B
What finding would you expect to see on a newborn born at 42 weeks?
Dry, cracked skin
Newborns who are postmature have dry, cracked skin that feels like parchment paper
A nurse reinforcing teaching about vitamin K with a client who is postpartum
Vitamin K decreases the newborn's risk of hemorrhagic disorders.
Newborns cannot produce vitamin K until about 8 days after birth. It is administered in the delivery suite to prevent hemorrhagic disorders.
Best method to evaluate newborn hydration?
The number of wet diapers per day
The easiest and most reliable method to evaluate hydration is urinary output. Six to eight wet diapers per day is generally considered adequate.
A nurse is reinforcing teaching about umbilical cord care with a client who is postpartum (when should stump fall off).
The stump should fall off in 10 to 14 days.
Cord separation will vary by the type of cord care, type of birth, and other prenatal events, but usually the cord will fall off in 10 to 14 days
How many stools should a breastfed newborn have a day?
If you breastfeed your newborn, expect two to three stools per day.
A client is concerned that her newborn has "crossed eyes." Which statements is a therapeutic response by the nurse?
"Newborns lack the necessary muscle control to regulate eye movement."
Transient strabismus or nystagmus are common until the third or fourth month of life; therefore, the nurse should reassure the client that this is an expected finding.
A baby has Generalized petechiae, should this be reported to charge nurse or is it expected?
Generalized petechiae can indicate a clotting factor deficiency or infection; therefore, the nurse should report these findings to the provider for further evaluation.
When caring for a newborn following a vaginal delivery. Which actions should the nurse perform first?
Clear the respiratory tract.
Using the airway, breathing, circulation (ABC) priority-setting framework, the first action the nurse should take is to open the airway of a newborn who was just delivered
When does Jaundice usually present in a newborn with an underlying disease/disorder?
Jaundice occurring within the first 24 hr of life is related to some type of hemolytic pathology and requires notifying the charge nurse immediately.
What is nurse’s highest priority is to monitor for a newborn immediately cesarean delivery ?
Respiratory distress
The priority observation when using the airway, breathing, circulation (ABC) approach to client care is to monitor the newborn for respiratory distress. During a vaginal delivery, pressure on the chest from passage through the birth canal helps rid the newborn of amniotic fluid in the lungs and stimulates respiration. With a cesarean delivery, the newborn does not go through the birth canal and, therefore, is at risk for respiratory problems
patient is 4 hr postpartum, nurse finds a small amount of lochia rubra on the client's perineal pad, fundus is midline and firm at the umbilicus. Which actions should the nurse take?
Check for blood under the client’s buttock
The nurse should check for blood under the client’s buttock to evaluate the amount of lochia flow and to check for pooling of blood that would otherwise be missed.
A nurse is collecting data from a client who is 14 hr postpartum, nurse notes, breasts soft; fundus firm, slightly deviated to the right; moderate lochia rubra; temperature 37.7° C (100° F), pulse rate 88./min, respiratory rate 18/min. Which actions should the nurse perform?
Ask the client to empty her bladder.
Whenever the fundus is deviated from the midline, a full bladder should be considered as a potential cause. A full bladder could result in complications such as uterine atony or infection
What should a newborn who weighs 5,160 g (11 lb, 6 oz) and whose mother has diabetes mellitus be assessed for?
Hypoglycemia
Newborns of clients who have diabetes are at high risk for hypoglycemia as the constant supply of glucose creates fetal hyperinsulinemia. It can take several days for the newborn to adjust to secreting appropriate amounts of insulin for the new, lesser supply of glucose. Because severe hypoglycemia can lead to cyanosis and seizures
What complication would a newborn of 34 weeks of gestation, who weighs 1,550 g, has nasal flaring, intercostal retractions, expiratory grunting, and mild cyanosis, be manifesting that would make a nurse place the newborn in an incubator
The newborn’s temperature control mechanism is immature.
Preterm newborns have poor body control of temperature and need immediate attention to keep from losing heat. Reasons for heat loss include little subcutaneous fat and poor insulation, large body surface for weight, immaturity of temperature control, and lack of activity. They require an external heat source that regulates their immediate environment via a sensor attached to the skin.
A newborn has mucus bubbling out of the mouth and nose. Which of the following actions should the nurse take first?
Suction the newborn’s mouth with a bulb syringe.
The nurse should first suction the newborn’s mouth with a bulb syringe, followed by the nares. Suctioning the mouth first helps prevent aspiration of mucus into the newborn’s airway.
A nurse is collecting data from a client who gave birth one week ago. What finding should the nurse identify as a manifestation of endometritis?
Pelvic pain
Manifestations of endometritis, the most common postpartum infection, include chills, fever, tachycardia, anorexia, fatigue, and pelvic pain.
A nurse is reinforcing teaching with a parent about using an iron fortified formula to feed her newborn. What information should the nurse include in the teaching?
The newborn’s iron source will start to deplete.
Iron sources deplete and need to be supplemented in newborns
what is the purpose of administering vitamin K to her newborn following delivery.
Bleeding
A newborn is unable to manufacture vitamin K, which is necessary for blood clotting, without intestinal flora. Vitamin K also promotes production of clotting factors II, VII, IX, and X in the liver. Vitamin K is usually produced by day 8; therefore, it is routinely given to newborns to prevent bleeding problems
12 hrs Following a spontaneous vaginal delivery. The nurse should expect to find the uterine fundus at which of the following positions on the client’s abdomen?
At the level of the umbilicus
Within 12 hr, the fundus should rise to the level of the umbilicus and then recede 1 to 2 cm each day.
3.A nurse is assisting a client with breastfeeding her newborn. The nurse should explain that which reflexes will initiate sucking?
Rooting
The nurse elicits the rooting reflex by stroking the newborn’s cheek. The newborn will turn his head while making sucking motions with his mouth.
"When will breast milk come in?
In 3 to 5 days after delivery
:By day 3 to 5, most clients who are breastfeeding begin to produce copious amounts of breast milk.
What findings should alert the nurse to the 8hr postpartum client’s need to urinate?
Fundus three fingerbreadths above the umbilicus
A full bladder can raise the level of uterine fundus and deviate it to the side
TRUE OR FALSE
Should a breastfeeding mom reduce her intake of iron?
TRUE
Reduce intake of iron." Recommendations for some nutrients, such as iron and folic acid, are less during lactation than during pregnancy. Because maternal blood volume decreases after childbirth, the client’s need for these nutrients also diminishes.
A nurse is collecting data from a newborn. Which of the following anatomical landmarks should the nurse use to measure chest circumference?
Nipple line
The nurse should measure the chest circumference at the nipple line.
If a mom states "I am concerned about my baby's hearing because my mother was born deaf." What statements should the nurse make?
"We do routine hearing screenings on newborns. You’ll know the results before you leave the hospital."
Most states mandate hearing screening for all newborns. The two tests in use do not diagnose hearing loss, but determine whether a newborn requires further evaluation.