Nursing Care of the Newborn Quizlet

Nursing Care of the Newborn Quizlet Related

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Which assessment finding of a newborn requires prompt action by the nurse?

  • A. Respiratory rate of 50 breaths per minute
  • B. Cyanosis of the extremities
  • C. Pause in breathing lasting 20 seconds
  • D. Pause in breathing for 15 seconds followed by rapid respirations
Correct Answer: C

Rationale: The correct answer is C: Pause in breathing lasting 20 seconds. This finding indicates a potential apnea episode in the newborn, which requires immediate attention to prevent further complications like hypoxia. The pause in breathing lasting 20 seconds exceeds the normal range for apnea in newborns, typically defined as a pause lasting more than 15 seconds. Prompt action is necessary to assess and address the underlying cause of the apnea episode.

Choice A (Respiratory rate of 50 breaths per minute) is within the normal range for newborns (30-60 breaths per minute) and does not require immediate action. Choice B (Cyanosis of the extremities) may indicate poor circulation but is not as urgent as a prolonged pause in breathing. Choice D (Pause in breathing for 15 seconds followed by rapid respirations) is incorrect as it does not meet the criteria for apnea in newborns and does not require immediate action.

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When the nurse determines they have a high-risk newborn and birthing person in their care, what can they do to mitigate the situation?

  • A. Document in the chart.
  • B. Reassure the parent that everything will be fine.
  • C. Refer the couplet to social work for early intervention.
  • D. Refer to a pediatric health-care provider for well-baby checkup.
Correct Answer: C

Rationale: The correct answer is C: Refer the couplet to social work for early intervention. This is the best course of action as social work can provide support and resources to address the high-risk situation. Documenting in the chart (A) is important but not sufficient for immediate intervention. Reassuring the parent (B) may be helpful, but it doesn't address the risk factor. Referring to a pediatric provider (D) is important but social work intervention can provide more comprehensive support in this specific situation.

The nurse completes an initial newborn examination. The nurses findings include the following: heart rate 136 beats/minute; respiratory rate 64 breaths/minute; temperature 98.2F (36.8C). The nurse also documents a heart murmur,absence of bowel sounds symmetry of ears and eyes no grunting or nasal flaring and full range of movement of all extremities. Which finding requires immediate consultation with the health-care provider?

  • A. Absent bowel sounds
  • B. Heart murmur
  • C. Respiratory rate
  • D. Temperature
Correct Answer: A

Rationale: Bowel obstruction in the neonate is often first identified by an absence of bowel sounds in a small

The nurse is providing discharge teaching to a woman who delivered her first child 2 days ago. The nurse understands that additional information is needed if the client makes which statement?

  • A. The flow will increase if I am too active.
  • B. I should expect a lighter flow next week.
  • C. My bleeding will remain red for about a month.
  • D. I will be able to use a pantiliner in a day or two.
Correct Answer: C

Rationale: Postpartum bleeding typically transitions from red to pink to white over several weeks. Persistent bright red bleeding for a month indicates a potential problem.

The labor and delivery nurse understands that some neonates spontaneously take a breath once the head and chest is delivered. Which understanding does the nurse have for the neonate that requires chemical stimuli to breathe?

  • A. Oxygen is applied immediately to start respirations.
  • B. Carbon dioxide is administered in small doses.
  • C. Mild hypoxia and decreased pH stimulates the brain.
  • D. Suctioning is used to stimulate breathing efforts.
Correct Answer: C

Rationale: Step 1: Mild hypoxia and decreased pH stimulate the brain to initiate breathing in neonates.
Step 2: This chemical stimuli trigger the respiratory centers in the brainstem.
Step 3: Oxygen administration may not be necessary as the neonate's own respiratory drive is initiated by chemical stimuli.
Step 4: Carbon dioxide administration is not needed as high levels can be harmful.
Step 5: Suctioning is not used to stimulate breathing but to clear airways if necessary.
Summary: Choice C is correct as it aligns with the physiological response of neonates to chemical stimuli for breathing, while the other choices are not relevant or could be potentially harmful.

Which nursing action is designed to avoid unnecessary heat loss in the newborn?

  • A. Maintain room temperature at 21°C (70°F).
  • B. Place a blanket over the scale before weighing the infant.
  • C. Take the rectal temperature every hour to detect early changes.
  • D. Undress the infant completely for assessments so that they can be finished quickly.
Correct Answer: B

Rationale: The correct answer is B because placing a blanket over the scale before weighing the infant helps prevent unnecessary heat loss by keeping the baby warm during the process. This action maintains the baby's body temperature and reduces the risk of hypothermia.

A: Maintaining room temperature at 21°C may not be sufficient to prevent heat loss during specific procedures.
C: Taking rectal temperature every hour is not necessary and may expose the baby to unnecessary heat loss.
D: Undressing the infant completely for assessments can lead to rapid heat loss and should be avoided to maintain the baby's body temperature.

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