The Neonatal Client Flashcards
Neonatal Care 1. A primiparous woman has recently given birth to a term infant. Priority teaching for the client includes information on: 1. Sudden Infant Death Syndrome (SIDS). 2. Breast-feeding. 3. Infant bathing. 4. Infant sleep-wake cycles.
Neonatal Care
1. 2. Breast-fed infants should eat within the first hour of life and approximately every 2 to 3
hours. Successful breast-feeding will likely require sustained support, encouragement, and instruction
from the nurse. Information on SIDS, infant bathing, and sleep-wake cycles are also important topics
for the new parent, but can be done at any time prior to discharge.
CN: Health promotion and maintenance; CL: Analyze
- A newborn who is 20 hours old has a respiratory rate of 66, is grunting when exhaling, and has
occasional nasal flaring. The newborn’s temperature is 98°F (36.6°C); he is breathing room air and is
pink with acrocyanosis. The mother had membranes that were ruptured 26 hours before birth. Based
on these data, the nurse should include which of the following in the management of the infant’s care? - Continue recording vital signs, voiding, stooling, and eating patterns every 4 hours.
- Place a pulse oximeter and contact the primary health care provider for a prescription to draw
blood cultures. - Arrange a transfer to the neonatal intensive care unit with diagnosis of possible sepsis.
- Draw a complete blood count (CBC) with differential and feed the infant.
- The concern with this infant is sepsis based on prolonged rupture of membranes before birth.
Blood cultures would provide an accurate diagnosis of sepsis, but will take 48 hours from the time
drawn. Frequent monitoring of infant vital signs, looking for changes, and maintaining contact with the
parents is also part of care management while awaiting culture results. Continuing with vital signs,
voiding, stooling, and eating every 4 hours is the standard of care for a normal newborn, but a
respiratory rate greater than 60, grunting, and occasional flaring are not normal. Although not normal,
the need for the intensive care unit is not warranted as newborns with sepsis can be treated with
antibiotics at the maternal bedside. The CBC does not establish the diagnosis of sepsis but the
changes in the WBC levels can identify an infant at risk. Many experts suggest that waiting until an
infant is 6 to 12 hours old to draw a CBC will give the most accurate results.
CN: Reduction of risk potential; CL: Synthesize
- The concern with this infant is sepsis based on prolonged rupture of membranes before birth.
- A neonate is born by primary cesarean section at 36 weeks’ gestation. The temperature in the
birthing room is 70°F (21.1°C). To prevent heat loss from convection, which action should the nurse
take? - Dry the neonate quickly after birth.
- Keep the neonate away from air conditioning vents.
- Place the neonate away from outside windows.
- Prewarm the bed.
- The neonate should be kept away from drafts, such as from air conditioning vents, which may
cause heat loss by convection. Evaporation is one of the most common mechanisms by which the
neonate will lose heat, such as when the moisture on the newly born neonate’s body is converted to
vapor. Radiation is heat loss between solid objects that are not in contact with one another such as
walls and windows. Conduction is when heat is transferred between solid objects in contact with one
another, such as when a neonate comes in contact with a cold mattress or scale.
CN: Reduction of risk potential; CL: Synthesize
- The neonate should be kept away from drafts, such as from air conditioning vents, which may
- The primary health care provider prescribes ampicillin 100 mg/kg/dose for a newly admitted
neonate. The neonate weighs 1,350 g. How many milligrams should the nurse administer?
_______________ mg.
4. 135 mg The recommended dose of ampicillin for a neonate is 100 mg/kg/dose. First, determine the neonate's weight in kilograms, and then multiply the kilograms by 100 mg. The nurse should use this formula: 1,000 g = 1 kg 1,350 g = 1.35 kg 100 mg x 1.35 kg = 135 mg / kg
CN: Pharmacological and parenteral therapies; CL: Apply
- A neonate born at 30 weeks’ gestation and weighing 2,000 g is admitted to the neonatal
intensive care unit. What nursing measure will decrease insensible water loss in a neonate? - Bathing the baby as soon after birth as possible.
- Use of eye patches with phototherapy.
- Use of humidity in the incubator.
- Use of a radiant warmer.
- Adding humidity to the incubator adds moisture to the ambient air, which helps to decrease
the insensible water loss. Bathing and the use of eye patches has no impact on insensible water loss.
The use of a radiant warmer will increase the insensible water loss by drawing moisture out of the
skin.
CN: Reduction of risk potential; CL: Synthesize
- Adding humidity to the incubator adds moisture to the ambient air, which helps to decrease
- A septic preterm neonate’s IV was removed due to infiltration. While restarting the IV, the
nurse should carefully assess the neonate for: - Fever.
- Hyperkalemia.
- Hypoglycemia.
- Tachycardia.
- Neonates that are septic use glucose at an increased rate. During the time the IV is not
infusing, the neonate is using the limited glucose stores available to a preterm neonate and may
deplete them. Hypoglycemia is too little glucose in the blood; without the constant infusion of IV
glucose, hypoglycemia will result. Fevers and hyperkalemia are not related to glucose levels.
Tachycardia is the result of untreated hypoglycemia.
CN: Reduction of risk potential; CL: Analyze
- Neonates that are septic use glucose at an increased rate. During the time the IV is not
- The nurse makes a home visit to a 3-day-old full-term neonate who weighed 3,912 g (8 lb, 10
oz) at birth. Today the neonate, who is being bottle-fed, weighs 3,572 g (7 lb, 14 oz). Which of thefollowing instructions should the nurse give to the mother? - Continue feeding every 3 to 4 hours since the weight loss is normal.
- Contact the primary health care provider if the weight loss continues over the next few days.
- Switch to a soy-based formula because the current one seems inadequate.
- Change to a higher-calorie formula to prevent further weight loss.
- This 3-day-old neonate’s weight loss falls within a normal range, and therefore no action is
needed at this time. Full-term neonates tend to lose 5% to 10% of their birth weight during the first
few days after birth, most likely because of minimal nutritional intake. With bottle-feeding, the
neonate’s intake varies from one feeding to another. Additionally, the neonate experiences a loss of
extracellular fluid. Typically, neonates regain any weight loss by 7 to 10 days of life. If the weight
loss continues after that time, the primary health care provider should be called.
CN: Health promotion and maintenance; CL: Synthesize
- This 3-day-old neonate’s weight loss falls within a normal range, and therefore no action is
- Commercial formulas contain 20 calories per 30 mL. A 1-day-old infant was fed 45 mL at 2 AM , 5:30
AM , 8 AM , 11 AM , 2 PM , 4:30 PM , 8 PM , and 10:30 PM . What is the total amount of calories the infant
received today?
______________ calories.
- 240 calories
8 feedings x 45 ml per feeding equals 360 ml
360 ml x 20 cal / 30 ml = 240 cal
CN: Basic care and comfort; CL: Apply
- A healthy neonate was just born in stable condition. In addition to drying the infant, what is the
preferred method to prevent heat loss? - Placing the infant under a radiant warmer.
- Wrapping the infant in warmer blankets.
- Applying a knit hat.
- Placing the infant skin-to-skin on the mother.
- Placing an infant on a mother’s bare chest or abdomen facilitates transition to extrauterine
life and is the preferred method of thermoregulation for stable infants. A radiant warmer should be
used if an infant is unstable and needs medical intervention. Blankets may be placed over a newborn
and mom’s chest. A hat may be added to prevent heat loss from the head, but these methods are
supplemental to skin-to-skin care.
CN: Health promotion and maintenance; CL: Apply
- Placing an infant on a mother’s bare chest or abdomen facilitates transition to extrauterine
- After the nurse explains to the mother of a male neonate scheduled to receive an injection of
vitamin K soon after birth about the rationale for the medication, which of the following statements by
the mother indicates successful teaching? - “My baby doesn’t have the normal bacteria in his intestines to produce this vitamin.”
- “My baby is at a high risk for a problem involving his blood’s ability to clot.”
- “The red blood cells my baby formed during pregnancy are destroying the vitamin K.”
- “My baby’s liver is not able to produce enough of this vitamin so soon after birth.
- For vitamin K synthesis in the intestines to begin, food and normal intestinal flora are
needed. However, at birth, the neonate’s intestines are sterile. Therefore, vitamin K is administered
via injection to prevent a vitamin K deficiency that may result in a bleeding tendency. When
administered, vitamin K promotes formation in the liver of clotting factors II, VII, IX, and X.
Neonates are not normally susceptible to clotting disorders, unless they are diagnosed with
hemophilia or demonstrate a deficiency of or a problem with clotting factors. Hemolysis of fetal red
blood cells does not destroy vitamin K. Hemolysis may be caused by Rh or ABO incompatibility,
which leads to anemia and necessitates an exchange transfusion. Vitamin K synthesis occurs in the
intestines, not the liver.
CN: Pharmacological and parenteral therapies; CL: Evaluate
- For vitamin K synthesis in the intestines to begin, food and normal intestinal flora are
- The nurse is teaching the mother of a newborn to develop her baby’s sensory system. To
further improve the infant’s most developed sense, the nurse should instruct the mother to: - Speak in a high-pitched voice to get the newborn’s attention.
- Place the newborn about 12 inches from maternal face for best sight.
- Stroke the newborn’s cheek with her nipple to direct the baby’s mouth to nipple.
- Give infant formula with a sweetened taste to stimulate feeding.
- Currently, touch is believed to be the most highly developed sense at birth. It is probably
why neonates respond well to touch. Auditory sense typically is relatively immature in the neonate, as
evidenced by the neonate’s selective response to the human voice. By 4 months, the neonate should
turn his eyes and head toward a sound coming from behind. Visual sense tends to be relativelyimmature. At birth, visual acuity is estimated at 20/100 to 20/150, but it improves rapidly during
infancy and toddlerhood. Taste is well developed, with a preference toward glucose; however, touch
is more developed at birth.
CN: Health promotion and maintenance; CL: Synthesize
- Currently, touch is believed to be the most highly developed sense at birth. It is probably
- The nurse has completed discharge teaching with new parents who have been discharged
home bottle-feeding a normal term newborn. Which of the following responses indicates the need for
further teaching? - “Our baby will require feedings through the night for several weeks/months after birth.”
- “The baby should burp during and after each feeding with no projective vomiting.”
- “Our baby should have 1 to 3 soft, formed stools a day.”
- “We should weigh our baby daily to make sure he is gaining weight.”
- Healthy infants are weighed during their visits to their primary care provider, so it is not
necessary to monitor weights at home. Infants may require 1 to 3 feedings during the night initially. By
3 months, 90% of babies sleep through the night. Projective vomiting may indicate pyloric stenosis
and should not be seen in a normal newborn. Bottle-fed infants may stool 1 to 3 times daily.
CN: Health promotion and maintenance; CL: Evaluate
- Healthy infants are weighed during their visits to their primary care provider, so it is not
- The nurse knows the mother of a neonate has understood her car seat safety instructions when
she comments: - “I did not realize that even children between 1 to 2 years old are safer in rear-facing car
seats.” - “I should put my car seat in the front so I can watch my baby when I drive.”
- “I plan to use the car seat I saved from my last baby 10 years ago.”
- “The front-facing car seats do a better job supporting the head and neck of my baby.”
- The head and neck are best supported in a rear-facing seat in infants and toddlers, and
infants should remain rear facing for as long possible until they outgrow their car seat. In the United
States, the American Academy of Pediatrics recommends a rear-facing car seat for children younger
than 2 years. The middle of the back seat is safest for a car seat. Because plastic can become brittle
over time, car seats have an expiration date that must be checked before use. Ten years would
generally be outside of most car seats’ expiration dates.
CN: Health promotion and maintenance; CL: Evaluate
- The head and neck are best supported in a rear-facing seat in infants and toddlers, and
- While making a home visit to a primiparous client and her 3-day-old son, the nurse observes
the mother changing the baby’s disposable diaper. Before putting the clean diaper on the neonate, the
mother begins to apply baby powder to the neonate’s buttocks. Which of the following statements
about baby powder should the nurse relate to the mother? - It may cause pneumonia to develop.
- It helps prevent diaper rash.
- It keeps the diaper from adhering to the skin.
- It can result in allergies later in life.
- The nurse should inform the mother that baby powder can enter the neonate’s lungs and
result in pneumonia secondary to aspiration of the particles. The best prevention for diaper rash is
frequent diaper changing and keeping the neonate’s skin dry. The new disposable diapers have
moisture-collecting materials and generally do not adhere to the skin unless the diaper becomes
saturated. Typically, allergies are not associated with the use of baby powder in neonates.
CN: Reduction of risk potential; CL: Synthesize
- The nurse should inform the mother that baby powder can enter the neonate’s lungs and
- After teaching a new mother about the care of her neonate after circumcision with a Gomco
clamp, which of the following statements by the mother indicates to the nurse that the mother needs
additional instructions? - “The petroleum gauze may fall off into the diaper.”
- “A few drops of blood oozing from the site is normal.”
- “I’ll leave the gauze in place for 24 hours.”
- “I’ll remove any yellowish crusting gently with water.”
- The mother needs further instruction when she says that a yellowish crust should be
removed with water. The yellowish crust is normal and indicates scar formation at the site. It should
not be removed, because to do so might cause increased bleeding. The petroleum gauze prevents the
diaper from sticking to the circumcision site, and it may fall off in the diaper. If this occurs, the
mother should not attempt to replace it but should simply apply plain petroleum jelly to the site. The
gauze should be left in place for 24 hours, and the mother should continue to apply petroleum jelly
with each diaper change for 48 hours after the procedure. A few drops of oozing blood is normal, but
if the amount is greater than a few drops the mother should apply pressure and contact the primary
health care provider. Any bleeding after the first day should be reported.
CN: Reduction of risk potential; CL: Evaluate
- The mother needs further instruction when she says that a yellowish crust should be
- After completing discharge instructions for a primiparous client who is bottle-feeding her
term neonate, the nurse determines that the mother understands the instructions when the mother says
that she should contact the primary health care provider if the neonate exhibits which of the
following? - Ability to fall asleep easily after each feeding.
- Spitting up of a tablespoon of formula after feeding.
- Passage of a liquid stool with a watery ring.
- Production of one to two light brown stools daily.
- The mother demonstrates understanding of the discharge instructions when she says that she
should contact the primary health care provider if the baby has a liquid stool with a watery ring,
because this indicates diarrhea. Infants can become dehydrated very quickly, and frequent diarrhea
can result in dehydration. Normally, babies fall asleep easily after a feeding because they are
satisfied and content. Spitting up a tablespoon of formula is normal. However, projectile or forceful
vomiting in larger amounts should be reported. Bottle-fed infants typically pass one to two light
brown stools each day.
CN: Reduction of risk potential; CL: Evaluate
- The mother demonstrates understanding of the discharge instructions when she says that she
- The nurse instructs a primiparous client about bottle-feeding her neonate. Which of the
following demonstrates that the mother has understood the nurse’s instructions? - Placing the neonate on his back after the feeding.
- Bubbling the baby after 1 oz (30 mL) of formula.
- Putting three-fourths of the bottle nipple into the baby’s mouth.
- Pointing the nipple toward the neonate’s palate.
- Placing the neonate on his back after the feeding is recommended to minimize the risk forsudden infant death syndrome (SIDS). Placing the neonate on the abdomen after feeding has been
associated with SIDS. The mother should bubble or burp the baby after 1⁄2 oz (15 mL) of formula has
been taken and then again when the baby is finished. Waiting until the baby has eaten 1 oz (30 mL) of
formula can lead to regurgitation. The entire nipple should be placed on top of the baby’s tongue and
into the mouth to prevent excessive air from being swallowed. The nipple is pointed directly into the
mouth, not toward the neonate’s palate, to provide adequate sucking.
CN: Reduction of risk potential; CL: Evaluate
- Placing the neonate on his back after the feeding is recommended to minimize the risk forsudden infant death syndrome (SIDS). Placing the neonate on the abdomen after feeding has been
- The nurse is to draw a blood sample for glucose testing from a term neonate during the first
hour after birth. The nurse should obtain the blood sample from the neonate’s foot near which of the
following areas?
1.
2.
3.
4.
- In a neonate, the lateral aspect of the heel is the most appropriate site for obtaining a blood
specimen. Using this area prevents damage to the calcaneus bone, which is located in the middle of
the heel. The middle of the heel is to be avoided because of the increased risk for damaging the
calcaneus bone located there. The middle of the foot contains the medial plantar nerve and the medial
plantar artery, which could be injured if this site is selected. Using the base of the big toe as the site
for specimen collection would cause a great deal of discomfort for the neonate; therefore, it is not the
preferred site.
CN: Reduction of risk potential; CL: Apply
- In a neonate, the lateral aspect of the heel is the most appropriate site for obtaining a blood
- After circumcision with a Plastibell, the nurse should instruct the neonate’s mother to cleanse
the circumcision site with which of the following? - Antibacterial soap.
- Warm water.
- Povidone-iodine (Betadine) solution.
- Diluted hydrogen peroxide.
- After circumcision with a Plastibell, the most commonly recommended procedure is to
clean the circumcision site with warm water with each diaper change. Other treatments are necessary
only if complications, such as an infection, develop. Antibacterial soap or diluted hydrogen peroxide
may cause pain and is not recommended. Povidone-iodine solution may cause stinging and burning,
and therefore its use is not recommended.
CN: Health promotion and maintenance; CL: Apply
- After circumcision with a Plastibell, the most commonly recommended procedure is to
20. Approximately 90 minutes after birth, the nurse should encourage the mother of a term neonate to do which of the following? 1. Feed the neonate. 2. Allow the neonate to sleep. 3. Get to know the neonate. 4. Change the neonate's diaper.
- As part of the neonate’s physiologic adaptation to birth, at 90 minutes after birth the neonate
typically is in the rest or sleep phase. During this time, the heart and respiratory rates slow and the
neonate sleeps, unresponsive to stimuli. At this time, the mother should rest and allow the neonate to
sleep. Feedings should be given during the first period of reactivity, considered the first 30 minutes
after birth. During this period, the neonate’s respirations and heart rate are elevated. Getting to know
the neonate typically occurs within the first hour after birth and then when the neonate is awake and
during feedings. Changing the neonate’s diaper can occur at any time, but at 90 minutes after birth the
neonate is usually in a deep sleep, unresponsive, and probably hasn’t passed any meconium.
CN: Health promotion and maintenance; CL: Apply
- As part of the neonate’s physiologic adaptation to birth, at 90 minutes after birth the neonate
Physical Assessment of the Neonatal Client
21. The nurse is to assess a newborn for incurving of the trunk. Which illustration indicates the
position in which the nurse should place the newborn?
1.
2.
3.
4.
Physical Assessment of the Neonatal Client
21. 1. When assessing the incurving of the trunk tests for automatic reflexes in the newborn, the
nurse places the infant horizontally and in a prone position with one hand, and strokes the side of the
newborn’s trunk from the shoulder to the buttocks using the other hand. If the reflex is present, the
newborn’s trunk curves toward the stimulated side. Answer 2 shows a figure for testing for a stepping
response. Answer 3 shows a figure for testing for a tonic neck reflex. Answer 4 shows a figure for
testing for the Moro (startle) reflex.
CN: Physiological adaptation; CL: Apply
A full-term neonate is admitted to the normal newborn nursery. The nurse notes a Moro
reflex. What should the nurse do next?
1. Call a code.
2. Identify this reflex as a normal finding.
3. Place the neonate on seizure precautions.
4. Start supplemental oxygen.
- The Moro reflex is a normal reflex of a neonate and requires no intervention. Calling a
code, placing the neonate on seizure precautions, and starting supplemental oxygen are not necessary
for a normally occurring reflex.
CN: Basic care and comfort; CL: Synthesize
- The Moro reflex is a normal reflex of a neonate and requires no intervention. Calling a
- After the birth of a neonate, a quick assessment is completed. The neonate is found to be
apneic. After quickly drying and positioning the neonate, what should the nurse do next? - Assign the first Apgar score.
- Start positive pressure ventilation.
- Administer oxygen.
- Start cardiac compressions.
- If an infant is not breathing after the initial steps of resuscitation, the next thing the nurse
must do is begin positive pressure ventilation. Apgar scores are an evaluation of the neonate’s status
at 1 and 5 minutes of life. Waiting to restore respirations until after assigning an Apgar score would
be a waste of valuable time. Oxygen alone does little good if the infant is not breathing. Chest
compressions must be accompanied by adequate oxygenation.
CN: Physiological adaptation; CL: Synthesize
- If an infant is not breathing after the initial steps of resuscitation, the next thing the nurse
- A 6-lb, 8-oz (2,948 g) neonate was born vaginally at 38 weeks’ gestation. At 5 minutes of
life, the neonate has the following signs: heart rate 110, intermittent grunting with respiratory rate of
70, flaccid tone, no response to stimulus, and overall pale white in color. The Apgar score is: - 2.
- 3.
- 4.
- 6.
- The neonate has a heart rate >100, which earns him 2 points. His respiratory rate of 70 is
equivalent to a 2 on the scale. His flaccid muscle tone is equal to 0 on the scale. The lack of response
to stimulus also equals 0, as does his overall pale white color. Thus, the total score equals 4.
CN: Basic care and comfort; CL: Apply
- The neonate has a heart rate >100, which earns him 2 points. His respiratory rate of 70 is