A nurse is caring for three newborns Sample Assignment

A nurse is caring for three newborns. Which of the following newborns should be assessed first?  

A large for gestational age, post-term newborn born 2 hours ago

A priority safety measure of a Maternal Newborn nurse is infant safety in the acute care setting.  What measures can the nurse implement to prevent infant abduction?

Always verify the newborn’s ID band against the mother’s ID band when the newborn is brought to the parents; ensure that all facility staff who assist in caring for the newborn are wearing photo ID badges; the parent should always keep the infant with them at all times.

A nurse is caring for a postpartum client who is breastfeeding her newborn.  Identify five (5) teaching points to discuss with the client regarding the postpartum infection, mastitis.   

Wash hands thoroughly prior to breastfeeding; maintain cleanliness of breasts with frequent changes of breast pads; allow nipples to air-dry; teach proper infant positioning and latching techniques; instruct to completely empty breasts with each feeding to prevent milk stasis; encourage using ice or warm packs for discomfort.

A nurse is caring for a client in the second trimester that is experiencing backaches. Have education should the nurse provide?

Exercise regularly; perform pelvic tilt exercises; use proper body mechanics; use side-lying position.

A nurse is caring for a 2-week-old infant. What are the expected findings when eliciting a startle reflex?

The reflex is elicited by clamping hands or by a loud noise. The newborn will abduct arms at the elbows and the hands will remain unclenched.

A nurse is providing client education regarding the advantages and disadvantages of intrauterine devices. What information should the nurse include?

Advantages of an IUD are that an IUD can maintain effectiveness for 1-10 years; contraception can be reversed; safe for breastfeeding mothers; and is 99% effective in preventing pregnancy. Disadvantages of an IUD are that the IUD can increase the risk of PID, uterine perforation, or ectopic pregnancy; does not protect against STIs; and a client should report to the provider late or abnormal bleeding/spotting, abdominal pain, abnormal or foul-smelling vaginal discharge, fever, chills, change in string length, or if IUD cannot be located.

A nurse is caring for a newborn and notes signs of abstinence syndrome (withdrawal). The nurse uses the neonatal abstinence scoring system.  What is assessed and scored with this tool?

CNS – increased wakefulness, a high-pitched, shrill cry, incessant crying, irritability, tremors, hyperactivity with increased Moro reflex, increased DTRs, increased muscle tone, abrasions and/or excoriations on the face and knees and convulsions.

Metabolic, vasomotor, and respiratory – nasal congestion with flaring, frequent yawning, skin mottling, tachypnea greater than 60/min, sweating, and a temp over 99 degrees F.

GI – poor feeding, regurgitation, diarrhea and excessive, uncoordinated, and constant sucking.

A nurse is caring for a newborn.  One complication that the nurse monitors for is hypoglycemia.  Identify the criteria for hypoglycemia in the newborn.

Hypoglycemia is a serum glucose level less than 40 mg/dl.