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A nursery nurse is caring for a newborn who was born 2 hours ago. Upon review of the prenatal records, the nurse notes the following prenatal panel results:

 

A positive, Hepatitis B positive, RPR negative, Rubella immune, HIV negative, GBS positive. In addition to Vitamin K and Erythromycin ophthalmic ointment, what injection(s) should the newborn receive?

A nurse is caring for a newborn who was born at 39 weeks gestation and weighs 3350 g. Based on the weight and gestational age, what is the most appropriate way to document the findings?

The nurse is preparing to teach the postpartum mom about newborn feeding cues. Which of the following behaviors of the infant would be considered early hunger cues? Select all that apply.

A nurse is preparing to administer 0.5% Erythromycin ophthalmic ointment to a newborn. Which route and dose should the nurse apply?

A nurse is caring for a newborn 4 hours after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice?

A nurse is caring for a newborn whose mother has diabetes mellitus. The nurse should recognize which of the following potential newborn complications as the priority focus of care?

A nurse is performing a newborn assessment and notes depressed fontanels. Which of the following is true regarding depressed fontanels in newborn assessment?

A nurse is providing discharge instructions for newborn care. The parents have chosen to formula feed their infant. What should the nurse include in the discharge teaching about bottle feeding? (Select all that apply)

A nurse is completing the admission assessment of a newborn. Which of the following anatomical landmarks should the nurse use when measuring the newborn’s chest circumference?

A nurse is assessing a newborn 1 hour after birth. Which of the following respiratory rates is within the expected reference range for a newborn?

A nurse is caring for a neonate in the neonatal unit.

History and Physical

The neonate was delivered via vaginal birth approximately 1 hour ago. Apgar scores were 8 at 1 minute and 9 at 5 minutes. Vitamin K was administered in the left vastus lateralis. The neonate weighs 4337 grams (9 lb 9 oz) and is 52 cm (20.5 in) in length. Gestational age assessment indicates 39 weeks, and the neonate is classified as large for gestational age.

Nurses Notes

The neonate is noted to be jittery and has decreased muscle tone. The neonate’s skin appears slightly mottled, and there is a weak cry. The neonate is also observed to have poor feeding and is irritable when handled. The mother reports that the neonate has not passed urine since birth. The neonate’s reflexes appear diminished.

Vital Signs

• Heart rate: 170/min (apical)
• Respiratory rate: 68/min (auscultation)
• Temperature: 36.1°C (96.9°F) (axillary)

Diagnostic Results

Blood glucose level is 30 mg/dL. A complete blood count (CBC) shows a slightly elevated white blood cell count. Serum calcium levels are within normal limits. Blood culture results are pending.

Physical Examination Results

The neonate exhibits signs of hypoglycemia, including jitteriness and decreased muscle tone. The skin is slightly mottled, and the neonate has a weak cry. There is poor feeding and irritability when handled. Reflexes are diminished, and the neonate has not passed urine since birth.

Which of the following actions should the nurse take first?