Newborn And Infant Care Support - NCLEX-PN

About 1–2 weeks. The stump dries and separates as the umbilical vessels necrose naturally, with this timeline indicating normal healing.

Foul odor, purulent drainage, or spreading redness. These signs indicate potential infection, necessitating medical intervention to prevent systemic spread in vulnerable newborns.

Keep cord clean and dry; fold diaper below stump. This promotes natural drying and prevents infection by avoiding moisture accumulation around the stump.

Audible swallowing with at least 6 wet diapers/day after day 4. These signs confirm effective milk transfer and hydration, essential for preventing weight loss and supporting growth.

Moro (startle) reflex. This reflex assesses neurological integrity, mimicking a startle response to protect against falling in primitive survival instincts.

Rooting reflex. This reflex aids in feeding by prompting the newborn to turn toward a stimulus, facilitating nipple location for breastfeeding.

Maintain airway and administer oxygen as ordered. These signs indicate respiratory distress, so ensuring airway patency and oxygenation addresses potential hypoxia immediately.

30–60 breaths/min. This rate supports adequate oxygenation in newborns due to their immature respiratory system and higher metabolic demands.

36.5–37.5°C (97.7–99.5°F). This range maintains thermoregulation in newborns, who are prone to heat loss due to limited subcutaneous fat and immature sweating mechanisms.

Jaundice present in the first 24 hours. Early onset suggests pathologic causes like hemolysis or infection, requiring prompt evaluation to prevent complications such as kernicterus.

Onset after 24 hours of life. Physiologic jaundice results from normal bilirubin accumulation after birth, typically appearing after the first day as the liver matures.

Meconium to transitional stools by day 3–4. Meconium clears fetal waste, transitioning to milk-based stools as the gastrointestinal tract matures with feeding.

At least 6 wet diapers/day. This output indicates sufficient hydration and intake, as newborns concentrate urine less efficiently early on.

Firm mattress, no soft bedding or loose items. A bare, firm sleep surface minimizes suffocation hazards from soft materials that could cover the infant's face.

Supine for every sleep. Back sleeping decreases SIDS risk by preventing airway obstruction from prone positioning and reducing rebreathing of exhaled air.

Supine with neck in neutral “sniffing” position. This position aligns the airway optimally, reducing obstruction risk in newborns with relatively large heads and short necks.

Dry the newborn thoroughly and remove wet linens. Evaporation causes rapid heat loss in wet newborns, so immediate drying minimizes this risk and stabilizes body temperature.

Palmar grasp reflex. This primitive reflex demonstrates intact neurological function, with the infant's fingers curling around the object instinctively.

110–160 beats/min. Newborns have a higher heart rate to meet circulatory needs during the transition from fetal to neonatal physiology.

Positive Ortolani or Barlow maneuver (hip “clunk”). These maneuvers detect hip instability from developmental dysplasia, prompting early intervention to prevent long-term issues.

Sunken fontanelle with decreased urine output. These indicate fluid deficit, as fontanelles reflect intracranial pressure and urine output measures renal perfusion.

Stop feeding, position side-lying, and clear airway as needed. This intervention clears the airway and prevents aspiration, prioritizing respiratory safety during the episode.

Erythromycin ophthalmic ointment. This prevents ophthalmia neonatorum from maternal gonorrhea, providing broad-spectrum coverage against bacterial conjunctivitis.

Vitamin K (phytonadione) IM. Newborns have low vitamin K levels, increasing bleeding risk, so administration supports clotting factor production.