Silvestri -- Newborn Content

The nurse is admitting a newborn infant to the nursery and notes that the health care provider (HCP) has documented that the newborn has an omphalocele and will require a surgical procedure. Preoperative nursing care should include which nursing interventions? Select all that apply.

Protect defect from trauma. Maintain a thermoneutral environment. Assess for associated birth defects such as cleft palate.

Which newborn is most at risk for a brachial plexus injury?

A large for gestational age infant with a history of shoulder dystocia at delivery

The nurse is monitoring a preterm newborn for respiratory distress syndrome (RDS). Which finding in the newborn should alert the nurse to the possibility of this syndrome?

Tachypnea and retractions

Which is considered a normal finding in a newborn less than 12 hours old?

Bluish discoloration of the hands and feet

The nurse in the labor room is performing an initial assessment on a newborn infant. On assessment of the head, the nurse notes that the ears are low set. Which nursing action would be appropriate?

Notify the health care provider (HCP).

The nurse is planning to administer an intramuscular injection of vitamin K to a newborn. To administer the injection, which site should the nurse select?

The lateral aspect of the middle third of the vastus lateralis muscle

The nurse in the delivery room is performing an initial assessment on a newborn infant. When examining the umbilical cord, the nurse observes only 2 vessels. How should the nurse interpret this finding?

Finding 2 vessels may indicate an increased risk for other congenital anomalies.

Which is considered a normal finding in a newborn less than 12 hours old?

Has not passed meconium yet

The nurse in the delivery room is performing an assessment on a newborn to determine the Apgar score. The nurse notes a heart rate of 92, a weak cry, some flexion of extremities, grimacing with stimulation, and pink body with blue extremities. On the basis of this score, what should the nurse determine?

The newborn requires some resuscitative interventions.

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with this syndrome?

Abnormal palmar creases

The nurse is performing an initial assessment on a newborn infant. When assessing the infant's head, the nurse notes that the ears are low-set. Which nursing action is most appropriate?

Notify the health care provider.

An initial assessment of a large for gestational age (LGA) newborn infant is being done. Which physical assessment technique should the nurse assist in performing to assess for evidence of birth trauma?

Palpate the clavicles for a fracture.

To prevent heat loss by conduction during physical examination of a newborn infant, which action should the nurse implement?

Place a warm blanket on the examining table before placing the newborn on the table.

The nurse is performing an admission assessment on a newborn infant with the diagnosis of subdural hematoma after a difficult vaginal delivery. Which assessment technique assists to support the newborn's diagnosis?

Stimulating for reflex responses in the extremities

The nurse has provided instructions to a client on how to bathe her newborn. The nurse demonstrates the procedure to the client and on the following day asks the client to perform the procedure. Which observation, if made by the nurse, indicates that the client is performing the procedure correctly?

The client begins to wash the newborn by starting with the eyes and face.

An infant is born to a mother with hepatitis B. Which prophylactic measure is indicated for the infant?

Hepatitis B immune globulin (HBIG) and hepatitis B vaccine given within 12 hours after birth

A newborn infant of a mother who has human immunodeficiency virus (HIV) infection is tested for the presence of HIV antibodies. An enzyme-linked immunosorbent assay (ELISA) is performed, and the results are positive. Which is the correct interpretation of these results?

Indicates the presence of maternal infection

The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which findings should the nurse expect to note during the assessment of this newborn? Select all that apply.

Irritability Constant crying Difficult to comfort

The nurse is performing Apgar scoring for a newborn infant immediately after birth. The nurse notes that the heart rate is greater than 100 beats/min, the respiratory effort is good, muscle tone is active, the newborn infant sneezes when suctioned by the bulb syringe, and the skin color is pink. On the basis of these findings, the nurse should document which Apgar score?

10

The nurse in the labor room measures the Apgar score in a newborn infant and notes that the score is 4. Which action by the nurse has highest priority?

Administer oxygen via resuscitation bag to the newborn infant.

A 4-day-old newborn is receiving phototherapy at home for a bilirubin level of 14 mg/dL (238 mcmol/L). The nurse should plan to include which instruction in the teaching plan of care during the home visit to the mother of the newborn?

Assessing skin integrity and fluid status of the newborn

The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings should alert the nurse to the possibility of this syndrome? Select all that apply

Cyanosis Tachypnea Retractions Audible grunts

The nurse in the newborn nursery is performing admission vital signs on a newborn infant. The nurse notes that the respiratory rate of the newborn is 50 breaths per minute. Which action should the nurse take?

Document the findings.

The nurse assisted with the birth of a newborn. Which nursing action is most effective in preventing heat loss by evaporation?

Drying the infant with a warm blanket

An infant returns to the nursing unit following surgery for a diagnosis of esophageal atresia with tracheoesophageal fistula (TEF). The infant is receiving intravenous fluids and a gastrostomy tube is in place. Following assessment, the nurse positions the infant and performs which action?

Elevates the gastrostomy tube