The nurse prepares to administer a phytonadione (vitamin K) injection to a newborn, and the mother asks the nurse why her infant needs the injection. What best response should the nurse provide?
"Your newborn needs the
...
The nurse prepares to administer a phytonadione (vitamin K) injection to a newborn, and the mother asks the nurse why her infant needs the injection. What best response should the nurse provide?
"Your newborn needs the medicine to develop immunity."
"The medicine will protect your newborn from being jaundiced." "Newborns have sterile bowels, and the medicine promotes the growth of
bacteria in the bowel."
"Newborns are deficient in vitamin K, and this injection prevents your
newborn from bleeding."
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 Acrocyanosis and grunting Hypotension and bradycardia
The presence of a barrel chest and acrocyanosis
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 is the expected finding.
Finding 2 vessels is correlated to a high incidence of Down syndrome.
Finding 2 vessels may indicate an increased risk for other congenital
anomalies.
Finding 2 vessels means the newborn has been stressed previously with fetal hypoxia.
The nurse is creating a plan of care for a newborn diagnosed with fetal alcohol syndrome. The nurse should include which priority intervention in the plan of care?
Allow the newborn to establish own sleep-rest pattern. Maintain the newborn in a brightly lighted area of the nursery.
Encourage frequent handling of the newborn by staff and parents.
Monitor the newborn's response to feedings and weight gain pattern.
The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care? Select all that apply.
Avoid stimulation. Decrease fluid intake.
Expose all of the newborn's skin.
Monitor skin temperature closely.
Reposition the newborn every 2 hours.
Cover the newborn's eyes with eye shields or patches.
The nurse is planning care for a newborn of a mother with diabetes mellitus.
What is the priority nursing consideration for this newborn?
Developmental delays because of excessive size
Maintaining safety because of low blood glucose levels Choking because of impaired suck and swallow reflexes Elevated body temperature because of excess fat and glycogen
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.
Contact the health care provider (HCP). Apply an oxygen mask to the newborn infant.
Cover the newborn infant with blankets and reassess the respiratory rate in 15 minutes.
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 gluteal muscle
The lower aspect of the rectus femoris muscle
The medial aspect of the upper third of the vastus lateralis muscle
The lateral aspect of the middle third of the vastus lateralis muscle
A newborn is delivered via spontaneous vaginal delivery. On reception of the crying newborn, the nurse's highest priority at this time is to perform which action?
Auscultate the heart rate. Determine the Apgar score.
Thoroughly dry the newborn.
Take the newborn's rectal temperature.
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?
Document the findings. Arrange for hearing testing. Cover the ears with gauze pads.
Notify the health care provider (HCP).
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?
3
5
7
10
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.
Protect sac or viscera with dry gauze.
Maintain a thermoneutral environment.
Feed newborn every 4 hours, 2 to 3 ounces (60 to 90 ml) of D5W.
Assess for associated birth defects such as cleft palate.
The nurse has provided instructions about measures to clean the penis to a mother of a male newborn who is not circumcised. Which statement, if made by the mother, indicates an understanding of how to clean the newborn's penis?
"I should retract the foreskin and clean the penis every time I change the diaper."
"I need to retract the foreskin and clean the penis every time I give my infant a bath."
"I need to avoid pulling back the foreskin to clean the penis because this
may cause adhesions."
"I should gently retract the foreskin as far as it will go on the penis and then pull the skin back over the penis after cleaning."
The nurse is performing Apgar scoring for a newborn immediately after birth. The nurse notes that the heart rate is less than 100 beats per minute, respiratory effort is irregular, and muscle tone shows some extremity flexion. The newborn grimaces when suctioned with a bulb syringe, and the skin color indicates some cyanosis of the extremities. What should be the immediate nursing intervention for this newborn?
Continued monitoring of vital signs
Oxygen supplementation and suctioning
Initiating cardiopulmonary resuscitation
Documenting findings and notifying the health care provider (HCP)
The nurse is performing an assessment of a newborn admitted to the nursery after birth. On assessment of the newborn's head, what should the nurse anticipate to be the most likely findings related to the fontanels? Select all that apply.
A bulging anterior fontanel A depressed anterior fontanel
A soft and flat anterior fontanel
A triangular-shaped anterior fontanel
A triangular-shaped posterior fontanel Size of posterior fontanel is 4 cm by 6 cm
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 vigorous resuscitation.
The newborn is adjusting well to extrauterine life.
The newborn requires some resuscitative interventions.
The newborn is having some difficulty adjusting to extrauterine life.
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?
Monitoring the urine for blood Monitoring the urinary output pattern
Testing for contractures of the extremities
Stimulating for reflex responses in the extremities
The nurse is caring for a post-term, small for gestational age (SGA) newborn infant immediately after admission to the nursery. What should the nurse monitor as the priority?
Urinary output
Total bilirubin levels
Blood glucose levels
Hemoglobin and hematocrit levels
The home care nurse is visiting a mother 1 week after she gave birth to an infant who is at risk for developing neonatal congenital syphilis. After teaching the mother about the signs and symptoms of this disorder, the nurse instructs the mother to monitor the infant for which findings? Select all that apply.
Loose stools High-pitched cry
Vigorous feeding habits
A copper-colored skin rash
Mucopurulent nasal drainage (snuffles)
The nurse is preparing to administer an injection of vitamin K to a newborn and provides the mother with information about the injection. Which information should the nurse provide?
"It's a single injection given by the intravenous route."
"The injection is given after birth and then again one month later."
"The injection is extremely important to prevent bleeding in your
baby."
"It's fine if you want to refuse giving it to your baby. Once your baby starts on baby food vitamin K deficiency will be replaced."
The nurse is preparing to teach a new mother how to sponge bathe a 1-day- old newborn. Which actions should the nurse take? Select all that apply.
Pat the baby dry gently.
Use shampoo to wash the scalp and hair.
Support the newborn's body during the bath.
Make sure that the room temperature is 75°F (23.9°C).
Cleanse one body area at a time keeping other body areas covered.
The nurse is performing an assessment on a newborn and is preparing to measure the head circumference of the newborn. Which item is essential to perform this assessment?
Tape measure
A 12-inch yardstick Pediatric head restraint
Pediatric physical assessment table
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. Auscultate the heart for a cardiac defect. Blanch the skin for evidence of jaundice. Perform Ortolani's maneuver for hip dysplasia.
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.
Auscultate the heart for a cardiac defect. Blanch the skin for evidence of jaundice. Perform Ortolani's maneuver for hip dysplasia.
The nurse is checking the reflexes of a newborn. Which action should the nurse perform in eliciting the rooting reflex?
Clap hands or slap the mattress.
Stimulate the perioral cavity with a finger.
Stimulate the ball of the infant's foot with firm pressure. Stimulate the pads of the infant's hands with firm pressure.
The nurse is caring for a term newborn. Blood samples for serum chemistries are drawn, and the total calcium level is reported as 8.0 mg/dL (2 mmol/L). Based on this information, which nursing action should be implemented?
Administer an oral calcium channel blocker.
Document the finding in the electronic health record.
Contact the health care provider (HCP) with the abnormal results. Prepare to insert an intravenous infusion containing parenteral calcium.
The nurse is preparing to instruct a client on how to bathe a newborn. Which statement should the nurse include in the instruction?
"Begin with the eyes and face."
"Begin with the feet and work upward."
"Do the back side first, and then the front side."
"Start with the chest, move to the face, and then finish the rest of the body."
Which statement, if made by the mother of a 1-day-old newborn, indicates the understanding of gastrointestinal system functioning in the infant? Select all that apply.
10 to 20 mL is the stomach capacity of a 1-day-old newborn 30 to 60 mL is the stomach capacity of a 1-day-old newborn 75 to 100 mL is the stomach capacity of a 1-week-old infant
90 to 150 mL is the stomach capacity of a 1-month-old infant 250 to 400 mL is the stomach capacity of a 1-month-old infant
The nurse determines the apical heart rate of a 2-day-old newborn to be 140 beats/minute. Which intervention is most appropriate related to this finding?
Reassess the heart rate in 15 minutes. Contact the health care provider (HCP).
Document the finding in the electronic health record.
Attach the newborn to a cardiac monitor to obtain additional data.
The nurse employed in a neonatal intensive care nursery receives a telephone call from the delivery room and is told that a newborn with spina bifida (myelomeningocele type) will be transported to the nursery. The maternity nurse prepares for the arrival of the newborn and places which priority item at the newborn's bedside?
A rectal thermometer A blood pressure cuff
A specific gravity urinometer
A bottle of sterile normal saline
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.
Lethargy Sleepiness
Irritability
Constant crying
Difficult to comfort Cuddles when being held
The staff nurse in a neonatal intensive care unit is aware that red electrical outlets denote emergency power and will function in the event of an outage. There are only 2 red outlets in the room of a 4-day-old male newborn being treated for physiological jaundice and to rule out sepsis from group B streptococcal exposure. Which pieces of equipment requiring power would the nurse select to be plugged into the red outlets in case of a power outage? Select all that apply.
Call bell Feeding pump
Vital sign machine
Phototherapy lights
Intravenous (IV) pump
The nurse is preparing to care for a newborn with respiratory distress syndrome. Which initial action should the nurse plan to best facilitate bonding between the newborn and the parents?
Encourage the parents to touch their newborn.
Identify specific caregiving tasks that may be assumed by the parents.
Explain the equipment that is used and how it functions to assist the newborn.
Give the parents pamphlets that will help them understand their newborn's condition.
The nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is most appropriate?
Apply gentle pressure. Reinforce the dressing.
Document the findings.
Contact the health care provider (HCP).
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