Newborn Reflexes – Describe how to test each of the following Newborn Reflexes
Newborn Reflexes – Describe how to test each of the following Newborn Reflexes
1. Rooting:
2. Palmar grasp:
3. Extrusion:
4. Tonic Neck (fencing):
5. Moro:
6. Stepping:
7. Babinski:
Vital Signs: List the normal vital sign ranges for the newborn:
1. Heart Rate:
2. Respiratory Rate:
3. Temperature:
Define the following variations that may be present in the newborn:
1. Milia:
2. Mongolian spots:
3. Telangiectatic nevi (stork bites):
4. Nevus flammeus (port wine stain):
5. Erythema toxicum:
6. Caput succedaneum:
7. Cephalohematoma:
8. Hydrocephalus:
9. Microcephaly:
Multiple Choice
11. A newborn, at 5 hours old, wakes from a sound sleep and becomes very active. He exhibits the following signs when assessed. Which one would require further assessment?
a. Increased mucous production
b. Passage of meconium
c. Heart rate of 160 beats per minute
d. Two apneic episodes of 20 and 24 seconds’ duration
12. When assessing a newborn boy at 12 hours of age, the nurse notes a rash on his abdomen and thighs. The rash appears as irregular reddish blotches with pale centers. The nurse would
a. Document the finding as erythema toxicum
b. Isolate the newborn and his mother until infection is ruled out
c. Apply an antiseptic ointment to each lesion
d. Request non–allergenic linen from the laundry
13. As part of a thorough assessment of a newborn, the nurse should check for hip dislocation and dysplasia. Which if the following techniques would the nurse most likely use?
a. Check for syndactyly bilaterally
b. Stepping or walking reflex
c. Magnet reflex
d. Ortolani’s maneuver
14. Newborns are at risk for cold stress.
a. State the dangers that cold stress poses for the newborn
b. Heat loss can occur by the following four mechanisms. Define each.
i. Conduction
ii. Convection
iii. Evaporation
iv. Radiation
c. Describe care measures the nurse should implement to prevent cold stress from occurring via the four mechanisms you outlined above.
15. After a long and difficult labor, baby boy James was born with a caput succedaneum and significant molding over the occipital are. Low forceps were used for the birth, resulting in ecchymotic areas on both cheeks. Describe what you would tell the parents of James about these assessment findings.
16. Mary and Jim are concerned that their baby boy who weighed 8lb 6oz at birth now, at 2 days of age, “weighs only 7lb 14oz.” Describe how you would respond to their concern.
17. Tonya and Sam, an African-American couple, express concern that their new baby girl has several bruises on her back and buttocks. They ask if their baby was injured during birth or in the nursery. Describe the appropriate response of the nurse to this couple’s concern.
Nursing Care of the Newborn
Multiple Choice
18. The nurse evaluates the laboratory test results of a newborn who is 4 hours old. Which of the following results would require notification of the pediatrician?
a. Hemoglobin 20g/dL
b. Hematocrit 54%
c. Glucose 34mg/dL
d. Total serum bilirubin 0.6mg/dL
19. A newborn male has been designated as Large for Gestational Age (LGA). His mother was diagnoses with gestational diabetes late in her pregnancy. The nurse should be alert for signs of hypoglycemia. Which of the following assessment findings would be consistent with a diagnosis of hypoglycemia?
a. Unstable body temperature
b. Cyanosis
c. Loose, watery stools
d. Abdominal distension
20. A radiant warmer will be used to help a newborn girl to stabilize her temperature. The nurse implementing this care measure should
a. Dress the infant before putting her under the warmer.
b. Dress and wrap the infant prior to placing her under the warmer.
c. Place the infant only in a diaper under the warmer, with the skin probe attached to the newborn’s skin.
d. Place the infant under the warmer with the heat set to maximum.
21. A newborn male has been scheduled for a circumcision. Essential nursing care measures as part of this surgical procedure would include which one of the following?
a. Feed the infant just prior to the procedure to help him remain relaxed and quiet.
b. Apply petroleum jelly to the site with every diaper change until the for at least 24 hours.
c. Check the penis for bleeding every 15minutes for the first 4 hours.
d. Teach the parents to remove the yellowish crust/exudate that forms over the glans using a diaper wipe
22. Apgar scoring is a method of newborn assessment used in the immediate post birth period, at 1 and 5 minutes. Indicate the Apgar score of the following newborns:
a. BB Smith, at 1 minute after birth:
• Heart rate 160 beats/min
• Respiratory effort – good, crying vigorously
• Muscle tone – active movement, well flexed
• Reflex irritability – cries with stimulus to soles of feet
• Color – body pink, feet and hands cyanotic
i. Score:
ii. Interpretation:
b. BG Doe at 5min after birth:
• Heart rate – 102 beats/min
• Respiratory effort – slow, irregular with weak cry
• Muscle tone – some flexion of extremities
• Reflex irritability – grimace with stimulus to soles of feet
• Color – pale
i. Score:
ii. Interpretation:
23. Parents of BB Marion are concerned about the color of their baby who has developed hyperbilirubinemia at 30hours of age, and the need to put the baby under special lights. “My uncle was yellow just like our baby and he died of liver cancer!”
a. Describe how the nurse should respond to the parents’ concern.
b. Identify the expected assessment findings and physiologic effects related to hyperbilirubinemia.
c. List the precautions and care measures that are required by the nurse caring for a newborn under phototherapy in order to prevent injury to the newborn yet maintain the effectiveness of the treatment.
Newborn Feeding and Nutrition
Multiple Choice
24. The nurse should teach breastfeeding mothers about breast care measures to preserve the integrity of the nipples and areola. Which of the following should the nurse include in these instructions?
a. Cleanse nipples and areola twice daily with mild soap and water
b. Apply vitamin E cream to nipples and areola at least 4 times daily before feedings
c. Insert plastic-lined pads into the bra to absorb leakage and protect clothing
d. Apply modified lanolin to both dry and sore nipples
In: Nursing
