EAQ Nursing Care of The Newborn Flashcards
Which statement by the nurse to a newborn’s parent explains the reasoning for a vitamin K shot after birth?
• A “There may be internal bleeding the vitamin K will stop.”
• B “A newborn’s body cannot make vitamin K on its own yet.”
• C “The vitamin K helps newborns to gain weight after birth.”
• D “The health care providers prescribe vitamin K for every newborn.”
• B “A newborn’s body cannot make vitamin K on its own yet.”
Rationale
Newborns do not have adequate intestinal flora to synthesize vitamin K on their own, so an intramuscular shot of vitamin K is administered at birth. Although newborns have low prothrombin levels at birth and are a risk for hemorrhage, th statement may lead the parent to believe their newborn is actively bleeding. Administration of vitamin K does not have an effect on the newborn’s weight gain.
Which action would the nurse determine is needed for a newborn infant with blue coloring of the hands and feet?
• A Report the finding.
• B Cover the infant’s head.
• C Obtain a rectal tempOrature.
• D Assure parents this is normal.
• D Assure parents this is normal.
Rationale
Assuring the parents this is normal in the newborn can be helpful in easing fears about the discoloration of their newborn’s hands and feet. While documentation of the assessment is important, reporting this finding is unnecessary as it is normal in a newborn. Newborns have poor peripheral circulation, which causes acrocyanosis, a blue coloring of the hands and feet. The blue coloring of the infant’s hands and feet is not indicative of the core body temperature and does not indicate the need for a rectal temperature at this time.
Which statement would the nurse make when educating the client on the administration of vitamin K in the newborn? Select all that apply.
One, some, or all responses may be correct.
• A “Vitamin K helps the blood to clot.”
• B “Newborns are deficient in vitamin K.”
• C “Newborns are susceptible to hemorrhagic disease.”
• D “Vitamin K is administered via an injection in the thigh.”
• EVitamin K is routinely administered within 1 hour of birth.”
All of the above
Rationale
Vitamin K is vital for the production of factor II, VII, IX, and X, which aid in the clot formation. Newborns are deficient in vitamin K because they lack the bacteria gut flora that is responsible for producing vitamin K and have not yet consumed this fat-soluble vitamin in their diet. Newborns are susceptible to hemorrhagic disease in the first 5 to 8 days aft birth because they lack appropriate clotting factors. Vitamin is routinely administered in the hospital via injection in the lateral region of the thigh within 1 hour of birth.
Which statement made by the parent of a premature newborn indicates a need for further teaching about kangaroo care?
• A “I will place my baby on my bare chest.”
• B “My baby can still wear a diaper and cap.”
• C “I wish fathers could do this with the baby.”
• D “My baby’s temperature will be monitored.”
• C “I wish fathers could do this with the baby.”
Rationale
Kangaroo care is a method of care for preterm infants involving skin-to-skin contact. The infant is placed unclothed on the mother or father’s bare chest, which provides warmth and promotes bonding. The baby can wear a diaper during kangaroo care and a cap keeps the newborn’s head warm. The nurse will monitor the newborn’s temperature and other vital signs during kangaroo care to assess the newborn’s response and stability.
Which postpartum client statement indicates a correct understanding regarding newborn bottle-feeding practices?
• A “I will burp my baby every 5 minutes.”
• B “I will microwave my baby’s formula to warm it.”
• C “I should feed my baby every 3 to 4 hours.”
• D “I can substitute cow’s milk for formula once we are home.”
• C “I should feed my baby every 3 to 4 hours.”
Rationale
Newborns who are bottle-fed formula should eat every 3 to 4 hours; therefore, this client statement indicates a Correct understanding of newborn bottle-feeding practices. The bottle-fed newborn is burped after every 1 to 1.5 oz of formula is ingested. Warming formula in the microwave is contraindicated due to the risk for hot spots, which increases the risk for oral burns. Cow’s milk is not introduced into the diet until the infant is 12 months of age.
Which intervention would the nurse implement when a client voices anxiousness about
breastfeeding for the first time?
• A Show the client the best position for feeding.
• B Tell the client bottle feeding is a better option.
• C Initiate feedings as soon as possible after birth.
• D Share other clients’ breastfeeding experiences.
• E Refer the client to behavioral health for anxiety.
• C Initiate feedings as soon as possible after birth.
Rationale
Initiating feedings as soon as possible after birth allows the nurse to assess for correct latch and positioning of the newborn, as well as the client’s readiness to breastfeed. There is not one “best” position for feeding; showing the client different positions for feeding aids in the comfort for both th client and newborn, encouraging successful feeding. Telling the client bottle feeding is a better option is not therapeutic or encouraging for the client.
Which action would the nurse take first after obtaining a pulse rate greater than 160 beats per minute in a newborn infant?
• A Report the finding.
• B Document the finding.
• C Print a cardiac rhythm strip.
• D Administer vagal maneuvers.
• A Report the finding
Rationale
The nurse always reports abnormal vital signs prior to intervention. A pulse rate greater than 160 beats per minute or less than 110 beats per minute in a newborn is abnormal.
While documenting the finding is important, the nurse must first determine if the newborn requires interventions. Printing a cardiac rhythm strip may be helpful, but reporting the abnormal finding is a priority. Before providing an interventi such as vagal maneuvers, the nurse first needs to report the abnormal finding.
For which sign or symptoms would the nurse assess as directed in a preterm newborn diagnosed with sepsis? Select all that apply. One, some, or all responses may be correct.
• A Lethargy
• B Irritability
• C Poor feeding
• D Low temperature
• E Localized infection
• A Lethargy
• B Irritability
• C Poor feeding
• D Low temperature
• E Localized infection
Rationale
The preterm newborn is at risk for sepsis due to immaturity of many body systems and little to no immunity received from the mother. Some signs of sepsis are low body temperature, lethargy, irritability, poor feeding, and respiratory distress.
Although localized infection may not be apparent, an infectio is required to progress to a sepsis diagnosis.
Which skin manifestation would the nurse recognize as common in the term newborn? Select all that apply.One, some, or all responses may be correct.
• A Cyanosis of the hands and feet
• B Lacelike blue pattern on skin surface
• C Peeling of the skin on knees and elbows
• D White papules on midline of upper palate
• E Dark blue discoloration in lumbosacral area
• A Cyanosis of the hands and feet
• B Lacelike blue pattern on skin surface
• C Peeling of the skin on knees and elbows
• D White papules on midline of upper palate
• E Dark blue discoloration in lumbosacral area
Rationale
Acrocyanosis, a blueness in the hands and feet, is normal and happens due to poor peripheral circulation. A lacelike red or blue pattern on the newborn’s skin is a normal vasomotor response to low environmental temperature. Peeling of the skin, called desquamation, occurs in areas all over the body; however, areas such as the knees and elbows may break dow because of friction from rubbing on sheets. Pearly white papules on midline of the hard palate are called Epstein pearls and are caused by a collection of epithelial cells.
A mother whose newborn infant son has a cleft lip and palate asks how to feed her baby because he has difficulty suckling. Which information would the nurse provide concerning safe feeding technique for this infant?
• A “Because he tires easily, it’s best to have him lying in bed while he is being fed.”
• B “Hold him in a horizontal position and feed him slowly to help prevent aspiration.”
• C “Try using a soft nipple with an enlarged opening so he can get the milk through a chewing motion.”
• D “Give him brief rest periods and frequent burping during feedings so he can get rid of swallowed air.”
Rationale
Cleft lip and palate, a congenital defect, prevents the infant from creating a tight seal with the lips to facilitate suckling. As a result, the infant swallows large amounts of air when feeding. The mother should be taught to provide frequent rest periods and to burp the infant often to expel excess air in the stomach. Infants with cleft lip and palate should be held upright during feedings. Newborn infants cannot chew and do not make chewing movements.
The nurse is caring for a preterm infant diagnosed with respiratory distress syndrome (RDS). The newborn’s plasma glucose is 28 mg/dL after a blood draw. Which statement by the nurse explains the newborn’s glucose result?
• A “Hypoglycemia is attributed to low glycogen stores.”
• B “Hypoglycemia is likely caused by missed feedings.”
• C “Hyperglycemia is attributed to stressful body states.”
• D “Hyperglycemia is likely caused by parenteral feedings.”
• A “Hypoglycemia is attributed to low glycogen stores.”
Rationale
Hypoglycemia is common in preterm infants due to insufficient stores of glycogen and fat. Additionally, respiratory distress syndrome (RDS) causes an increased need for and consumption of glycogen for the body’s tissues. There is no information in this scenario indicating the infant has missed feedings. This infant is hypoglycemic, not hyperglycemic. Any serum glucose below 30 mg/dL is considered hypoglycemia a preterm infant.
Which sign in the newborn infant would reflect an Apgar score of 1 in the category of respiration?
• A Heart rate 102
• B Limp
• C Absent respiration
• D Slow, weak cry
• D Slow, weak cry
Rationale
A slow, weak cry would be scored as a 1 in the category of respiration in the Apgar score system. A good cry would receive a score of 2. A grimace is a sign that is evaluated in the category of reflex irritability, not respiration. Absent respiration would receive a score of 0 in the respiration category of the Apgar score system. A heart rate of 102 would equal 2 points.
Which condition would the nurse document when a newborn infant is noted to have small, flat pink spots on the nape of the neck?
• A Nevi
• B Desquamation
• C Mongolian spots
• D Erythema toxicum
• A Nevi
Rationale
Nevi, described as small, flat pink spots, are the result of a superficial capillary defect and are most commonly found on the upper eyelids, nose, upper lip, and nape of the neck.
Desquamation is peeling skin that occurs a few days after birth. Mongolian spots are bluish-black areas of pigmentation.
Erythema toxicum is a transient rash that appears 24 to 72 hours after birth and can last up to 3 weeks of age.
Which client behavior indicates that a woman needs further teaching regarding breastfeeding her newborn?
• A She leans forward to place her breast in the infant’s mouth.
• B She holds the infant level with her breast while in a side-lying position.
• C She touches her nipple to the infant’s cheek at the beginning of the feeding
• D She puts her finger in the infant’s mouth to break the suction after the feeding-
Rationale
When the breast is pushed into the infant’s mouth, typically the infant’s mouth closes too soon, resulting in inadequate latching on. The infant should be brought to the breast rather than the other way around. Holding the infant level with her breast while in a side-lying position facilitates latching on and maintains the infant’s head in correct alignment, which promotes sucking and swallowing.
Which nursing care is most important for a newborn with respiratory distress syndrome (RDS)?
• A Keeping the infant in a warm environment
• B Turning the infant frequently to prevent apnea
• C Tapping the infant’s toes to stimulate deep breathing
• D Maintaining the infant’s oxygen administration level at the same rate
• A Keeping the infant in a warm environment
Rationale
The infant is kept in a warm environment because any attempt by the infant’s body to maintain body temperature further compromises physical status by increasing metabolic activity and oxygen demands. Increased physical activity will also increase oxygen demands. The amount of oxygen administered should vary with the infant’s laboratory values.
