PrepU: Chapter 17: Newborn Transitioning

A nursing student observes that the babies in the nursery are wrapped up warmly and are wearing knit caps. Which explanation by the nursery staff would be correct?

"Newborns lose body heat easily and need to be kept warm until their body temperature stabilizes."

A nurse is explaining the Apgar scoring to new mother and her partner. What should the nurse point out about this scoring method? Select all that apply.

- It is done at 1 and 5 minutes after birth. -The baby is considered vigorous if the 5-minute score is above 7. -The Apgar score is an immediate assessment of newborn cardiopulmonary adaptation.

The nurse is reviewing the laboratory test results of a newborn. Which results would the nurse identify as normal? Select all that apply.

- hemoglobin 17 g/dL - platelets 200,00 u/L -red blood cells 5.3 (1,000,000/uL) -white blood cells 8,000 /mm3

The nurse is assessing reflexes in a newborn infant. What can the nurse do to elicit the rooting reflex?

Gently stroke the newborn's cheek.

A nurse is doing an admission assessment on a female newborn. Which findings would warrant notification of the physician? Select all that apply.

-Scaphoid abdomen -Head circumference of 38 cm

The nurse is providing teaching to a new mother who is breastfeeding. The mother demonstrates understanding of teaching when she identifies which characteristics as being true of the stool of breastfed newborns? Select all that apply.

-Yellowish gold color -Stringy to pasty consistency

The nurse has completed assessing the blood glucose levels of several infants who are 24 hours old. Which result should the nurse prioritize for intervention?

30 mg/dL

The nurse receives a report from labor and delivery on an infant and mother couplet. Which reported Apgar score will the nurse prioritize for close observation for the entire transition period?

5 at 1 minute; 6 at 5 minutes

A student nurse is reviewing newborn physical measurements and asks the charge nurse if her client's weight of 2800 g and length of 51 cm falls within normal parameters. The charge nurse would respond to the student nurse in which manner?

A birth weight of 2800 g falls within the normal weight parameters for a full-term newborn.

A nurse teaches new parents that the bestway to help prevent infections in the newborn is which method?

Breastfeed.

Which intervention would be the best way for the nurse to prevent heat loss in a newborn while bathing?

Bathe the baby under a radiant warmer.

A nurse is called into the room of one of the clients where the grandparents are visiting. The grandmother is visibly upset, and says "Just look at my grandson! His head is all soft and swollen here and it shouldn't be. The doctor injured him when he was born." The nurse assesses the newborn and finds an area of swelling about the size of a half-dollar at the center of the upper scalp. The nurse determines this finding is most likely which condition?

Caput succedaneum

The nurse is weighing an infant and is ensuring that the scale is warmed and the procedure is performed as quickly as possible. Doing so allows the nurse to minimize the effects of heat loss by what method?

Conduction

The nurse walks into a client's room and notes a small fan blowing on the mother as she holds her infant. The nurse should explain this can result in the infant losing body heat based on which mechanism?

Convection

The nurse is assessing a newborn who appears healthy and at term. Which assessment finding of the feet does the nurse predict to observe to confirm the status of at-term birth?

Creases on two-thirds of the foot

The LPN assists the RN while performing the Ortolani maneuver on a newborn. When asked by the mother the reason for this maneuver, which is the best response from the nurse?

Hip for dislocation

When teaching a mother to care for her newborn's umbilical cord, which of the following instructions would you include?

Keeping it dry

A 2-month-old infant is admitted to a local health care facility with an axillary temperature of 96.8° F (36° C). Which observed manifestation would confirm the occurrence of cold stress in this client?

Lethargy and hypotonia

The nurse is assisting with the admission of a newborn boy to the nursery. The nurse notes what appears to be bruising on the left upper outer thigh of htis dark-skinned infant. Which documentation should the nurse provide?

Mongolian spot noted on left upper outer thigh

The nurse is conducting an assessment on a newborn and witnesses a startled response with the extension of the arms and legs. The nurse should document this as which response?

Moro

The nurse is responding to an infant crying and notes it is very high pitched and shrill. The nurse predicts this is most likely related to which situation?

Neurologic dysfunction

A nursing student is preparing a class for new mothers about adaptations they can expect in their newborns. Which information about newborn vision should the student include in the presentation?

Newborns have the ability to focus only on objects in close proximity.

On a newborn's initial assessment, it is noted that the newborn's head is misshapen and elongated with swelling of the soft tissue of the skull. What nursing intervention is needed?

No interventions are needed. This will resolve on its own over the next several days.

According to Brazelton's Neonatal Behavioral Assessment Scale, a newborn would be in what state if the eyes are open and looking at people nearby, and the newborn has minimal activity or body movement?

Quiet alert

During which state of Brazelton's Neonatal Behavioral Assessment Scale would be the best time for new parents to interact with their newborn?

Quiet alert state

A nurse is teaching a new mother about what to expect for bowel elimination in her newborn. Because the mother is breastfeeding, what should the nurse tell her about the newborn's stools?

Stools should be yellow-gold, loose, and stringy to pasty.

The nurse prepares to give the first bath to a newborn and notes a white cheese-like substance on the skin. The nurse should document this as which substance?

Vernix

Assisting in the initiation of breast-feeding is a role of the nurse. When should the nurse recommend that a newborn have his or her initial feeding?

Within the first 30 minutes after birth

A newborn has a 5-minute Apgar score of 9. What intervention should the nurse take for this client?

Wrap the infant in a blanket and hand to the mother for bonding.

Upon assessing the newborn's respirations, which finding would cause the nurse to notify the primary care provider?

a respiratory rate of 15 breaths per minute with nasal flaring

A preterm infant is experiencing cold stress after birth. For which symptom should the nurse assess to best validate the problem?

apnea

A nurse is providing care to a 3-hour-old neonate. The nurse ensures that her hands are warm prior to touching the neonate to prevent heat loss by which mechanism?

conduction

The nurse is describing fetal circulation to new parents and how the circulation changes after birth. The nurse describes a structure that allows the pulmonary circulation to be bypassed, but that shortly after birth this structure should close. Which structure is the nurse describing?

ductus arteriosus

The nurse is explaining to new parents that a potential complication of a cesarean birth is transient tachypnea. The nurse explains that this is due to which occurrence?

lack of thoracic compressions during birth

A nurse needs to monitor the blood glucose levels of a newborn under observation at a health care facility. When should the nurse check the newborn's initial glucose level?

on admission to the nursery

On inspection, the nurse notes that a newborn has a normal newborn head/body proportion. This proportion for the head is:

one-fourth his total length

A nurse is observing the interaction between a new mother and her neonate. The nurse notes that the neonate moves his head and eyes to focus on the mother's voice and smile. The nurse interprets this as which behavioral response?

orientation

When the nurse is applying a skin temperature probe to a newborn who is lying on his side, which location would be most appropriate?

over the liver

A mother points out to the nurse that following three meconium stools, her newborn has had a bright green stool. The nurse would explain to her that:

this is a normal finding.

The nurse is assessing the stools of a 36-hour-old neonate who is being breastfed. The nurse determines that the stools are within normal parameters based on which finding?

yellowy mustard color with seedy appearance

The mother calls the nurse to check her baby after noting the right side of the body is dark red while the left side of the baby is pale. Which question to the mother should the nurse prioritize when assessing the situation?

"Was the baby recently crying?"

The nurse is assessng a newborn male in the presence of the parents and notes that he has a hypospadias. How should the nurse respond when questioned by the parents as to what this means?

"His urinary meatus in located on the under surface of the glans."

A nursing mother calls the nurse and is upset. She states that her newborn son just bit her when he was nursing. Upon examining the newborn's mouth, two precocious teeth are noted on the lower central portion of the gums. What would be the nurse's best response?

"Precocious teeth can occur at birth but we may need to remove them to prevent aspiration."

The newborn weighing 6 lb 6 oz (2856 g), now weighs 5 lbs 14 oz (2632 g), 2 days later. Which response should the nurse prioritize to address the mother's concerns about the weight loss?

"This is a normal response."

A nurse is assessing a newborn's temperature. Which reading would the nurse document as normal?

37.0° C (98.6° F)

A mother is upset because her newborn has lost 6 ounces since birth 2 days ago. The nurse informs the mother that it is normal for a newborn to lose which percentage of their birth weight within the first week of life?

5% to 10% of their birth weight

The nurse performs a quick assessment of an infant who is now 5-minutes old and determines the heart rate is 110 bpm, has a weak cry, acrocyanosis, extremities are held in partial flexion, and a catheter placed in the nose produces grimacing. What Apgar score does the nurse record and what action should the nurse prioritize?

5; repeat Apgar scoring in 5 minutes

A newborn is born and, at 1 minute of life, is acrocyanotic, HR is 110, is floppy with some flexion, has a weak cry and grimaces. What Apgar score would the nurse assign this infant?

6

A nurse is assessing a newborn during the first 24 hours after birth. Which findings would the nurse recognize as normal?

body temperature of 97.9° to 99.7° F (36.5° to 37.5° C)

A nurse does an initial assessment on a newborn and notes a pulsation over the anterior fontanelle that corresponds with the newborn's heart rate. How would the nurse interpret this?

It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanelle.

The nurse enters the room and notes the infant is in it's bed sleeping, close to the outside window. Which action should the nurse prioritize?

Move the infant away from the window.

A newborn's vital signs are documented by the nurse and are as follows: HR 144, RR- 36, BP- 128/78, and T- 98.6℉ (37℃). Which finding would be concerning to the nurse?

blood pressure

The nurse notices that a newborn has a white discharge from his breasts. The nurse would explain to his parents that this is:

caused by his mother's hormones.

A 12-hour-old infant is receiving IV fluids for polycythemia. For which complication should a nurse monitor this client?

fluid overload

A nursing student is aware that fetal gas exchange takes place in which area?

placenta

A nurse is teaching newborn care to students. The nurse correctly identifies which mechanism as the predominant form of heat loss in the newborn?

radiation, convection, and conduction

A nurse is assessing a newborn with the parents. The nurse explains that which aspect of newborn behavior is an important indication of neurologic development and function?

reflex

A nurse working in the neonatal nursery anticipates the primary care provider to prescribe which medication for a premature newborn having difficulty breathing?

surfactant

What is the primary goal of nursing care immediately after birth?

to maintain the safety of the neonate from intrauterine to extrauterine life

A mother asks the nurse why her newborn is getting a Vitamin K injection in the birth room. The nurse explains that the injection is necessary because:

vitamin K is needed for coagulation, and the newborn does not produce vitamin K in the few days following birth.

At what point should the nurse expect a healthy newborn to pass meconium?

within 24 hours after birth

A nursing instructor informs students that recent research has shown that delayed cord clamping provides which advantages? Select all that apply

- improving the newborn's -cardiopulmonary adaptation - preventing childhood anemia -increasing blood pressure -improving oxygen transport -increasing red blood cell flow

While teaching a newborn nutrition class to a group of pregnant women, the nurse encourages breastfeeding because it is a major source of which immunoglobulin?

IgA

The nursing instructor is teaching a class on the physiologic properities involved with the birthing process. The instructor determines the session is successful when the students correctly match surfactant with which function?

It keeps alveoli from collapsing with breaths.

The nursery nurse notes that one of the newborn infants has white patches on his tongue that look like milk curds. What action would be appropriate for the nurse to take?

Report the finding to the pediatrician.

The nursing instructor is conducting a training session on the basic care for a newborn male. The instructor determines the session is successful after the students correctly choose which action to avoid?

Retracting the foreskin over the glans to assess for secretions

The new mother is holding her infant, speaking softly and gently stroking the baby's face. She giggles and asks the nurse why the baby turns toward her finger when she strokes the cheeks. The nurse should explain that this is which common newborn reflex?

Rooting

Parents tell the nurse that they have been told to keep their newborn away from windows and be sure to cover the baby with a light blanket. They do not understand why this is necessary. What rationale would the nurse provide for this care?

Since newborns cannot shiver to produce heat, parents need to be sure to keep them covered up and away from sources of heat loss like a window.

A 1-day-old newborn is being examined by the nurse practitioner, who makes the following notation: face and sclera appear mildly jaundiced. What causes this finding?

The breakdown of RBCs release bilirubin, which the liver cannot excrete.

Which statement is true regarding fetal and newborn senses?

The rooting reflex is an example that the newborn has a sense of touch.

When assessing the newborn's umbilical cord, what should the nurse expect to find?

Two smaller arteries and one larger vein