Care of the Newborn

The nurse assisted with the birth of a newborn. Which nursing action is most effective in preventing heat loss by evaporation?

The mother of a newborn calls the clinic and reports that when cleaning the umbilical cord, she noticed that the cord was moist and that discharge was present. What is the most appropriate nursing instruction for this mother?

The nurse in a neonatal intensive care unit (NICU) receives a telephone call to prepare for the admission of a 43-week gestation newborn with Apgar scores of 1 and 4. In planning for admission of this newborn, what is the nurse’s highest priority?

The nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is most appropriate?

The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings should alert the nurse to the possibility of this syndrome? Select all that apply.

1. Cyanosis
2. Tachypnea
3. Hypotension
4. Retractions
5. Audible grunts
6. Presence of a barrel chest

The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast-fed. The nurse should provide which instruction to the mother?

The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which findings should the nurse expect to note during the assessment of this newborn? Select all that apply.

1. Lethargy
2. Sleepiness
3. Irritability
4. Constant crying
5. Difficult to comfort
6. Cuddles when being held

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with this syndrome?

The nurse is creating a plan of care for a newborn diagnosed with fetal alcohol syndrome. The nurse should include which priority intervention in the plan of care?

The nurse administers erythromycin ointment (0.5%) to the eyes of a newborn and the mother asks the nurse why this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis?

The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care? Select all that apply.

1. Avoid stimulation.
2. Decrease fluid intake.
3. Expose all of the newborn’s skin.
4. Monitor skin temperature closely.
5. Reposition the newborn every 2 hours.
6. Cover the newborn’s eyes with eye shields or patches.

The nurse creates a plan of care for a woman with human immunodeficiency virus (HIV) infection and her newborn. The nurse should include which intervention in the plan of care?

The nurse is planning care for a newborn of a mother with diabetes mellitus. What is the priority nursing consideration for this newborn?

Which statement reflects a new mother’s understanding of the teaching about the prevention of newborn abduction?

The nurse prepares to administer a phytonadione (vitamin K) injection to a newborn, and the mother asks the nurse why her infant needs the injection. What best response should the nurse provide?