THE NEWBORN
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 nurse is assessing 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 woman who is about to be discharged after a vaginal birth notices a flea-like rash on her newborn's chest that consists of tiny red lesions all across the nipple line. What is the best response from the nurse when explaining this to the woman?
"It is a normal skin finding in a newborn." -This most likely is erythema toxicum, also known as newborn rash and is a common finding which will gradually disappear and not need any treatment.This is often mistaken for staphylococcal pustules. This is not a sign of mistreatment by the mother, nor is it caused by a virus or group beta streptococcal infection.
A young mother is concerned for her baby and asks the nurse if her baby is okay. What is the best response if the nurse notes: RR 66, nostrils flaring, and grunting sounds during respiration?
"Your baby is having a little trouble breathing. I'll let the RN know."
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" -The infant has a 5% to 10% loss of birth weight during the first few days of life as the body loses excess fluid and has limited food intake. This physiologic weight loss amounts to a total loss of 6 to 10 oz. There would be no need to assess for other problems. It is also not related to feeding, nor would a breast-feeding mother need to offer supplementary formula feedings. These responses would be inappropriate.
A new mother asks the nurse what her neonate can actually see. When responding to the mother, the nurse integrates knowledge that newborns typically can focus on objects at which distance?
8 to 10 inches (20 to 25 cm) -Newborns have ability to focus only on close objects (8 to 10 inches away [20 to 25 cm]) with a visual acuity of 20/140; they can track objects in midline or beyond (90 inches [229 cm]). This is the least mature sense at birth.
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 blood pressure of a newborn should be quite low—around 60-70 over 35 to 50. The heart rate and respiratory rate are both high, which are normal findings. The temperature falls within a normal range of 97.7℉ to 99.5℉ (36.5℃ to 37.5℃).
The nursing instructor is teaching a class on the physiologic properties 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 role of surfactant is to act on surface tension and assist in keeping the alveoli open in the lungs so the lungs do not collapse with the respiratory effort of the newborn. Surfactant does not expand the lungs, remove fluid from the lungs, or allow oxygen to move in the lungs.
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 this dark-skinned infant. Which documentation should the nurse provide?
Mongolian spot noted on left upper outer thigh.
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 2/3 of foot -As an infant matures in utero, sole creases become prominent to a greater amount. The term infant should have at least two-thirds of the foot covered by creases. These creases should be horizontal and not longitudinal, They should be in the ball of the foot before moving to the heel.
When the nurse is describing the events that occur in a newborn when he or she experiences a cold environment, which event would the nurse identify as occurring first?
increased release of norepinephrine
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 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 -response to stimuli
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?
-Average birth weight for a newborn is between 5 lb, 8 oz (2500 g) and 8 lb, 13 oz. (4000 g). Average length at birth for a newborn is between 19 and 21 inches (48 to 53 cm).
A nursing instructor informs the student that which stimuli initiate respirations in the newborn? Select all that apply.
-hypercapnia -hypoxia -acidosis -The first breath of life is a gasp that generates an increase in transpulmonary pressure and results in diaphragmatic descent. Hypercapnia, hypoxia, and acidosis resulting from normal labor become the stimuli for initiating respirations.
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 -is swelling of the soft tissue of the scalp caused by pressure of the presenting part on a partially dilated cervix or trauma from a vacuum-assisted delivery. This finding is often of concern for the families. Reassure them that the caput will decrease in a few days without treatment. Increased intracranial pressure would involve the entire scalp and not just a small portion. There would also be other neurologic signs accompanying it. Molding is an elongated head shape caused by overlapping of the cranial bones as the fetus moves through the birth canal. This will also resolve in a few days without treatment. The Harlequin sign is characterized by a clown-suit-like appearance of the newborn where the skin is dark red on one side of the body and the other side is pale. This is a harmless condition which occurs most frequently with vigorous crying or with the infant lying on his or her side.
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 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 should look for signs of lethargy and hypotonia in the newborn in order to confirm the occurrence of cold stress. Cold stress leads to a decrease, not increase, in the newborn's body temperature, blood glucose, and appetite.
When assessing the newborn's umbilical cord, what should the nurse expect to find?
two smaller arteries and one larger vein
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?
upon admission to the nursery -Typically, a newborn's blood glucose levels are assessed with use of a heel stick sample of blood on admission to the nursery, not 4 or 24 hours after admission to the nursery. It is also not necessary or even reasonable to check the glucose level only after the newborn has been fed
A client gives birth to a baby at a local health care facility. The nurse observes that the infant is fussy and begins to move her hands to her mouth and suck on her hand and fingers. How should the nurse interpret these findings?
The infant is attempting self-consoling maneuvers. -The hand-to-mouth movement of the baby indicates the self-quieting and consoling ability of a newborn. The other options are states of behavior of a newborn but are not applicable to this situation.
Which statement is true regarding fetal and newborn senses?
The rooting reflex is an example that the newborn has a sense of touch. -Newborns experience pain, have vision, and can discriminate between tastes. The rooting reflex is an example of a newborn's sense of touch. The fetus can hear in utero.
