Coursepoint: Nursing Care of a Postpartal Family

Question 1

The nurse institutes measures to maintain thermoregulation based on the understanding that newborns have limited ability to regulate body temperature because they:

Answer 1

Have difficulty maintaining their body heat through shivering and other mechanisms. They have a large body surface area relative to body weight and have limited sweating ability. Additionally, newborns lack subcutaneous fat to provide insulation.

Question 2

Congenital dermal melanocytosis (slate gray nevi, previously known as Mongolian spots)

Answer 2

Blue or purple splotches that appear on the lower back and buttocks of newborns

Question 3

Milia

Answer 3

Unopened sebaceous glands frequently found on a newborn’s nose

Question 4

Stork bites

Answer 4

Superficial vascular areas found on the nape of the neck and eyelids and between the eyes and upper lip

Question 5

Birth trauma would be manifested by

Answer 5

Bruising, swelling, and possible deformity

Question 6

What should the nurse expect for a full-term newborn’s weight during the first few days of life?

Answer 6

Decrease by 5% to 10% [from birth weight] in both formula-fed and breastfed newborns

Question 7

What is the best way to prevent the newborn from becoming ill?

Answer 7

Handwashing is the best way to prevent infections in newborn infants.

Question 8

The nurse is caring for a newborn who has a large surface area to body mass ratio. What action will the nurse take to help this newborn regulate temperature?

Answer 8

Assure the newborn has a cap on the head and is kept covered.

Question 9

What is considered a normal range for a newborn’s heart rate?

Answer 9

A heart rate from 100 to 160

Question 10

True or false: The nurse should immediately alert the provider is episodic breathing is observed in a newborn?

Answer 10

False: Episodic breathing is an expected finding

An episodic breathing pattern is where the respirations are irregular with small pauses interspersed with rapid respirations.

Question 11

True or false: Overlapping cranial sutures are also an expected finding.

Answer 11

Overlapping cranial sutures are also normal, especially if it is the mother’s first baby.

Question 12

What is considered a normal range for a newborn’s head circumference?

Answer 12

33 to 35.5 cm

Question 13

What is the expected finding for a newborn’s abdomen?

Answer 13

Rounded or protuberant

A scaphoid abdomen would be considered an abnormal finding.

Question 14

The term “hypospadias” refers to

Answer 14

“The opening of his urethra in located on the under surface of the tip of the penis.”

The urinary meatus (external opening of the urethra) being abnormally located on the ventral (under) surface of the glans (the rounded head or tip of the penis).

Question 15

Cryptorchidism

Answer 15

Undescended testes

Question 16

Hydrocele

Answer 16

The collection of fluid in the scrotal sac

Question 17

The nurse is conducting an assessment on a newborn and witnesses a startled response with the extension of the arms and legs. The nurse should document this as which response?

Answer 17

The Moro reflex, also known as the startle reflex.

When the infant is startled, he/she extends the arms and legs away from the body.

Question 18

The fencing reflex is also called the

Answer 18

Tonic neck reflex and is a total body assessment

Question 19

The rooting reflex assesses the infant’s ability to

Answer 19

“look” for food

Question 20

The new mother is holding her infant, speaking softly and gently stroking the baby’s face. She giggles and asks the nurse why the baby turns toward her finger when she strokes the cheeks. The nurse should explain that this is which common newborn reflex?

Answer 20

This is the rooting reflex and is used to encourage the infant to feed. This reflex and the sucking reflex work together to assist the infant with cues for feeding at the breast.

Question 21

How should secretions be cleared from their infant’s mouth and nose

Answer 21

Position the newborn on side with head slightly below body; use a bulb syringe to clear

The infant needs to have bulb suction used to remove the secretions from the mouth first; the head should be held slightly lower than the body to facilitate use of gravity. A bulb syringe, not a small suction catheter, is used to suction the mouth and nose of a newborn. The mouth should be cleared first to prevent possible aspiration of secretions. Suctioning the nose first could cause the infant to inhale the secretions in the mouth.

Question 22

The nurse encourages the mother of a healthy newborn to put the newborn to the breast immediately after birth for which reason?

Answer 22

to facilitate maternal–infant bonding

Breastfeeding can be initiated immediately after birth. This immediate mother–newborn contact takes advantage of the newborn’s natural alertness and fosters bonding. This contact also reduces maternal bleeding and stabilizes the newborn’s temperature, blood glucose level, and respiratory rate. It is not associated with maturing the sucking reflex, encouraging the development of maternal antibodies, or aiding in clearing of the newborn’s respiratory passages.

Question 23

Unopened sebaceous glands are generally called milia. When they are in the mouth and gums, they are called

Answer 23

Epstein pearls

Question 24

The Apgar score is based on which 5 parameters?

Answer 24

Heart rate, muscle tone, reflex irritability, respiratory effort, and color

A newborn can receive an Apgar score ranging from 0 to 10. The score is based on 5 factors, each of which is assigned a 0, 1, or 2. Heart rate (should be above 100), muscle tone (should be able to maintain a flexion position), reflex irritability (newborn should cry or sneeze when stimulated), and respiratory effort are evaluated by the presence of a strong cry and by color. Color is evaluated by noting the color of the body and hands and feet.

Question 25

Using a warmed cloth diaper or blanket to cover any cold surface, such as a scale, that touches a newborn directly helps to prevent heat loss through

Answer 25

conduction

Question 26

Drying a newborn and promptly changing wet linens, clothes, or diapers help reduce heat loss via

Answer 26

evaporation

Question 27

Keeping the newborn out of a direct cool draft, working inside an isolette as much as possible, and minimizing the opening of portholes help prevent heat loss via

Answer 27

convection

Question 28

Keeping cribs and isolettes away from outside walls, cold windows, and air conditioners and using radiant warmers while transporting newborns and performing procedures will help reduce heat loss via

Answer 28

radiation

Question 29

The anterior fontanel is diamond-shaped and measures about 3.5 cm. The posterior fontanel is triangular shaped and measures about 1 cm.

Answer 29

The anterior fontanel is diamond-shaped and is larger than the posterior fontanel, which is triangular in shape.

Question 30

A newborn at 1 minute of life is acrocyanotic, HR is 110, is floppy with some flexion, has a weak cry, and grimaces. What Apgar score would the nurse assign this infant?

Answer 30

According to the Apgar criteria, acrocyanosis is scored as 1, HR over 100 is scored as 2, grimace is scored as 1, some flexion is scored as 1, and a weak cry is scored as 1. This totals 6 for the 1-minute Apgar score.

Question 31

A new mother asks the nurse why her newborn must receive a vitamin K injection after birth. Which is the best response made by the nurse?

Answer 31

“It will decrease the risk of bleeding immediately after birth.”

Vitamin K is necessary for the formation of clotting factors. It is synthesized by normal flora in the gastrointestinal (GI) tract. Because a newborn’s GI tract is sterile at birth, the newborn cannot synthesize vitamin K. Newborns are routinely given a vitamin K injection to decrease the risk of hemorrhage. Vitamin K cannot prevent hemorrhage, nor does it prevent infections.

Question 32

Swaddling is a useful measure to comfort a fretful newborn. The only identified problem is that the newborn can become

Answer 32

too tightly wrapped, leading to respiratory compromise and breathing difficulties.

Swaddling reduces the need to be held, there is no risk of the newborn not responding to it after being swaddled in the past, and the parent does not have to use the same blanket every time.

Question 33

Caput succedaneum is

Answer 33

Swelling of the soft tissue of the scalp caused by pressure of the presenting part on a partially dilated cervix or trauma from a vacuum-assisted delivery.

Reassure parents that the caput will decrease in a few days without treatment.

Question 34

When assessing the newborn for intracranial pressure, the mother should consider

Answer 34

Increased intracranial pressure would involve the entire scalp and not just a small portion. There would also be other neurologic signs accompanying it.

Question 35

Molding is

Answer 35

an elongated head shape caused by overlapping of the cranial bones as the fetus moves through the birth canal.

Molding is self limiting & will resolve in a few days without treatment.

Question 36

Which items will be on matching identification bracelets?

Answer 36

Newborn’s sex and date and time of birth

Information included on the bands is the mother’s name, hospital number, care provider’s name, newborn’s sex, and date and time of birth.

Question 37

Blood glucose levels between ____________ mg/dl during the first 24 hours of life are considered normal.

Answer 37

50 & 60

Question 38

Glucose levels less than 50 mg/dl are indicative of

Answer 38

hypoglycemia in the newborn.

Question 39

The nurse reviews the newborn’s morning laboratory levels and notes a bilirubin level of 5.8 mg/dl (99.20 µmol/l). What will the nurse expect to assess in the newborn?

Answer 39

Yellow tinted skin on head & face

Question 40

A new mother of a newborn girl calls the clinic in a panic, concerned about the blood-tinged soiled diaper. What is the best response from the nurse?

Answer 40

“This can be from the sudden withdrawal of your hormones. It is not a cause for alarm.”

The mother is describing pseudomenstruation and is usually the result of the infant no longer having the mother’s hormones in the body. This is not a cause for alarm. It is always appropriate to offer to schedule an appointment if the mother continues to be upset. The nurse should know that the infant’s “bleeding” is not indicative of a pathologic process and should be careful to not upset the mother further. The statement of it being related to the way the mother is cleaning the perineum is incorrect for it places the blame on the mother for the infant’s problem. The instruction to call back if it continues does not meet the mother’s need to know why this is happening to her baby, and it negates her concern for her infant.

Question 41

A nurse is assessing a newborn. Which finding would alert the nurse to the possibility of respiratory distress in a newborn?

Answer 41

Sternal retractions, cyanosis, tachypnea, expiratory grunting, and nasal flaring are signs of respiratory distress in a newborn.

Question 42

Typical respiratory findings in a newborn.

Answer 42

Symmetrical chest movements and a respiratory rate between 30 to 60 breaths/minute

Question 43

The nurse is preparing the delivery room before the birth occurs. What supplies would the nurse have available to care for the newborn?

Answer 43

In preparing the delivery room, the nurse should preheat a warmer bed, have suction equipment at bedside, and have the identification bands ready for both the mother and newborn.

Question 44

While performing a physical assessment of a newborn boy, the nurse notes diffuse edema of the soft tissues of his scalp that crosses suture lines. The nurse documents this finding as:

Answer 44

caput succedaneum

Caput succedaneum is localized edema on the scalp, a poorly demarcated soft tissue swelling that crosses the suture lines.

Question 45

The nurse is caring for a newborn who was delivered via a planned cesarean birth. The nurse determines the infant requires closer monitoring than a vaginal delivery infant based on which factor?

Answer 45

Excessive fluid in the infant’s lungs, making respiratory adaptation more challenging.

Question 46

Reflex testing for spinal cord integrity are testing which reflexes?

Answer 46

The magnet, crossed extension, and trunk incurvation reflexes.

Question 47

The nurse observes creases on two-thirds of the foot. What gestational age does this reflect?

Answer 47

This observation reflects an at-term birth

As an infant matures in utero, sole creases become prominent to a greater amount. The term infant should have at least two-thirds of the foot covered by creases. These creases should be horizontal and not longitudinal, They should be in the ball of the foot before moving to the heel.

Question 48

The nurse is preparing to assess the pulse on a newborn who has just arrived to the nursery after being cleaned in the labor and birth suite and swaddled in a blanket. Which action should the nurse prioritize?

Answer 48

Infection control is a priority nursing intervention. Gloves need to be worn when in contact with the infant who has not been bathed after birth.

Question 49

The nurse is concerned that the nares of a newborn are not patent bilaterally. What can the nurse do to address this concern?

Answer 49

If a nurse is concerned that the nostrils are patent in a newborn, the nurse will occlude the nares one at a time to see if the newborn can breath easily.

Question 50

When assessing the head of a newborn, the nurse notes that when pressing the skull, an indentation is made and then the area returns to normal after removing the pressure. What would the nurse do next?

Answer 50

Document this as a normal finding.

Question 51

Craniotabes

Answer 51

localized softening of the cranial bones probably caused by pressure of the fetal skull against the pregnant client’s pelvic bone in utero

more common in first-born infants than in infants born later because of the lower position of the fetal head in the pelvis during the last 2 weeks of pregnancy

Question 52

A 30-minute-old newborn starts crying in a high-pitched manner and cannot be consoled by the mother. Which action should the nurse prioritize if jitteriness is also noted and the infant is unable to breastfeed?

Answer 52

Check blood glucose

Question 53

The nurse is conducting a pre admission class for a group of parents on the safety features that are utilized to help prevent infant abduction. The nurse should prioritize which factor as most essential to ensure the program’s success?

Answer 53

Cooperation by the parents with the hospital policies

Question 54

Neonatal screening is done before the infant leaves the hospital. Blood is drawn through a heel stick and tested for several disorders that can cause lifelong disabilities. When is the ideal time to collect this specimen?

Answer 54

24 hours after the newborn’s first protein feeding

The laws in most states require this initial screening, which is done within 72 hours of birth. The ideal time to collect the specimen is after the newborn is 36 hours old and 24 hours after he has his first protein feeding.

Question 55

New parents report to the nurse that their newborn has “crying jags” in the afternoon each day. They are worried that if they hold the newborn every time she cries, she will become spoiled. What advice would the nurse give these parents?

Answer 55

Holding and comforting the newborn will not cause the infant to become spoiled.

Newborns often have periods of crying; the parents should first check for a physical reason for crying such as hunger or a soiled diaper. If this is not the cause, then the parents need to try to soothe the newborn by holding, walking, rocking the newborn or even taking the infant for a ride in the car. Reassure the parents that they will not spoil the newborn by meeting its needs.

Question 56

Which action will the nurse avoid when performing basic care for a newborn male?

Answer 56

Retracting the foreskin over the glans to assess for secretions

The foreskin in male newborns does not normally retract and should not be forced

Question 57

The new mother should call her health care provider if the newborn does not void within which time period?

Answer 57

12 hours

The mother should call the health care provider if her infant does not void at all within a 12-hour period. The mother should not wait 18 to 24 hours before calling. It is fine for the infant to go 6 hours without voiding; however, the mother should be aware that this needs to be monitored.

Question 58

A nurse is providing care to a newborn in the immediate newborn period. Which nursing intervention is priority?

Answer 58

Administer Vitamin K, which is used to promote blood clotting in the newborn and is priority to administer to the newborn. The hearing test, hepatitis B vaccine, and newborn screening should all be completed prior to discharge.