The nurse completes an initial newborn examination. The nurses findings include the following: heart rate 136 beats/minute; respiratory rate 64 breaths/minute; temperature 98.2F (36.8C). The nurse also documents a heart murmur,absence of bowel sounds symmetry of ears and eyes no grunting or nasal flaring and full range of movement of all extremities. Which finding requires immediate consultation with the health-care provider?

Correct Answer: A

Rationale: In this scenario, the finding that requires immediate consultation with the health-care provider is "Absent bowel sounds" (Option A). Absence of bowel sounds in a newborn may indicate an underlying serious condition like intestinal obstruction or ileus, which requires prompt evaluation and intervention to prevent complications. The other options are not as urgent: - Heart murmur: It is common for newborns to have innocent heart murmurs due to physiological changes after birth. Most innocent murmurs resolve on their own without treatment. - Respiratory rate: A respiratory rate of 64 breaths/minute falls within the normal range for a newborn, so it does not warrant immediate consultation. - Temperature: The newborn's temperature of 98.2F (36.8C) is within the normal range, so it does not pose an immediate concern. Understanding these findings is crucial for nurses caring for newborns as it helps in early identification of potential health issues and timely intervention, ensuring optimal care and outcomes for the newborns. Being able to differentiate between normal variations and concerning findings is essential in providing safe and effective nursing care to newborns.

Correct Answer: B

Rationale: The nurse should observe standard precautions when handling a neonate until all blood and amniotic fluid has been removed to avoid possible infection. Then the nurse can take the baby and suction the babys mouth and then the nares if needed. Auscultating the babys heart and lungs will occur later. The parents may not name the baby immediately but even if they have recording the name would not take priority over using standard precautions to prevent the spread of disease.

Correct Answer: C

Rationale: In this scenario, the correct action for the nurse to demonstrate to the parents when the newborn starts gagging during suctioning is to turn the baby's head to the side (Option C). This is the correct choice because turning the baby's head to the side helps prevent aspiration if the baby vomits, allowing the secretions to flow out of the mouth instead of blocking the airway. Option A, picking the baby up and comforting her, is incorrect because in this situation, the priority is to ensure the baby's airway is clear and safe. Option B, placing the baby on her back, is also incorrect as this position can increase the risk of aspiration if the baby vomits. Option D, wiping secretions out with a cloth, is not the best choice as it may not effectively clear the airway in case of vomiting. From an educational perspective, it is important for nurses and parents to understand the correct positioning and actions to take in such situations to ensure the newborn's safety and prevent potential complications. Proper education on newborn care, including suctioning techniques and airway management, is crucial for healthcare providers and parents to promote the well-being of the newborn.

Correct Answer: A

Rationale: The babys 5-minute Apgar score is 8 (motion 2; pulse 2; grimace 2; appearance 1; respirations 1). If a 5-minute Apgar score is less than 9 the nurse should stabilize the infant instead of leaving the baby with the parents in the birthing unit. Because it appears that this babys problems are related to either oxygenation or perfusion the nurse should assess the oximetry reading and administer oxygen if needed.

Correct Answer: b

Rationale: In this scenario, the correct answer is B) Erythromycin (Eyemycin) for preventing ophthalmia neonatorum. Erythromycin is the recommended prophylactic medication for newborns to prevent this condition caused by Neisseria gonorrhoeae and Chlamydia trachomatis. Erythromycin ointment is considered more effective and less irritating than silver nitrate. Penicillin is not used for ophthalmia neonatorum prophylaxis. Educationally, understanding the rationale behind using erythromycin is crucial for nursing students as it highlights evidence-based practice in neonatal care. It also emphasizes the importance of preventing ophthalmia neonatorum, a serious eye infection that can lead to blindness if left untreated. This knowledge equips nurses with the necessary information to provide safe and effective care to newborns. It also reinforces the significance of following established protocols and guidelines in medication administration to ensure optimal patient outcomes.