Newborn Care

A nurse is caring for the 1-hour-old newborn of a mother with diabetes mellitus. Which actions will the nurse include in the newborn's plan of care? Select all that apply. A) Assess blood glucose frequently. B) Assess for SGA. C) Assess for hyperthyroidism. D) Assess the newborn's temperature hourly. E) Assess for hyperbilirubinemia.

A & E In a newborn of a mother with​ diabetes, the onset of hypoglycemia occurs at​ 1-3 hours after birth and can continue for several days. Blood glucose levels should be checked frequently during the first several days. The nurse should assess lab results for​ hypocalcemia, hyperbilirubinemia, and polycythemia. Alterations in temperature and thyroid hormone levels are not associated with newborns of mothers with diabetes. Newborns of mothers with diabetes are often LGA​ (large for gestational​ age), not SGA​ (small for gestational​ age).

A new mother plans to feed the newborn every 3 hours. Which response should the nurse make? A. "Babies do not conform to a strict schedule." B. "That is not often enough." C. "That sounds like a good plan." D. "That is too often."

A. "Babies do not conform to a strict schedule." Breastfed babies eat every 2-3 hours, but the parent should be able to identify hunger cues, as all babies do not adhere to a strict schedule. The nurse should not reinforce the plan or comment that the feeding schedule is too often or not often enough.

A patient who is HIV positive gives birth and states, "I want to breastfeed my baby." Which response should the nurse make? A. "It is not recommended that you breastfeed." B. "You can breastfeed once your baby is started on antiretroviral therapy." C. "Breastfeeding is only recommended if you and your baby are on antiretroviral therapy." D. "You can breastfeed as long as you continue with antiretroviral therapy."

A. "It is not recommended that you breastfeed." HIV can be transmitted through the breast milk. Breastfeeding is contraindicated for the patient with HIV, regardless of whether the patient or the newborn is treated with antiretroviral therapy.

The mother of a newborn who is small for gestational age (SGA) asks, "What does this mean?" Which statement should the nurse make in response? A. "Your baby's weight falls below the 10th percentile." B. "Your baby's head circumference is at the 50th percentile." C. "Your baby weighs less than 2500 g (5.5 lb)." D. "Your baby was exposed to bacteria in utero."

A. "Your baby's weight falls below the 10th percentile." Infants classified as small for gestational age (SGA) weigh below the 10th percentile. Intrauterine bacterial exposure is not associated with SGA. Newborns can weigh less than 5 lb, 8 oz (2500 g) and, based on gestational age, still be classified as appropriate for gestational age or large for gestational age. A head circumference at the 50th percentile is appropriate for gestational age.

The nurse notes that 1 minute after birth, a newborn has a heart rate of 140 beats/min, prompt crying with stimulation occurs, blue extremities, a lusty cry, and is able to maintain minimal flexion with sluggish movement. Which Apgar score should the nurse assign the newborn? A. 8 B. 7 C. 9 D. 10

A. 8 The Apgar scoring system is used to evaluate the physical condition of the newborn at birth. The newborn is rated 1 minute after birth and again at 5 minutes and receives a total score (Apgar score) ranging from 0 to 10 based on the following assessments: heart rate, respiratory effort, muscle tone, reflex irritability, and skin color. The score for each category ranges from 0-2. Two points each are assigned for heart rate, respiratory effort, and reflex irritability. One point each is assigned for color and muscle tone, for a total score of 8.

The nurse is performing an assessment of a newborn immediately after birth. Which initial nursing assessment should the nurse use to identify if the newborn is at-risk? A. Apgar score B. Skin color of the newborn C. Newborn's respiratory effort D. Maternal pregnancy history

A. Apgar score The Apgar scoring system is used to evaluate the physical condition of the newborn at birth. The newborn is rated 1 minute after birth and again at 5 minutes and receives a total score (Apgar score) ranging from 0 to 10 based on the following assessments: heart rate, respiratory rate, muscle tone, reflex irritability, and skin color. The maternal pregnancy history can provide some information, but the Apgar score is an initial nursing assessment of the newborn.

The hemoglobin and hematocrit levels of a 10-day-old newborn reflects anemia. Which factor should the nurse understand contributes to the decreased hemoglobin level of the newborn? A. Decrease in red blood cell mass B. Decrease in oral fluids in the newborn C. Increase in plasma volume D. Decrease in the number of red blood cells

A. Decrease in red blood cell mass The primary contributing factor to the physiological anemia of infancy is a decrease in the red blood cell mass. An additional factor that influences the degree of physiological anemia is the nutritional status of the newborn. Supplies of vitamin E, folic acid, and iron may be inadequate given the amount of growth in the later part of the first year of life. The decrease in the lifespan of the red blood cells and lifespan of plasma contribute to the physiological anemia of the newborn. A decrease in oral fluids increases the hematocrit level.

A newborn is diagnosed as large for gestational age (LGA). Which maternal health problem should the nurse expect? A. Diabetes B. Substance abuse C. Hyperthyroidism D. Sickle cell disease

A. Diabetes LGA infants are associated with maternal diabetes. Hyperthyroidism, substance abuse, and sickle cell disease are not associated with LGA.

The nurse is providing care to a newborn born at 37​ 2/7 weeks' gestation. The​ newborn's weight is 1750 g​ (3 pounds, 10​ ounces). What statement would the nurse use to describe these assessment​ findings? A. Early term small for gestational age B. Preterm appropriate for gestational age C. Term appropriate for gestational age D. Preterm small for gestational age

A. Early term small for gestational age The infant is term at 37​ 2/7 weeks. Early term is defined as births that occur between 37 weeks 0 age and 38 weeks 6 days. Because the weight is below the 10th​ percentile, the infant is not appropriate for gestational age but is considered small for gestational age.

A patient in labor admits to illegal substance abuse throughout the pregnancy. Which neonatal assessment finding should the nurse anticipate after delivery of the newborn? A. Intrauterine growth restriction B. Lethargy C. Hypoglycemia D. Polycythemia

A. Intrauterine growth restriction A newborn habitually exposed to an illegal substance is at risk for intrauterine growth restriction (IUGR). Lethargy, polycythemia, and hypoglycemia are not associated with illegal substance abuse.

During labor, a patient's amniotic membranes rupture and the fluid appears green in color. Which collaborative intervention should the nurse anticipate? A. Neonatal intubation B. Emergency cesarean birth C. Surfactant replacement D. Maternal antibiotic administration

A. Neonatal intubation Green amniotic fluid indicates that the neonate has passed meconium into the amniotic fluid. Meconium is passed in utero secondary to stress or hypoxia. This fluid may be aspirated into the tracheobronchial tree in utero or during the first few breaths taken by the newborn. Meconium causes chemical irritation and also forms small balls that become lodged in terminal airways, allowing some air to enter the alveoli but not allowing air to escape. The neonate may need to be intubated after birth, so additional suctioning of the airway can be performed to prevent aspiration. A maternal antibiotic, surfactant replacement, and a cesarean birth are not necessary in the treatment of meconium-stained fluid.

A newborn is awake, alert, and appears to react to visual stimuli. Which behavioral state should the nurse document in the newborn's medical record? A. Quiet alert B. Drowsy C. Active alert D. Light sleep

A. Quiet alert Based on the assessment findings, the newborn's behavioral state is quiet alert. In the quiet alert state, the newborn is alert and follows and fixates on attractive objects, faces, or auditory stimuli. The active-alert stage includes intense motor activity and sensitivity to environmental stimuli. The light-sleep stage is characterized by irregular respirations, eyes closed with REM, irregular sucking motions, minimal activity, and irregular but smooth movement of the extremities. The behaviors common to the drowsy state are open or closed eyes, fluttering eyelids, semi-dozing appearance, and slow, regular movements of the extremities.

The nurse conducting a​ 5-minute Apgar assessment on a newborn assigns the following​ ratings: Heart rate​ <100 beats per minute​ (1 point);​ slow, irregular respirations​ (1 point); some flexion of the extremities​ (1 point); a vigorous cry with flicking of the​ baby's foot​ (2 points); and a pink body with blue extremities​ (1 point). Based on this​ data, which nursing action is​ appropriate? A. Repeating the assessment every 5 minutes for up to 20 minutes B. Placing the newborn in the​ mother's arms and asking her to monitor her​ baby's breathing C. Having the aide reassess the​ newborn's heart rate and respiratory rate when admitted to the nursery D. Swaddling the newborn to decrease the risk of increased energy expenditure

A. Repeating the assessment every 5 minutes for up to 20 minutes With a​ 5-minute Apgar of​ 6, this newborn is at increased risk for complications compared to those with Apgar scores in the range of 7 to 10. The nurse will reassess the client every 5 minutes for up to 20 minutes. The nurse should have resuscitative equipment ready for use. The other actions are not appropriate based on the data provided.

The nurse is teaching a postpartum patient on newborn care. Which information should the nurse include about the normal voiding pattern of a newborn? A. Void at least 5 times per day after the first few days B. Have 2-4 wet diapers per day by the end of the first day C. Have 4-6 wet diapers per day by the end of the first week D. Have at least 10 wet diapers per day by the end of the first week

A. Void at least 5 times per day after the first few days The newborn should void at least 5 times per day after the first few days. During the first 2 days after birth, the newborn voids 2-6 times daily, with a urine output of 15 mL/kg per day.

The nurse is instructing a new mother on how to care for the newborn's circumcision site. Which statements indicate that the nurse's education session was effective? Select all that apply. A) "I should not use petroleum jelly on the penis." B) "Every time I change the diaper I am to wash the area with warm water." C) "I should report any pus drainage or change in diaper wetness to the physician." D) "Swelling is expected." E) "I am to use soap and water to remove yellow tissue on the penis."

B & C The nurse should instruct the mother to wash the area with warm water after every diaper​ change, to use petroleum jelly to protect the penis and prevent​ bleeding, and to report any pus drainage or change in urine output to the physician. Yellow tissue on the penis is granulation​ tissue, which is evidence of healing and should not be washed off with soap and water. Swelling is not expected after a circumcision and should be reported to the physician.

When administering an intramuscular dose of vitamin K (phytonadione) to a newborn, which actions by the nurse are appropriate? Select all that apply. A) Using a 23-gauge 1/2-inch needle B) Cleaning the skin with an alcohol swab C) Preparing 5 mg of the medication for injection D) Using the middle third of the vastus lateralis muscle E) Washing the skin with soap and water

B & D A single dose of vitamin K​ (phytonadione) is administered to newborns within 1 hour of birth. The nurse should use the middle third of the vastus lateralis​ muscle, clean the skin with an alcohol​ swab, and use a​ 27-gauge 1/2-inch needle. The skin is not to be washed with soap and water before the injection. The medication dosage is between 0.5 and 1.0 mg.

Immediately after delivery, a mother asks, "Am I doing something wrong? My baby is not breastfeeding." Which response should the nurse make? A. "We can give the baby a bottle, and you can try to breastfeed later." B. "You are doing nothing wrong; babies are not always interested in breastfeeding right away." C. "I will get the lactation consultant to help you later." D. "Some babies prefer a bottle because it is easier for them to suck the nipple of a bottle."

B. "You are doing nothing wrong; babies are not always interested in breastfeeding right away." Babies are not always interested in breastfeeding right away. There is no need to provide the baby with a bottle or consult the lactation specialist.

A 4-week-old formula-fed newborn had a birth weight of 7 lb (3.17 kg). Which newborn weight should the nurse anticipate? A. 8 lb, 7 oz (3.82 kg) B. 7 lb, 14 oz (3.57 kg) C. 8 lb, 14 oz (4.02 kg) D. 7 lb, 7 oz (3.37 kg)

B. 7 lb, 14 oz (3.57 kg) It is normal for the newborn to lose weight after birth, but the newborn is expected to continue gaining weight after 2 weeks of age at the rate of 1 oz (28.3 g) per day. The newborn is expected to weigh approximately 7 lb, 14 oz (3.57 kg) after 4 weeks, based on an expected gain of 1 oz (28.3 g) per day. The nurse would not expect the infant to gain more than this amount during this time frame.

The nurse is performing an assessment on a newborn. Which assessment finding should the nurse identify as normal? A. Central cyanosis B. Acrocyanosis C. Panting D. Grunting

B. Acrocyanosis Acrocyanosis is a normal finding in a newborn. It occurs due to vasomotor instability and can last up 24-48 hours after birth. Grunting may indicate respiratory distress and may require close monitoring by the nurse but not necessarily immediate intervention. Central cyanosis is a sign of severe respiratory distress and would require immediate intervention by the nurse.

The nurse is caring for a newborn who has just been born and placed on the mother's chest. Which action should the nurse take next? A. Obtaining the 1-minute Apgar B. Drying the baby C. Initiating breastfeeding D. Assessing the heart rate

B. Drying the baby The newborn should be dried and removal of wet blankets is necessary to prevent heat loss. The assessment of the heart rate, Apgar score, and initiation of breastfeeding can be initiated after the neonate has been dried.

The nurse learns during handoff communication that a newborn is quiet alert. Which should the nurse expect when assessing this patient? A. Moving arms and legs B. Fixating on objects C. Fluttering eyelids D. Breathing irregularly

B. Fixating on objects In the quiet alert state, the newborn is alert and follows and fixates on attractive objects, faces, or auditory stimuli. The active-alert stage includes intense motor activity and sensitivity to environmental stimuli. The light-sleep stage is characterized by irregular respirations, eyes closed with REM, irregular sucking motions, minimal activity, and irregular but smooth movement of the extremities. The behaviors common to the drowsy state are open or closed eyes, fluttering eyelids, semi-dozing appearance, and slow, regular movements of the extremities.

The nurse is caring for a newborn boy who was circumcised an hour ago. Which is the priority nursing diagnosis for the​ newborn? A. Risk for Injury B. Risk for Infection C. Risk for Imbalanced Nutrition D. Risk for Ineffective Breathing Pattern

B. Risk for Infection The client is at increased risk for infection because of the circumcision. Risk for Injury would be appropriate if the client were having difficulty metabolizing bilirubin. Risk for Ineffective Breathing Pattern would be appropriate if the client were demonstrating signs of ineffective breathing. Risk for Imbalanced Nutrition would be appropriate if the client were demonstrating signs of ineffective feeding behaviors.

A patient whose 48-hour-old newborn is jaundiced states, "I think I should supplement the baby with formula; my breast milk is causing the jaundice." Which statement should the nurse provide in response? A. "Supplementation will definitely help decrease the chances of the jaundice worsening." B. "You can pump your breast milk and store it until the jaundice is cleared up." C. "It is not necessary to supplement your baby to prevent jaundice." D. "Jaundice is an abnormal finding in the breastfed newborn. I have contacted the healthcare provider."

C. "It is not necessary to supplement your baby to prevent jaundice." Breastfeeding jaundice occurs during the first days of life in breastfed newborns. It appears to be related to inadequate fluid intake with some element of dehydration and not with any abnormality in milk composition. Prevention of early breastfeeding jaundice includes encouraging frequent (every 2-3 hours) breastfeeding, avoiding supplementation if the newborn is not dehydrated, and accessing maternal lactation counseling. Breastfeeding jaundice is self-limiting; it peaks around day 3 as enteral intake increases, then resolves.

A patient who had no prenatal care wants to know how prenatal care affects the newborn. Which statement should the nurse make to this patient? A. "An infant born to a mother with no prenatal care has most likely been exposed to illicit drugs." B. "The health of the newborn is independent of the prenatal care of the mother." C. "The health of the newborn is based on the prenatal care of the mother." D. "A mother of low socioeconomic status has a strong correlation with no prenatal care."

C. "The health of the newborn is based on the prenatal care of the mother." The health of the infant is based on the prenatal care of the mother. The infant's health is directly affected by the health of the mother, not independent of the health of the mother. Women with no prenatal care are not necessarily of low socioeconomic status. An infant born to a mother with no prenatal care has not necessarily been exposed to illicit drugs.

A patient who delivered a newborn 12 hours prior states, "There is something wrong with my baby; his hands and feet are blue." Which response should the nurse make? A. "Your baby is cold. I will get some warm blankets and rewrap him." B. "I am going to take the baby to the nursery for further observation." C. "This is a normal finding as the baby's circulatory system adjusts." D. "The ducts in the heart have not closed yet."

C. "This is a normal finding as the baby's circulatory system adjusts." Acrocyanosis occurs due to vasomotor instability and can last 24-48 hours after birth. Acrocyanosis does not occur in relation to cardiac duct closure after birth. It is unnecessary to further observe the neonate in the nursery and is not an immediate reflection of hypothermia in the neonate.

A client delivers a newborn son and plans to breastfeed. When the nurse attempts to help the newborn latch on for​ breastfeeding, the client​ states, "I would like to bottle feed my baby for the first few​ days." Which reason might the nurse hear regarding why the client wants to delay​ breastfeeding? A. The birthing process spoils breast milk. B. It will cause​ "evil eye." C. Colostrum is bad for the baby. D. Newborns require feeding on demand.

C. Colostrum is bad for the baby. Some​ Asian, Haitian,​ Hispanic, Eastern​ European, and Native American cultures believe breastfeeding should be delayed because colostrum is bad for the baby. A Haitian client may believe that strong​ emotions, not the birthing​ process, spoil breast milk. Some Latin American cultures do not believe that breastfeeding causes evil eye but rather that touching the head or the face of the baby when admiring it will ward off the​ "evil eye." Many Cambodian refugees practice breastfeeding on demand or provide a comfort bottle between feedings. Next question

A newborn has meconium-stained skin and poor turgor with a peeling, leathery appearance. Which gestational age should the nurse document in the newborn's medical record? A. 37 completed weeks B. 38-41 completed weeks C. Greater than 42 weeks D. 34-36 completed weeks

C. Greater than 42 weeks A newborn who is older than 42 weeks gestation will have peeling skin with poor turgor and possible staining from meconium. The skin will not have this appearance at the other gestational ages.

The nurse is teaching a patient who is breastfeeding about the color of stools that can be anticipated for the newborn after the meconium stool. How should the nurse describe the stool? A. Thick and green B. Thin and brown C. Pale yellow D. Continue to be thick and tarry

C. Pale yellow After the meconium stool, the color of stool for a baby being breastfed is pale yellow. Thin brown stools, thick tarry stools, and thick green stools are not a normal finding for baby being breastfed.

The nurse has suctioned the airway of a term neonate immediately after a spontaneous vaginal delivery. Which action should the nurse take next? A. Obtaining the neonate's weight B. Placing identification bracelets on the neonate C. Placing the neonate skin-to-skin with the mother D. Instilling erythromycin in the baby's eyes

C. Placing the neonate skin-to-skin with the mother After suctioning the infant, the neonate should be placed skin-to-skin with the mother to prevent cold stress and promote bonding. Instilling erythromycin in the neonate's eyes, obtaining a weight, and placing identification bracelets on the neonate are not priority actions.

The nurse is assessing a newborn. Which data should the nurse use to determine the newborn's gestational age? A. Presence of milia B. Apgar score C. Plantar creases on the sole D. Size of the anterior fontanel

C. Plantar creases on the sole The plantar creases on the sole are used to determine gestational age. Other indicators for gestational age include skin texture, lanugo, breast tissue, eyes and ears, and genitalia. The Apgar score, size of the anterior fontanel, and the presence of milia are not used to determine gestational age.

The nurse is performing a general physical assessment on a newborn. Which finding should indicate the need to assess the blood glucose level? A. Excessive sleeping B. Hyperreflexia C. Tremors D. Hyperthermia

C. Tremors Tremors are a sign of hypoglycemia. Hypoglycemia is further characterized by temperature instability, jitteriness, and poor feeding. Hyperthermia, hyperreflexia, and sleeping are not findings associated with hypoglycemia.

The nurse is providing care to a newborn during the first 24 hours of life. Which is an abnormal​ finding? A. Heart rate of 140 beats per minute B. Respiratory rate of 58 breaths per minute C. Yellowing of the skin D. Presence of meconium stool

C. Yellowing of the skin Yellowing of the skin within the first 24 hours of life is caused by pathologic jaundice and often requires treatment with phototherapy. All of the other assessment findings are considered normal during the first 24 hours of life.

The nurse is providing discharge instructions for a​ first-time mother and her baby. Which statement is appropriate for the nurse to include in the teaching​ session? A. ​"Your baby may spit up frequently for the first few​ weeks." B. ​"You can wipe away any green drainage that might form around the umbilical​ cord." C. ​"Compress the bulb syringe before placing it in your​ baby's nose or​ mouth." D. ​"Your baby's stools will change to a dark green color when your milk comes​ in."

C. ​"Compress the bulb syringe before placing it in your​ baby's nose or​ mouth." A bulb syringe is often used to suction excess secretions from the​ baby's nose and mouth. The bulb syringe should be compressed before placing it gently in the​ baby's nose or mouth. Stool color is often seedy and yellow or golden brown in color when breastfeeding. The baby may spit up frequently in the first day or​ two, but this should not continue for several weeks. Green drainage from the umbilical cord is abnormal and should be reported to the​ baby's provider.

The nurse is providing care to a​ 1-hour-old newborn who was born at 39​ weeks' gestation. Which assessment data is cause for​ concern? Select all that apply. A. Presence of soft heart murmur B. Acrocyanosis C. Mean blood pressure of 52 mmHg D. Respiratory rate of 82 breaths per minute E. Negative Babinski reflex

D & E Assessment data that would cause this nurse concern include a respiratory rate of 82 breaths per minute and a negative Babinski reflex. Respirations within 2 hours of delivery are expected to be between 60 and 70 breaths per minute but can be as high as 80 breaths per minute. Anything above this is abnormal. A positive Babinski reflex is an expected finding. A negative Babinski could indicate neurologic compromise. The nurse would expect a mean blood pressure of 52 mmHg​ (normal range is​ 31-61 mmHg),​ acrocyanosis, and the presence of a soft heart murmur. Next question

The nurse will commonly need to work with all except which member of the healthcare team to provide care to the​ newborn? A. Audiology specialist B. Lactation consultant C. Pediatrician D. Cardiac surgeon

D. Cardiac surgeon The healthcare team works together to care for the newborn. The team commonly includes a pediatrician or neonatal​ specialist, a​ nurse, a lactation​ consultant, and an audiology specialist. A cardiac surgeon will only be involved in the​ newborn's care if the newborn is diagnosed with a congenital cardiac disorder or birth defect.

The nurse is discussing the initial respiratory effort of a newborn with colleagues. Which best describes the primary purpose of the mechanical action of chest recoil? A. Increase the rate at which fluid is absorbed B. Prevent aspiration of amniotic fluid C. Prevent atelectasis D. Clear accumulated fluid in the airway

D. Clear accumulated fluid in the airway The primary purpose of the mechanical action of chest recoil results in clearing of accumulated fluid in the airway. The primary purpose of chest recoil is not to increase the rate of fluid absorption, prevent aspiration of amniotic fluid, or prevent atelectasis.

The nurse is caring for a large for gestational age (LGA) newborn who was born to a mother with type I diabetes. Which condition should the nurse monitor in the newborn? A. Hypobilirubinemia B. Hypertension C. Bradypnea D. Polycythemia

D. Polycythemia Polycythemia in the newborn is associated with maternal diabetes. Polycythemia is a result of increased blood viscosity in the newborn. Bradypnea, hypobilirubinemia, and hypertension are not associated with maternal diabetes.

The nurse receives shift change report on infants born within the last 4 hours. Which newborn should the nurse assess​ first? A. Term newborn born 3 hours ago. Heart rate is 150 beats per minute. B. Term​ newborn, 2 hours​ old, who has not passed a meconium stool. C. Newborn born at 37​ weeks' gestation. Respiratory rate of 45 breaths per minute. D. Term newborn born 1 hour ago who is exhibiting grunting respirations.

D. Term newborn born 1 hour ago who is exhibiting grunting respirations. Grunting respirations are an indication of respiratory distress. This infant needs further assessment and possibly immediate intervention. A normal respiratory rate is​ 30-60 breaths per minute. A normal pulse is​ 110-160 beats per minute. If a meconium stool is not passed within the first 24​ hours, this would be cause for concern.