Newborn Nursing Care Worksheet

The nurse is developing a plan of care for an 18-hour-old newborn who is receiving phototherapy. Which of the following interventions should the nurse include in the plan?

• Apply lotion 15 minutes before therapy.

• Monitor the newborn’s temperature during therapy.

• Keep the genitals exposed during therapy.

• Administer intravenous (IV) fluids with therapy.

The nurse is assessing a newborn and suspects the neonate may have postnatal hypoglycemia. Which clinical manifestations from the box below support the nurse’s suspicion?

• 3, 4.

• 1, 2, 4.

• 2, 4.

• 1, 3, 4.

The nurse is assessing the vital signs (VS) of a 2-hour-old neonate. See chart below. Time | Disposition | Temperature | Pulse Rate | Respiratory Rate 1000 | Sleeping | 97° F (36.1° C) | 125 | 45 with abdominal breathing 1100 | Awake | 97° F (36.1° C) | 140 | 45 with abdominal breathing Which of the following actions should the nurse take?

• Notify the primary health care provider (PHCP).

• Place the neonate skin-to-skin with the parent.

• Document in the chart that the VS are normal.

• Wait 15 minutes and recheck the VS.

The nurse is caring for a newborn in the nursery. The nurse understands that there are several ways to maintain newborn thermoregulation. Which actions by the nurse from the box below can help promote thermoregulation?

• 1. Apply stockinet cap to newborn's head.

• 2. Place newborn near the window to get heat from the sunlight.

• 3. Dry the newborn well after birth.

• 4. Infuse warmed intravenous (IV) fluids.

• 5. Monitor oral temperature to assess effectiveness of therapy.

The nurse is assessing a term newborn for the palmar grasp reflex. Which of the following pictures demonstrates this reflex? See images below.

• A.

• B.

• C.

• D.

The nurse is preparing the first hepatitis virus B (HVB) vaccination for a newborn. After obtaining consent, which of the following actions should the nurse perform?

• Leave the injection area open to air.

• Administer in the deltoid muscle.

• Administer the injection within 12 hours of birth.

• Refrain from massaging the injection site.

The nurse is assessing a 2-week-old newborn at the outpatient clinic and notes dark blue areas of discoloration on the newborn's back, neck, and extremities. After reviewing the chart and noting that bruising was not present at discharge, which of the following actions should the nurse take next?

• Report the abuse of the newborn to the authorities per facility policy.

• Observe the parents’ interactions with the newborn.

• Ask the parents to leave the room to keep the newborn safe.

• Inform the charge nurse of the abuse to the newborn.

The nurse working in a birthing center is administering erythromycin to a newborn after birth. Which of the following actions observed by the nurse manager requires intervention?

• Informing the newborn’s parents that a second dose will be required.

• Applying a thin strip to both eyes.

• Beginning application at the inner canthus of the eye.

• Administering the medication within 1 hour of birth.

The nurse preceptor is discussing the Apgar score for newborns with a newly hired nurse. Which of the following assessment categories identified by the newly hired nurse indicates the need for additional teaching?

• Muscle tone.

• Skin color.

• Pulse rate.

• Blood pressure.

The nurse is working in the nursery caring for the following assigned newborns. Which newborn requires immediate intervention?

• Newborn who is 18 hours post-delivery and has Mongolian spots.

• Newborn who is 4 hours post-delivery and has not voided.

• Newborn who is 8 hours post-delivery and has grunting respirations.

• Newborn who is 10 hours post-delivery and has not passed meconium.