Newborn Nursing Care
When a nurse brings a newborn to the new mother, the mother comments about the milia on her infant's face. What information should the nurse include when responding? 1 They are common and will disappear in 2 to 3 days. 2 Avoid squeezing them and don't try to wash them off. 3 They are birthmarks that will disappear in 3 to 4 months. 4 Proper handwashing technique is important because milia are infectious.
. 2 Avoid squeezing them and don't try to wash them off. Attempts to remove milia will irritate the infant's skin, and such attempts are not needed because the milia will disappear during the first month of life. Although milia are common, they do not disappear for several weeks after birth. Milia are not birthmarks; the tiny plugged sebaceous glands are the result of maternal hormonal influence. The white material is not purulent and is not infectious.
A client who has just given birth examines her newborn. She notes a nevus vascularis on her infant's midthigh and becomes upset. How should the nurse respond? 1 "These areas usually spread and then regress." 2 "The mark is superficial and will fade in a few days." 3 "The mark is permanent; however, it can be covered with clothes." 4 "The area may require surgical removal when your baby is a little older."
1 "These areas usually spread and then regress." Spreading and then regressing is the usual pattern that a nevus vascularis, which involves the dermal and subdermal layers, follows. They do not fade in a few days. Saying that the area will be covered by clothes gives little reassurance. Surgical removal is not recommended. These are also referred to as strawberry hemangiomas. The lesions reach maximum growth by 6 to 8 months of age.
A nurse is assessing a newborn born after 32 weeks' gestation. Which clinical finding does the nurse anticipate? 1 Barely visible areola and nipple 2 Zero-degree square window sign 3 Pinnae that spring back when folded 4 Palms and soles with clearly defined creases
1 Barely visible areola and nipple Breast tissue is not developed or palpable in an infant of less than 33 weeks' gestation. A zero-degree square window sign is present in an infant of 40 to 42 weeks' gestation. The pinnae spring back after being folded in an infant of 36 weeks' gestation. Creases in the palms and on the soles are not clearly defined until after the 37th week of gestation.
As part of the physical assessment, a nurse inspects a newborn for the presence of an umbilical hernia. Which infant behavior will assist the nurse in identifying this problem? 1 Crying 2 Inhaling 3 Suckling 4 Sleeping
1 Crying Increased intraabdominal pressure associated with crying, coughing, or straining will cause protrusion of the hernia. Lowering of the diaphragm may increase intraabdominal pressure slightly but not enough to cause protrusion of an umbilical hernia. Suckling and sleeping do not increase intraabdominal pressure.
At 42 weeks' gestation a client gives birth to an 8 lb 5 oz (3771 g) newborn. On examining the infant, what does the nurse expect to observe? Select all that apply. 1 Long nails 2 Wrinkled skin 3 Edematous skin 4 Abundant body hair 5 Obvious blood vessels in the skin
1 Long nails 2 Wrinkled skin The longer the nails, the more mature the infant. Wrinkled skin is found in a postterm infant who has been exposed to amniotic fluid for too long; the skin is thick, parchmentlike, wrinkled, and peeling. Edematous skin is a characteristic of the preterm infant. Abundant body hair, known as lanugo, is another characteristic of the preterm infant. Obvious blood vessels in the skin are characteristic of the preterm infant because the skin is thin and translucent.
After a newborn has skin-to-skin contact with the mother, the nurse places the newborn under a radiant warmer. Which complication is the nurse attempting to prevent? 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis
1 Metabolic acidosis Uncorrected cold stress increases anaerobic glycolysis, which increases acid production, resulting in metabolic acidosis. Metabolic acidosis, not metabolic alkalosis, occurs when a neonate is stressed by cold. Cold stress causes a metabolic, not a respiratory, problem; metabolic acidosis, not respiratory acidosis, occurs. Cold stress causes a metabolic, not a respiratory, problem; metabolic acidosis, not respiratory alkalosis, occurs.
The nurse plans to weigh a newborn. What is the most appropriate way to obtain the newborn's weight most accurately? 1 Placing the naked infant on the scale 2 Removing the infant's clothes except for the diaper before weighing 3 Weighing the infant's clothes and then subtracting that weight from the clothed infant's weight 4 Having the mother hold the infant while on an adult scale and subtracting the mother's weight from the combined weight
1 Placing the naked infant on the scale Placing the naked infant on the scale is the most accurate method of weighing an infant because it removes all variables that could influence the weight. Removing the infant's clothes except for the diaper before weighing will result in an inaccurate measurement because the diaper and its contents have mass and will add to the measurement. Weighing the infant's clothes and then subtracting that weight from the infant's weight adds an unnecessary step to the procedure. An adult scale does not have the fine increments that are needed to obtain an accurate weight for an infant.
The nurse assesses a newborn and observes central cyanosis. What type of congenital heart defect usually results in central cyanosis? 1 Shunting of blood from right to left 2 Shunting of blood from left to right 3 Obstruction of blood flow from the left side of the heart 4 Obstruction of blood flow between the left and right sides of the heart
1 Shunting of blood from right to left Right-to-left shunting results in inadequate perfusion of blood; not enough blood flows to the lungs for oxygenation. Left-to-right shunting results in too much blood flowing to the lungs; blood is adequately perfused. Left-sided obstruction to the flow of blood results in decreased peripheral pulses, not cyanosis. Obstruction of blood flow between the left and right sides of the heart usually occurs with patent ductus arteriosus. There should be no shunting of blood between the right and left sides of the heart after the ductus arteriosus has closed. If the ductus remains open, the shunting is from left to right, and cyanosis is not a factor.
A 2-day-old infant who weighs 6 lb (2722 g) is fed formula every 4 hours. Newborns require about 73 mL of fluid per pound (454 g) of body weight each day. In light of this information, approximately how much formula should the infant receive at each feeding? 1 1 to 2 oz (30 to 60 mL) 2 2 to 3 oz (60 to 90 mL) 3 3 to 4 oz (90 to 120 mL) 4 4 to 5 oz (120 to 150 mL)
2 2 to 3 oz (60 to 90 mL) Infants require about 73 mL of fluid per pound (454 g) and 60 calories a day per pound (454 g) for growth. The infant's weight of 6 lb × 73 mL of fluid = 438 mL (2722 g/454 g x 73 mL = 438 mL). If fed every 4 hours the infant will have six feedings: 438 ÷ 6 = 73 mL; 73 ÷ 30 (30 mL/oz) = 2.4 oz (73 mL per feeding). Therefore the infant should be offered 2 to 3 oz (60 to 90 mL) per feeding. One or 2 oz (30 to 60 mL) is inadequate for this newborn. Three to 5 oz (90 to 150 mL) is excessive for this newborn.
A nurse is caring for a preterm neonate with physiologic jaundice who requires phototherapy. What is the physiologic mechanism of this therapy? 1 Stimulates the liver to dispose of the bilirubin 2 Breaks down the bilirubin into a conjugated form 3 Facilitates the excretion of bilirubin by activating vitamin K 4 Dissolves the bilirubin, allowing it to be excreted by the skin
2 Breaks down the bilirubin into a conjugated form Phototherapy changes unconjugated bilirubin in the skin to conjugated bilirubin bound to protein, permitting excretion in the urine and feces. Phototherapy does not affect liver function; the liver does not dispose of bilirubin. Vitamin K is necessary for prothrombin formation, not bilirubin excretion. The bilirubin is not excreted by way of the skin.
A new mother is feeding her baby girl, who was born 36 hours ago via spontaneous vaginal delivery. The nurse notes that the mother is crying and points to the top of her baby's head. She cries, "I don't know what's wrong with my baby! She didn't have this big lump on the right side of her head before now. I haven't dropped her! What happened?" What is the best response once the nurse has assessed the infant's head? 1 "Your baby's head is just slightly elongated, and that's nothing to be concerned about." 2 "She'll be examined again by the pediatrician before you leave later today, so there's no need to worry right now." 3 "Your baby may have a condition called cephalhematoma. It's common; however, I'll make a note to have the pediatrician assess it." 4 "Your baby may have a condition called caput succedaneum, which is common. I'll make a note to have the pediatrician assess it."
3 "Your baby may have a condition called cephalhematoma. It's common; however, I'll make a note to have the pediatrician assess it." A cephalhematoma usually develops on one side of the head over the parietal bones. The swelling is not generally present at birth; rather, it develops over the first 24 to 48 hours of life. Telling the mother not to worry dismisses her fears. Caput succedaneum appears over the vertex of the newborn's head and causes localized edema that varies in size. It is seen shortly after birth and resolves within 12 hours to several days after birth.
How does a nurse identify possible developmental dysplasia of the hip (DDH) during a newborn assessment? 1 Depressed dance reflex 2 Limited adduction of the leg 3 Asymmetry of the gluteal folds 4 Shortened leg on the unaffected side
3 Asymmetry of the gluteal folds The gluteal folds should be symmetric, as should all planes and folds of the body. An abnormality of the hips will cause asymmetry, a shorter leg on the affected side, or both. The dance reflex is not affected in DDH. With DDH, abduction of the leg is usually limited at the hip. The leg on the affected, not unaffected, side appears to be shorter with DDH.
A client had a rubella infection (German measles) during the fourth month of pregnancy. At the time of the infant's birth, the nurse places the newborn in the isolation nursery. Which type of infection control precautions should the nurse institute? 1 Enteric 2 Contact 3 Droplet 4 Standard
3 Droplet Because the rubella virus is found in the respiratory tract and urine, isolation is necessary; rubella is spread by droplets from the respiratory tract. "Enteric precautions" is an outdated term; the techniques used with this precaution are incorporated under contact precautions, and the techniques used with contact precautions are incorporated under standard precautions. The use of standard precautions alone is unsafe; additional precautions must be implemented to protect the nurse from droplet-transmitted infection.
A plan of care is created for a term small-for-gestational-age (SGA) neonate who has been admitted to the neonatal intensive care unit (NICU). The goal is for the newborn to reach 5 lb (2300 g) by a specified date. On the specified date the infant weighs 4 lb 2 oz (1871 g). What should the next step be in care planning for this infant? 1 Increase the daily number of calories 2 Change the goal to a more realistic number 3 Evaluate the problem before altering the plan 4 Postpone the evaluation date for another month
3 Evaluate the problem before altering the plan Before further intervention is undertaken, the reason for the inadequate weight gain should be evaluated. Evaluation should take place before the plan is changed or the goal altered to identify any barriers to achieving the goal. Postponing the evaluation date for another month is unsafe; the reason for the lack of goal attainment must be identified. The other interventions, increasing the daily number of calories or changing the goal to a more realistic number, are premature.
he nurse must continually assess a preterm infant's temperature and provide appropriate nursing care because, unlike the full-term infant, the preterm infant has what limitation? 1 Cannot use shivering to produce heat 2 Cannot break down glycogen to glucose 3 Has a limited supply of brown fat available to provide heat 4 Has a limited amount of pituitary hormones with which to control internal heat
3 Has a limited supply of brown fat available to provide heat Because neonates are unable to shiver, they use the breakdown of brown fat to supply body heat; the preterm infant has a limited supply of brown fat available for this purpose. An inability to use shivering to produce heat is not specific to preterm neonates; all newborns are unable to use shivering to supply body heat. The breakdown of glycogen into glucose does not supply body heat. Pituitary hormones do not regulate body heat.
A nurse who is assessing a full-term newborn elicits the magnet reflex. How is this reflex elicited? 1 Striking the surface of the newborn's crib suddenly 2 Stroking the outer sole of the newborn's foot from the heel to the little toe 3 Maintaining the supine position and applying pressure to the soles of the newborn's feet 4 Holding the newborn's body upright and allowing the feet to touch the surface of the crib
3 Maintaining the supine position and applying pressure to the soles of the newborn's feet Applying pressure to the sole of the foot produces the magnet reflex, in which the legs extend in response to the pressure on the soles of the feet. Jarring the crib produces a startle response (Moro reflex). Stroking the outer sole of the foot from the heel to the little toe produces the Babinski or plantar reflex; all of the toes hyperextend. Allowing the feet to touch the surface of the crib produces the stepping reflex, in which one foot is placed before the other in a simulated walk, with the weight on the toes.
Which newborn assessment finding will probably necessitate prolonged follow-up care? 1 Apgar score of 5 2 Weight of 3500 g 3 Umbilical cord with two blood vessels 4 Blood glucose level of 50 mg/dL (1.7 to 3.3 mmol/L)
3 Umbilical cord with two blood vessels The congenital absence of a blood vessel in the umbilical cord is often associated with life-threatening congenital anomalies. There should be two arteries and one vein. The interval at which the Apgar score was obtained was not provided. A weight of 3500 g is average for a full-term newborn. The expected glucose level in a healthy newborn is 40 to 69 mg/dL (1.7 to 3.3 mmol/L)
A new mother exclaims to the nurse, "My baby looks like a Conehead!" How should the nurse respond? 1 "Are you disappointed in how your baby looks?" 2 "Don't worry—your baby's head will be round in a few days." 3 "Is there anyone in your family whose head shape is similar to your baby's?" 4 "This often happens as the baby's head moves down the birth canal—the bones move for easier passage."
4 "This often happens as the baby's head moves down the birth canal—the bones move for easier passage." The shape of the newborn's head is most likely the result of " molding." As the baby's head moves down the birth canal, the bones move for easier passage of the head through the birth canal. The mother needs information that is straightforward and understandable. Telling the client that this often happens as the baby's head moves down the birth canal is accurate information. Asking whether the mother is disappointed in her baby's appearance is an assumed reflection of the mother's feelings and does not address her concern; the nurse should recognize that the mother is disappointed and offer an explanation. Telling the mother that her baby's head will be round in a few days may add to the mother's anxiety because the reason for the infant's appearance has not been explained. It will take several days to determine whether the head is malformed. Asking whether anyone else in the client's family has a similarly shaped head may add to the mother's anxiety.
What is the first nursing intervention for a newborn with a 1-minute Apgar score of 7? 1 Administering oxygen 2 Performing a brief physical assessment 3 Cutting the umbilical cord and attaching a clamp 4 Drying and placing the infant in a warm environment
4 Drying and placing the infant in a warm environment Preventing heat loss conserves the newborn's oxygen and glycogen reserves; this is a priority. Warming the infant will reduce cyanosis if no respiratory obstruction is present. Performing a brief physical assessment is important; however, it is not a priority; assessment should be delayed until the infant is warm. Cutting the umbilical cord and attaching a clamp may be done after provisions to prevent heat loss have been made.
Hydramnios is diagnosed in a primigravida at 35 weeks' gestation. For what condition should the nurse assess the newborn? 1 Cardiac defect 2 Kidney disorder 3 Diabetes mellitus 4 Esophageal atresia
4 Esophageal atresia Esophageal atresia is associated with hydramnios. There is usually a history of polyhydramnios because the fetus in unable to swallow the amniotic fluid. Cardiac defects are not associated with hydramnios. Kidney disorders are associated with oligohydramnios, not hydramnios. Diabetes in the newborn is not associated with hydramnios.
Immediately after birth, a newborn is dried before being placed in skin-to-skin contact with the mother. What type of heat loss does this intervention prevent? 1 Radiation 2 Convection 3 Conduction 4 Evaporation
4 Evaporation Evaporative heat loss is a result of the conversion of moisture into vapor, which is avoided when the newborn is dried. Radiation is the loss of heat to colder solid surfaces that are not in direct contact. Convective heat loss is a result of contact of the exposed skin with cooler surrounding air currents. Conductive heat loss is a result of direct skin contact with a cold solid object.
An infant born with hydrocephalus will be discharged after insertion of a ventriculoperitoneal shunt. Which common complication should the nurse instruct the parents to report if it occurs at home? 1 Visibility of the sclerae above the irises 2 Violent involuntary muscle contractions 3 Excessive fluid accumulation in the abdomen 4 Fever accompanied by decreased responsiveness
4 Fever accompanied by decreased responsiveness Fever accompanied by decreased responsiveness is associated with infection. This is the greatest postoperative hazard for children with shunts for hydrocephalus. Eyes with sclerae visible above the irises occur with progressively increasing intracranial pressure, usually before shunt insertion. Violent involuntary muscle contractions may occur as the result of an infected shunt; however, it is not the most common sign of an infectious process. The peritoneum absorbs cerebrospinal fluid adequately; ascites is not a problem.
Shortly after birth a newborn is found to have Erb palsy. Which condition does the nurse suspect caused this problem? 1 Disorder acquired in utero 2 X-linked inheritance pattern 3 Tumor arising from muscle tissue 4 Injury to brachial plexus during birth
4 Injury to brachial plexus during birth Erb palsy is caused by forces that alter the alignment of the arm, shoulder, and neck; stretching or pulling away of the shoulder from the head during birth damages the brachial plexus. Erb palsy is not acquired in utero. Erb palsy is not caused by an X-linked inherited disease. Erb palsy is not caused by a tumor.
After a spontaneous vaginal birth, the nurse's first actions are clearing the airway and stimulating the newborn to cry. Which nursing intervention should be implemented next? 1 Checking the heart rate 2 Administering oxygen by mask 3 Performing a complete physical assessment 4 Placing the infant in skin-to-skin contact with the mother
4 Placing the infant in skin-to-skin contact with the mother Once the airway has been cleared, the nurse should first dry and place the newborn in a warm environment; skin-to-skin contact with the mother is the best strategy for preventing chilling. Checking the heart rate is done later during the newborn assessment. There are no data to indicate that the newborn requires oxygen. The physical assessment is not the priority at this time; conserving body heat takes precedence.
When a preterm newborn requires oxygen, the nurse in the neonatal intensive care unit monitors and adjusts the oxygen concentration. Which complication do these adjustments attempt to prevent? 1 Cataracts 2 Strabismus 3 Ophthalmia neonatorum 4 Retinopathy of prematurity
4 Retinopathy of prematurity Retinopathy of prematurity is caused by the high concentration of oxygen that may have to be used to support some preterm neonates; oxygen must be administered cautiously and, depending on the neonate's blood oxygen level, adjusted accordingly. Cataracts and strabismus (crossed eyes) are not caused by a high oxygen concentration. Ophthalmia neonatorum refers to an inflammation of the eyes caused by a gonorrheal or chlamydial infection contracted as the fetus passes through the birth canal.
The parent of a newborn asks, "Why do I have to scrub my baby's formula bottles?" Which information regarding the normal newborn should the nurse consider before replying in language that the parent will understand? 1 Gastric acidity is low and does not provide bacteriostatic protection 2 Absence of hydrochloric acid renders the stomach vulnerable to infection 3 Infants are almost completely lacking in immunity and require sterile fluids 4 Escherichia coli, a bacterium that is found in the stomach, does not act on milk
1 Gastric acidity is low and does not provide bacteriostatic protection Low gastric acidity in newborns predisposes them to gastrointestinal infections, so it is necessary to clean bottles with soap and water. Hydrochloric acid is present in the gastric juices but not in quantities sufficient to protect the infant. The infant is born with passive immunity from maternal antibodies. Escherichia coli is an intestinal bacterium; it is not found in the stomach.
While reviewing the health history of a newborn with suspected jaundice, the nurse recalls that some risk factors place infants at a higher risk for developing jaundice. Which conditions are risk factors for jaundice? Select all that apply. 1 Infection 2 Female sex 3 Prematurity 4 Breast-feeding 5 Formula feeding 6 Maternal diabetes
1 Infection 3 Prematurity 4 Breast-feeding 6 Maternal diabetes Infants are at a higher risk of jaundice if they have an infection, are born prematurely, are exclusively breast-fed, or if their mothers have diabetes. Jaundice is more common in male infants. Infants who are fed formula do not develop jaundice as often as breast-fed babies do.
A nurse who is assessing a full-term newborn elicits the Moro reflex. Which method would the nurse utilize to best elicit this reflex? 1 Touching the infant's cheek 2 Striking the surface of the infant's crib suddenly 3 Allowing the infant's feet to touch the surface of the crib 4 Stroking the sole of the foot along the outer edge from the heel to the toe
2 Striking the surface of the infant's crib suddenly Jarring the crib produces a startle response ( Moro reflex); the legs and arms extend, and the fingers fan out, while the thumb and forefinger form a C. When the cheek is touched, the head turns toward the side that was touched; this is the rooting reflex. When the feet touch the crib surface the stepping reflex is elicited; one foot is placed before the other in a simulated walk with the weight on the toes. When the bottom of the foot is stroked along the outer edge of the sole from the heel to the toe, the toes flare out. This is the Babinski reflex, which is expected because of the newborn's immature nervous system. In an adult, this reflex is a sign of neurological damage.
During a vertex vaginal birth the nurse notes meconium-stained amniotic fluid. What is the prioritynursing intervention for the newborn? 1 Stimulating crying 2 Suctioning the airway 3 Using an Ambu bag with oxygen support 4 Placing the infant in the reverse Trendelenburg position
2 Suctioning the airway Suctioning must be done to minimize the possibility of the aspiration of meconium into the lungs. If the newborn cries before being suctioned, meconium may be aspirated. If the newborn is bagged, any meconium present will be forced into the lungs. If the newborn is positioned in reverse Trendelenburg, meconium may be aspirated.
Which intervention should the nurse take immediately when an apnea monitor sounds an alarm 10 seconds after cessation of respirations? 1 Assess for changes in skin color 2 Use tactile stimuli on the chest or extremities 3 Check the monitor for signs of a malfunction 4 Resuscitate with a facemask and an Ambu bag
2 Use tactile stimuli on the chest or extremities The nurse applies tactile stimulation after confirming that respirations are absent; this action may be sufficient to reestablish respirations in the high-risk neonate with frequent episodes of apnea. Assessment will not interrupt the period of apnea; respirations must be reestablished immediately. The monitor should be assessed for proper function before use. Resuscitation with a bag-valve mask is too invasive and aggressive for an initial intervention; gentle stimulation should be attempted first.