Which of the following actions must a nurse perform before weighing the newborn during the admission procedure?

(Select all that apply.)

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Clean the scale

Take the infant’s temperature

Cover the scale

Zero the scale

Wrap the infant tightly in a blanket to prevent heat loss

•This action should be performed to prevent cross infection.

•This action should be performed to monitor heat loss.

•This action should be performed to prevent cross infection.

•This action should be performed to ensure an accurate measurement.

•The nurse should remove all clothing and blankets to ensure an accurate measurement. To prevent heat loss, the infant should instead be placed under a radiant warmer.

The nurse has received a shift change report on infants born within the last four hours. Which newborn should the nurse see first?

37-week male, respiratory rate 45

8 pound, 1 ounce female, pulse 15

Term male, grunting respirations

39-week female, temperature 97.0°F

A normal respiratory rate is 30–60. This infant has no unexpected findings.

A normal pulse is 110–160. This infant has no unexpected findings.

Grunting respirations are an indication of respiratory distress. This infant needs further assessment and possibly intervention immediately.

A normal temperature is 96.8°F-97.7°F. This infant has no unexpected findings.

The nurse assesses the following in a sleeping 1-hour-old, 39-weeks’-gestation newborn. The assessment data that would be of greatest concern would be:

Skin temperature 97.6°F

Respirations 68/min

Blood pressure 72/44

Heart rate 156 beats/min

This is within the normal temperature range of 96.8–97.7°F.

Normal respiratory rate is 40–60 breaths/min. 68 could represent a less-than-expected transition.

This blood pressure is within the normal range of 90–60/50–40 mmHg.

This heart rate is within the normal range of 120–160 beats/min.

Which of the following information is NOT recorded as a part of the initial newborn assessment?

Resuscitative measures required in the birthing area

Blood draw for PKU screening

Presence or absence of meconium-stained fluid

Parents’ desires regarding circumcision for a male infant

The condition of the newborn, including resuscitative measures required in the birthing area, should be recorded as part of the newborn assessment.

Blood is often drawn for laboratory testing, which should be recorded. However, blood draws for PKU screening must occur more than 24 hours after birth.

The labor and birth record, including the presence or absence of meconium-stained fluid, should be recorded as part of the newborn assessment.

Parent-newborn attachment information, including the parents’ desires regarding care, should be noted during the newborn assessment.

The parents of a newborn male ask the nurse if they should circumcise their son. The best response by the nurse is: “Circumcision:

“Should be undertaken to prevent problems in the future.”

“Might decrease the risk of developing a urinary tract infection.”

“Can sometimes cause complications. What questions do you have?”

“Is painful and should be avoided unless you are Jewish.”

Although this is a common reason parents give for requesting circumcision, it is still an opinion not based in medical fact.

Although this is a true statement, getting more information from the parents about their questions or concerns is better.

Asking this question allows the nurse to determine what the questions or concerns are and address them specifically.

Although circumcision can be painful, most providers administer a penile nerve root block to prevent or minimize procedural pain. Both Jewish and Muslim males are circumcised because of religious law or tradition.

The nurse tells the mother that the doctor is preparing to circumcise her newborn. The mother verbalizes concern that the infant will be uncomfortable during the procedure. The nurse explains to the mother that the physician will numb the area before the procedure. Additional methods of comfort often used during the procedure can include:

(Select all that apply.)

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Non-nutritive sucking.

Stroking the head.

Swaddling.

Talking to the baby.

•This is an accepted method of soothing during the circumcision.

•This is an accepted method of soothing during the circumcision.

•The infant must be placed on a padded circumcision board without a diaper. A warm blanket can be applied to the upper body, but the infant cannot be swaddled.

•This is an accepted method of soothing during the circumcision.

The nurse is discussing parent–infant attachment with a prenatal class. Which statement indicates that teaching was successful?

“I should avoid looking directly into the baby’s eyes to prevent frightening the baby.”

“My baby will be very sleepy immediately after birth, so he can go to the nursery.”

“Newborns cannot focus their eyes, so it doesn’t matter how I hold my new baby.”

“Giving the baby his first bath can really give me a chance to get to know him.”

Eye contact is an important aspect of parent–infant attachment and should be promoted, especially in the immediate time after birth.

Babies are usually wide awake and alert and responsive in the first few hours after birth. Interacting with the newborn during this first period of reactivity facilitates parent–infant attachment.

Newborns can focus at a distance of 7–8 inches, the distance from a baby being held to the parent’s face. Eye contact is an important aspect of parent–infant attachment and should be promoted, especially in the immediate time after birth.

When parents give the first bath with the nurse, the nurse can point out behaviors and characteristics that help the parents understand their infant as unique and can model ways to respond to the baby’s behavior.

The nurse is working with new parents who have recently immigrated to the United States. The nurse is not familiar with the cultural background of the family. What statement is best?

“You appear to be Muslim. Do you want your son circumcised?”

“Let me explain how newborn care takes place here in the U.S.”

“Your baby is a U.S. citizen. You must be very happy about that.”

“Could you explain what your preferences are regarding childbearing?”

Avoid making assumptions about clients based on appearance. It is much better to respectfully ask questions regarding preferences and practices.

The nurse should not assume the family doesn’t understand the U.S. healthcare system. It is much better to respectfully ask questions regarding preferences and practices.

This is an assumption often based on the false idea that people from other countries only come to have their babies in the U.S. so they will be citizens and therefore eligible for federal aid. It is much better to respectfully ask questions regarding preferences and practices.

Sensitive, nonjudgmental exploration of the family’s cultural beliefs regarding newborn care allows the nurse to gain valuable knowledge that will be applied when planning culturally competent care.