Quiz #1

Which assessments are included when nurse assesses the newborn's cardiovascularrespiratory status?

Assess airway Auscultate HS Determine cap refill time

During newborn assessment, the nurse notes poor muscle tone, low temp, and lethargy. Which action should nurse take?

Assess the newborn's blood flucose

The nurse examines a newborn three hours after birth. Which assessment findings are expected?

Alert Alert/active or fully awake Decreased Temp

The mother of a one-day-old newborn questions nurse regarding an adhesive dressing on heel. Which statement is most appropriate for the nurse to make?

All children are tested for metabolic disorders after delivery

Nurse notes a newborn who is formula-fed showing signs of hunger despite being fed every 3-4 hours. Which question does the nurse ask the parents?

Are you diluting ready-to-use formula bottles

Parent expresses concern about cracking and peeling of skin of newbron. How does the nurse respond?

"cracking and peeling of the newborn skin is normal"

Nurse assesses a newborn's respirations for 60 seconds. Which describes a normal RR for newborns?

35 bpm

Nurse weights a full-term newborn delivered without complications. Which results are within normal weight range for a full-term newborn?

3800g 2600g

The nurse is preparing to administer required medications to a newborn after a vaginal delivery to prevent eye infection. Which action should the nurse take?

Administer erythromycin ointment

Nurse is caring for a 10-month-old newborn. Nurse notes RR 34, HR 122, flexed extremities, lusty cry. Which HCP should the nurse implement first?

Administer vitamin K

The nurse is assessing the feeding of a bottle-fed newborn and notes a slightly distended abdomen and fussiness right after feeding. The nurse suspects excessive air swallowing and makes which suggestions to parents regarding feeding?

Burp newborn during feedings Seek medical attentions in s/s do not approve Hold bottle up so no air is allowed into nipple Position newborn in semi-fowlers

Nurse is assessing the breastfeeding of a new mother and notes the newborn "spit up" immediately after feedings. Which does the nurse know could help?

Burping the newborn halfway through feedings

Nurse is caring for a breastfed newborn with yellow sclera and lethargy, Which priority dx test would the nurse expect to be ordered?

Check bilirubin level

A mother with a newborn with a history of anorexia voices concern over her ability to nourish a newborn by breastfeeding. Which info should nurse provide?

Continue to take multivitamin while breastfeeding Ensure a balanced diet to maintain energy levels Breast milk for undernourished mothers contain nearly the same nutrients

Nurse is assessing a newborn and notes newborn has single palmar crease at base of fingers. Nurse knows that this is a soft sign for what and should be reported to HCP?

Down Syndrome

When assessing a newborn and new mother. The mother tells the nurse "I am worried about breastfeeding. I often do not have enough money to eat and want my baby to get everything he needs" what is the nurses' best response?

Even if you miss a meal, your breast milk will have about the same amount of nutrients as if you hadn't. Lets talk about some resources that you can use to get free or low-cost food

Newborn's heel stick reveals a glucose reading of 39mg/dL. Which priority interventions does the nurse implement?

Feed the newborn

the student nurse is describing formula to the clinical instructor. The NS demonstrates understanding through which statement?

Formula may be used for newborns with special dietary needs such as lactase deficiency

After heel stick of a newborn, the nurse anticipates which lab finding?

High WBC High hgb Elevated erythrocytes

The nurse is teaching a new mother on proper newborn positioning. Which statement, made by the parent, indicates that the teaching was effective?

I have been keeping one hand behind his hand whenever I pick him up

The mother of a newborn expresses concern regarding the appearance of the umbilical cord. Which statements, made by the mother, indicate the need for further teaching?

I will pull off the stump in a few days to keep it from getting infected I need to apply petroleum jelly over the area with every diaper change I should buy diapers one size larger to prevent irritation around the cord I need to clean around the cord with alcohol swabs whenever I change the diaper

The nurse is teaching patients regarding cord care knows that teaching is effective when patient makes which statement?

I'm glad I don't have to pull this cord stump off

Nurse is teaching a parent regarding post circumcision care. Which statement made by parent indicates that teaching was effective?

If the penis has a foul odor, we should call the HCP

Place the steps of neonatal cardio adaptation in order of which they occur.

Increase in oxygen level Shift in pressure in heart and lung Closing of umbilical vessels Closing of ductus arterious, foramen ovale, ductus venosus

A new mother reports enlarged, hardened breasts, which actions do the nurse take?

Instruct the mother to continue breastfeeding Encourage the mother to breast feed every 2-3 hours

Methods of hear loss with nursing action that would prevent heat loss. Evaporation.

Keep newborn dry and covered

Which factors contribute to heat loss in newborn

Large skin surface BV close to surface Little SubQ fat

When performing a newborn assessment, which finding should be reported to HCP?

Large, protruding tongue

Match the method of neonatal heat loss with it's description

Liquid on skin converting to water vapor: evaporation Laying newborn on cool weight scale: conduction Placing newborn near an air vent: convection Placing newborn near a window or outside wall: radiation

A new mother is hesitant to breastfeed because she has inverted nipples. Which recommendations should the nurse make to promote latching?

Massage nipples prior to feeding Use a nipple shield during breastfeeding Use breast pump for a few mins before feeding

Because newborns are unable to shiver, they use which body process for warming?

Metabolism of brown fat

Nurse is performing a home visit for new parents. Which findings would indicate need for further teaching and needs for a follow-up?

Mobile is placed 2ft above a crib Parents sitting watching TV while child is awake and alert in swing Parents having a dinner party of 60 people, while newborn sits in a bouncy seat

Which assessment finding is represented in this picture?

Molding

Methods of hear loss with nursing action that would prevent heat loss. Convection.

Move crib away from air vents

Methods of hear loss with nursing action that would prevent heat loss. Radiation.

Move crib away from window or outside wall

The nurse is teaching a new mother about breastfeeding. Which statements made by a new mother would concern the nurse?

My baby has 1-2 stools a day My baby's poop is the consistency of paste

When assessing a newborn's resp. system. The nurse should report which finding to the HCP?

Nasal flaring and grunting

Axillary temp of 99 degrees F means what?

Newborn has a temp within the normal range

The. nurse touches the base of the newborn's fingers and notes the fingers flex and close into a tight fist. Which reflex is this?

Palmar grasp reflex

Nurse assesses genitalia of a newborn female and should report which findings to HCP?

Perineal skin irritation Diminished urine output

Methods of hear loss with nursing action that would prevent heat loss. Conduction.

Place a blanket between the newborn and exam table

The nurse notes a 2-hour-old newborn is grunting and lethargic with a respiratory rate of 72. Which actions does the nurse immediately implement?

Place newborn Suction oral cavity with bulb syringe Apply a pulse ox and apnea monitor

While taking an axillary temperature of a newborn, the nurse notes a temp of 96.62 degrees F. Which actions should the nurse take?

Place newborn under a warmer Allow for skin to skin contact with mother Keep legs covered when assessing abdomen

When teaching parents of a breastfed newborn about home tx for jaundice, which info does the nurse include?

Signs of worsened jaundice Breastfeed at least 8-12 times a day Notify HCP if child does not void at least 6 times a day

Nurse assessing newborn who had shoulder dystocia at delivery for a fractured clavicle. Nurse would expect which clinical signs if it is suspected the newborn has a fracture?

Swelling Crepitus Redness

Newborn's initial breath requires a large negative pressure for which reason?

TO force remaining pulmonary fluid out of alveoli and into interstitial spaces

Nurse is caring for new mother who presents with erythema over right breast. The mother reports tenderness on palpation but denies history of fever. What action should nurse take?

Teach breast massage technique

Which factors stimulate respiratory center and initiates respirations after birth?

Thermal, sensory, chemical, mechanical

Nurse expects a newborn's stools to have which appearance after birth?

Thick, greenish black

A mother who breastfeeds voices concern regarding her newborn receiving enough vitamins and nutrients. Which responses by the nurse are appropriate?

You may need to give iron supplements Exclusively breastfed newborns should receive vitamin K supplements

Nurse is visiting with a new mom who has chosen to breastfeed. Mother reports pain with sucking and removal of newborn from breast and that her milk supply seems low. What recommendations should the nurse make?

You should wait until the mouth is open wide to insert the nipple into the newborn's mouth

Mother of a newborn who has a two-year-old voices concern regarding newborn's sleep schedule. Which is the appropriate statement to include in teaching the patient?

Your baby will not be disturbed by other children during quiet sleep

Nurse observes the newborn during feeding and is able to gather info about about newborn's ability to coordinated which actions?

sucking, rooting, breathing

Nurse notes that a breastfeeding mother stops feeding a newborn when he falls asleep after 2-3 mins of sucking. Which info does the nurse include in patient teaching regarding feeding the newborn?

the baby needs to be awakened, so gently move the arms and legs of the newborn Take newborn off the breast and rub the newborn's back to help the baby get the amount of needed breast milk

The parents of a newborn ask the nurse why newborn must receive vitamin K/

to activate clotting factors