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Newborn immediately after birth
The priority nursing care of the newborn immediately after birth includes all except:
- A. Support thermoregulation.
- B. Identify the infant.
- C. Promote normal respirations.
- D. Announcement of the delivery.
Correct Answer: D
Rationale: Announcement of the delivery is not a priority in nursing care of the newborn immediately after birth. While it may be a joyful moment for the parents and family, it does not affect the health and well-being of the newborn. Therefore, it can be done later after the essential newborn care has been completed.
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Postpartum woman, 4-day-old infant, breastfeeding
A postpartum woman telephones about her 4-day-old infant. She is not scheduled for a weight check until the infant is 10 days old, and she is worried about whether breastfeeding is going well. Effective breastfeeding is indicated by the newborn who:
- A. has at least six to eight wet diapers per day.
- B. has at least one breast milk stool every 24 hours.
- C. sleeps for 6 hours at a time between feedings.
- D. gains 1 to 2 ounces per week.
Correct Answer: A
Rationale: Six to eight wet diapers per day indicate adequate hydration and milk intake, a reliable sign of effective breastfeeding.
Newborn born at 37 weeks, 12 hours old, tachypnea, grunting, nasal flaring, substernal retractions, acrocyanosis
Complete the diagram by dragging from the choices below to specify what condition the newborn is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the newborn's progress.
- A. Initiate phototherapy as prescribed.
- B. Obtain a urine drug screen.
- C. Administer Surfactant as prescribed.
- D. Administer 30 mL of oral glucose water.
- E. Provide Oxygen Therapy as needed
- F. Hypoglycemia.
- G. Respiratory distress syndrome.
Correct Answer: B
Rationale: Respiratory distress syndrome is likely due to respiratory symptoms. Administer surfactant and provide oxygen therapy address lung immaturity and oxygenation. Monitor arterial blood gases and oxygen saturation to assess progress.
Male newborn, genitalia assessment
The nurse is inspecting a male newborn's genitalia. Which action should the nurse avoid when conducting this assessment?
- A. Inspecting if the urethral opening appears circular.
- B. Retracting the foreskin over the glans to assess for secretions.
- C. Palpating if testes are descended into the scrotal sac.
- D. Inspecting the genital area for irritated skin.
Correct Answer: B
Rationale: Retracting the foreskin over the glans should be avoided as it can cause pain, bleeding, and infection in the newborn. The foreskin is usually adhered to the glans and should not be forcibly retracted.
Newborn placed under radiant heat warmer after birth
A nurse places a newborn under a radiant heat warmer after birth. The purpose of this action is to prevent which of the following in the newborn?
- A. Basal metabolic rate reduction.
- B. Brown fat production.
- C. Shivering.
- D. Cold stress.
Correct Answer: D
Rationale: A radiant heat warmer prevents cold stress by maintaining the newborn's body temperature, avoiding complications like hypoxia and hypoglycemia.
Infant with axillary temperature of 35.9C (96.6F)
An infant's axillary temperature is 35.9C (96.6F). The priority nursing action is to:
- A. chart the normal axillary temperature.
- B. recheck the infant's temperature rectally.
- C. place the infant in a radiant warmer.
- D. have the mother breastfeed the infant.
Correct Answer: C
Rationale: The low temperature indicates hypothermia, and placing the infant in a radiant warmer is the priority to stabilize body temperature and prevent complications.