OB Chapter 18 PrepU

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's pearls.

The nurse orienting a student to the nursery determines that teaching has been effective when the student states that the signs of neonate respiratory distress include which findings? Select all that apply.

1. Nasal flaring 2. Respiratory rate of 64 breaths per minute 3. Chest retractions

When the nurse performs the Ortolani maneuver, which action would be appropriate? Select all that apply.

1. Place the newborn in a supine position. 2. Attempt to abduct the hips 180 degrees while applying upward pressure.

A nurse has been handed the just-born term infant who is not crying and has decreased tone. In which order should the following actions be accomplished? All options must be used.

1. Transfer the newborn to a preheated radiant warmer. 2. Dry the newborn. 3. Clear the airway. 4. Stimulate the newborn by rubbing the back. 5. Check the heart rate.

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.

1. Warmer bed 2. Suction equipment 3. Identification bands

In a class teaching new parents basic information on how to care for their new infant, the nurse should suggest that the parents plan to use how many diapers on a daily basis?

10

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

The nurse is preparing discharge teaching for a young couple and their infant. Which axillary temperatures should the nurse point out should be reported to the primary care provider?

less than 97.7° F (36.5° C) or greater than 100° F (37.8° C)

he parents of a newborn are concerned that something is wrong with their newborn's eyesight. What should the nurse instruct the parents as being an expected finding in the newborn?

Follows a light to the midline

A nurse is changing a newborn's diaper and realizes that the bassinet is out of diapers. What would be the best choice of action to alleviate the problem?

Go get another pack of diapers for the bassinet from the supply closet.

While reviewing a newborn's hospital record, which of the following would be most important for you to locate?

If he breathed spontaneously at birth

Which assessment finding indicates to the nurse that a newborn has hip subluxation?

Inability of the right hip to abduct

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

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

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.

A newborn infant at 36 hours of age is jaundiced. The mother is breast-feeding. What intervention is appropriate to increase the excretion of bilirubin?

Instruct the mom to feed every two to three hours.

A local hospital has a home visitation program for new families after discharge from the hospital. What benefit would this program have for parents?

It allows the parents an opportunity to demonstrate competency in caring for their infant and ask any questions.

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.

What instructions should the nurse include when teaching a mother to care for her newborn's umbilical cord?

Keep it dry.

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

Notify the physician of the finding and get a serum bilirubin ordered.

The nurse is assisting with the circumcision of a 16-hour-old male infant. Immediately after the procedure, what kind of dressing would the nurse apply to the surgical area?

Petrolatum gauze dressing

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

Placing the diapered newborn skin-to-skin with the mother and cover them both with a blanket.

The nurse is conducting a prenatal class explaining the various activities which will occur within the first 4 hours after birth. The nurse determines the session is successful when the couples correctly choose which reason for the use of an antibiotic ointment?

Prevent infection of the eyes from vaginal bacteria

The nurse is teaching discharge instructions to the young parents of a healthy newborn boy, whose vital signs are stable and whose circumcision appears clean and intact. The nurse should encourage the parents to call the health care provider if which situation is discovered?

Redness at the base of the umbilical cord

The nurse documents that a newborn has a normal head-to-body proportion. What did the nurse document in the baby's medical record?

Retracting the foreskin over the glans to assess for secretions

The nurse has administered an opthlalmic agent for eye prophylaxis, as prescribed. What outcome indicates that this intervention has been effective?

The infant remains free of opthalmia neonatorum

The parents of a newborn baby boy ask the nurse about circumcising their son. They are undecided as to what to do. Which response by the nurse is best?

"There are pros and cons to circumcision. Let me ask the pediatrician to come and talk to you about the procedure."

A nurse teaches new parents about how to soothe their crying newborn. Which statement by the parents indicates that they understand how to soothe their newborn if he becomes upset?

"We'll turn the mobile on that's hanging above his head in his crib."

The parents of a newborn are upset that their newborn needs treatment for ophthalmia neonatorum. The nurse should explain this is related to which maternal infection? Select all that apply.

1. Chlamydia 2. Gonorrhea

To maintain a sufficient fluid intake in a 3-month-old infant, the nurse should make which suggestions to the infant's mother?

1. Keeping track of the number of wet diapers/day is a good way of knowing the infant is getting enough fluid. 2. The infant will need about 150-200 mL/kg of fluid intake/day. 3. If the breast fed infant is having sufficient wet diapers, she is getting enough fluid.

When a newborn is experiencing physiologic depression, the Apgar characteristics will disappear in a predictable manner. In which order, from first to last, will the nurse expect these characteristics disappear? All options must be used.

1. Pink coloration is lost. 2. Respiratory effort decreases. 3. Muscle tone decreases. 4. Reflex irritability is noted. 5. Heart rate decreases.

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.

1. Provide oxygen supplementation. 2. Ensure the newborn's warmth. 3. Observe respiratory status frequently.

Neonatal screening is done before the infant leaves the hospital. Blood is drawn through a heel stick and tested for several disorders that can cause lifelong disabilities. When is the ideal time to collect this specimen?

24 hours after the newborn's first protein feeding

When caring for a newborn several hours after birth, what would the nurse assess as a normal newborn's respiratory rate?

30 to 60 breaths/min

A newborn male has just returned to the mother's room after being circumcised. What behaviors should the nurse be looking for to indicate that the newborn is in pain from the procedure?

Appearing restless and crying

The parents of a newborn become concerned when they notice that their baby seems to stop breathing for a few seconds. After confirming the parents' findings which action should the nurse prioritize?

Assess the newborn for signs of respiratory distress.

A new mother does not want the baby to return to the nursery because of the fear of someone taking the baby without her permission. What should the nurse explain to the mother to allay her fears?

Both the mother and infant have identification bands that need to match.

The newborn should have the neurologic status evaluated to determine its maturity and to identify any potential problems. The nurse tests the newborn's Babinski reflex. Which response would the nurse interpret as normal for the newborn?

Toes fan out when sole of foot is stroked.

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.

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.

The nurse is assessing a term newborn. Which finding should the nurse expect when assessing the patterns of sole creases?

Creases on two-thirds of the foot

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.

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.

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

A newborn is discharged from the hospital before undergoing metabolic screening. A community health nurse scheduling a follow-up home visit knows that the most appropriate time to perform the heel stick is:

at least 24 hours after birth.

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

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

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

On an Apgar evaluation, how is reflex irritability tested?

flicking the soles of the feet and observing the response

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.

The AGPAR score is based on which 5 parameters?

heart rate, muscle tone, reflex irritability, respiratory effort, and color

The nurse is completing an assessment of a newborn. When auscultating the newborn's heart, the nurse would place the stethoscope at which area to auscultate the point of maximal impulse?

lateral to the midclavicular line at the fourth intercostal space

The Ballard scoring system evaluates newborns on which two factors?

physical maturity and neuromuscular maturity

he nurse is preparing to apply a thermistor probe to a newborn to monitor the newborn's temperature. At which location would the nurse apply the probe?

right upper abdominal quadrant

All of the following are ways the nurse can encourage bonding between the parents and the newborn except:

telling the mother that the best way to bond with her baby is to breastfeed.

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

the fat pads on the lateral aspects of the foot

Which measurements were most likely obtained from a normal newborn born at 38 weeks to a healthy mother with no maternal complications?

weight = 3500 g, length = 20 inches (51 cm), head circumference = 34 cm, and chest circumference = 32 cm

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