Reproduction: Exemplar 33.D Newborn Care

The nurse is proving care to a 1-hour-old newborn who was born at 39 weeks' gestation. Which assessment data is cause for concern? Select all that apply.

A) Respiratory rate of 82 breaths per minute

B) Negative Babinski reflex

C) Mean blood pressure of 52 mmHg

D) Acrocyanosis

E) Presence of soft heart murmur

AB

The nurse receives shift change report on infants born within the last 4 hours. Which newborn should the nurse assess first?

A) Newborn born at 37 weeks' gestation. Respiratory rate of 45 breaths per minute.

B) Term newborn, 2 hours old, who has not passed a meconium stool.

C) Term newborn born 3 hours ago. Heart rate is 150 beats per minute.

D) Term newborn born 1 hour ago who is exhibiting grunting respirations.

D

A client delivers a newborn son and plans to breastfeed. When the nurse attempts to help the newborn latch on for breastfeeding, the client states, "I would like to bottle feed my baby for the first few days." Which reason might the nurse hear regarding why the client wants to delay breastfeeding?

A) Colostrum is bad for the baby.

B) The birthing process spoils breast milk.

C) It will cause "evil eye."

D) Newborns require feeding on demand.

A

The nurse is caring for a newborn boy who was circumcised an hour ago. Which is the priority nursing diagnosis for the newborn?

A) Risk for Injury

B) Risk for Infection

C) Risk for Imbalanced Nutrition

D) Risk for Ineffective Breathing Pattern

B

A nurse is caring for the 1-hour-old newborn of a mother with diabetes mellitus. Which actions will the nurse include in the newborn's plan of care? Select all that apply.

A) Assess blood glucose frequently.

B) Assess for SGA.

C) Assess for hyperthyroidism.

D) Assess the newborn's temperature hourly.

E) Assess for hyperbilirubinemia.

AE

The nurse is instructing a new mother on how to care for the newborn's circumcision site. Which statements indicate that the nurse's education session was effective? Select all that apply.

A) "I should not use petroleum jelly on the penis."

B) "Every time I change the diaper I am to wash the area with warm water."

C) "I should report any pus drainage or change in diaper wetness to the physician."

D) "Swelling is expected."

E) "I am to use soap and water to remove yellow tissue on the penis."

BC

When administering an intramuscular dose of vitamin K (phytonadione) to a newborn, which actions by the nurse are appropriate? Select all that apply.

A) Using a 23-gauge 1/2-inch needle

B) Cleaning the skin with an alcohol swab

C) Preparing 5 mg of the medication for injection

D) Using the middle third of the vastus lateralis muscle

E) Washing the skin with soap and water

BD

The nurse is providing discharge instructions for a first-time mother and her baby. Which statement is appropriate for the nurse to include in the teaching session?

A) "Your baby's stools will change to a dark green color when your milk comes in."

B) "Your baby may spit up frequently for the first few weeks."

C) "Compress the bulb syringe before placing it in your baby's nose or mouth."

D) "You can wipe away any green drainage that might form around the umbilical cord."

C

The nurse is providing care to a newborn during the first 24 hours of life. Which is an abnormal finding?

A) Respiratory rate of 58 breaths per minute

B) Heart rate of 140 beats per minute

C) Presence of meconium stool

D) Yellowing of the skin

D

The nurse conducting a 5-minute Apgar assessment on a newborn assigns the following ratings: Heart rate <100 beats per minute (1 point); slow, irregular respirations (1 point); some flexion of the extremities (1 point); a vigorous cry with flicking of the baby's foot (2 points); and a pink body with blue extremities (1 point). Based on this data, which nursing action is appropriate?

A) Having the aide reassess the newborn's heart rate and respiratory rate when admitted to the nursery

B) Swaddling the newborn to decrease the risk of increased energy expenditure

C) Placing the newborn in the mother's arms and asking her to monitor her baby's breathing

D) Repeating the assessment every 5 minutes for up to 20 minutes

D

The nurse is providing care to a newborn born at 37 2/7 weeks' gestation. The newborn's weight is 1750 g (3 pounds, 10 ounces). What statement would the nurse use to describe these assessment findings?

A) Preterm appropriate for gestational age

B) Term appropriate for gestational age

C) Preterm small for gestational age

D) Term small for gestational age

D

The nurse will commonly need to work with all except which member of the healthcare team to provide care to the newborn?

A) Audiology specialist

B) Cardiac surgeon

C) Lactation consultant

D) Pediatrician

B