When newborns have been on formula for 36-48 hours, they should have a:
-
Solution
Screening for PKU.
By now the newborn will have ingested an ample amount of the amino acid phenylalanine, which, if not metabolized because of a lack of the liver enzyme, can deposit injurious metabolites into the bloodstream and brain; early detection can determine if the liver enzyme is absent.
A newborn has small, whitish, pinpoint spots over the nose, which the nurse knows are caused by retained sebaceous secretions. When charting this observation, the nurse identifies it as:
-
Solution
Milia.
Milia occur commonly, are not indicative of any illness, and eventually disappear.
To help limit the development of hyperbilirubinemia in the neonate, the plan of care should include:
-
Solution
Monitoring for the passage of meconium each shift.
Bilirubin is excreted via the GI tract; if meconium is retained, the bilirubin is reabsorbed.
The nurse is aware that a healthy newborn’s respirations are:
-
Solution
Irregular, abdominal, 30-60 per minute, shallow.
Normally the newborn’s breathing is abdominal and irregular in depth and rhythm; the rate ranges from 30-60 breaths per minute.
The expected respiratory rate of a neonate within three (3) minutes of birth may be as high as:
-
Solution
60.
The respiratory rate is associated with activity and can be as rapid as 60 breaths per minute; over 60 breaths per minute are considered tachypneic in the infant.
Within three (3) minutes after birth the normal heart rate of the infant may range between:
-
Solution
120 and 160.
The heart rate varies with activity; crying will increase the rate, whereas deep sleep will lower it; a rate between 120 and 160 is expected.
When performing a newborn assessment, the nurse should measure the vital signs in the following sequence:
-
Solution
Respirations, pulse, temperature.
This sequence is least disturbing. Touching with the stethoscope and inserting the thermometer increase anxiety and elevate vital signs.
The primary critical observation for Apgar scoring is the:
-
Solution
Heart rate.
The heart rate is vital for life and is the most critical observation in Apgar scoring. Respiratory effect rather than rate is included in the Apgar score; the rate is very erratic.
A baby is born precipitously in the ER. The nurses initial action should be to:
-
Solution
Establish an airway for the baby.
The nurse should position the baby with head lower than chest and rub the infant’s back to stimulate crying to promote oxygenation. There is no haste in cutting the cord.
A nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment into the eyes if a neonate. The instructor determines that the student needs to research this procedure further if the student states:
-
Solution
“I will flush the eyes after instilling the ointment.”
Eye prophylaxis protects the neonate against Neisseria gonorrhoeae and Chlamydia trachomatis. The eyes are not flushed after instillation of the medication because the flush will wash away the administered medication.