Nursing Care of the Newborn (Level 1)
An infant is admitted to the nursery after a difficult shoulder birth. For what condition should the nurse
assess this newborn?
Facial paralysis
Cephalhematoma
Brachial plexus injury
Spinal cord syndrome - ANS Brachial plexus injury
Brachial plexus paralysis (Erb-Duchenne palsy) is the most common injury associated with dystocia
related to a shoulder presentation; it is caused by pressure and traction on the brachial plexus during
the birth process. The newborn's face is not involved with a shoulder presentation. Cephalhematoma is
a soft-tissue injury of the head and is not related to shoulder dystocia. Spinal cord syndrome is
associated with a breech presentation and is not related to shoulder dystocia.
Phenylketonuria (PKU) testing is performed on a newborn. The nurse plans to explain to the mother the
purpose of this screening test. What does this test reveal?
Whether the infant is positive for PKU
Whether the mother is a carrier of PKU
The mother's risk for later development of PKU
The infant's risk for development of PKU later in life - ANS Whether the infant is positive for PKU
,The major purpose of this screening test is to determine whether the infant has phenylketonuria (PKU),
which can be detected after the infant has started feedings. Determining whether the mother is a carrier
for PKU is not the objective of the test for PKU. Epidemiological information is a purpose of genetic
screening; in this instance the most important determination is whether the infant has PKU. Risk for
later development of the disorder is not the purpose of PKU testing; it is to determine whether the
neonate has the disorder.
During the second reactive period a newborn becomes more alert and responsive and there is an
increase in mucus production and gagging. What should the nurse do first?
Report this finding.
Administer nasal oxygen.
Lower the head of the bassinette.
Remove secretions from the pharynx. - ANS Remove secretions from the pharynx.
An increase in mucus production is expected during the second reactive period; mucus should be
removed either by swiping the oral cavity with a gloved finger or with the use of an aspiration device.
Reporting this finding is unnecessary; identifying and treating human responses is within the scope of
nursing practice. Oxygen administration is useless if mucus is blocking the respiratory passages.
Although lowering the head of the bassinette may help secretions drain, the newborn cannot remove
secretions that block respirations.
A nurse is assessing a newborn of 33 weeks' gestation. Which sign alerts the nurse to notify the health
care provider?
Flaring nares
,Acrocyanosis (bluish or purple coloring of the hands and feet caused by slow circulation)
Heartbeat of 140 beats/min
Respirations of 40 breaths/min - ANS Flaring nares
Preterm neonates are prone to respiratory distress; flaring nares are a compensatory mechanism in a
neonate with respiratory distress syndrome, the body's attempt to lessen resistance of narrow nasal
passages and increase oxygen intake. Acrocyanosis is not related to respiratory distress but is caused by
vasomotor instability; this is an expected occurrence in the newborn. A heartbeat of 140 beats/min is an
expected finding in the newborn. A respiratory rate of 40 breaths/min is an expected finding in the
newborn.
While inspecting her newborn a mother asks the nurse why her baby has flat feet. Before responding,
what information should the nurse consider?
Flat feet are common in children, requiring them to wear orthotic shoes.
The newborn's feet are so small that it is difficult to determine whether there is an arch.
Flat feet are associated with deformities of the bones of the feet such as clubfoot.
The arch of the newborn's foot is covered with a fat pad, giving the foot the appearance of being flat. -
ANS The arch of the newborn's foot is covered with a fat pad, giving the foot the appearance of being
flat.
, Newborns and infants have fat pads where the arch should be; the arch develops when the toddler
begins to walk. Flat feet are no more common in children than in adults. The size of the feet is not
relevant. Flat feet are not associated with foot deformity.
A nurse in the newborn nursery receives a call from the emergency department saying that a woman
with active herpes virus lesions gave birth in a taxicab while coming to the hospital. What does the nurse
consider about the transmission of the herpes virus?
Contact precautions are necessary.
It occurs during sexual intercourse.
It can be acquired during a vaginal birth.
Protection is provided by way of maternal immunity. - ANS It can be acquired during a vaginal birth.
Herpes virus infection can be fatal to a newborn, and the infant should be admitted to the neonatal
intensive care unit. Although contact precautions are necessary, herpes infection can occur during
sexual intercourse, and protection is conferred on the fetus by the mother, these statements are not
relevant in meeting the needs of this neonate who has been exposed to herpes virus during the birthing
process.
A nurse teaches a group of postpartum clients that all their newborns will be screened for
phenylketonuria (PKU) to:
Assess protein metabolism.
Reveal potential retardation.
An infant is admitted to the nursery after a difficult shoulder birth. For what condition should the nurse
assess this newborn?
Facial paralysis
Cephalhematoma
Brachial plexus injury
Spinal cord syndrome - ANS Brachial plexus injury
Brachial plexus paralysis (Erb-Duchenne palsy) is the most common injury associated with dystocia
related to a shoulder presentation; it is caused by pressure and traction on the brachial plexus during
the birth process. The newborn's face is not involved with a shoulder presentation. Cephalhematoma is
a soft-tissue injury of the head and is not related to shoulder dystocia. Spinal cord syndrome is
associated with a breech presentation and is not related to shoulder dystocia.
Phenylketonuria (PKU) testing is performed on a newborn. The nurse plans to explain to the mother the
purpose of this screening test. What does this test reveal?
Whether the infant is positive for PKU
Whether the mother is a carrier of PKU
The mother's risk for later development of PKU
The infant's risk for development of PKU later in life - ANS Whether the infant is positive for PKU
,The major purpose of this screening test is to determine whether the infant has phenylketonuria (PKU),
which can be detected after the infant has started feedings. Determining whether the mother is a carrier
for PKU is not the objective of the test for PKU. Epidemiological information is a purpose of genetic
screening; in this instance the most important determination is whether the infant has PKU. Risk for
later development of the disorder is not the purpose of PKU testing; it is to determine whether the
neonate has the disorder.
During the second reactive period a newborn becomes more alert and responsive and there is an
increase in mucus production and gagging. What should the nurse do first?
Report this finding.
Administer nasal oxygen.
Lower the head of the bassinette.
Remove secretions from the pharynx. - ANS Remove secretions from the pharynx.
An increase in mucus production is expected during the second reactive period; mucus should be
removed either by swiping the oral cavity with a gloved finger or with the use of an aspiration device.
Reporting this finding is unnecessary; identifying and treating human responses is within the scope of
nursing practice. Oxygen administration is useless if mucus is blocking the respiratory passages.
Although lowering the head of the bassinette may help secretions drain, the newborn cannot remove
secretions that block respirations.
A nurse is assessing a newborn of 33 weeks' gestation. Which sign alerts the nurse to notify the health
care provider?
Flaring nares
,Acrocyanosis (bluish or purple coloring of the hands and feet caused by slow circulation)
Heartbeat of 140 beats/min
Respirations of 40 breaths/min - ANS Flaring nares
Preterm neonates are prone to respiratory distress; flaring nares are a compensatory mechanism in a
neonate with respiratory distress syndrome, the body's attempt to lessen resistance of narrow nasal
passages and increase oxygen intake. Acrocyanosis is not related to respiratory distress but is caused by
vasomotor instability; this is an expected occurrence in the newborn. A heartbeat of 140 beats/min is an
expected finding in the newborn. A respiratory rate of 40 breaths/min is an expected finding in the
newborn.
While inspecting her newborn a mother asks the nurse why her baby has flat feet. Before responding,
what information should the nurse consider?
Flat feet are common in children, requiring them to wear orthotic shoes.
The newborn's feet are so small that it is difficult to determine whether there is an arch.
Flat feet are associated with deformities of the bones of the feet such as clubfoot.
The arch of the newborn's foot is covered with a fat pad, giving the foot the appearance of being flat. -
ANS The arch of the newborn's foot is covered with a fat pad, giving the foot the appearance of being
flat.
, Newborns and infants have fat pads where the arch should be; the arch develops when the toddler
begins to walk. Flat feet are no more common in children than in adults. The size of the feet is not
relevant. Flat feet are not associated with foot deformity.
A nurse in the newborn nursery receives a call from the emergency department saying that a woman
with active herpes virus lesions gave birth in a taxicab while coming to the hospital. What does the nurse
consider about the transmission of the herpes virus?
Contact precautions are necessary.
It occurs during sexual intercourse.
It can be acquired during a vaginal birth.
Protection is provided by way of maternal immunity. - ANS It can be acquired during a vaginal birth.
Herpes virus infection can be fatal to a newborn, and the infant should be admitted to the neonatal
intensive care unit. Although contact precautions are necessary, herpes infection can occur during
sexual intercourse, and protection is conferred on the fetus by the mother, these statements are not
relevant in meeting the needs of this neonate who has been exposed to herpes virus during the birthing
process.
A nurse teaches a group of postpartum clients that all their newborns will be screened for
phenylketonuria (PKU) to:
Assess protein metabolism.
Reveal potential retardation.
