BN Ch. 67 Care Of The Normal Newborn

Question 1

The five criteria assessed by the Apgar score are Appearance, Pulse, Grimace, _____ and Respiratory effort.

Answer 1

Activity

Question 2

Vitamin K is administered to the neonate by the _____ route during the first hour after birth.

Answer 2

Intramuscular

Question 3

In many birth centers, a cap is placed on the newborn’s head because the infant loses a lot of ______ from the head.

Answer 3

Heat

Question 4

The _________ are the “soft spots” in the newborn’s skull, formed at the junction of the individual skull bones.

Answer 4

Fontanels

Question 5

The fine, downy hair found on the face, shoulders, and back of a newborn is called __________.

Answer 5

Lanugo

Question 6

Newborn’s foot fans out when the foot is held and stroked up the lateral edge
and across the ball of the foot

Answer 6

Babinski Reflex

Question 7

Newborn turns head in the direction of the touch when lip or cheek is stroked

Answer 7

Rooting Reflex

Question 8

Newborn throws out arms and draws up legs in response to sudden noise

Answer 8

Moro Reflex

Question 9

Newborn holds tightly onto an object that is placed , in his or her hand

Answer 9

Grasp Reflex

Question 10

1. A plastic clamp is applied, and the Kelly clamp is removed.
2. The cord is cut between the two clamps.
3. The baby is dried and handed to the nurse or mother.
4. A cord blood sample is collected.

Answer 10

2The cord is cut between the two clamps.
4A cord blood sample is collected.
3The baby is dried and handed to the nurse or mother.
1A plastic clamp is applied, and the Kelly clamp is removed.

Question 11

What is an Apgar score? What does it indicate?

Answer 11

The Apgar score, named for Dr. Virginia Apgar, is also an acronym for Appearance, Pulse, Grimace, Activity, and Respiratory effort.
This scoring method provides a quick and accurate means to assess the newborn’s physical condition at the time of birth.
The score is used to determine whether the baby needs immediate assistance or resuscitation.
It should be determined at 1 minute and again at 5 minutes after birth.
The 1-minute score is most accurate in predicting immediate survival, whereas the 5-minute score may be better in predicting long-term survival and any neurologic damage.
If the Apgar score is 7 or less, it indicates a need for neonatal resuscitation and calls for immediate assistance.

Question 12

How is the newborn baby protected from developing eye infections after birth?

Answer 12

During delivery, if the mother has gonorrhea or chlamydia infecting her reproductive organs, the birth process could result in the infant being exposed to those organisms, leading to the development of blindness or ophthalmia neonatorum if left untreated in the infant.
Even babies born by cesarean section can be exposed to these microor- ganisms.
This is prevented by the use of erythromycin ointment, which is effective against both gonorrhea and chlamydia and is the drug of choice. Treatment may safely be delayed for 2 to 3 hours while the baby and parents are getting to know each other.

Question 13

Why is vitamin K administered to most newborn infants?

Answer 13

Newborn babies are at risk of developing bleeding complications during the first week of life because their gastrointestinal tract is sterile. The lack of intestinal bacterial flora means that the newborn is unable to produce an adequate amount of vitamin K which is important for production of certain clot- ting factors by the liver. Therefore, an intramuscular injection of 0.5 to 1.0 mg of vitamin K is usually administered during the first hour after birth.

Question 14

What are the indications for bottlefeeding?

Answer 14

Although breastfeeding is highly preferred, in certain instances it is contraindicated. Breastfeeding may be undesirable if the mother has a chronic disease (such as HIV infection), if the nipples are severely inverted, or if the baby has certain abnor- malities. In the event of a premature delivery and in some other situations, the mother may express her breast milk, which may then be bottle-fed to the baby. Some women choose to bottle-feed for social or personal reasons. Various formulas have been developed that are satisfactory breast milk replace- ments. These formulas have their own advantages and are selected by the baby’s healthcare provider as appropriate for the newborn’s needs.

Question 15

A nurse assessing a newborn records an Apgar score of 5 and determines that the baby needs resuscitation.
a. What is the importance of assessing the vital signs and physical condition of the newborn?

Answer 15

The newborn baby is vulnerable to various inter- nal and external factors which, if not countered as soon as possible, can lead to serious complica- tions. Assessing the respiratory and circulatory systems and checking vital signs are important for identifying and taking emergency measures to combat various disorders and conditions that can develop in neonates.

Question 16

What are the steps in performing neonatal resuscitation?

Answer 16

The steps in performing neonatal resuscitation are as follows:
• Wash hands thoroughly and wear gloves.
• Place the newborn in the supine position, with
the head slightly lower than the body.
• Maintain the neck in a neutral or “sniffing”
position.
• Provide gentle suction. If using a bulb syringe,
compress the bulb before insertion. Suction
the mouth before the nose.
• Occasionally a newborn needs to be intubated
in the delivery room, a procedure that can safely be performed only by anesthesia person- nel, the birth attendant, or a specially trained nurse.
• Provide oxygen by mask or anesthesia bag. The mask must be of the proper size to seal over the newborn’s mouth and nose.
• Physical stimulation, such as rubbing the new- born’s chest and feet, may help breathing. However, if the baby does not respond to stim- ulation, do not keep trying it.
• Medication may be necessary to stimulate the newborn to breathe on his or her own.
• The newborn usually takes nothing by mouth (NPO) until respiration is stabilized.
• Administration of antibiotics may be necessary if extensive resuscitation has been done.
• On completion of neonatal resuscitation, chart in the nurse’s notes any complications that occurred during the treatment.

Question 17

A nurse is required to guide and assist a client who has recently given birth in breastfeeding her baby.
a. What are the advantages of breastfeeding?

Answer 17

The advantages of breastfeeding are as follows:
• Better nutrition.
• Lower risk of the baby’s developing allergies.
• Reduced risk of infections in the newborn,
because maternal antibodies pass through the
breast milk.
• Enhanced maternal-newborn bonding.
• Involution of the uterus promoted by breast- feeding.
• Delayed ovulation for women who breastfeed only.
• Correct temperature of breast milk.
• Availability and convenience of breast milk.
• Economical aspects

Question 18

What are the steps in assisting the client to breastfeed her baby?

Answer 18

When assisting the nursing mother, the nurse should perform the following steps:
• Wash hands, dress the newborn warmly, and carry the baby carefully using the cradle or football hold.
• Ensure that the right baby is with the right mother.
• Instruct the mother to wash her hands to prevent infection.
• Provide privacy and assist the mother into a comfortable position.
• Show the mother how to hold and burp the newborn. Have her do a return demonstration.
• When the feeding is finished, check with the mother about how the baby fed. Ask whether the baby was burped.
• Ensure that the baby is clean and dry. Place the baby on the back or side, because sleeping on the back decreases the risk of sudden infant death syndrome (SIDS).
• Wash the hands and document the feeding on the baby’s chart, including how well the baby breastfed, or how much formula was taken, and any other pertinent observations.

Question 19

A nurse is required to instruct a client on how to give a tub bath to their newborn.
a. What are the precautions to be taken?

Answer 19

The nurse should inform the client that a tub bath should not be given until the cord falls off. The following precautions are to be taken when giving a tub bath to a newborn:
• Ensure that the room air is warm enough and that the newborn is protected from drafts.
• Never leave the baby unattended during the bath, to prevent accidents such as falling or drowning.
• Have the following equipment ready: baby bath tub, bath thermometer, two washcloths, towels, baby soap, clean clothes and diaper, and lotion.
• Wash hands to prevent spreading infection.
• Check the water temperature carefully; it
should be warm, not hot (98.68°F or 378°C is
the usual maximum temperature).
• Chart toleration of bath.

Question 20

A nurse is required to instruct a client on how to give a tub bath to their newborn.
B. How is it performed?

Answer 20

The following are the steps in giving a tub bath to a newborn:
• Carefully support the newborn’s head and body with a moderately firm grip while placing the baby in the tub.
• Use a soft washcloth, towel, and only a small amount of soap.

Clean the eyes with separate ends of the wash- cloth.
• Rinse all soap off.
• Dry the baby, paying particular attention to
drying the skin folds well.
• Look for skin irritation or abnormalities.

Question 21

When inspecting a newborn, the nurse notices a flat, purple-red area with sharp borders on the infant’s skin. Which condition does this indicate?
a. Epstein pearls
b. Milia spots
c. Stork bite
D. Port-wine stain

Answer 21

D. Port-wine stain

• rAtionAle: A port-wine stain is a flat, purple-red area with sharp borders. This is a permanent birth- mark. Epstein pearls are white- or grayish-colored bumps that are sometimes found on the hard and soft palate of the mouth. Milia spots are pinhead- sized white spots that appear on the nose and cheeks and are caused by unopened oil and sweat glands. Stork bites are marks that often appear on the newborn’s eyelids or forehead.

Question 22

A nurse is assigned to manage and care for a newborn immediately after delivery. Which should be the immediate action of the nurse?

A. Establish and maintain airway and respirations.
b. Assist and guide the mother in nursing the baby.
c. Give a warm water tub bath to the infant.
d. Record the weight of the newborn infant.

Answer 22

A. Establish and maintain airway and respirations.

• rAtionAle: The most important goal for immediate care of the newborn is to establish and maintain the airway and respiration. Assisting the mother to nurse the child and assessing the weight of the child are mandatory; however, these steps can be performed after the physical condition of the child is stabilized. A warm tub bath can be given only after the cord falls off, which is usually 10 to 14 days after birth.

Question 23

A nurse is assessing a newborn baby. Which characteristic indicates an abnormality in the newborn?
a. Baby weighs 2,700 g or 5.95 lbs
b. Baby’s length is 50 cm or 19.69 in
c. Head circumference is 35 cm or 13.77 in
d. Chest circumference is 32 cm or 12.59 in

Answer 23

d. Chest circumference is 32 cm or 12.59 in.

• rAtionAle:
  The chest circumference of a normal newborn ranges from 10 to 12 in or 25.5 to 30.5 cm.
  Thus, 32 cm is an abnormality.
  The normal newborn weighs 5.5 to 9.5lbs or 2,500 to 4,250 g.
  Normal newborn length ranges from 18 to 22 in (46 to 56 cm).
  The head usually has a circumference of 13 to 14 in or 33 to 35.5 cm.

Question 24

A client notices that their newborn has a slightly elongated skull. How should the nurse explain this to the client?
a. Caput succedaneum
b. Cephalhematoma
C. Molding
d. Ophthalmia neonatorum

Answer 24

C. Molding

• rAtionAle: Temporary molding or elongation of the infant’s skull occurs during the birthing process when the infant is delivered vaginally, because of the overlap of the skull bones. Caput succedaneum is a swelling that results from an accumulation of fluid within the newborn’s scalp. It is caused by pressure to the head during delivery and usually disappears within a few days. Cephal- hematoma is an accumulation of blood between the bones of the skull and the periosteum, the membrane that covers the skull. Ophthalmia neonatorum is a condition of the eye that occurs in a newborn exposed to gonorrhea or chlamydia organisms in the mother.

Question 25

Which finding should the nurse reassure the client is normal in their newborn?
a Flattened ears
b. Protruding chin
c. Pointed nose
d. Flat abdomen

Answer 25

a. Flattened ears

• rAtionAle: Flattened ears and nose are a normal finding in newborns. The chin is usually receding and not protruding. The nose is not pointed but rather flattened. The abdomen is usually not flat but protruding in newborns.

Question 26

When inspecting a newborn, a nurse notices that the child’s urinary meatus is on the underside of the penis (near the scrotum).
Which condition does this indicate?
a. Prepuce
b. Phimosis
c. Epispadias
d Hypospadias

Answer 26

d. Hypospadias

rAtionAle: Hypospadias is the term used for a condition in male babies in which the urinary meatus is on the underside of the penis (near the scrotum). Prepuce (also called foreskin) is a layer of skin that covers the glans of the penis and is often adherent at birth. Phimosis is a condition in which the opening of the foreskin is so small that it cannot be pulled back at all. Epispadias is the location of the urinary meatus on the upper side of the penis.

Question 27

A client has just finished bottle-feeding their, otherwise, healthy baby. The baby is still crying and is believed to have swallowed air from the bottle. What step should the nurse instruct the client to take?
a. Give gentle but firm pressure on the abdomen.
B. Hold the baby, rock, and pat lightly on the back.
c. Give a little water so that the air settles down.
d. Eliminate milk from the diet for 2 weeks.

Answer 27

B. Hold the baby, rock, and pat lightly on the back.

• rAtionAle: If the baby has swallowed air from the bottle, the mother should hold the baby, rock him, and pat him lightly on the back. This helps the baby to burp out the air. Firm pressure on the abdomen is unnecessary and may irritate the baby further. The air does not settle down on giving water to the baby. Elimination of milk from the diet of the breastfeeding mother is done when cow’s milk causes colic and not when the baby has swallowed air from the bottle.

Question 28

When inspecting the skin of a 2-day-old newborn, the nurse notices a white, thick, cheesy material in the hair and skin folds.
Which should the nurse consider this to be?
a. Erythema toxicum
b. Lanugo
C. Vernix caseosa
d. Acrocyanosis

Answer 28

C. Vernix caseosa

• rAtionAle: Vernix caseosa is a white, thick, cheesy material that may be especially noticeable in the hair and skin creases of newborns. It is composed of epithelial cells and the secretions of glands and mainly functions to protect the skin from the drying effects of amniotic fluid in utero. Erythema toxicum is the development of a red, raised rash on the skin of most newborns, whose skin is highly sensitive. Lanugo is the development of fine, downy hair on the face, shoulders, and back of newborns. Acrocyanosis is the cyanotic appear- ance of the newborn’s arms and legs caused by slowed peripheral circulation.

Question 29

Which route is contraindicated for recording body temperature in the newborn?
a. Rectal route
b. Axillary route
C. Oral route
d. Tympanic route

Answer 29

C. Oral route

*rAtionAle: The oral route of recording temperature is contraindicated in newborns because of the risk that the thermometer (probe) might break in the baby’s mouth. Most newborn nurseries use the tympanic (ear) method to measure the newborn’s temperature. The tympanic temperature probe may be set to convert to the rectal temperature equivalent. If the tympanic method is not used, axillary temperatures may be ordered. In some cases, a rectal temperature may be preferred.

Question 30

A nurse is informing a new parent about the various types of immunizations that the baby may need. Which forms a part of the recommended regimen for vaccination against hepatitis B?
a. First dose within 24 hr after birth
b. Second dose at 3 months
C. Third dose at 6 months
d. Fourth dose at 1 year

Answer 30

C. Third dose at 6 months

• rAtionAle: The nurse should inform the new mother that the third dose of vaccination against hepatitis B is given at 6 months of age. The first dose is given within 12 hours, not 24 hours, of birth. The second dose is given at age 1 to
  2 months and not 3 months. The third dose is given at 6 months. There is no fourth dose.