Newborn Assessment
What is the first action a nurse should take immediately after birth?
Suction the airway to ensure patency and initiate breathing.
Where should the fundus be located immediately after birth?
Firm, midline, at or just below the umbilicus.
Why is vitamin K given at birth?
To prevent vitamin K deficiency bleeding (VKDB).
What are signs of respiratory distress in a newborn?
Grunting, nasal flaring, retractions, tachypnea, cyanosis.
What phase is the mother in when she wants to talk about her labor and birth?
Taking-in phase.
What is a normal respiratory rate for a newborn?
30–60 breaths per minute.
What does a displaced fundus most often indicate?
A full bladder
What is the action of methylergonovine (Methergine)?
Stimulates sustained uterine contractions to treat postpartum hemorrhage.
What are signs of endometritis?
Fever, foul-smelling lochia, uterine tenderness, tachycardia.
What reflex is tested by stroking the cheek?
Rooting reflex.
What is the name of the scalp swelling that crosses suture lines?
Caput succedaneum.
What should the nurse do if the fundus is boggy?
Massage the fundus.
When is RhoGAM given?
Within 72 hours after birth if the mother is Rh-negative and baby is Rh-positive.
What causes uterine atony?
Overdistended uterus, prolonged labor, high parity, retained placenta.
What is engrossment?
A father's intense interest and bonding with his newborn.
How many vessels are in a normal umbilical cord?
Three (2 arteries, 1 vein).
How much should the fundus descend each day postpartum?
About 1 cm (or 1 fingerbreadth) per day.
What are the three medications commonly given to newborns at birth?
Vitamin K, erythromycin eye ointment, hepatitis B vaccine.
What’s the priority intervention for postpartum hemorrhage with a firm fundus and steady trickle of bright red blood?
Suspect cervical laceration and notify provider
What differentiates postpartum blues from postpartum depression?
Blues resolve in 2 weeks; depression lasts longer and impairs function.
What score would a newborn with pink body, blue extremities, HR 120, crying, flexed, and strong cry get on the APGAR?
8
What is the recommended time to administer rubella postpartum if the client is non-immune?
Before discharge, after delivery, and instruct to avoid pregnancy for 1 month.
What lab must be negative for RhoGAM to be administered?
Indirect Coombs test.
What’s a priority complication for a newborn with a bilirubin level of 18 at 36 hours of life?
Pathologic jaundice → initiate phototherapy.
What reflex is shown when the baby's toes fan outward after stroking the sole?
Babinski reflex.