Nursing Management of the Newborn
When instructing a new mom on providing skin care to her newborn, which of the following should NOT be included in the teaching? a) "Use talc powders to prevent diaper rash." b) "Change diapers frequently." c) "Give the newborn sponge baths until the umbilical cord falls off." d) "Daily tub baths are not necessary."
"Use talc powders to prevent diaper rash." Talc powders can be a respiratory hazard and should not be used with a newborn.
Which of the following statements by the parents of a newborn indicate that they understand how to soothe their newborn if he becomes upset? a) "We'll place him on his belly on a blanket on the floor." b) "We'll hold off on feeding him for a while because he might be too full." c) "We'll vigorously rub his back as we play some music." d) "We'll turn the mobile on that's hanging above his head in his crib."
"We'll turn the mobile on that's hanging above his head in his crib." 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 rather than having him lie on a blanket on the floor provides security and comfort. Feeding or burping can be helpful in relieving air or stomach gas.
A patient expresses concern to the nurse that her baby is dehydrated and is not getting enough milk from breastfeeding. What is the best response from the nurse? a) "You should supplement with formula because your baby is 24 hours old and has not passed meconium yet." b) "We will give him some water through a bottle in the nursery tonight while you rest." c) "You can tell that your baby is adequately hydrated because he is making 8 wet diapers a day." d) "Does he pass urine that is a light amber color right after eating?"
"You can tell that your baby is adequately hydrated because he is making 8 wet diapers a day." Explanation: The nurse will know that a newborn is adequately hydrated if he has 6 to 12 wet diapers a day. It is still within normal limits if the newborn has not passed meconium by 24 hours of age. Although urinating after feeding is common, it is not essential to ensure adequate hydration.
When caring for a newborn several hours after birth, you assess his respiratory rate. In a normal newborn, this would be a) 30 to 60 breaths per minute. b) 12 to 16 breaths per minute. c) 20 to 30 breaths per minute. d) 16 to 20 breaths per minute.
30 to 60 breaths per minute. Explanation: Newborns typically breathe more rapidly than adults or older children, at a rate of 30 to 60 breaths per minute.
What is the expected range for respirations in a newborn? a) 20-40 breaths per minute b) 40-80 breaths per minute c) 30-60 breaths per minute d) 10-30 breaths per minute
30-60 breaths per minute Although episodic breathing is normal and short periods of apnea can occur, the normal respiratory rate for a newborn is 30-60 breaths per minute. For adults, it is typically 8-20 breaths per minute.
You record a newborn's Apgar score at birth. A normal 1-minute Apgar score is a) 7 to 10. b) 5 to 9. c) 12 to 15. d) 1 to 2.
7 to 10. An Apgar score of 7 to 10 implies the infant is breathing well and cardiovascular adaptation is occurring.
You are admitting a 10-pound newborn to the nursery. You know that it will be important to monitor what during the transition period? a) Blood sugar b) Apgar score c) Heart rate d) Temperature
Blood sugar 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).
A newborn male is circumcised. Which of the following instructions would you include in the discharge teaching plan for his parents? a) Cleanse the glans daily with alcohol. b) Cover the glans generously with Vaseline. c) Notify her physician if it appears red and sore. d) Soak the penis daily in warm water.
Cover the glans generously with Vaseline. Covering the surgical site with an ointment such as petroleum jelly (Vaseline) 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. You would not tell the parents to use alcohol on the glans.
The AGPAR score is based on which 5 parameters? a) Heart rate, muscle tone, reflex irritability, respiratory effort, and color b) Heart rate, breaths per minute, irritability, reflexes, and color c) Hear rate, breaths per minute, irritability, tone, and color d) Heart rate, respiratory effort, temperature, tone, and color
Heart rate, muscle tone, reflex irritability, respiratory effort, and color 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 evaluted by the presence of a strong cry and by color. Color is evaluated by noting the color of the body and hands and feet.
A father is asking questions about the circumcision of his son. He is asking the nurse if there are any disadvantages to the procedure. How should the nurse respond? a) Fewer complications than if done later in life b) Pain administration may not be effective during the procedure c) Reduced risk of penile cancer d) Lower rate of urinary tract infections
Pain administration may not be effective during the procedure The anesthetic block is not always effective. Not all providers use anesthetics prior to the procedure and 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 not disadvantages to the procedure; they are advantages.
You are assisting with the circumcision of a 16-hour-old male infant. Immediately after the procedure, what kind of dressing would you apply to the surgical area? a) Petrolatum gauze dressing b) Steri strips c) Small pressure dressing d) Sterile 2×2s and paper tape
Petrolatum gauze dressing Explanation: Immediately after the procedure, place a petrolatum gauze dressing, as ordered by the physician.
Baby Tarik has been circumcised, his temperature is stable, his breathing and heart rate are healthy, and he is ready to be discharged from the hospital. What can the nurse tell his parents to be on the lookout for that might indicate that Tarik needs medical attention? a) Straining when he is passing stools b) A yellowish crusty substance on the circumcision site c) Redness at the base of the umbilical cord d) Crying for 2 hours or more each day
Redness at the base of the umbilical cord Explanation: The cord should dry and fall off in the 7 to 10 days after delivery. If the cord base changes color or develops drainage the health care provider needs to be notified as these could be signs of infection. A yellowish crusty substance on the circumcision site indicates normal healing. Crying for two hours or more each day and straining at stools are normal in a newborn.
On an Apgar evaluation, reflex irritability is tested by which of the following? a) Dorsiflexing a foot against pressure resistance b) Tightly flexing the infant's trunk and then releasing it c) Raising the infant's head and letting it fall back d) Slapping the soles of the feet and observing the response
Slapping the soles of the feet and observing the response Explanation: Reflex irritability means the ability to respond to stimuli. It can be tested by slapping the foot or evaluating the response to a catheter passed into the nose.
When assessing the umbilical cord of a newborn, which of the following would the nurse expect to find? a) Two arteries and one vein b) One artery and two veins c) Three arteries and no veins d) Two arteries and two veins
Two arteries and one vein The normal umbilical cord contains three vessels: two arteries and one vein.
Discharge teaching is an important part of the labor and delivery room nurse's position. New parents need to know the basics of baby care, like how to monitor fluid volume and when to call the physician. What are the parameters for calling the physician in regards to an infants' temperature? a) less than 96 °F or greater than 101 °F b) less than 97 °F or greater than 100.5 °F. c) less than 96.7 °F or greater than 99.5 °F. d) Less than 97.7 °F or greater than 100 °F.
ess than 97.7 °F or greater than 100 °F. Correct Explanation: Temperatures of less than 97.7 °F or greater than 100 °F should be reported to the physician.
Choice Multiple question - Select all answer choices that apply. Which of the following findings would the nurse identify as normal when assessing a newborn? Select all that apply. a) Temperature of 37 degrees C b) Weight of 3,300 grams c) Length of 54 cm d) Apical pulse rate of 100 beats/minute e) Chest circumference of 35 cm f) Head circumference of 30 cm
• Length of 54 cm • Weight of 3,300 grams • Temperature of 37 degrees C Explanation: Typical newborn findings include length of 45 to 55 cm, weight of 2,700 to 4,000 grams, head circumference of 33 to 35 cm, chest circumference of 30 to 33 cm, temperature of 36.5 to 37.5 degrees C, and apical pulse rate of 120 to 160 beats/minute.
Drag and Drop question - Click and drag the following steps to place them in the correct order. Question: A 23-year-old P1011 has just delivered a term infant who is not crying and has decreased tone. Place the nursing actions in the order they should be carried out. 1.Stimulate the newborn by rubbing the back. 2.Dry the newborn. 3.Clear the airway. 4.Check the heart rate. 5.Transfer the newborn to a preheated radiant warmer.
-Transfer the newborn to a preheated radiant warmer. -Dry the newborn. -Clear the airway. -Stimulate the newborn by rubbing the back. -Check the heart rate. Explanation: Commonly the first step in a nursing intervention cascade is assessment. However, the nurse already has assessed that the newborn is term, is not crying, and has decreased tone that would require intervention. The first step is to warm the newborn and then to decrease any further loss of heat through evaporation by drying the newborn. The airway should be cleared before the newborn is stimulated to avoid aspiration. The nurse would then check the heart rate to see if further resuscitation efforts are necessary.
Ophthalmia neonatorum is contracted when a mother has which sexually transmitted infection(s)? a) Chlamydia b) Gonorrhea c) Trichomonas d) Both A and B e) Both B and C
Both A and B Explanation: Colonization of chlamydia and gonorrhea in the vaginal tract can lead to ophthalmia neonatorum in the newborn.
On inspecting a newborn's abdomen, which finding would you note as abnormal? a) Liver palpable 2 cm under the right costal margin b) Abdomen slightly protuberant (rounded) c) Clear drainage at the base of the umbilical cord d) Bowel sounds present at two to three per minute
Clear drainage at the base of the umbilical cord Explanation: Clear drainage at the base of the umbilical cord suggests the child may have a patent urachus or a fistula to the bladder.
How can the nurse be instrumental in preventing hypoglycemia in the newborn? Choose the best answer. a) Assessing the newborn's blood pressure within 1 hour of delivery b) Encouraging early and frequent feedings c) Encouraging skin to skin for the first few minutes after birth d) Administering vitamin K within 1 hour of birth
Encouraging early and frequent feedings Explanation: The best way listed above to prevent hypoglycemia in the newborn is encouraging early and frequent feedings with the breast or a bottle. Skin to skin will aid in keeping the newborn warm and preventing hypothermia, which in time will also help to prevent hypoglycemia. However, a few minutes is not enough to prevent low glucose levels. It would need to be done as often as possible. Vitamin K is given to prevent hemorrhage. Blood pressure is not routinely checked in healthy, term newborns.
Which of the following would the nurse expect to administer for eye prophylaxis in the newborn? a) Silver nitrate solution b) Vitamin K c) Erythromycin ophthalmic ointment d) Gentamicin ophthalmic ointment
Erythromycin ophthalmic ointment Erythromycin or tetracycline ophthalmic ointment is the agent of choice for newborn eye prophylaxis. Silver nitrate solution was once used for eye prophylaxis, but it is no longer used because it has little efficacy in preventing chlamydial eye disease. Vitamin K is used to promote blood clotting in the newborn. Gentamicin is not used for newborn eye prophylaxis.
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? a) Conductive b) Evaporative c) Convective d) Radiating
Evaporative Evaporative heat loss occurs with the evaporation of fluid from the infant.
The standard of care and recommendation by the Centers for Disease Control is to administer an immunization to all newborns. Which immunization is recommended to be administered prior to discharge? a) DTaP b) Prevnar c) HiB d) Hep B
Hep B Explanation: Hep B is the vaccination again Hepatitis B recommended by the CDC. All the other immunizations are recommended to be started at 2 months of age. Therefore options A, C, and D are incorrect.
Which of the following nursing diagnosis would be highest in priority for a newborn? a) Altered nutrition less than body requirement related to limited formula intake. b) Ineffective airway clearance related to mucous obstruction. c) Ineffective thermoregulation related to heat loss to the environment. d) Altered urinary elimination related to post-circumcision status.
Ineffective airway clearance related to mucous obstruction. Any airway clearance or obstruction issue is the highest priority for nursing interventions. Options A, B, and C are valid nursing diagnoses for some newborns; however, they would not take precedence over an airway problem.
The infant's temperature is 97.2F axillary an hour after birth. Which intervention is the appropriate for the nurse? a) Administer a warm bath with temperature slightly higher than usual b) Place a second stockinette on the baby's head c) Place the infant under a radiant warmer or in a heated isolette. d) Take the infant to the mother for bonding.
Place the infant under a radiant warmer or in a heated isolette. Explanation: If the infant has a low temperature of 97.2F, the nurse should place the infant in a radiant warmer or in an isolette. Once the infant has a core temperature of greater than 97.7F, the nurse will double bundle and re-check the temperature in 30 minutes. If an infant has a temperature that is considered low you would not take the infant to its mother for bonding nor administer a warm bath. You would initiate interventions to stabilize the infant's temperature within normal range.
Newborn Ming has secretions in his mouth and nose. What are the first steps the nurse should take to clear his airways? a) Position Ming on his side with his head slightly below his body; use a bulb syringe to clear his nose. b) Position Ming on his side with his head slightly below his body; use a bulb syringe to clear his mouth. c) Position Ming on his side with his head slightly below his body; use a small suction catheter to clear his nose. d) Position Ming on his side and guide his caregivers in suctioning his mouth with a bulb syringe.
Position Ming on his side with his head slightly below his body; use a bulb syringe to clear his mouth. Explanation: The infant needs to have bulb suction used to remove the secretions, the head should be held slightly lower than the body to facilitate use of gravity. Right after birth is not the time for the parents of the newborn to be instructed in how to suction their infant. A bulb syringe, not a small suction catheter, is used to suction the mouth and nose of a newborn. Option D is incorrect as it does not clear the infant's mouth of secretions.
A father asks the nurse what medication is in the baby's eyes and why it is needed. Which of the following is the appropriate explanation? a) Destroy an infectious exudate of the vaginal canal. b) Prevent the baby's eyelids from sticking together to help see. c) Prevent potentially harmful virus from invading the tear ducts. d) Prevent infection of the baby's eyes by bacteria which may have been in the vaginal canal.
Prevent infection of the baby's eyes by bacteria which may have been in the vaginal canal. Explanation: Antibiotic ointment is used in the infant's eyes at delivery to prevent opthalmia neonatorum, an infection which can lead to blindness. Option A is incorrect as it gives misinformation to the father. Antibiotic ointment is not used for a potentially harmful virus; therefore option C is incorrect. Option D is incorrect as it also gives misinformation to the father of the infant.
As you are examining the newborn female, you notice a small pinkish discharge from the vaginal area. What should you suspect? a) Evidence of birth trauma b) Pseudomenstruation, a normal finding c) Impending hemorrhage from a congenital defect d) Infection
Pseudomenstruation, a normal finding Explanation: Pseudomenstruation is seen when a newborn female has a small amount of pinkish discharge. It comes from the withdrawal of maternal hormones and is a normal finding.
Which of the following would the nurse do first after the birth of a newborn? a) Administer vitamin K. b) Apply identification bracelet. c) Suction the mouth and nose. d) Obtain footprints.
Suction the mouth and nose. Explanation: 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. Vitamin K is administered soon after birth but it does not take priority over ensuring a patent airway.
When caring for a newborn who is jittery and irritable 30 minutes after birth, what should the nurse do? a) Place the child beneath a radiant warmer. b) Assess the baby's temperature with a thermal skin probe. c) Take blood, using a heel stick, to check for hypoglycemia. d) Rule out hypoglycemia by checking the mother's chart for diabetes or other risk factors.
Take blood, using a heel stick, to check for hypoglycemia. One of the primary signs/symptoms of hypoglycemia in newborn infants is jitteryness and irritability. Anytime an infant is suspected of having hypoglycemia, the nurse needs to check the blood glucose level with a heel stick. The infant described in the scenario does not need to be placed under a radiant warmer or have its temperature assessed with a thermal skin probe. You do not rule out hypoglycemia in an infant by checking the mother's chart to see if she is diabetic or has other risk factors.
Which is the best place to perform a heel stick on a newborn? a) The vascularized flat surface of the foot b) The calcaneus c) The front of the heel (the outer arch) d) The fat pads on the lateral aspects of the foot
The fat pads on the lateral aspects of the foot Explanation: 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.
The American Academy of Pediatrics and the American Dietetic Association recommend breastfeeding exclusively for how long? a) The first 28 days b) The first 3 months c) The first 4 months d) The first 6 months
The first 6 months Both the AAP and the ADA recommend breastfeeding exclusively for the first 6 months of life. After 6 months, breastfeeding does not need to be exclusive, but it should be continued until 12 months.
The nurse is providing discharge education to a first time mother and father on their newborn female infant. The father notes the infant has a yellow skin color. How should the nurse explain what the father is noting? a) Yellow is the normal color for a newborn b) The tint is yellow from jaundice c) This might be a sign of a bleeding problem d) The infant needs to be in the sunlight to clear the skin
The tint is yellow from jaundice 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. Yellow is not the normal color for a newborn. Placing the infant in sunlight may help to clear the skin of the yellow color; however, unless instructed by the physician, this is not information provided in discharge teaching. Jaundice is not a sign of a bleeding problem.
Newborn Isaac has been taken to the nursery after delivery. He has been cleaned in the labor and delivery suite and swaddled in a blanket. The nurse is going to check his pulse. What must the nurse do? a) Use infection transmission precautions. b) Wear gloves. c) Clean his or her hands with a betadine scrub. d) Perform a 3-minute surgical type scrub before touching him.
Wear gloves. Explanation: Infection control is a priority nursing intervention. Gloves need to be worn when in contact with the infant who has not been bathed after delivery. All options are valid options. However, a three-minute surgical scrub is generally only required at the beginning of a shift. You should always wash your hands before putting on gloves to care for an infant and after taking your gloves off. Standard precautions are used with every patient.
