The Apgar score is based the nurse’s assessment of the neonate’s ___, ___, ___, ___, and ___.
heart rate
respiratory rate
muscle tone
reflex irritability
skin color
Immediately after birth, nursing care includes ___, ___, ___, ___, ___, and promoting parent-infant interaction.
maintaining an open airway
preventing heat loss
instilling a prophylactic agent into the eyes
administering vitamin K intramuscularly
providing umbilical cord care
Common problems in neonates include ___, ___, ___, ___, and ___.
soft tissue injuries
skeletal injuries
physiologic jaundice
hypoglycemia
hypocalcemia
Common tests for neonates include newborn screening tests and measurements of blood ___, ___, and ___.
glucose
bilirubin
drug serum levels
Suggested benefits of circumcision include a ___ and ___, ___, and ___.
decreased incidence of urinary tract infection
decreased risks of sexually transmitted infection
penile cancer
human papillomavirus infection
The nurse should teach parents the signs of illness in newborns, especially ___.
jaundice in newborns discharged early
All parents should be taught ___.
infant cardiopulmonary resuscitation
At 1 minute following birth, a newborn exhibited the following: heart rate of 155; loud, vigorous crying with active movement of all extremities; sneezing when nose was stimulated with a catheter; hands and feet bluish and cool to the touch. The Apgar score of this newborn should be recorded as:
B. 9.
The newborn receives 2 points each for a heart rate over 100 beats/min, a vigorous cry, active movement, and sneezing as a response to nasal stimulation. The newborn receives 1 point for color because he exhibits acrocyanosis. The point total is 9.
The nurse must administer erythromycin ophthalmic ointment to a newborn after birth. The nurse should:
B. Cleanse eyes from inner to outer canthus before administration.
T/F: Instillation of the erythromycin ophthalmic ointment can be delayed for up to 2 hours to facilitate eye-to-eye contact between the newborn and parents, an activity that fosters bonding and attachment, especially for fathers.
F: 1 hour
T/F: The nurse must administer erythromycin ophthalmic ointment to a newborn after birth. The nurse should apply directly over the cornea.
F: Erythromycin should be applied into the conjunctival sac to avoid accidental injury to the eye.
Newborns are at high risk for injury if appropriate safety precautions are not implemented. Parents should be taught to:
C. Use a rear-facing car seat until the infant weighs at least 20 lb.
T/F: Newborns are at high risk for injury if appropriate safety precautions are not implemented. Parents should be taught to use a crib with side-rail slats that are no more than 3 inches apart.
F: Slats in a crib should be no more than 2 inches apart.
Following circumcision of a newborn, the nurse provides instructions to his parents regarding postcircumcision care. The nurse should tell the parents to:
D. Expect a yellowish exudate to cover the glans after the first 24 hours.
Parents should be taught that a yellow exudate will develop over the circumcised glans and should OR should not be removed.
should not
The diaper is changed frequently, but the site is cleansed with ___ only because soap and baby wipes can cause pain/burning and irritation at the site.
warm water
T/F: Following circumcision of a newborn, the nurse provides instructions to his parents regarding postcircumcision care. The nurse should tell the parents to apply constant pressure to the site if bleeding occurs and call the physician.
F: Intermittent pressure is applied if bleeding occurs.
When placing a newborn under a radiant heat warmer to stabilize temperature after birth, the nurse should:
D. Prewarm the radiant heat warmer and place the undressed newborn under it.
T/F: When placing a newborn under a radiant heat warmer to stabilize temperature after birth, the nurse should place the thermistor probe on left side of the chest.
F: thermistor probe should be placed on the upper abdomen away from the ribs.
T/F: When placing a newborn under a radiant heat warmer to stabilize temperature after birth, the nurse should cover probe with a reflective material.
True
T/F: When placing a newborn under a radiant heat warmer to stabilize temperature after birth, the nurse should recheck temperature by periodically taking a rectal temperature.
F: Rectal temperatures should be avoided because rectal thermometers can perforate the intestine, and the temperature may remain normal until cold stress is advanced.
With regard to umbilical cord care, nurses should be aware that:
A. The stump can easily become infected.
The cord stump is an excellent medium for bacterial growth.
T/F: With regard to umbilical cord care, nurses should be aware that if bleeding from the vessels of the cord is found, they should immediately call for assistance.
F: The nurse should first check the clamp (or tie) and apply a second one. If the bleeding does not stop, then the nurse calls for assistance.
The cord clamp is removed after ___ hours when ___.
24
it is dry
T/F: With regard to umbilical cord care, nurses should be aware that the average cord separation time is 5 to 7 days.
F: The average cord separation time is 10 to 14 days.
7.During the complete physical examination 24 hours after birth:
D. The nurse can gauge the neonate’s maturity level by assessing its general appearance.
The nurse is able to gauge maturity level by assessing appearance. The nurse will be looking at skin color, alertness, cry, head size, and other features
T/F: During the complete physical examination 24 hours after birth blood pressure is not usually taken unless cardiac problems are suspected.
True
T/F: During the complete physical examination 24 hours after birth when the nurse listens to the heart, the S1 and S2 sounds can be heard; the first sound is somewhat higher in pitch and sharper than the second.
F: The second heart sound is higher and sharper than the first.
With regard to laboratory tests and diagnostic tests performed in the hospital after birth, nurses should be aware that:
A. If genetic screening is done before the infant is 24 hours old, it should be repeated at age 1 to 2 weeks.
If done very early, genetic screening should be repeated.
T/F: With regard to laboratory tests and diagnostic tests performed in the hospital after birth, nurses should be aware that all states test for phenylketonuria (PKU), hypothyroidism, cystic fibrosis, and sickle cell diseases.
F: All states test for PKUand hypothyroidism, but other genetic defects are not universally covered.
T/F: With regard to laboratory tests and diagnostic tests performed in the hospital after birth, nurses should be aware that federal law prohibits newborn genetic testing without parental consent.
F: Federal law mandates newborn genetic screening, but not screening for hearing problems (although more than half the states do mandate hearing screening).
APGAR ratings
@ 1 and 5 minutes
HR
absent: 0
< 100: 1
> 100: 2
RR
absent: 0
slow, weak cry: 1
good gry: 2
Muscle Tone
Flacid: 0
Some flexion: 1
Well flexed: 2
Reflex irratability
no response: 0
Grimace: 1
Cry: 2
Color
Blue, pale: 0
Body pink, extremities blue: 1
Completely pink: 2 (not usually born this way)
circumcision
Excision of the prepuce (foreskin) of the penis, exposing the glans
The nurse is performing a blood glucose test every 4 hours on an infant born to a diabetic mother. This is to assess the infant's risk of hypoglycemia. The nurse becomes concerned if the infant's blood glucose concentration falls below ___ mg/dl.
36
If the newborn has a blood glucose level below 36 mg/dl, intervention such as breastfeeding or bottle-feeding should be instituted. If levels remain low after this intervention, an intravenous infusion with dextrose may be warranted
hyperbilirubinemia
Elevation of unconjugated serum bilirubin concentrations
hypothermia
Temperature that falls below thenormal range, that is, below 35° C/ 95° F, usually caused by exposure to cold
kernicterus
Pathologic process characterized by deposition of bilirubin in the brain
late preterm infant
Infants born at 34-0/7 to 36-6/7weeks of gestation
ophthalmia neonatorum
Infection in the neonate's eyes usually resulting from gonorrheal, chlamydial, or other infection contracted when the fetus passes through the birth canal (vagina)
phototherapy
Use of lights to reduce serum bilirubin levels by oxidation of bilirubin into water-soluble compounds that are processed in the liver and excreted in bile and urine
physiologic jaundice
Yellow tinge to skin and mucous membranes in response to increased serum levels of unconjugated bilirubin; not usually apparent until after 24 hours; also called neonatal jaundice, physiologic hyperbilirubinemia
