Obstetric Nurse Newborn Assessment and Care Flashcards

A nurse is assessing a newborn one minute after birth. The findings include: heart rate of 110 bpm, a strong cry, active motion of all extremities, a grimace in response to suctioning, and a body that is pink with blue hands and feet. What Apgar score should the nurse assign?

Answer: 8

The Apgar score is calculated as follows: Heart Rate (>100 bpm) = 2 points; Respiratory Effort (strong cry) = 2 points; Muscle Tone (active motion) = 2 points; Reflex Irritability (grimace) = 1 point; Color (pink body, blue extremities/acrocyanosis) = 1 point. The total score is 2+2+2+1+1 = 8.

During a newborn head-to-toe assessment, the nurse observes a soft, edematous area on the infant's scalp that extends across the suture lines. This finding is most consistent with which condition?

Answer: Caput succedaneum

Caput succedaneum is generalized edema of the scalp that is present at birth. It feels soft and spongy and, crucially, crosses the cranial suture lines. It typically resolves within a few days. A cephalohematoma is a collection of blood that does not cross suture lines.

Which medication is administered prophylactically to a newborn shortly after birth to prevent ophthalmia neonatorum?

Answer: Erythromycin ophthalmic ointment

Erythromycin ophthalmic ointment is instilled in the newborn's eyes as a prophylactic measure to prevent ophthalmia neonatorum, which is conjunctivitis caused by Neisseria gonorrhoeae or Chlamydia trachomatis acquired during passage through the birth canal. Phytonadione (Vitamin K) is for preventing hemorrhagic disease, and the Hepatitis B vaccine is for immunization.

A nurse is providing care to a term newborn immediately following delivery. To prevent heat loss through convection, which nursing intervention is most appropriate?

Answer: Keeping the newborn away from open windows and air vents.

Convection is the loss of heat from the warm body surface to cooler air currents. Keeping the newborn away from drafts from open windows, doors, or air vents is a key intervention to prevent this type of heat loss. Drying the skin prevents evaporation, and placing the infant on a pre-warmed surface or skin-to-skin prevents conduction loss.

When assessing a newborn's reflexes, the nurse gently strokes the lateral aspect of the sole of the foot from the heel upward to the ball of the foot. Which response would indicate a normal Babinski reflex?

Answer: The toes hyperextend and fan out.

A positive (normal) Babinski reflex in a newborn is characterized by the fanning out (abduction) and hyperextension of the toes. This reflex is normal in infants up to about 1-2 years of age. A negative response, where the toes curl downward, is the normal finding in adults.

A nurse is assessing a 12-hour-old newborn and notes a yellowish tinge to the skin and sclera. This finding is most concerning for which of the following conditions?

Answer: Pathologic jaundice

Jaundice appearing within the first 24 hours of life is considered pathologic and requires immediate investigation. It is often caused by hemolysis (e.g., ABO/Rh incompatibility) or other underlying medical conditions. Physiologic jaundice typically appears after 24 hours of life.