Nursing Care of the Newborn

Nursing Care of the Newborn Related

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The nurse is completing a gestational assessment on a newborn whose parent was treated for preeclampsia during labor. The neonate is demonstrating 'frog-like' posturing. The nurse knows this is likely due to what medication during labor?

  • A. fentanyl in the epidural
  • B. penicillin for treatment of group B strep infection
  • C. magnesium sulfate for treatment of preeclampsia
  • D. prenatal vitamins
Correct Answer: C

Rationale: The correct answer is C: magnesium sulfate for treatment of preeclampsia. Magnesium sulfate is commonly used to manage preeclampsia in pregnant women. Neonates born to mothers who received magnesium sulfate may exhibit 'frog-like' posturing due to the effects of the medication crossing the placenta. The other choices, A: fentanyl in the epidural, B: penicillin for treatment of group B strep infection, and D: prenatal vitamins, are not associated with causing 'frog-like' posturing in newborns. Fentanyl in the epidural is a pain medication, penicillin is an antibiotic, and prenatal vitamins are supplements that do not typically cause this specific posturing.

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The nurse is completing an initial assessment of the newborn. The newborn’s ears appear to be parallel to the outer and inner canthus of the eye. How does the nurse document the ear placement?

  • A. low set
  • B. high set
  • C. a normal position
  • D. facial paralysis
Correct Answer: C

Rationale: Ears positioned parallel to the outer and inner canthus are considered normal.

The nurse is providing care for a neonate during the fourth stage of labor. Which action does the nurse take during this stage?

  • A. Dry the neonate immediately.
  • B. Compete neonate assessment within 1 hour.
  • C. Obtain neonate blood glucose levels.
  • D. Perform Apgar screening until scores are 7.
Correct Answer: A

Rationale: The correct answer is A: Dry the neonate immediately. This is crucial during the fourth stage of labor to prevent hypothermia in the neonate. Drying the neonate helps maintain body temperature and reduce heat loss. Choice B is incorrect because a complete neonate assessment should be done within the first 1-2 minutes, not within 1 hour. Choice C is incorrect as obtaining neonate blood glucose levels is not typically done during the immediate post-birth period unless indicated. Choice D is incorrect as Apgar screening is typically done at 1 and 5 minutes after birth, not until the scores are 7.

An infant who was stable for a day after birth now demonstrates pallor tachycardia tachypnea and circumoral cyanosis. The parent asks how the child might have a heart problem when he was stable yesterday. What information by the nurse is most accurate?

  • A. Blood incompatibilities can cause this problem so we will test the mothers blood.
  • B. Symptoms may not appear until fetal circulation routes begin to close after birth.
  • C. The extra blood from the umbilical cord may have kept the baby stable for a while.
  • D. Your baby may have gotten an infection during birth that now is causing problems.
Correct Answer: B

Rationale: This baby has clinical manifestations of tetralogy of Fallot. While the ductus arteriosus remains patent the infant remains stable. However when the ductus begins closing after the first 24 hours of life the infants cardiovascular system becomes unstable and manifestations appear. The other statements are inaccurate.

Developing a plan to achieve patient outcomes is included in which step of the CJMM?

  • A. prioritizing hypotheses
  • B. generating solutions
  • C. taking action
  • D. evaluating outcomes
Correct Answer: B

Rationale: Generating solutions involves creating strategies to address identified problems, which includes developing plans to achieve desired patient outcomes.

The nurse is assigned to the room of a 15-year-old person who gave birth to a newborn 72 hours ago. Why is this newborn a perfect candidate for the Brazelton assessment?

  • A. This parent-newborn couplet is at risk for delayed attachment.
  • B. The newborn is likely going home soon.
  • C. The EHR is prompting her to do so.
  • D. The infant is likely withdrawing from a substance.
Correct Answer: A

Rationale: Delayed attachment may occur in younger parents, making the Brazelton assessment valuable for evaluating bonding.

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