Newborn Assessment and Care: Key Concepts

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Questions and Answers

During the initial assessment of a newborn, which Apgar score range indicates that the newborn is experiencing moderate difficulty adjusting to extrauterine life?

  • 7–10
  • 0–3
  • 4–6 (correct)
  • 11-13

A newborn is noted to have bluish hands and feet but a pink trunk. This is documented as acrocyanosis. What is the appropriate nursing action?

  • Notify the physician for a cardiac consultation.
  • Prepare for immediate resuscitation.
  • Immediately administer oxygen.
  • Document the finding as normal and continue to monitor. (correct)

When assessing a newborn's anterior fontanelle, a nurse notes that it is bulging. Which condition should the nurse suspect based on this finding?

  • Dehydration
  • Increased intracranial pressure (correct)
  • Caput succedaneum
  • Normal finding in newborns

A nurse is teaching parents about newborn safety. Which statement by the parent indicates a need for further teaching regarding safe sleep practices to prevent SIDS?

<p>We will put soft blankets and toys in the crib to make it cozy. (D)</p> Signup and view all the answers

A newborn is 12 hours old and exhibiting jitteriness, poor feeding, and lethargy. Which condition should the nurse suspect, and what initial intervention is most appropriate?

<p>Hypoglycemia; check blood glucose levels. (D)</p> Signup and view all the answers

What is the primary purpose of administering erythromycin eye ointment to a newborn shortly after birth?

<p>To prevent ophthalmia neonatorum from gonorrhea or chlamydia. (B)</p> Signup and view all the answers

A nurse is assessing a 2-day-old newborn and observes jaundice that appeared within the first 24 hours of life. What is the most important nursing action?

<p>Report the finding to the physician as pathological jaundice. (D)</p> Signup and view all the answers

Which of the following newborn reflexes is characterized by the newborn extending their arms and fingers outwards, and then drawing their arms in towards their body in response to a sudden loud noise or sensation of falling?

<p>Moro reflex (C)</p> Signup and view all the answers

A nurse is assessing the umbilical cord of a newborn. Which finding would be considered normal?

<p>One artery and two veins (D)</p> Signup and view all the answers

During a postpartum assessment, a nurse palpates the uterine fundus and finds it to be boggy and displaced to the right of the umbilicus. What is the priority nursing intervention?

<p>Assess the mother's bladder and assist her to empty it. (A)</p> Signup and view all the answers

A postpartum woman, who is Rh-negative, has given birth to an Rh-positive newborn. Which medication is essential to administer to prevent Rh sensitization in future pregnancies?

<p>Rho(D) immune globulin (RhoGAM) (C)</p> Signup and view all the answers

What is the normal range for a newborn's axillary temperature in degrees Celsius?

<p>36.5°C to 37.5°C (C)</p> Signup and view all the answers

A nurse is teaching a new mother about formula feeding. How often should formula-fed newborns typically be fed?

<p>Every 3–4 hours (B)</p> Signup and view all the answers

Which assessment finding in a newborn would indicate potential respiratory distress and require immediate attention?

<p>Nasal flaring (A)</p> Signup and view all the answers

A nurse is educating parents about umbilical cord care. Which instruction is most appropriate?

<p>Keep the cord dry and exposed to air. (B)</p> Signup and view all the answers

During a newborn assessment, the nurse notes a swelling of the scalp that crosses suture lines. This is most likely:

<p>Caput succedaneum (B)</p> Signup and view all the answers

What is the purpose of administering vitamin K to newborns shortly after birth?

<p>To prevent bleeding. (A)</p> Signup and view all the answers

A postpartum mother reports heavy vaginal bleeding and feels lightheaded. On assessment, her fundus is boggy and lochia is saturated. What is the immediate nursing action?

<p>Massage the fundus and notify the healthcare provider. (A)</p> Signup and view all the answers

Which assessment finding in a postpartum woman is a potential sign of thromboembolic disease?

<p>Localized leg pain and swelling in one calf (C)</p> Signup and view all the answers

What is kangaroo care, and what is its primary benefit for newborns?

<p>Skin-to-skin contact between parent and newborn to promote bonding and thermoregulation. (D)</p> Signup and view all the answers

A nurse is assessing a newborn's gestational age using the Ballard score. Which physical maturity characteristic is assessed as part of this scoring system?

<p>Plantar creases (D)</p> Signup and view all the answers

What is the normal range for a newborn's heart rate in beats per minute?

<p>110–160 bpm (A)</p> Signup and view all the answers

Which of the following is considered a normal respiratory rate for a newborn in breaths per minute?

<p>30–60 breaths per minute (A)</p> Signup and view all the answers

A newborn is described as post-term. What gestational age classification does this indicate?

<p>Born after 42 weeks of gestation (B)</p> Signup and view all the answers

Which of the following infant behaviors is a feeding cue indicating readiness for feeding?

<p>Rooting and sucking motions (C)</p> Signup and view all the answers

What is the recommended position for placing a newborn in a crib to reduce the risk of Sudden Infant Death Syndrome (SIDS)?

<p>Supine (back) position (B)</p> Signup and view all the answers

Which of the following is a normal finding when assessing a newborn's skin texture?

<p>Smooth and slightly dry skin (C)</p> Signup and view all the answers

A nurse observes low-set ears on a newborn. This finding is most concerning for which potential condition?

<p>Chromosomal abnormalities (C)</p> Signup and view all the answers

What is the primary nursing intervention to prevent heat loss through evaporation in a newborn immediately after birth?

<p>Drying the newborn thoroughly with warm blankets. (B)</p> Signup and view all the answers

During a postpartum assessment, the nurse assesses lochia. What is lochia?

<p>Postpartum vaginal discharge. (C)</p> Signup and view all the answers

Flashcards

Apgar Score

Assesses heart rate, respiration, muscle tone, reflex irritability, and color at 1 and 5 minutes after birth.

Normal Newborn Weight

Between 2500 and 4000 grams (5.5 to 8.8 pounds).

Normal Newborn Length

Between 45 and 55 cm (18 to 22 inches).

Normal Head Circumference

Between 32 and 36.8 cm (12.5 to 14.5 inches).

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Normal Axillary Temperature

36.5°C to 37.5°C (97.7°F to 99.5°F).

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Normal Newborn Heart Rate

110 to 160 beats per minute.

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Normal Respiratory Rate

30 to 60 breaths per minute.

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Acrocyanosis

Bluish discoloration of hands and feet, common in newborns.

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Caput Succedaneum

Swelling of the scalp in a newborn.

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Cephalohematoma

Blood collection between the skull and periosteum.

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Ballard Score

Assess physical and neuromuscular maturity to determine gestational age.

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Preterm Newborns

Born before 37 weeks of gestation.

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Term Newborns

Born between 37 and 42 weeks of gestation.

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Post-Term Newborns

Born after 42 weeks of gestation.

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Signs of Respiratory Distress

Nasal flaring, grunting, and retractions.

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Signs of Hypoglycemia

Jitteriness, poor feeding, and lethargy.

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Obligate Nose Breathers

Newborns breathe primarily through their nose.

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Vitamin K

Prevents bleeding in newborns.

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Erythromycin Eye Ointment

Prevents ophthalmia neonatorum from gonorrhea or chlamydia.

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Newborn Metabolic Screening

Phenylketonuria (PKU) and congenital hypothyroidism.

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Rho(D) Immune Globulin (RhoGAM)

Administered to Rh-negative mothers with Rh-positive newborns.

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Emotional Attachment

Development of a bond between a parent and newborn.

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Postpartum Infection Signs

Fever, redness, and drainage.

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Postpartum Intervention

Encourage early ambulation, promote nutrition and hydration and educate about self & newborn care

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Postpartum Hemorrhage Signs

Excessive bleeding and decreased blood pressure.

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Study Notes

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