caused by overlapping of the cranial bones as the fetus moves through the birth canal. This will also resolve in a few days without treatment. The Harlequin sign is characterized by a clown-suit-like appearance of the newborn where the skin is dark red on one side of the body and the other side is pale. This is a harmless condition which occurs most frequently with vigorous crying or with the infant lying on his or her side. ricci, ch. 17, p. 600-602

The nurse explains the hospital's home visitation program for new families after discharge from the hospital. Which information will the nurse include regarding this program?

Caregivers can demonstrate competency in caring for the infant and ask questions. rationale: Home visitation programs provide caregivers with opportunities to do return demonstrations of care, ask questions of a professional, and be reassured of their ability to care for their infant. The visiting nurses do not take over care of the infant or serve as an arbitrator for disagreements. All necessary procedures will be completed in the hospital prior to discharge. ricci, ch. 18, p. 636

The nurse has admitted a small for gestational age infant (SGA) to the observation nursery from the birth room. Which action would the nurse prioritize in the newborn's care plan?

Closely monitor temperature. rationale: Difficulty with thermoregulation in SGA newborns is common due to less muscle mass, less brown fat, less heat-preserving subcutaneous fat, and limited ability to control skin capillaries. The priority would be to closely monitor the newborn's temperature. It is also is associated with depleted glycogen stores; therefore, this is hypoglycemia not hyperglycemia. Immaturity of CNS (temperature-regulating center) interferes with ability to regulate body temperature. Intake and output monitoring and observing feeding are not the priority. ricci, ch. 23, p. 850

The nurse walks into a client's room and notes a small fan blowing on the mother as she holds her infant. The nurse should explain this can result in the infant losing body heat based on which mechanism?

Convection rationale: There are four main ways that a newborn loses heat; convection is one of the four and occurs when cold air blows over the body of the infant resulting in a cooling to the infant. Conductive heat loss occurs when the newborn's skin touches a cold surface, causing body heat to transfer to the colder object. Heat loss occurs by radiation to a cold object that is close to, but not touching, the newborn. Evaporative heat loss happens when the newborn's skin is wet. As the moisture evaporates from the body surface, the newborn loses body heat along with the moisture. The cold air blowing on the infant's skin will cause heat loss. ricci, ch. 17, p. 571

A nurse is observing a new parent bottle feeding the newborn. The nurse notices that the newborn begins to get fussy during the feeding. Which action by the nurse would be appropriate?

Encourage the parent to burp the newborn to get rid of air. rationale: Newborns swallow air during feedings, which causes discomfort and fussiness. Parents can prevent fussiness by burping them frequently throughout the feeding. Therefore, the best suggestion would be to have the parent burp the newborn. The newborn may or may not be full; the newborn may still be hungry but excess air in the stomach is making the newborn fussy. Feeding is a time for closeness. Propping a bottle interferes with bonding and increases the risk of choking and other problems. Stopping the feeding and then restarting it would do nothing to help alleviate the swallowed air and may contribute to more air being swallowed. ricci, ch. 18

What are small unopened or plugged sebaceous glands that occur in a newborn's mouth and gums?

Epstein pearls rationale: Unopened sebaceous glands are generally called milia. When they are in the mouth and gums, they are called Epstein pearls. ricci, ch. 18, p. 598

The nurse is inspecting the mouth of a newborn and finds small, white cysts on the gums and hard palate. The nurse documents this finding as:

Epstein pearls. rationale: Epstein pearls are small, white epidermal cysts on the gums and hard palate that disappear in weeks. Thrush is white plaque inside the mouth caused by exposure to Candida albicans during birth, which cannot be wiped away with a cotton-tipped applicator. Milia are multiple pearly-white or pale yellow unopened sebaceous glands frequently found on a newborn's nose. Vernix caseosa is a thick white substance that protects the skin of the fetus. It is formed by secretions from the fetus's oil glands and is found during the first 2 or 3 days after birth in body creases and the hair. ricci, ch. 18, p. 603

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?

Evaporative ricci, ch. 18k p. 594

The nurse is caring for a newborn who was delivered via a planned cesarean delivery. The nurse determines the infant requires closer monitoring than a vaginal delivery infant based on which factor?

Excessive fluid in its lungs, making respiratory adaptation more challenging. rationale: During a vaginal birth the infant is squeezed by uterine contractions, which squeeze fluid out of the lungs and prepare them for breathing. The infant who is born via cesarean delivery without labor first does not have the mechanical removal of the fluid from the lungs. This places the infant at increased risk for respiratory compromise, so there is a need to more closely assess a newborn after birth. The lungs should inflate once the baby is delivered and not wait until the amniotic fluid is absorbed. The umbilical cord is not clamped until the infant is out of the womb and starts to take its first breaths. ricci, ch. 17, p. 569

A nurse is caring for an infant born with polycythemia. Which intervention is most appropriate when caring for this infant?

Focus on decreasing blood viscosity by increasing fluid volume. rationale: The nurse should focus on decreasing blood viscosity by increasing fluid volume in the newborn with polycythemia. Checking blood glucose within 2 hours of birth by a reagent test strip and screening every 2 to 3 hours or before feeds are not interventions that will alleviate the condition of an infant with polycythemia. The nurse should monitor and maintain blood glucose levels when caring for a newborn with hypoglycemia, not polycythemia. ricci, ch. 23, p 837

The nurse is caring for a 22-hour-old neonate male and notes on assessment at the beginning of the shift: Apgar score of 9, nursing without difficulty, and appeared healthy. As the nurse's shift goes on, subsequent assessment reveals his sclera and skin have begun to take on a yellow hue. The nurse would report this as a possible indication of what condition?

Hemolytic disease rationale: Any infant admitted to the newborn nursery should be examined for jaundice during the first 36 hours or more. Early development of jaundice (within the first 24 to 48 hours) is a probable indication of hemolytic disease. Heroin withdrawal symptoms commonly include tremors, restlessness, hyperactivity, disorganized or hyperactive reflexes, increased muscle tone, sneezing, tachypnea, vomiting, diarrhea, disturbed sleep patterns, and a shrill high-pitched cry. The hypoglycemic newborn's blood glucose would be low, and a newborn with hypoxia would show signs of respiratory distress. ricci, ch. 24, p. 905

The nurse is explaining to new parents the various injections their newborn will receive before being discharged home. Which injection should the nurse teach the parents about that will help decrease the incidence of hepatic disease later in life?

Hep B rationale: Hep B is the vaccination against hepatitis B and recommended by the CDC. It has been found to help prevent cirrhosis and liver cancer later in life. The HBV immunoglobin may be given in conjunction with the hep B if the mother is found to be HBV positive. The HiB is given later, usually at the 2-month visit. ricci, ch. 18, p. 637

A nurse is caring for an infant. A serum blood sugar of 40 was noted at birth. What care should the nurse provide to this newborn?

Ineffective thermoregulation related to decreased amount of subcutaneous fat rationale: In the condition of hypothermia, newborns typically metabolize brown fat. This requires the newborn to use glucose and oxygen. A premature infant is at risk for respiratory distress and hypoglycemia. The hypoglycemia can increase the infant's need for glucose and oxygen, which, in turn, could cause more severe disease or further complications. The other diagnoses are appropriate but not the highest priority. ricci, ch. 24, p. 870

The nurse is caring for a newborn after the parents have spent time bonding. As the nurse performs the assessment and evidence-based care, which eye care will the nurse prioritize?

Instill 0.5% ophthalmic erythromycin. rationale: The standard eye care to prevent ophthalmia neonatorum is 0.5% erythromycin ointment or 1% tetracycline eye drops. Although 1% silver nitrate drops were once used, it has been discontinued due to its ineffectiveness. The nurse would not wait to see if the eyes show signs of irritation before administering the medication. Delaying could lead to preventable blindness. ricci, ch. 18, p. 593

The nurse is concerned that the nares of a newborn are not patent bilaterally. What can the nurse do to address this concern?

Occlude the nares one at a time by applying pressure to each side to see if the newborn can breath comfortably. rationale: If a nurse is concerned that the nostrils are patent in a newborn, the nurse will occlude the nares one at a time to see if the newborn can breath easily. The nurse would never place something like a swab into the nares to check patency due to potential trauma. Nasal flaring is an abnormal finding and indicates respiratory distress, not ease of breathing. Passing an NG tube is traumatic to the newborn and is not needed in most cases. ricci, ch. 17, p. 602

A ventilated 33 weeks' gestation newborn in the neonatal intensive care unit (NICU) receives surfactant therapy. Which would the nurse expect to assess as a positive response to this therapy?

Oxygen saturation levels are at 98%. rationale: Rescue treatment is indicated for newborns with established RDS who require mechanical ventilation and supplemental oxygen. The earlier the surfactant is administered, the better the effect on gas exchange with an aim to have the O2 saturation level of 98%. Glucose level assessment does not correlate with this therapy. The HR of 60 bpm is an abnormal finding and not a positive result of the therapy. The PaCO2 indicates respiratory acidosis. ricci, ch. 24, p. 874

A nurse is required to obtain the temperature of a healthy newborn who was placed in an open crib. Which is the most appropriate method for measuring a newborn's temperature?

Place electronic temperature probe in the midaxillary area. rationale: The nurse should obtain a newborn's temperature by placing an electronic temperature probe in the midaxillary area. The nurse should not tape an electronic thermistor probe to the abdominal skin, as this method is applied only when the newborn is placed under a radiant heat source. Rectal temperatures are no longer taken because of the risk of perforation. Oral temperature readings are not taken for newborns. ricci, ch. 18., p. 588

The nurse notes a newborn has a temperature of 97.4° F (36.3° C) on assessment. The nurse acts to prevent which complication first?

Respiratory distress rationale: It takes oxygen to produce heat and an infant who has an episode of cold stress is at risk for respiratory distress. The infant needs to be warmed. The temperature should be in the range of 97.7°F to 98.6°F (36.5°C to 37°C). After respiratory distress sets in, it can be followed by seizures, cardiovascular distress, or hypoglycemia. ricci, ch. 17, p. 573

The nurse notes a newborn has a temperature of 97.4oF (36.3oC) on assessment. The nurse acts to prevent which complication first?

Respiratory distress rationale: It takes oxygen to produce heat and an infant who has an episode of cold stress is at risk for respiratory distress. The infant needs to be warmed. The temperature should be in the range of 97.7°F to 98.6°F (36.5°C to 37°C). After respiratory distress sets in, it can be followed by seizures, cardiovascular distress, or hypoglycemia. ricci, ch. 17, p. 573

The nurse assesses preterm infants as they come for routine well-baby checkups. The nurse will carefully assess the infant's vision to assess for which potential complication related to their birth?

Retinopathy rationale: Retinopathy of prematurity (ROP) is a form of retinopathy (degenerative disease of the retina) commonly associated with the preterm newborn. Cataracts is common among older adults and results from the lens becoming opaque. Amblyopia, or lazy eye, is not related to gestational age and is assessed when the child is a toddler. Nystagmus is also not related to gestational age but to neurologic dysfunction of the eye. ricci, ch. 24, p. 880

A nurse is caring for a preterm newborn who has developed rapid, irregular respirations with periods of apnea. Which additional assessment finding should the nurse identify as an indication of respiratory distress syndrome (RDS)?

Sternal retraction rationale: The nurse should identify sternal retraction as a sign of respiratory distress syndrome in the preterm newborn. Deep inspiration is not seen during respiratory distress; rather, a shallow and rapid respiration is seen. There is an inspiratory lag, instead of an expiratory lag, during respiratory distress. There is a grunting heard when the air is breathed out, which is during expiration and not during inspiration. ricci, ch. 23, p. 845

The nurse is working in the special care nursery caring for a newborn withdrawing from alcohol. Which nursing intervention promotes client comfort?

Swaddle and decrease stimulation rationale: Swaddling and decreasing stimulation is helpful in providing relaxation and comfort for the newborn withdrawing from alcohol. Benzodiazepines are to prevent seizure activity. Providing small amounts of formula frequently supports weight gain. Promoting parental bonding is important for the newborn and parents to help the infant meet developmental milestones. ricci, ch. 24, p. 902

The nurse is examining a newborn and notes that there is bruising and swelling on the newborn's head, limited to the right side of the scalp and does not cross the suture lines. How will the nurse interpret this finding?

This is a cephalohematoma that typically spontaneously resolves without interventions. rationale: The newborn is exhibiting signs of a cephalohematoma, a collection of blood under the periosteum of the skull. It is caused by birth trauma and should resolve spontaneously. If the swelling crosses the suture line, caput succedaneum is suspected. A subarachnoid hemorrhage in a newborn usually results in symptoms such as seizures, apnea, and bradycardia. ricci, ch. 17, p. 600-601

The nurse is examining a newborn and notes that there is bruising and swelling on the newborn's head, limited to the right side of the scalp and does not cross the suture lines. How will the nurse interpret this finding?

This is a cephalohematoma that typically spontaneously resolves without interventions. rationale: The newborn is exhibiting signs of a cephalohematoma, a collection of blood under the periosteum of the skull. It is caused by birth trauma and should resolve spontaneously. If the swelling crosses the suture line, caput succedaneum is suspected. A subarachnoid hemorrhage in a newborn usually results in symptoms such as seizures, apnea, and bradycardia. ricci, ch. 17, p. 600-601

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?

Using a bulb syringe, suction the mouth then the nose. rationale: A bulb syringe is used initially to suction secretions from a newborn's mouth and nose, starting with the mouth so the newborn does not aspirate the mucus into its lungs. Suctioning the nose first may stimulate the newborn to gasp or cry and this may lead to aspiration. A suction catheter is only used if the bulb syringe cannot manage all the secretions. Patting the newborn on the back will not clear out all the oral secretions. ricci, ch. 18, p. 591

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?

Wear clean gloves. rationale: Infection control is a priority nursing intervention. Gloves need to be worn when in contact with the infant who has not been bathed after birth. All options are valid options; however, a three-minute surgical scrub is generally only required at the beginning of a shift. The nurse should always wash the hands before putting on gloves to care for an infant and after taking gloves off. Standard precautions are used with every client. ricci, ch. 18, p. 612

Upon examination of the skin, which assessment findings would the nurse recognize as normal findings for a full-term newborn at 3 hours of age? Select all that apply. a. lanugo on the back b. acrocyanosis c. jaundice d. milia e. vernix caseosa over the abdomen and lower extremities

a. lanugo on the back b. acrocyanosis d. milia rationale: a full-term newborn may have thin patches of lanugo over his back, shoulders, or arms. he may also have milia, which appear as white papules on the face. acrocyanosis at 3 hours of age is also a normal finding. however, this should resolve by 24-48 hours. a newborn at 3 hours of age should never have jaundice. vernix on the abdomen and lower extremities is seen in preterm infants, not full-term ones. ricci, chapter 17, p. 597-598

What is the first action taken by a nurse caring for a newborn with suspected hypoglycemia? a. perform a heel stick to obtain a blood sample for testing for glucose level b. feed the newborn some formula immediately c. start IV to provide intravenous glucose d. check the client's blood sugar by venous blood draw

a. perform a heel stick to obtain a blood sample for testing for glucose level rationale: if a newborn is noted to be jittery or exhibiting symptoms of hypoglycemia, the nurse should first do a heel stick to check the client's glucose level. after the glucose level is determined, then the nurse will determine what interventions to implement. a venous blood draw is not needed to check the newborn's glucose levels. ricci, chapter 17, p. 622

The nurse describes the changes in stool that a new mother would see when feeding her newborn formula. Which description best indicates what the mother would observe after several days? a. yellow-green, pasty, unpleasant-smelling stool b. sour-smelling, yellowish-gold stool c. thin, yellowish, seedy brown stool d. greenish, tarry, thick black stool

a. yellow-green, pasty, unpleasant-smelling stool rationale: the stool of formula-fed newborns varies depending on the type of formula ingested, but it typically is yellow, yellow-green, or greenish, loose, pasty, or formed with an unpleasant odor. greenish-black tarry stool denotes meconium. thin, yellowish, seedy brown stool characterizes the transitional stool that occurs after meconium. sour-smelling yellowish-gold stool that is loose and stringy to pasty in consistency is typical of a breastfed newborn stool. Ricci: chapter 17, p. 577

When examining a newborn for developmental dysplasia of the hip (DDH), which motion would the newborn's hip be unable to accomplish?

abduction rationale: Infants with shallow acetabulums are unable to abduct their hips. ricci, ch. 24, p. 929

A newborn with high serum bilirubin is receiving phototherapy. Which nursing intervention is the most appropriate for this client?

application of eye dressings to the infant rationale: Continuous exposure to bright lights by phototherapy may be harmful to a newborn's retina, so the infant's eyes must always be covered while under bilirubin lights. Eye dressings or cotton balls can be firmly secured in place by an infant mask. The lights are placed 12 to 30 inches above the newborn's bassinet or incubator. Bilirubin is removed from the body by being incorporated into feces. Therefore, the sooner bowel elimination begins, the sooner bilirubin removal begins. Early feeding (either breast milk or formula), therefore, stimulates bowel peristalsis and helps to accomplish this. Gently shaking the infant is a method of stimulating breathing in an infant experiencing apnea. ricci, ch. 24, p. 907

The nurse is caring for an infant born to a mother with cocaine use disorder during her pregnancy. The nurse would likely notice that this infant:

cries when touched. rationale: Developmental delays occur in young children of mothers with a substance use disorder. Infants of mothers with cocaine use disorder do not like to be touched or held and avoid the caregiver's gaze, which contributes to bonding delays. Infants of mothers with cocaine use disorder are often restless and below average weight when born. ricci, ch. 24, p. 899

Upon assessing the newborn's respirations, which finding would cause the nurse to notify the primary care provider? a. short periods of apnea that last 10 seconds in a pink newborn b. coughing and sneezing in the newborn c. respiratory rate of 15 breaths per minute with nasal flaring d. respiratory rate of 45 breaths per minute with acrocyanosis

c. respiratory rate of 15 breaths per minute with nasal flaring rationale: coughing and sneezing are normal reflexes present in the newborn. the respiratory rate of a newborn should be between 30-60 breaths per minute. acrocyanosis can be a normal finding in a newborn and does not indicate respiratory distress. short periods of apnea that last longer than 15 seconds in the absence of cyanosis can be normal. nasal flaring is a sign of respiratory distress. Ricci: chapter 17, p. 568

The nurse is aware that the newborn's circulatory dynamics during transition can be positively affected by which action?

delayed umbilical cord clamping rationale: Early (before 30 to 40 seconds) or late (after 3 minutes) clamping of the umbilical cord changes circulatory dynamics during transition. Recent studies indicate that the benefits of delayed cord clamping include improving the newborn's cardiopulmonary adaptation, preventing iron-deficient anemia in full-term newborns without increasing hypervolemia-related risks and increased iron stores, increasing blood pressure, improving oxygen transport, and increasing red blood cell flow. Although a tailored approach is required in the case of cord clamping, current available data suggest that delayed cord clamping offers the newborn many benefits physiologically which include at least a 30 percent increase in blood volume for term infants and a 50 percent increase in preterm infants; improvement of systemic blood pressure; increase in the cerebral oxygen index; higher hemoglobin levels at 24 to 48 hours of age and increased serum iron levels at 4 to 6 months. ricci, ch. 17, p. 567

A new mother asks the nurse why her baby's back and groin have a red and raised rash. The nurses uses which term to correctly identify this condition?

erythema toxicum rationale: 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. ricci, ch. 18, p. 598

Which laboratory test results would the nurse consider as a normal finding in a newborn soon after birth?

hemoglobin: 17.5 g/dl rationale: Hemoglobin typically ranges from 17 to 20 g/dl. White blood cells are initially elevated soon after birth as a result of birth trauma, typically ranging from 10,000 to 30,000/mm3. The newborn's platelet count is the same as that for an adult, ranging between 100,000 and 300,000/uL. After birth, the red blood cell count gradually increases as the cell size decreases. Normal count ranges from 5,100,000 to 5,800,000/uL. ricci, ch. 17, p. 569

When planning preoperative care for a newborn with a cleft lip and palate, the nurse would plan interventions for which major need?

nutrition rationale: An infant with a cleft lip is unable to suck effectively, so obtaining adequate nutrition is a major concern. ricci, ch. 24, p. 920

When caring for a neonate receiving phototherapy, the nurse should remember to:

reposition the neonate frequently. rationale: Phototherapy works by the chemical interaction between a light source and the bilirubin in the neonate's skin. Therefore, the larger the skin area exposed to light, the more effective the treatment. Changing the neonate's position frequently ensures maximum exposure. Because the neonate will lose water through the skin as a result of evaporation, the amount of formula or water may need to be increased. The neonate is typically undressed to ensure maximum skin exposure. The eyes are covered to protect them from light, and an abbreviated diaper is used to prevent soiling. The skin should be clean and patted dry. Use of lotions would interfere with phototherapy. ricci, ch. 24, p. 907

when assessing the newborn's umbilical cord, what should the nurse expect to find?

two smaller arteries and one larger vein rationale: When inspecting the vessels in the umbilical cord, the nurse should expect to encounter one larger vein and two smaller arteries. In 0.5% of births (3.5% of twin births), there is only one umbilical artery, which can be linked to cardiac or chromosomal abnormalities. ricci, ch. 17, p. 565

The nurse is admitting a newborn male for observation with the diagnosis of preterm. What assessment finding corresponds with this gestational age diagnosis?

undescended testes rationale: Some common physical characteristics of preterm infants include: undescended testes in the male; absent to a few creases in the soles and palms; breast and nipples not clearly delineated; and abundant vernix caseosa. ricci, ch. 23, p. 841