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The nursery nurse is receiving a report on her assigned 4 neonates. Which of the following conditions is high risk for unconjugated bilirubin and jaundice?

A nursery nurse is admitting a neonate and is performing the neonatal assessment. The apical pulse is auscultated with a rate of 124 bpm, after one full minute of listening.

What is the next appropriate action should the nurse take?

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 assessing a newborn who was born at 42.5 weeks of gestation. Which of the following findings should the nurse expect?

A nurse is completing a newborn assessment and notes small raised pearly white spots on the nose and chin. This finding is characteristic of which of the following?

A nurse is caring for a newborn delivered by vaginal birth after 3 hours of pushing. The newborn’s mother asks about the swollen area on her son’s head. After palpation and identification that the swelling does cross the suture line, which of the following is an appropriate response by the nurse?

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

The nursery nurse is receiving a report on her assigned 4 neonates. Which of the following conditions is high risk for unconjugated bilirubin and jaundice?

A nurse in the newborn nursery is caring for a group of newborns. Which of the following newborns requires immediate intervention?

The nurse is caring for a newborn one hour after delivery. Which of the following assessment findings does the nurse identify as signs of respiratory distress? (Select all that apply)

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?