NSG 4525 Neonate

A nurse is caring for a newborn delivered by vaginal birth with a vacuum assist. The newborn's mother asks about the swollen area on her son's head. After palpation to identify that the swelling crosses the suture line, which of the following is an appropriate response by the nurse?

"A caput succedaneum occurs due to compression of blood vessels."

A nurse is reinforcing teaching about newborn care with a postpartum client. Which of the following statements by the client indicates a need for further teaching?

"Baby powder will help prevent a diaper rash."

A nurse in the nursery is caring for a newborn. The grandmother of the newborn asks if she can take the newborn to the mother's room. Which of the following is an appropriate response by the nurse?

"Have the mother call and I will take the baby to the room."

A nurse is teaching about crib safety with the parent of a newborn. Which of the following statements by the client indicates understanding of the teaching?

"I should remove extra blankets from my baby's crib."

A nurse is teaching about nutrition guidelines to a parent of a newborn. Which of the following statements by the parent indicates understanding of the teaching?

"I should wait to give fruit juice until my baby is 6 months of age."

A nurse is teaching the parent of a newborn about bottle feeding. Which of the following statements by the parent indicates a need for further instruction?

"I will tip the nipple so air is present as my baby sucks."

A nurse is caring for a client who is postpartum. The nurse should recognize which of the following statements by the client as an indication of inhibition of parental attachment?

"I wish he had more hair. I will keep a hat on his head until he grows some."

A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with the Plastibell technique. Which of the following client statements indicates understanding of circumcision care? (Select all that apply.)

"I'll expect the plastic ring to fall off by itself within a week" "I'll call the doctor if I see any bleeding" "I'll make sure his diaper is loose in the front"

A nurse is caring for a client who is 6 hr postpartum. The client is Rh-negative and her newborn is Rh-positive. The client asks why an indirect Coombs test was ordered by the provider. Which of the following is an appropriate response by the nurse?

"It detects Rh-positive antibodies in the mother's blood."

A nurse is caring for a client who is 16-hr postpartum and states "My baby has been breathing funny, fast and slow, off and on." Which of the following responses should the nurse provide?

"Let's sit here together and observe your baby while you feed him."

A nurse is teaching the parent of a newborn about car seat use. Which of the following information should the nurse include?

"Position the newborn at a 45-degree angle in the car seat."

A nurse is caring for a preterm newborn who is an incubator to maintain a neutral thermal environment. The father of the newborn asks the nurse why this is necessary. Which of the following responses should the nurse make?

"Preterm newborns lack adequate temperature control mechanisms."

A nurse is completing a home visit to a mother who is 3 days postpartum and breastfeeding her newborn. The mother expresses concern about the amount of weight the newborn has lost since birth. Which of the following is a response the nurse should make?

"The cause might be too short or infrequent feedings."

A nurse is teaching an assistive personnel to measure a newborn's respiratory rate. Which of the following statements indicates an understanding of why the respiratory rate should be counted for a complete minute?

"The rate and rhythm of breath are irregular in newborns."

A nurse is caring for a new mother who is concerned that her newborn's eyes cross. Which of the following statements is a therapeutic response by the nurse?

"This occurs because newborns lack muscle control to regulate eye movement."

A nurse is caring for a client who is beginning to breastfeed her newborn after delivery. The new mother states, "I don't want to take anything for pain because I am breastfeeding." Which of the following statements should the nurse make?

"We can time your pain medication so that you have an hour or two before the next feeding."

A nurse is caring for a client who is postpartum. The client tells the nurse that the newborn's maternal grandmother was born deaf and asks how to tell if her newborn hears well. Which of the following statements should the nurse make?"

"We do routine hearing screening on newborns. You'll know the results before you leave the hospital."

A nurse is completing discharge instructions for a new mother and her 2-day-old newborn. The mother asks, "How will I know if my baby gets enough breast milk?" Which of the following responses should the nurse make?

"Your baby should we 6 to 8 diapers per day."

A nurse is preparing to administer 1 mg vitamin K to a newborn. The medication is available in 1 mg/0.5 mL. How much should the nurse administer?

0.5

A nurse is assessing a newborn 1 hr after birth. Which of the following respiratory rates is within the expected reference range for a newborn?

48/min

A nurse in the newborn nursery is caring for a group of newborns. Which of the following newborns requires immediate intervention?

A newborn who is 12 hr post-delivery and has a temperature of 37.5 C (99.5 F)

A nurse is assessing a newborn the day after delivery. The nurse notes a raised, bruised area on the left side of the scalp that does not cross the suture line. How should the nurse document this finding?

Cephalhematoma

A nurse is caring for a client who just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn?

Clear the respiratory tract.

A nurse is planning care for a preterm newborn. Which of the following nursing interventions to promote development should be included in the plan of care?

Cluster the newborn's care activities

A nurse places a newborn under a radiant heat warmer after birth. The purpose of this action is to prevent which of the following in a newborn?

Cold stress

A nurse is preparing to assess a newborn who is postmature. Which of the following findings should the nurse expect? (Select all that apply.)

Cracked, peeling skin Positive Moro reflex

A nurse is caring for a newborn and auscultates an apical heart rate fo 130/min. Which of the following actions should the nurse take?

Document this as an expected finding.

A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action?

Dry the skin.

A nurse is assessing a newborn who was born at 42.5 weeks of gestation. Which of the following findings should the nurse expect?

Dry, cracked skin

A nurse on the labor and delivery unit is caring for a newborn immediately following birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn?

Drying the newborn's skin thoroughly

A nurse is teaching a newborn's parent to care for the umbilical cord stump. Which of the following instructions should the nurse include?

Give a sponge bath until the cord stump falls off.

A nurse is caring for a newborn 4 hr after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice?

Initiate early feeding.

A nurse is teaching a client who is postpartum and has a new prescription for an injection of Rh0 (D) immunoglobulin. Which of the following should be included in the teaching?

It prevents the formation of Rh antibodies in mothers who are Rh negative.

A nurse is completing the admission assessment of a newborn. Which of the following anatomical landmarks should the nurse use when measuring the newborn's chest circumference?

Nipple line

A nurse is caring for a client who is at 40 weeks of gestation and is in labor. The client's ultrasound examination indicates that the fetus is small for gestational age (SGA). Which of the following interventions should be included in the newborn's plan of care?

Observe for meconium in respiratory secretions.

A nurse is caring for a newborn and observes signs of diaphoresis, jitteriness, and lethargy. Which of the following actions should the nurse take?

Obtain blood glucose by heel stick.

A nurse is caring for a newborn and assessing newborn reflexes. To elicit the Moro reflex, the nurse should take which of the following actions?

Perform a sharp hand clap near the infant

A nurse is providing teaching to the mother of a newborn born small for gestational age. Which of the following should the nurse include as a possible cause of this condition?

Placental insufficiency

A nurse is completing a newborn gestation age assessment. Which of the following findings should be recorded as part of this assessment on the newborn?

Plantar creases over 2/3 of sole

A nurse is assessing a newborn immediately following a scheduled cesarean delivery. Which of the following assessments is the nurse's priority?

Respiratory distress

A nurse is assisting a client with breastfeeding. The nurse explains that which of the following reflexes will promote the newborn latch?

Rooting

A nurse is caring for a client who has just delivered a newborn. The nurse notes secretions bubbling out of the newborn's nose and mouth. Which of the following actions is the nurse's priority?

Suction the mouth with a bulb syringe.

A nurse in a pediatric clinic is caring for a client who is postpartum and asks the nurse what to do when her newborn cries persistently. Which of the following strategies should the nurse suggest? (Select all that apply.)

Take the newborn for a ride in the car. Carry the newborn in a front or back pack. Swaddle the newborn in a receiving blanket.

A nurse is observing a new mother bathing her newborn son for the first time. For which of the following actions should the nurse intervene?

The mother plans to use a cotton-tipped swab to clean the nares.

A nurse in labor and delivery is caring for a client. Following delivery of the placenta, the nurse examines the umbilical cord. Which of the following vessels should the nurse expect to observe in the umbilical cord?

Two arteries and one vein

A nurse is assisting with the care of a newborn immediately following birth. Which of the following medications should the nurse anticipate administering? (Select all that apply.)

Vitamin K injection Hepatitis B immunization Antibiotic ointment

A nurse is caring for a newborn who has macrosomia and whose mother has diabetes mellitus. The nurse should recognize which of the following newborn complications as the priority focus of care?

hypoglycemia