ATI unit 4 newborn

nurse is caring for NB born at 38 wks gestation, weighs 3200 grams(7LBS) & in 60th percentile for wght. based on gestational age the nurse should assign the NB which of the following classifcations?

"appropriate" for gestational age (btwn 10th & 90th percentile)

-low birth wt is below 2500 g(5.5LBs) & less than 10th percentile

-large gestational is greater than 90th percentile

nurse checks HR of newborn immediately following birth. Auscultate the HR w stethoscope on apex of newborn heart.

apex=apical, pediatric stethoscope head placed on 4th or 5th intercostal space at left midclavicular line over apex of heart. for one full minuten

nurse collecting data from NB following birth. which data indicates NB is adapting to extrauterine life?

1. periods of apnea lasting less than 20 sec

2. newborns are obligatory nose breathers

indications that NB is NOT ADAPTING to extrauterine life:

crackles/wheezing = fluid or infection in lungs

nasal flaring/expiratory grunting = respiratory distress

nurse teaching new licensed nurse how to bathe NB and observes a bluish brown marking across the NB lower back. Nurse includes what info in the teaching?

Mongolian spots commonly found over lumbosacral area of NB w dark skin & can be linked to genetics

hyperbilirubinemia

jaundice

forceps marks

present as cephalohematoma

birth trauma

presents as ecchymosis

Eccymosis

bruising

nurse collecting on NB & observes small pearly white nodules on roof of NB mouth. This finding is characteristics of:

Epstein's pearls (small yellow white nodules that appear on roof of NB mouth

milia

small pearly white bumps that appear on the nose due to clogged sebaceous glands

erythema toxicum

transient maculopapular rash seen in newborns

nurse is checking reflexes of NB in checking for Moros reflex, the nurse should perform what?

moros reflex nurse holds NB in semi sitting position then allows head and trunk to fall backwards

stepping reflex

holding NB vertically under the arms, allowing 1 foot to touch table

grasp reflex

stimulating pads of NB hands elicits grasp reflex

Babinski reflex

stimulating the outer lateral portion of NB sole

-Reflex in which a newborn fans out the toes when the sole of the foot is touched

nurse reviewing contraindications for circumcision w new nurse. which conditions are contraindications?

hypospadias & fam Hx of hemophilia

What are NOT contraindications of a circumcision?

-hyperbilirubinemia and hydrocele = collection of fluid in scrotal sac are not contraindications

nurse takes NB to parent following circumcision, which action does nurse take for security purposes?

match parents identification band with the newborns band

nurse assisting w newborn care, immediately following birth. which nurse interventions is HIGHEST priority?

covering NB head w cap. BC greatest risk to NB is cold stress so highest priority intervention is to prevent heat loss. covering head w cap prevents cold stress due to excessive evaporation heat loss

a newborn was not dried completely after birth. this places NB at risk for which type of heat loss?

EVAPORATION: loss of heat that occurs when liquid is converted to a vapor. In newborns, heat loss by vaporization of the moisture from the skin.

nurse should identify newborn is at risk for heat loss due to evaporation

nurse preparing to administer prophylactic antibiotic eye ointment to NB to prevent ophthalmia neonatorum. which following med should nurse anticipate administering?

erythromycin ophthalmic ointment 0.5%

the antibiotic provides prophylaxis against Neisseria gonorrheae & Chlamydia trachomatis

nurse reinforcing teaching w new parents about proper bottle feeding techniques. What should nurse include?

keep nipple full of formula through entire feeding to prevent NB from sucking air, NB should be burped q 1/2 oz of formula, cradle in semi upright position, & discard any unused formula due to possibility of bacterial contamination

As a nurse, What should you instruct the parents of a newborn about home safety?

inform parents about safety info, never leave the nb unattended w pets/small children, keep small items out reach of nb due to choking hazards, never leave nb alone on the bed, couch, table; never place nb on stomach to sleep during first few months, back lying is position of choice, reinforce edu importance of tummy time: 3-5 min per day and 2-3 times each day, never provide nb soft surface to sleep on, mattress should be firm, never put pillows, toys, bumper pads, or loose blanket in crib, do not tie anything around neck, monitor safety of crib, space btwn mattress and side of crib should be less than 2 fingerbreadths, slats no more than 2.25 in apart, crib/playpen away from window blinds and drapery cords, bassinet/crib placed on inner wall and not by window, prevent cold stress, eliminate any potential fire hazard, away from radiators, heaters, & heat vents

nurse assisting with an in-service for new nurse about neonatal opioid withdrawal syndrome(NOWS) in newborns. What indicates an understanding of the teaching?

new nurse understands findings associated w NOWS when they state the nb will have a high-pitched, continuous cry; increased muscle tone; sleep pattern disturbances; difficulty sleeping for 2-3 hrs after feeding; moderate to severe tremors when undisturbed

nurse care for preterm and has respiratory distress syndrome. What condition should nurse monitor following administration of synthetic surfactant?

oxygen saturation

-surfactant administration has no direct effect on the heart

nurse assisting care w nb born at 32 weeks gestation. birth weight is 1,100 g(2.4 LBS). What are the expected findings?

• lanugo

• weak grasp reflex

• translucent skin(thin,smooth,shiny)

nurse care of client who is 42 weeks gestation and in labor. client ask nurse what to expect bc baby is postmature. What is the correct statement from nurse?

expect baby to have: leathery, cracked, wrinkled skin in postmature due to placental insufficiency & postmature infants have excess body fat or long nails

expected findings for preterm newborns:

flat areolars w/out breast buds & heels that are movable fully to the ears

macrosomic finding

plump face

nursing care for NB w high bilirubin level receiving phototherapy. What is the priority change that the nurse needs to report to the charge nurse?

sunken fontanels is priority bc NB receiving phototherapy is at risk for dehydration from loose stools due to increases bilirubin excretion