Newborn Assessment and Care, Exams of Nursing

Download Newborn Assessment and Care and more Exams Nursing in PDF only on Docsity! NURS1142 U WORLD NEWBORN The nurse is performing an assessment on a 39-week neonate an hour after a spontaneous vaginal delivery. What are common expected newborn findings? Select all that apply. 1. One artery and one vein in the umbilical cord 2. Plantar creases up the entire sole 3. Skin on the nose blanches to a yellowish hue 4. Toes fan outward when the lateral sole surface is stroked 5. White pearl-like cysts on gum margins Explanation: The number of plantar creases on the bottom of the feet is indicative of the neonate's age. The more creases over the greater proportion of the foot, the more mature the neonate. The Babinski reflex is present at birth and disappears at 1 year. The toes hyperextend and fan out when the lateral surface of the sole is stroked in an upward motion. Absent Babinski or a weak reflex may indicate a neurological defect. Epstein's pearls are white, pearl-like epithelial cysts on gum margins and the palate. They are benign and usually disappear within a few weeks. (Option 1) The cord should be opaque or whitish-blue with two arteries and one vein and covered with Wharton's jelly. The presence of only one umbilical artery and vein is associated with heart or kidney malformation. The cord should also be assessed for bleeding. It will become dry and darker within 24 hours and detach from the body within 2 weeks. (Option 3) Jaundice is best assessed in natural lighting, with gentle pressure to the skin over a firm surface such as the nose, forehead, or sternum. It first appears on the face and extends to the trunk and eventually the entire body. Jaundice within the first 24 hours is pathological. It is usually related to problems of the liver. Jaundice after 24 hours is referred to as physiological jaundice and is related to the increased amount of unconjugated bilirubin in the system. Educational objective: Expected (normal) findings for a term newborn include plantar creases up the sole of the foot, presence of Babinski reflex, and Epstein's pearls. A A A: A neonate on ventilator support is diagnosed with trisomy 18 (Edwards syndrome). What would be an appropriate action by the nurse? 1. Discuss a plan to decrease ventilator support as the lungs become stronger with the parents [7%] 2. Provide parents with information on the medical treatment plan for the neonate [37%] 3. Provide the test results to the parents and give them information to read about trisomy 18 [16%] 4. Request a meeting with the palliative care team and the parents to discuss end- of- life choices [38%] Explanation: Life expectancy of a neonate with trisomy 18 is typically a few weeks. A discussion of end- of-life choices would be appropriate in this situation as the neonate is already experiencing respiratory difficulty. A palliative care team will be an asset in this discussion. (Option 1) Trisomy 18 is a genetic disorder with a short life expectancy. Discussing the improvement of the neonate's lungs will give the parents false hope regarding recovery and would be inappropriate at this time. (Option 2) There is no cure or treatment for a neonate with trisomy 18 at this time. (Option 3) Providing test results to the parents is out of the scope of nursing practice as it is the health care provider (HCP) who discusses this with them. The nurse may provide information for the parents to read, but this would be appropriate after the HCP has discussed the disorder. Educational objective: Trisomy 18 (Edwards syndrome) is a chromosome anomaly characterized by severe cardiac defects and multiple musculoskeletal deformities. Life expectancy for trisomy 18 is a few weeks after birth, neonates rarely survive to their first birthday. End-of-life issues should be discussed early after the diagnosis is confirmed. Trisomy 13 (Patau syndrome) also results in early death. A A A The registered nurse is teaching a class of expectant parents about infant safety. Which statement by a class participant indicates a need for further instruction? 1. "I will make sure there is a firm mattress in the crib." [1%] 2. "I will put my baby to bed with a pacifier." [26%] 3. "I will tie bumper pads to the sides of the crib to protect my baby's head." [42%] Circumcision care at home includes: Wash hands before providing care Avoid using alcohol-based prepackaged wipes as alcohol prevents healing and causes discomfort. Instead, clean with warm water (without soap) every 4 hours to remove urine and feces. Apply petroleum jelly at diaper changes (unless PlastiBell used); the diaper should be loose over the penis. The diaper should be changed at least every 4 hours to prevent adhesion to the penis. Yellow exudate forms as part of the normal healing process after the first 24 hours. It is not a sign of infection and should not be removed forcefully. The exudate will disappear in 2-3 days as healing progresses. Redness, odor, or discharge indicates infection. (Option 1) Bleeding is a concern only if the amount exceeds the size of a quarter. (Option 2) Petroleum jelly or a water-based ointment should be used for the first 3-5 days to prevent the exposed glans from sticking to the diaper. (Option 3) Absence of voiding indicates damage to the urethra during circumcision. Excess swelling can also obstruct urine flow. The appropriate number of wet diapers is about 4-6 in 24 hours. If there are fewer, the health care provider should be notified about inadequate urine output. Educational objective: Yellow exudate forming on the second day after circumcision indicates a normal healing process and should not be removed forcefully. Excess bleeding, unusual swelling, redness, discharge, odor, or decreased urine output indicates complications and should be reported to the health care provider. A A A The nurse performs the first Apgar assessment of a newborn at 1 minute of life. The baby is completely blue, with a heart rate of 110/min and is emitting a weak cry. The baby is actively moving and grimaces when the nares are suctioned. What is this baby's Apgar score? 1. 4 [17%] 2. 5 [29%] 3. 6 [33%] 4. 7 [20%] Explanation: The Apgar score is a screening assessment used to determine a newborn's need for assistance in transitioning from intrauterine to extrauterine life. Scoring is done at 1 minute and at 5 minutes of life for all newborns. An Apgar score of 10 is unusual as most newborns have acrocyanosis (cyanosis of the extremities) and will receive only 1 point for appearance/color. If the score at 5 minutes is <7, the Apgar assessment should be repeated every 5 minutes for a maximum of 20 minutes (ie, at 10, 15, and 20 minutes after birth). If a newborn needs resuscitation at birth, the health care provider should never wait for the 1-minute Apgar score to initiate resuscitation efforts. The Apgar score does not predict future neurologic outcomes. This client's heart rate is >100/min, indicating 2 points for pulse. The weak cry receives 1 point for respiratory effort. Active flexion indicates a score of 2 for muscle tone. This client's grimace on nare suctioning is valued at 1. The body is completely blue, which gives 0 points for color. These ratings add up to an Apgar score of 6, which indicates that this client is demonstrating moderate difficulty adjusting to life outside of the womb. Apgar scores below 7 indicate that resuscitation efforts may be necessary in addition to routine postpartum care, which includes drying, warming, and suctioning the newborn. Educational objective: The Apgar score assessment is performed at 1 minute and at 5 minutes after birth to assess neonatal adjustment to extrauterine life. Most neonates have scores between 7 - 9 and require no intervention. Scores <7 may require further evaluation or resuscitation. An Apgar score of 10 is unusual as most newborns have acrocyanosis (cyanosis of the extremities) and will receive only 1 point for appearance/color. A A A A neonate requires respiratory resuscitation. Which is the proper head position of the neonate for rescue breathing? 1. [37%] 2. [6%] 3. [51%] 4. [4%] Explanation: The neonate should be placed on the back with the neck slightly extended. This is a neutral or "sniffing" position. A blanket or towel roll can be placed under the shoulders, elevating them 0.75-1.0 in (19-25.4 mm) off the mattress. This is particularly useful if the infant has a large occiput from molding or edema. The nurse must watch that the infant's head does not shift to an improper position during caregiving activities. (Option 2) This is underextension of the neck, which can decrease air entry. (Option 3) This is hyperextension of the neck, which can decrease air entry. (Option 4) A blanket or towel under the head results in neck flexion and decreases air entry. Educational objective: Position a neonate with the head in a slightly extended position, as if the infant is "sniffing" a flower, to allow proper air entry for rescue breathing. 1. Assess the infant's hemoglobin, hematocrit, and platelet levels [10%] 2. Measure and document the size and location of the markings [77%] 3. Notify the health care provider of the markings immediately [4%] 4. Review the delivery record for evidence of a traumatic birth [8%] Explanation: Congenital dermal melanocytosis (mongolian spots) is a benign discoloration of the skin most often seen in newborns of ethnicities with darker skin tones (eg, African American, Native American, Hispanic, Asian). Mongolian spots are usually bluish gray and fade over the first 1-2 years of life. Because they are easily misidentified as bruises, it is important for the nurse to measure and document the area for reference during future health care assessments. (Option 1) Mongolian spots are common birthmarks and are not associated with abnormal laboratory values. (Option 3) Mongolian spots are benign, so immediately notifying the health care provider is not indicated. (Option 4) Although often mistaken for bruises, mongolian spots are normal skin variations and are not due to trauma. Educational objective: Congenital dermal melanocytosis (mongolian spots) is a benign discoloration of the skin typically found on the back or buttocks. It is most often seen in newborns of ethnicities with darker skin tones. The spots are usually bluish gray and may be misidentified as bruising in future health care assessments. Proper documentation is essential to avoid misinterpretation of findings. A A A The nurse is caring for a baby born at 30 weeks gestation and diagnosed with necrotizing enterocolitis. Which nursing action should be implemented? 1. Encourage parents to increase skin-to-skin care [10%] 2. Measure abdominal girth daily [62%] 3. Measure rectal temperature every 3-4 hours [7%] 4. Position client on side and check diaper for stool [18%] Explanation: Necrotizing enterocolitis occurs predominantly in preterm infants secondary to gastrointestinal and immunologic immaturity. On initiation of enteral feeding, bacteria can be introduced into the bowel, where they can proliferate excessively due to compromised immune clearance. This results in inflammation and ischemic necrosis of the intestine. As the disease progresses, the bowel becomes congested and gangrenous with gas collections forming inside the bowel wall. Measuring the client's abdominal girth daily is an important nursing intervention to note any worsening intestinal gas-associated swelling. Clients are made NPO and receive nasogastric suction to decompress the stomach and intestines. Parenteral hydration and nutrition and IV antibiotics are given. (Option 1) Skin-to-skin care (kangaroo care) promotes bonding with a healthy newborn. It is allowed in some instances for premature infants depending on the condition and week of gestation. Skin-to-skin care should be avoided in infants who are not stable as it may cause additional stress. (Option 3) Taking a client's temperature every 3-4 hours is important; however, rectal temperatures should be avoided due to the risk of perforation of the gangrenous, friable colon. (Option 4) To avoid pressure on the abdomen and facilitate observation for a distended abdomen, clients are placed supine and undiapered. Educational objective: Necrotizing enterocolitis is a life-threatening complication in premature infants due to underdeveloped intestine and gut immunity. Frequent abdominal girth measurements are essential to assess for worsening distension. Clients are placed supine and undiapered. Rectal temperatures should be avoided due to the risk of perforation A A A A nurse is teaching a postpartum client about cord care for the newborn. Which statement by the client indicates a need for further teaching? 1. "I can expect the cord to turn black in a few days." [13%] 2. "I should let the cord fall off by itself, in about 1-2 weeks." [2%] 3. "I should use a cotton swab to gently apply alcohol to the cord." [79%] 4. "I will fold the diaper below the cord to allow the cord to dry." [3%] Explanation: The primary goal of cord care is to keep the cord stump clean and dry to facilitate healing and reduce infection risk. Additional teaching points regarding cord care include: Keep the cord stump open to air when possible to allow for adequate drying. Do not apply antiseptics (eg, alcohol, triple dye, chlorhexidine) to the cord stump, which can cause skin irritation (Option 3). Report any signs of infection (eg, redness, purulent drainage, swelling) to the health care provider. (Option 1) The umbilical cord is usually clamped and cut a few minutes after birth. The clamp is left in place until the cord begins to dry, usually around 24 hours after birth. The remaining cord stump begins to shrivel and turn black in 2-3 days. (Option 2) The cord usually separates spontaneously from the umbilicus around 1-2 weeks after birth. Parents should be instructed to not pull on the cord stump or attempt to hasten cord separation, which could result in bleeding or other complications. (Option 4) The diaper should be folded below the cord to keep the cord dry and prevent contamination with urine or feces. Educational objective: The primary goal of cord care is to keep the cord stump clean and dry. Parents should keep the umbilical area dry, not apply antiseptics to the stump, and report any signs of infection. A A A The nurse is caring for 4 hospitalized clients. Which client should the nurse assess first? 1. Breastfeeding 2. Co-sleeping in parent's bed 3. Side-lying sleeping position 4. Smoking cessation by parents 5. Up-to-date vaccinations Explanation: SIDS is the sudden unexplained death of an infant age <1 year. It is the leading cause of death among infants, with the highest occurrence at 2-4 months. Smoking cessation, breastfeeding, up-to-date vaccinations, and pacifier use are protective factors against SIDS. Pacifier use has been associated with an increased risk of otitis media and early cessation of breastfeeding; however, its use is also associated with a dramatic reduction in SIDS. Because the data is more beneficial for SIDS reduction, pacifiers can be used at naptime and bedtime for newborns once the breastfeeding technique has been well established (age 1 month). (Option 2) Co-sleeping in parent's bed (bed sharing) is a risk factor for SIDS and should be avoided. However, room sharing without bed sharing has been shown to reduce the risk of SIDS. (Option 3) Infants should be placed only on their backs to sleep; side and prone positions increase the risk of SIDS. Due to the infant's body shape (barrel chest and flat uncurved spine), a side position would facilitate rolling to a prone position. In addition, sleep positioners should not be used. Infants can be left in their preferred sleeping position when they are able to roll over on their own (usually at age 4-5 months). Educational objective: SIDS is the leading cause of death among infants age <1 year. Loose bedding, prone/side sleeping, and maternal substance abuse (eg, alcohol, illicit drugs, tobacco) have been found to increase the risk of SIDS. Protective factors include room sharing without bed sharing, smoking cessation, breastfeeding, up-to-date immunizations, and pacifier use. A A A The charge nurse should intervene if the new graduate nurse performs which action when caring for a jaundiced newborn being treated with phototherapy? 1. Allowing the parents to feed the newborn [2%] 2. Applying a shirt while the newborn is exposed to phototherapy [88%] 3. Assessing the temperature of the incubator while the newborn is inside [5%] 4. Covering the newborn's eyes with protective shields [3%] Explanation: Phototherapy is the use of fluorescent lights to treat hyperbilirubinemia or jaundice in newborns. The light is absorbed by the newborn's skin and converts bilirubin into a water- soluble form, allowing it to be excreted in the stool and urine. The newborn should be fully exposed, except for a diaper, when placed under the phototherapy lights. Lotions and ointments should not be applied as they can absorb the heat and cause burns. Maintaining skin integrity is important as bilirubin products in the stool can cause loose stool with frequency and produce skin excoriation and breakdown. (Option 1) Allowing parents to feed the newborn promotes bonding. The newborn should not be removed from the lights except during feedings for optimal effect of the phototherapy. Adequate hydration with human milk or infant formula (not water) is important as infants are prone to dehydration from phototherapy. (Option 3) Temperature should be monitored closely, with the incubator placed on a low- heat setting. (Option 4) The newborn's eyes should be covered with patches or guards to prevent retinal damage or cataracts when under the phototherapy lights. Educational objective: The newborn should be fully exposed, except for a diaper, when placed under phototherapy lights. Lotions and ointments should not be applied as they can absorb heat and cause burns. Newborns should wear eye shields and be monitored for adequate hydration and urine output. A A A The nurse is assisting with a vaginal delivery of a full-term infant. Which assessment finding of the newborn is most important for the nurse to follow-up? 1. Flat bluish discolored area on the buttocks [6%] 2. Localized soft tissue edema of the scalp [24%] 3. Small amount whitish substance in axilla [3%] 4. Tuft of hair at the base of the spine [66%] Explanation: The neural tube develops into the brain and spinal cord. Spina bifida is a defect in which the spinal cord contents can protrude through the vertebrae that did not close. The mildest form is spina bifida occulta, most often at the fifth lumbar or first sacral vertebrae. A tuft of hair or a hemangioma may be seen over the site. This is distinguished from lanugo, which is fine downy hair on the back that gradually falls out; a term infant will have minimal lanugo. There has been less incidence of spina bifida as there is awareness of the role of folic acid during pregnancy. The defect needs surgical repair. Depending on the location of the defect, the child can have bowel and bladder incontinence, hydrocephalus, and sensory loss. (Option 1) Congenital dermal melanocytosis (Mongolian spots) are flat, bluish discolored areas on the lower back and/or buttock. It is most common in African American, Asian, Hispanic, and Native American infants. Although the nurse would document the size and location, it is benign and usually resolves on its own by school age. (Option 2) Caput succedaneum is a localized soft tissue edema of the scalp from the prolonged pressure of the head against the mother's cervix during labor. It feels "spongy" and crosses the suture line (caput succedaneum = crosses suture); cephalhematoma does not cross the suture lines. Caput succedaneum resolves within the first week of life. (Option 3) Vernix caseosa is a protective substance secreted by the sebaceous glands that covers the fetus during pregnancy. Described as white and cheesy, it is most likely to be seen in the axillary or genital area. Full-term infants typically have very little present. Educational objective:A tuft of hair at the base of the spine can be indicative of spina bifida occulta. Caput succedaneum, congenital dermal melanocytosis, and vernix caseosa are expected findings in a newborn. A A A Feeding every 3–4 hours; more frequent feedings may be tiring for the infant and the mother. Some infants may need to be fed more frequently if they are not consuming adequate amounts of formula. (Option 1) Bottle should be pointed down, away from the cleft, in order to prevent formula from flowing back into the nose area. This backflow would cause nasal regurgitation, and milk or formula may commonly escape through the nose. This is dangerous and the infant will sneeze or cough in order to clear the nose. (Option 4) Feeding should take about 20–30 minutes. The infant may be working too hard and tire out if feeding takes 45 minutes or more. In addition, the extra work of feeding will burn up calories that are needed for growth. Educational objective: Children with cleft palates are at increased risk for inadequate intake as well as aspiration. Actions to promote intake and reduce aspiration risk include feeding in an upright position, pointing the nipple away from cleft, feeding over no more than 20–30 minutes, using special nipples or bottles, and feeding every 3–4 hours. The infant should be burped at regular intervals to reduce gastric distension. A A A A nurse is teaching the parent how to care for a newly circumcised newborn. Which statement by the parent indicates that further teaching is needed? 1. "Discharge and odor indicate infection of the circumcision site." [3%] 2. "I will clean the area with alcohol-based wipes or soap water." [77%] 3. "Infant crying during petrolatum gauze changes is expected." [6%] 4. "The diaper should be changed at least every 4 hours." [12%] Explanation: Common complications of circumcision include hemorrhage, infection, and voiding difficulty. Parents should clean the area with warm water (without soap) to remove urine and feces and prevent infection. Prepackaged alcohol-based wipes delay healing and cause discomfort; they should be avoided until the circumcision site has healed (usually takes 5-6 days). (Option 1) Immediately after the procedure, the glans penis should appear dark red and, after 24 hours, will be covered with a yellow exudate. Parents should not try to wipe or forcefully remove the exudate that will persist for 2-3 days; this is a normal healing process. Redness, swelling, odor, and discharge indicate infection. (Option 3) Infant crying is expected during diaper and petroleum (Vaseline) gauze changes. Parents are often anxious and concerned about inflicting pain on their newborn. They should be informed that the discomfort is only brief and be encouraged to provide extra comfort measures (holding, feeding, nonnutritive suckling) after diaper changes. (Option 4) Diapers should be changed when soiled or at least every 4 hours to keep the area clean and assess for evidence of infection or bleeding. Petroleum gauze or ointment should be applied at every diaper change (unless Plastibell used) to prevent sticking. The diaper should be secured loosely to minimize pressure against the healing circumcision site. Educational objective: In a recently circumcised newborn, parents should be taught to use only warm water for cleaning and avoid soap and alcohol-based wipes. After 24 hours, a yellow exudate forms as part of the normal healing process; it should not be removed. Pain is expected, and parents can provide additional comfort measures after diaper changes to minimize discomfort. A A A The nurse is observing a student nurse care for a mother who has been unsuccessful with breastfeeding her newborn infant. Which action by the student would require the nurse to intervene? 1. Assesses the baby's position and sucking behavior during breastfeeding [6%] 2. Demonstrates to the mother how to use an electric breast pump [13%] 3. Provides supplemental formula feedings until improved breastfeeding occurs [63%] 4. Shows the mother how to hand express breast milk [16%] Explanation: Ineffective breastfeeding can be attributed to many factors, including prematurity; breast anomaly or previous breast surgery; poor infant latch or sucking reflex; or the use of formula feeding. The use of supplemental formula feedings and artificial nipples should be avoided, as research demonstrates it interferes with the mother's ability to exclusively breastfeed (Option 3). Supplemental formula feeds are only provided for medical indications (eg, newborn hypoglycemia, dehydration, excessive weight loss) and if alternate breastfeeding techniques are unsuccessful. A mother having difficulty with breastfeeding may be able to pump or hand express small amounts of colostrum that can be fed to the newborn by syringe, cup, or spoon. Hand expression may be preferable before the mature milk supply is established and is also useful when a breast pump is not available. If ineffective breastfeeding occurs, the nurse should: Assess the baby's sucking reflex and physical condition Assess the mother's breastfeeding technique (positioning, behavior/anxiety during breastfeeding) (Option 1) Teach how to express milk by hand and use an electric pump to enhance milk production (Options 2 and 4) Refer to a lactation consultant for a thorough assessment and breastfeeding plan if ineffective breastfeeding occurs longer than 24 hours Educational objective: Supplemental formula feedings and the use of artificial nipples are avoided when ineffective breastfeeding is present, as they interfere with the mother's ability to breastfeed exclusively. Supplemental formula feeds are only used after a full assessment and if other techniques are unsuccessful. A A A A neonate is born with exstrophy of the bladder. Which intervention would be appropriate for the nurse to complete first? 1. Cover the bladder with petroleum jelly gauze [28%] 2. Insert a urinary catheter into the bladder [3%] 3. Place a protective film over the bladder [47%] 4. Prepare the neonate for immediate surgery [19%] Explanation: Bladder exstrophy is a congenital disorder in which the bladder was not developed in the abdominal cavity during fusion in the embryo and is exposed externally. The priority before surgical repair is to prevent injury. Placing a protective film of plastic (Saran wrap) over the exposed bladder will keep the tissue moist and help prevent infection. (Option 1) Petroleum jelly in the gauze may be irritating to the delicate bladder tissue and should be avoided. (Option 2) Inserting a urinary catheter is not an appropriate intervention at birth. (Option 4) Surgery will be necessary to correct the defect but is not considered an emergent procedure. Educational objective: Bladder exstrophy is a congenital anomaly in which the bladder is abnormally formed outside the abdominal wall and requires surgery to correct. It is imperative to keep the external portion of the bladder moist with a protective film of plastic before surgery to prevent tissue injury and decrease the risk of infection. A A A 3. Continue stimulating the newborn [40%] 4. Start chest compressions [19%] Explanation: Newborns are evaluated immediately after birth for adaptation to extrauterine life. Newborns requiring resuscitative measures should be cared for using structured, evidence- based interventions, such as the neonatal resuscitation program (NRP) algorithm. Each step of the NRP algorithm requires rapid assessment and decision-making at 30-second intervals. NRP dictates that positive pressure ventilation (PPV) be started when a newborn's heart rate is <100/min. Effective PPV will often result in a rising heart rate and return of spontaneous respirations. (Option 1) Epinephrine is administered after chest compressions, if the heart rate remains < 60/min. (Option 3) The newborn has already been stimulated for 30 seconds, and placed in the optimal "sniffing" position. The next step is initiation of PPV if the heart rate remains <100/min. (Option 4) Chest compressions are started after at least 30 seconds of quality PPV, if the newborn's heart rate remains <60/min. The landmark for compressions is the middle third of the sternum just below an imaginary line drawn between the nipples. Either the two- finger, or two-thumb technique may be used for newborn chest compressions. Educational objective: Neonatal resuscitation interventions after birth are initiated at 30-second intervals, with continual assessment of the newborn's adaptation to extrauterine life. Positive pressure ventilation (PPV) is started if heart rate is <100/min; compressions are started if the newborn's heart rate remains <60/min after at least 30 seconds of quality PPV. A A A A full-term newborn of a mother with gestational diabetes is slightly jittery with a blood glucose level of 45 mg/dL (2.2 mmol/L). What is the nurse's first action? 1. Administer oral glucose [25%] 2. Feed the newborn [62%] 3. Notify the pediatrician [5%] 4. Warm the room [6%] Explanation: In women with poorly controlled diabetes mellitus during pregnancy, the fetus is subjected to high blood glucose levels. Fetal hyperglycemia leads to insulin hypersecretion by the fetus, which promotes abnormal growth and storage of excess calories as fat (macrosomia). After birth, the infant is no longer exposed to the mother's high blood glucose levels, but a transient hyperinsulinemic state will persist for several days, during which the infant is susceptible to developing hypoglycemia. The normal range for serum glucose in a newborn at day 1 is 40-60 mg/dL (2.2-3.3 mmol/L); however, no standard definition for newborn hypoglycemia currently exists. Treatment plans are based on clinical signs and overall status of the infant. The most common sign of low blood glucose is jitteriness or tremors. If the blood glucose is low, newborns should be fed immediately with formula or breast milk (Option 2). If the infant continues to exhibit signs of hypoglycemia and/or blood glucose levels are <40-45 mg/dL (2.2-2.5 mmol/L) after feeding, the pediatrician should be notified (Option 3). Further treatment, such as oral or IV glucose, may be required. (Option 1) A hypertrophied pancreas is very sensitive to blood glucose levels. Oral glucose administration would cause massive release of insulin and produce rebound hypoglycemia. Feeding the newborn with breast milk or formula would be sufficient in most situations. (Option 4) Although cold stress may exacerbate existing hypoglycemia, warming the room is not the best initial intervention. Feeding this infant is the priority as there are early clinical signs of hypoglycemia. Educational objective: Hypoglycemia can occur in infants born to mothers with gestational diabetes due to elevated insulin levels and consumption of stored glucose. The most common sign of hypoglycemia is jitteriness or tremors. The newborn should be fed breast milk or formula immediately. A A A The nurse is caring for a full-term newborn following vaginal delivery. Which nursing interventions should be implemented? Select all that apply. 1. Always wear gloves when handling the newborn before bathing 2. Cover the newborn to maintain a body temperature of 97.5-99 F (36.4-37.2 C) 3. During the initial bath, remove as much vernix caseosa as possible 4. Give a single dose of vitamin K intramuscularly 5. Suction the pharynx first, then the nasal passages Explanation: Nursing interventions for a newborn immediately after delivery include: Standard precautions - The unbathed newborn is covered in maternal blood and bodily fluid. Standard precautions (eg, gloves) are implemented when contact with blood or bodily fluid is anticipated. Maintain a clear airway - Suction the pharynx first followed by the nasal passages to prevent aspiration if the newborn gasps with nasal suctioning. Thermoregulation (97.5-99 F [36.4-37.2 C]) reduces oxygen and stored calorie consumption. Hypothermia predisposes the newborn to metabolic acidosis, hypoxia, and shock. A radiant warmer is used while performing assessments and interventions. Use pre-warmed linens, an infant stocking cap, and a thermal skin sensor for monitoring. Skin- to-skin contact aids in thermoregulation. Vitamin K is administered intramuscularly in the vastus lateralis (midanterior lateral thigh) within 6 hours of birth to prevent bleeding due to absence of vitamin K-producing intestinal bacteria. Ophthalmic ointment - Prophylactic antibiotic eye ointment for Neisseria gonorrhoeae is legally required; application may be delayed up to 1 hour after delivery. Initial bathing of the newborn is limited to removing blood, bodily fluids, or meconium. Vernix caseosa, a waxy, white coating, protects the skin and should not be vigorously removed (Option 3). Educational objective: Nursing management of a newborn includes using standard precautions when in contact with blood or body fluids (eg, bathing), maintaining the infant's airway (suction the pharynx before the nose), thermoregulation, and administering vitamin K and prophylactic ophthalmic ointment. A A A The nurse performing an initial newborn assessment after birth observes a bluish discoloration of the hands and feet. The trunk has a pink color. What is the nurse's initial action? 1. Apply oxygen and count respirations [13%] 2. Assess heart sounds for a murmur [9%] 3. Observe for expiratory grunting [11%] 4. Place infant skin-to-skin with mother [65%] Explanation: Acrocyanosis is peripheral cyanosis that is considered normal during the first day of life or up to 7-10 days after birth if the infant becomes cold. It manifests as a bluish discoloration of the hands and feet and sometimes the skin around the mouth. It results from poor perfusion of blood to the periphery of the body as an initial mechanism to reduce