NURSING PROCESS IN THE
CARE OF THE NEWBORN
NUR200
The Newborn

An infant is admitted to the nursery after a difficult
shoulder birth. For what condition should the nurse assess this
newborn?
Facial paralysis
Cephalhematoma
Brachial plexus injury
Spinal cord syndrome
The Newborn
Phenylketonuria (PKU) testing is performed on a newborn.
The nurse plans to explain to the mother the purpose of
this screening test. What does this test reveal?
Whether the infant is positive for PKU
Whether the mother is a carrier of PKU
The mother's risk for later development of PKU
The infant's risk for development of PKU later in life
The Newborn

During the second reactive period a newborn becomes
more alert and responsive and there is an increase in mucus
production and gagging. What should the nurse do first?
A. Report this finding.
B. Administer nasal oxygen.
C. Lower the head of the bassinette.
D. Remove secretions from the pharynx.
The Newborn
A nurse is assessing a newborn of 33 weeks'
gestation. Which sign alerts the nurse to notify the
health care provider?
Acrocyanosis
Flaring nares
Heartbeat of 140 beats/min
Respirations of 40 breaths/min
 .
The Newborn

While inspecting her newborn a mother asks the nurse why her baby has
flat feet. Before responding, what information should the nurse consider?
Flat feet are common in children, requiring them to wear orthotic shoes.
The newborn's feet are so small that it is difficult to determine whether
there is an arch.
Flat feet are associated with deformities of the bones of the feet such as
clubfoot.
The arch of the newborn's foot is covered with a fat pad, giving the foot
the appearance of being flat.
The Newborn

A nurse in the newborn nursery receives a call from the
emergency department saying that a woman with active
herpes virus lesions gave birth in a taxicab while coming to
the hospital. What does the nurse consider about the
transmission of the herpes virus?
Contact precautions are necessary.
It occurs during sexual intercourse.
It can be acquired during a vaginal birth.
Protection is provided by way of maternal immunity.
The Newborn

A nurse teaches a group of postpartum clients that all
their newborns will be screened for phenylketonuria
(PKU) to:
Assess protein metabolism.
Reveal potential retardation.
Detect chromosomal damage.
Identify thyroid insufficiency.
The Newborn

How should the nurse assess a newborn's grasp reflex?
By putting direct pressure along the sole of the newborn's
foot
By jarring the crib and watch the movement of the
newborn's hands
By pressing the examining fingers against the palms of
the newborn's hands
By holding the body upright and allowing the newborn's
feet to touch a surface
The Newborn

A nurse must continually assess a preterm infant's
temperature and provide appropriate nursing care
because, unlike the full-term infant, the preterm infant:
Cannot use shivering to produce heat
Cannot break down glycogen to glucose
Has a limited supply of brown fat available to
provide heat
Has a limited amount of pituitary hormones with which
to control internal heat
The Newborn

A nurse in the birthing room gives an injection of vitamin
K to a newborn. The vitamin K is prescribed because it:
Prolongs prothrombin time
Improves absorption of biliary salts
Promotes formation of clotting factors in the liver
Replaces bacteria that are absent in the intestinal tract
The Newborn

The nurse identifies a swelling on the scalp when
assessing a newborn. What assessment finding indicates
a cephalohematoma?
Unusually wide suture line
Ecchymotic area over the affected eye
Diffuse discoloration over the entire scalp
Swelling confined to the area over one skull bone
The Newborn

What characteristic that may be a potential
nutrition problem should the nurse identify in a
preterm neonate?
Inadequate sucking reflex
Diminished metabolic rate
Rapid digestion of formula
Increased absorption of nutrients
The Newborn

The nurse is caring for a newborn with caput
succedaneum. The nurse is able to differentiate caput
succedaneum from cephalhematoma because caput
succedaneum features scalp edema that:
Becomes ecchymotic
Crosses the suture line
Increases after several hours
Is tender in the surrounding area
The Newborn

A nurse is planning to use a newborn's foot to obtain
blood for the required newborn metabolic testing.
What part of the foot is the best site to use for the
puncture?
Big toe
Foot pad
Inner sole
Outer heel
The Newborn

A client's membranes rupture during the transition phase of labor,
and the amniotic fluid appears pale green. . What priority
intervention for the infant can the nurse anticipate implementing
upon delivery?
Stimulating crying
Administering oxygen
Putting a moist saline dressing on the cord stump
Providing for suctioning of the oropharynx as the head emerges
The Newborn

An infant of a diabetic mother is admitted to the
neonatal intensive care unit. What is the priority nursing
intervention for this infant?
Clamping the cord a second time
Obtaining heel blood to test the glucose level
Starting an intravenous infusion of glucose in water

Instilling an ophthalmic antibiotic to prevent an eye
infection
.
The Newborn

During the initial assessment of a dark-skinned neonate
the nurse observes several dark round areas on a
newborn's buttocks. How should this observation be
documented?
Stork bites
Forceps marks
Mongolian spots
Ecchymotic areas
The Newborn

Shortly after birth the nurse instills erythromycin
ophthalmic ointment in the newborn's eyes. The father
asks why an antibiotic is needed because the mother
does not have an infection. The nurse explains that it
protects the newborn from:
Chlamydia and gonorrhea
Syphilis and toxoplasmosis
Rubella and retrolental fibroplasia

Cytomegalovirus and varicella zoster
The Newborn

After the birth of a neonate, a parent asks, "What is
that white substance over the baby's body?" The nurse
initially responds:
"It's a fungal infection called thrush."
"It's unexpected, and it's called milia."
"It's expected, and it's called vernix caseosa."
"It's a group of capillaries called telangiectatic nevi."
The Newborn

The nurse is helping a mother breastfeed her newborn.
What is the best indication that the newborn has
achieved an effective attachment to the breast?
The tongue is securely on top of the nipple.
The mouth covers most of the areolar surface.
Loud sucking sounds are heard during the 15 minutes
spent at each breast.
Vigorous suckling occurs for the 5 minutes the infant
spends at each breast before falling asleep.
The Newborn

During a vertex vaginal birth the nurse notes
meconium-stained amniotic fluid. What is the priority
nursing intervention for the newborn?
Stimulating crying
Suctioning the airway
Using an Ambu bag with oxygen support

Placing the infant in the reverse Trendelenburg position
.
The Newborn

Respiratory distress syndrome (RDS) develops in a
neonate born at 33 weeks' gestation 6 hours after
birth. What would the nurse's assessment of the
newborn at this time reveal?
High-pitched cry
Intercostal retractions
Respirations of 30 breaths/min
Heart rate of 140 beats/min
The Newborn

While a mother is inspecting her newborn she
expresses concern that her baby's eyes are crossed.
How should the nurse respond?
"This is expected. Your baby is trying to focus."
"You're right. I'll contact your health care provider.“
"This is expected. Your baby is trying to focus."
The Newborn

24. A client at 36 weeks' gestation exhibits
oligohydramnios. What newborn complication should
the nurse anticipate?
Spina bifida
Imperforate anus

Tracheoesophageal fistula
Intrauterine growth restriction (IUGR)
The Newborn

A newborn male is admitted to the nursery. He weighs
10 lb 2 oz, which is 2 lb more than the birth weight of
any of his siblings. What should the nurse do in relation
to the baby's weight?
Document the findings.
Place him in a heated crib.
Delay starting oral feedings.
Perform serial glucose readings.
.
The Newborn

A nurse gives a nasogastric feeding to a preterm male infant. As the mother
watches, she asks, "Would it hurt my baby to suck on a pacifier during the
feeding?" How should the nurse respond?
"There's no real benefit in using a pacifier. Also, there's a relationship
between using a pacifier and the development of buck teeth."
"If you want, he can suck on a pacifier now, but he may have problems later
when he starts to suck from the breast or bottle"
"It's difficult to determine the color of his lips while he's sucking on a
pacifier. We'd rather wait until he's a little older."
"Sucking on a pacifier during tube feedings may help him associate
sucking with food so that he'll adjust better to oral feedings."
The Newborn

A nurse plans to administer vitamin K to a newborn.
What site should the nurse use for the injection?
Deltoid muscle
Rectus femoris
Vastus lateralis
Gluteus maximus
The Newborn

Phototherapy is prescribed for a preterm neonate with
hyperbilirubinemia. Which nursing intervention is appropriate to
reduce the potentially harmful side effect of the phototherapy?
Covering the trunk to prevent hypothermia
Using shields on the eyes to protect them from the light
Massaging vitamin E oil into the skin to minimize drying
Turning after each feeding to reduce exposure of each surface area


A nurse decides on a teaching plan for a new mother
and her infant. What should the plan include?
A schedule for teaching infant care
A demonstration and explanation of infant care
A discussion of mothering skills presented in a
nonthreatening manner
Emotional support and that will foster dependence on
the nurse's expertise

A male newborn has been exposed to HIV in utero.
Which assessment supports the diagnosis of HIV
infection in the newborn?
Delay in temperature regulation
Continued bleeding after circumcision
Hypoglycemia within the first day of birth

Thrush that does not respond readily to treatment
.
The Newborn

A small-for-gestational-age (SGA) newborn has just been
admitted to the nursery. Nursing assessment reveals a highpitched cry, jitteriness, and irregular respirations. With what
condition are these signs associated?
Hypervolemia
Hypoglycemia
Hypercalcemia
Hypothyroidism

A newborn male is circumcised. What post circumcision
care does the mother propose that alerts the nurse that
she requires additional teaching?
"I'll need to change his diapers a lot more often."
"I need to call the doctor if there's a lot of bleeding."
"I'll be sure to give him a tub bath tomorrow."
"I need to apply petrolatum gauze to his penis with
each diaper change."

What is most important parameter for the nurse to
monitor during the first 24 hours after the birth of
an infant at 36 weeks' gestation?
Duration of cry
Respiratory distress
Frequency of voiding
Decreased temperature
The Newborn

The nurse is assessing a newborn for
developmental dysplasia of the hip (DDH). Where
does the nurse look for extra skin folds?
Calf muscles
Popliteal area
Back of the thigh
Lower portion of the abdomen
The Newborn

A nurse in the clinic determines that a 4-day-old neonate
who was born at home has a purulent discharge from the
eyes. What condition does the nurse suspect?
HIV infection
Chlamydia trachomatis infection
Retinopathy of prematurity (retrolental fibroplasia)
A reaction to the ophthalmic antibiotic instilled after birth
Chlamydia trachomatis infection
The Newborn

After her baby's birth a client wishes to begin
breastfeeding. How can the nurse assist the client at this
time?
Giving the infant a bottle first to evaluate the sucking reflex
Positioning the infant to grasp the nipple to express
colostrum
Leaving the infant and parents alone to promote attachment
behaviors
Touching the infant's cheek adjacent to the nipple to elicit
the rooting reflex
The Newborn

A nursing instructor provides education for the students
on thermoregulation in the nursery. The students
determine that in the healthy full-term neonate, heat
production is accomplished by:
Oxidization of fatty acids
Shivering when chilled
Metabolism of brown fat
Increased muscular activity
The Newborn

Fetal heart rate tracing abnormalities are observed on
the fetal monitor when a client in active labor turns to
the supine position. What nursing action is most
beneficial at this time?
Helping the client change her position
Informing the client of the problem with the fetus
Administering oxygen by mask to the client at 2 L/min
Readjusting placement of the fetal monitor on the
client's abdomen
The Newborn

A nurse assesses a healthy 8-lb 8-oz (3860-gm)
newborn who was given Apgar scores of 9 at 1 minute
and 10 at 5 minutes. Which category of the Apgar
score received a 1 rating at one minute?
Color
Heart rate
Respirations
Reflex irritability
The Newborn

A nurse teaches a new mother about neonatal
weight loss in the first 3 days of life. What does the
nurse explain is the cause of this weight loss?
An allergy to formula
A hypoglycemic response
Ineffective feeding techniques
Excretion of accumulated excess fluids
The Newborn

On the third postpartum day a mother visits the clinic
and asks why her newborn's skin has begun to appear
yellow. The nurse explains that the change in her infant's
skin tone is the result of:
Breakdown of fetal red blood cells
Breast milk ingestion
Inadequate fluid intake
Immaturity of the vascular system
The Newborn

The practice of separating parents from their newborn
immediately after birth and limiting their time with the
infant during the first few days after delivery
contradicts studies of which of the following?
Early rooming-in
Taking-in behaviors
Taking-hold behaviors
Parent-child attachment
The Newborn




What is Meconium?
A dark green substance forming the first feces of
a newborn infant.
When is it passed
What does passage of meconium indicate
The Newborn

After an emergency cesarean birth, a neonate born at 35
weeks' gestation is admitted to the neonatal intensive care
unit. The neonate has a Silverman-Anderson score of 6.
What nursing intervention is needed?
Monitoring of cardiac status
Assessment of neurological reflexes
Ensuring increased caloric intake and fluids
Administration of respiratory support and observation
The Newborn

45. An infant has surgery for repair of a
myelomeningocele (defect of the spine). For which early
sign of impending hydrocephalus should the nurse
monitor the infant?
Frequent crying
Bulging fontanels
Change in vital signs
Difficulty with feeding
The Newborn

A newborn has just begun to breastfeed. Although the neonate has latched on to the
mother's nipple, soon after beginning to suck the infant begins to choke, has an
excessive quantity of frothy secretions, and exhibits unexplained episodes of
cyanosis. How should the nurse intervene?
Tell the client to use the other breast and continue breastfeeding.
Delay the feeding to allow more time for the infant to recover from the birthing
process.
Contact the lactation consultant to help the client learn a more successful
breastfeeding technique.
Halt the feeding and notify the health care provider to evaluate the infant for a
tracheoesophageal fistula (an abnormal connection (fistula) between the
esophagus and the trachea).
The Newborn

After birth, while inspecting her newborn, a mother notices
a discharge from the nipples of her infant's breasts. She
asks why this is happening. How should the nurse respond?
"It's a nomal effect of your hormones."
"It's caused by Monilia contracted during birth."
"There may be a congenital hormonal imbalance."
"You had a uterine infection during the pregnancy."
The Newborn

The parents of a newborn ask the nurse about several areas of
deep-blue coloring on their baby's lower back and buttocks. The
nurse's response is based on the information that:
These areas usually are normal and will fade within the first
year.
Color changes represent transient mottling that occurs when the
baby is cold.
These are characteristic of the harlequin color change that occurs
when the newborn lies on the side.
Discolorations are probably bruises requiring observation of the
infant for the development of jaundice.
The Newborn

A postpartum client is changing her female newborn's
diaper, sees what appears to be red-tinged mucus on the
diaper, and calls the nursing station for assistance. What
nursing intervention is necessary?
Notifying the pediatrician
Collecting and sending a sample to the lab
Monitoring diapers to see whether this continues
Explaining that this is a normal reaction to the mother's
hormones
The Newborn

A client asks the nurse what advantage breastfeeding holds
over formula feeding. What major group of substances in
human milk are of special importance to the newborn and
cannot be reproduced in a bottle formula?
Amino acids
Gamma-globulins
Essential electrolytes
Complex carbohydrates
The Newborn

When is the umbilical cord clamp
removed?
The Newborn

The nurse assures a breastfeeding mother that one way
she will know that her infant is getting an adequate
supply of breast milk is if the infant gains weight. What
behavior does the infant exhibit if an adequate amount
of milk is being ingested?
Has several firm stools daily
Voids six or more times a day
Spits out a pacifier when offered
Awakens to feed about every four hours
The Newborn

A client expresses a desire to breastfeed her preterm neonate, who
is in the neonatal intensive care unit (NICU). The client states that she
will pump her breasts until her baby is ready to breastfeed. The
infant has been sucking on a pacifier for 1 week in accordance with
protocol. How should the nurse respond to the mother's request?
By telling the client that this is unnecessary because the infant is
being fed by gavage
By discouraging the client because of the time and effort it will take
to pump her breasts
By instructing the client that breast milk is inadequate because it
does not contain the necessary nutrients
By supporting the client's decision and explaining that the infant
may lie close to her breast for nippling as desired
The Newborn


Why do we administer vitamin K intramuscularly to
a newborn immediately after birth?
Promote the synthesis of prothrombin.
The Newborn

Since giving birth six months ago, a woman has breastfed her infant.
The woman becomes hysterical after learning that her husband has
been seriously injured in an automobile accident. Culturally this
woman believes that emotional stress while breastfeeding can "sour
the milk," and she indicates that she must wean her infant
immediately. What should the nurse do?
Instruct the mother about formula feeding.
Explain to the mother that these beliefs are wrong.
Provide the mother with books indicating that the milk does not sour.
Encourage the mother to take an anti anxiety drug while continuing
breastfeeding.
The Newborn

After being shown to the parents, a preterm male newborn weighing
3 lb 15 oz (1500 g) is moved to the neonatal intensive care unit.
What should the nurse's plan for parental visits include?
Taking them to visit their son as soon as possible
Securing a prescription for them to be allowed to visit their son
Determining whether their son's condition is satisfactory before
taking them to see him
Discouraging them from being involved with their son until his
prognosis is established
APGAR SCORE

What is the Apgar score used for?
APGAR SCORE






What are the five areas that are assessed in the
Apgar score?
heart rate,
respiratory effort,
muscle tone,
reflex irritability,
color.

Five minutes after being born, a newborn is given an Apgar
score of 8. Twelve hours later the newborn becomes
hyperactive and jittery, sneezes frequently, and has
difficulty swallowing. What does the nurse suspect is the
cause of these clinical findings?
Cerebral palsy
Neonatal syphilis
Fetal alcohol syndrome
Opioid drug withdrawal