Nursing Care of the Newborn
A nurse is reinforcing teaching about home care with the parent of a newborn. Which of the following statements indicates an understanding of the teaching?
a.) "I should make sure the baby's bath water is between 115 and 120 degrees F."
b.) "I should let my baby sleep on the sofa until he is old enough to roll over."
c.) "I should ensure the airbag is functional when my baby is riding in the front seat of the car."
d.) "I should remove the bumper pad and stuffed toys from my baby's crib."
d.) "I should remove the bumper pad and stuffed toys from my baby's crib."
A nurse is assisting in the care of a newborn who is LGA and is jittery. Which of the following actions should the nurse take first?
a.) Check the newborn's blood glucose level.
b.) Place the newborn under a radiant warmer.
c.) Provide nonnutritive sucking.
d.) Swaddle the newborn.
a.) Check the newborn's blood glucose level
The first action the nurse should take using the nursing process is to collect data from the client; therefore, the first action the nurse should take is to check the newborn's blood glucose level.
A nurse is reinforcing teaching with new parents about safe sleeping recommendations to reduce the risk of SIDS. Which of the following instructions should the nurse include?
a.) "Room sharing is recommended during infant sleep."
b.) "Bundle the infant snuggly in 2 blankets at bedtime."
c.) "Only use bumper pads that can be securely attached to the crib rails."
d.) "The side-lying position is safest for sleeping."
a.) "Room sharing is recommended during infant sleep."
A nurse is caring for a 12-hour-old newborn who is asymptomatic and has a blood glucose level of 32mg/dL. Which of the following actions should the nurse take?
a. Advise the parent to feed the newborn
b. Give the newborn 60 mL of glucose water
c. Recheck the glucose level in 4 hr
d. Initiate phototherapy for the newborn
a. Advise the parent to feed the newborn
A nurse is reinforcing teaching about formula feeding with a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching?"
a.) "After boiling the water, I should allow it to cool for 45 min prior to mixing it with the formula."
b.) "I should add 2 scoops of powdered formula to an 8 oz bottle of water."
c.) "I can store prepared bottles in my refrigerator for 72 hrs."
d.) "I will warm the bottle of formula by placing it in a pan of hot water."
d.) "I will warm the bottle of formula by placing it in a pan of hot water."
A nurse is contributing to the plan of care for a newborn who has hyperbilirubinemia and a new prescription for phototherapy. Which of the following interventions should the nurse include in the plan?
a.) Reposition the newborn q3hr.
b.) Apply lotion to the newborn's exposed skin 2x daily.
c.) Feed the newborn 1 oz. of glucose water q2hr.
d.) Dress the newborn in a diaper and a thin cotton t-shirt.
a.) Reposition the newborn q3hr.
The nurse should reposition the newborn q2-3 during phototherapy to maximize skin exposure to the light.
A nurse is reinforcing teaching about newborn skin care with a group of new parents. Which of the following instructions should the nurse include?
a. Gently retract the foreskin to wash the glans with soap and water
b. Sponge bath the baby every other day
c. Use an antimicrobial soap for baths
d. Bathe the newborn with a water at a temp between 46 and 49 degrees C
b. Sponge bath the baby every other day
A nurse is reinforcing teaching with new parents about formula feeding. Which of the following instructions should the nurse include?
a.) The bedtime bottle can be placed in the crib after the infant is 6 months of age.
b.) Discard opened cans of formula after 48 hr. of refrigeration
c.) Powdered and concentrated formula can be reconstituted with tap water from the faucet.
d.) Bottles and nipples can be hand-washed in hot, soapy water.
b.) Discard opened cans of formula after 48 hr. of refrigeration
A nurse is assisting with the care of a preterm newborn who is receiving O2 therapy. Which of the following findings should the nurse identify as a potential complication from the O2 therapy?
a.) Atelectasis
b.) Retinopathy
c.) Interstitial emphysema
d.) Necrotizing enterocolitis
b.) Retinopathy
O2 therapy can cause retinopathy of prematurity, especially in preterm newborns.
A nurse is reinforcing discharge teaching with the parent of a newborn regarding the immunization schedule. Which of the following parent statements indicates an understanding of the teaching?
a.) "My baby should not have a hep B vaccine if I test negative."
b.) "My baby will receive the first varicella vaccine at 6 months."
c.) "My baby will start getting immunizations once daycare begins."
d.) "My baby will receive the next immunization at 2 months old."
d.) "My baby will receive the next immunization at 2 months old."
Newborns should receive the next scheduled immunization 2 months after birth.
A nurse is collecting data from a newborn. For which of the following findings should the nurse notify the provider?
a.) HR 136/min
b.) Acrocyanosis
c.) Mottling
d.) RR 60/min
c.) Mottling
This is an indication of hyperthermia or respiratory distress.
A nurse is reinforcing teaching about the selection of commercial formula with the guardian of a newborn. Which of the following pieces of information should the nurse include?
a.) Soy-based formula is recommended to decrease colic.
b.) Amino acid formula is recommended to increase the newborn's protein intake.
c.) Cow's milk-based formula is recommended for healthy newborns.
d.) Low-iron formula is recommended to prevent excess iron intake.
c.) Cow's milk-based formula is recommended for healthy newborns.
A nurse is collecting data from a newborn who is 2 hr. old. Which of the following findings should the nurse report to the provider?
a.) Overlapping suture lines
b.) Generalized petechiae
c.) Acrocyanosis
d.) Transient strabismus
b.) Generalized petechiae
This manifestation can be associated with an infection or clotting factor deficiency.
A nurse is collecting data from a newborn who was born with meconium-stained amniotic fluid. Which of the following findings should the nurse report as an indication of meconium aspiration syndrome?
a. High Apgar score
b. Rapid respirations
c. Flushed skin
d. Elevated PO2
b. Rapid respirations
A nurse is reinforcing teaching with a client who is breastfeeding. Which of the following pieces of info should the nurse include?
a.) "You should allow your baby to nurse for a total of 20 min per feeding."
b.) "Your baby should have 5 wet diapers/day"
c.) "Your baby should have bursts of 15 sucks or swallows at a time"
d.) "You can expect your baby to have dark black stools for the first week of life"
c.) "Your baby should have bursts of 15 sucks or swallows at a time"
a. is wrong because breastfeeding should be for approx. 30 to 40 min
b. is wrong because the baby should have 6 to 8 wet diapers/day
d is wrong because the blacks stools should transition to greenish yellow stools by day four
A nurse is collecting data from a newborn who has a light skin tone and Rh isoimmunization. Which of the following findings should the nurse expect when inspecting the newborn's skin?
a.) Jaundice
b.) Cyanosis
c.) Pallor
d.) Dark red skin
a.) Jaundice
Jaundice during the first 24 hr after birth can indicate RH isoimmunization ABO incompatibility, or increased hemolysis.