The nurse is caring for a neonate born at 36 weeks, 2 days by primary cesarean birth and weighing 6 pounds, 4 ounces. The infant cried at delivery, had flexion in all extremities, had a heart rate of 135, had acrocyanosis in hands and feet, and was pale. The infant was placed skin-to-skin with the birthing person and has been latching and cuddling for the past 15 minutes. At 45 minutes, the neonate is found grunting and cool to the touch. What are the nurse’s next steps?

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Nursing Care of the Newborn and Family Questions

Question 1 of 5

The nurse is caring for a neonate born at 36 weeks, 2 days by primary cesarean birth and weighing 6 pounds, 4 ounces. The infant cried at delivery, had flexion in all extremities, had a heart rate of 135, had acrocyanosis in hands and feet, and was pale. The infant was placed skin-to-skin with the birthing person and has been latching and cuddling for the past 15 minutes. At 45 minutes, the neonate is found grunting and cool to the touch. What are the nurse’s next steps?

Correct Answer: C

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 2 of 5

A new parent is concerned about a mass on the newborn’s head. The nurse assesses this to be a cephalohematoma based on what characteristics?

Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 3 of 5

How would the nurse elicit a rooting reflex in a newborn?

Correct Answer: A

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 4 of 5

The nurse knows that a full-term newborn presents with ears that include what assessment characteristics?

Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 5 of 5

When assessing the newborn for the presence of lanugo, where should the nurse look for it?

Correct Answer: D

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

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