Healthy Newborn free essay sample

Drying the infant quickly and placing her under a radiant warmer reduces heat loss through evaporation and radiation. C)  Newborns in an incubator are more difficult to access than those in a radiant warmer. INCORRECT Although a radiant warmer allows healthcare personnel easy access to the infant, that is not the reason for its use in this situation. D)  Bonding is promoted by enhancing the infants appearance. INCORRECT Drying and warming do not necessarily enhance the infants appearance or promote bonding. 2. Which action should the nurse take prior to drying the infants back? A)  Note if the infant has passed any meconium stool. INCORRECT Although this observation is important, it is not related to drying the back. B)  Observe the sacral area for possible Mongolian spots. INCORRECT Mongolian spots are normal variations in the pigment of the skin, and they do not hinder drying the back. C)  Assess the amount and location of vernix caseosa. INCORRECT The amount of vernix caseosa is related to gestation age, but is not related to drying the back. D)  Inspect the back for possible neurological defects. CORRECT To prevent harm while drying the newborn, the back should always be inspected for possible neurological defects, like spinal bifida. At 1 minute of age, the infant is crying and has a heart rate of 160 and a respiratory rate of 58. Both of the infants arms and legs are flexed, and her hands and feet are cyanotic. 3. Which APGAR score should the nurse assign? A)  10. INCORRECT Review the findings again. B)  9. CORRECT One point is deducted for acrocyanosis. C)  8. INCORRECT Review the findings again. D)  7. INCORRECT Review the findings again. The nurse conducts a physical assessment of the infant looking for normal as well as abnormal findings. 4. Upon inspection of the  umbilical cord, which finding should the nurse report to the healthcare provider? A)  The cord is covered with Whartons jelly. INCORRECT This is a normal finding. B)  Pulsations are felt at the base of the cord. INCORRECT This is a normal finding. C)  One artery and one vein are present. CORRECT Two arteries and one vein should be present. D)  The cord is glistening with a pearl-like coloring. INCORRECT This is a normal finding. The Carson babys head is molded from the vaginal delivery. Upon seeing the baby, Ms. Carson says, Oh, she is so beautiful, but something is wrong with her head. 5. How should the nurse respond? A)  No nothing is wrong with her head. She really is a beautiful baby. INCORRECT This response does not fully address the mothers concern. B)  Yes, it is misshaped, but we will show you how to change it over time. INCORRECT Parents can be taught to change an infants sleeping positions to correct a misshaped head, but this is not the best response. C)  Her head has been molded from delivery through the birth canal, which is normal. CORRECT Molding commonly occurs in babies delivered vaginally, and the head will become more symmetrical over time. D)  I know you are concerned. Would you like to talk further with the midwife? INCORRECT Acknowledging Ms. Carsons feelings is a thoughtful response, but referral to the midwife is not necessary. Ms. Carson is offered the opportunity to  breastfeed. After securing a comfortable position for herself and the baby, Ms. Carson puts the infant to her breast. The baby latches onto the nipple, and with some encouragement, she begins to nurse. After a time of family interaction, Ms. Carson is taken to the postpartum unit, and the infant is transferred to the transition care nursery. Transition Care The  nurse checks  the identification bands for both the baby and the mother upon  admission  to the nursery. One ID number is incorrect. 6. Which action should the nurse take to solve this problem? A)  Document the presence of the incorrect number on the charts for the baby and the mother. INCORRECT Although the nurse should probably document the discrepancy, it does not solve the problem. B)  Explain to the mother that there is an incorrect number on one of the bands. INCORRECT Although an explanation should be given to the mother, that will not solve the problem. C)  Redo the identification bands with another nurse witnessing the process. CORRECT Identification bands must be correct to ensure the safety and security of all hospitalized clients, especially newborns. D)  Mark the incorrect numbers in red to denote the correction made to the bands. INCORRECT This is not the proper action for the nurse to take to solve this problem. Upon admission to the transition care nursery, the Carson babys axillary temperature is 97. 4 ° F. 7. Which action should the nurse take? A)  Continue monitoring and document this finding in the record. INCORRECT Another action should be taken in this situation. B)  Place the infant in a radiant warmer and monitor her temperature. CORRECT The babys temperature is not within normal range (97. 5 °-99 ° F). The infant should remain in the radiant heat warmer until her temperature has stabilized. C)  Remove a blanket from the infant and check the temperature again. INCORRECT This action will make the situation worse, not improve it. D)  Notify the healthcare provider immediately about the temperature. INCORRECT The nurse is capable of providing care to remedy this situation. It is not necessary to notify the healthcare provider. Newborn Assessment While examining the infants head, the nurse notes soft swelling of the scalp that extends across the suture lines of the fetal skull. 8. Which action should the nurse take in response to this finding? A)  Document the finding in the record. CORRECT This finding indicates caput succedaneum, which commonly occurs after a vaginal birth. B)  Monitor the tension of the anterior fontanel. INCORRECT Although the anterior fontanel should be monitored, it is not related to this finding. C)  Report the finding to the healthcare provider. INCORRECT It is not necessary to report this finding to the healthcare provider. D)  Apply cool compresses to prevent more swelling. INCORRECT Applying cool compresses is not the proper action for the nurse to take. The nurse notes a bluish discoloration of the skin across the infants sacral area. 9. Which should the nurse do in response to this finding? A)  Assess the infant for cold stress. INCORRECT An overall mottled appearance is usually more indicative of cold stress. B)  Refer the parent to the care of a pediatric specialist. INCORRECT A referral to a pediatric specialist is not necessary as a result of this assessment. C)  Document this finding in the record. CORRECT This bluish discoloration of the skin is a birthmark, commonly referred to as Mongolian spots. They are merely a dense collection of normal skin cells deep in the skin. This is a common finding, which should simply be noted in the babys record. D)  Evaluate the infants neurological status. INCORRECT It is not necessary to further evaluate the infants neurological status based on this finding. However, tufts of hair or dimples in the sacral area might indicate a need for a more in-depth neurological evaluation. 10. Which physical finding, if present, should the nurse report to the  healthcare  provider? A)  Presence of unopened sebaceous glands. INCORRECT These pinhead-size whiteheads on the newborn are referred to as milia, and they usually disappear without treatment. Their presence does not need to be reported. B)  Loose natal teeth that are not covered by the gums. CORRECT Natal teeth present at birth is an unusual occurrence that should be reported to the healthcare provider. Loose natal teeth are frequently removed to prevent aspiration. C)  White, cream cheese-like substance on skin. INCORRECT This substance is vernix caseosa, which covers and protects the fetus from the amniotic fluid in utero. Because its presence on the infant at birth is normal, this finding does not need to be reported. D)  Enlarged breasts secreting a thin, watery discharge. INCORRECT This temporary condition in the newborn is caused by the influence of the mothers hormones on the fetus prior to birth. The secretion is often referred to as witchs milk. This is a normal finding that does not need to be reported. 11. When examining the babys extremities, which finding would warrant additional assessment by the nurse? A)  Toenails blanch with pressure and quickly refill. INCORRECT This is a normal response that does not require additional assessment. B)  Feet that turn in, but can be manipulated to midline. INCORRECT This is a normal finding that does not require additional assessment. C)  Hands are plump and clenched into fists. INCORRECT This is a normal finding and does not require additional assessment. D)  Limited hip abduction in the supine position. CORRECT Because this finding could indicate developmental dysplasia of the hip, formerly known as congenital hip dislocation, additional assessment is warranted. 12. Which finding by the nurse is consistent with an infant born at 39 weeks gestation? A)  Presence of abundant lanugo hair across face and back. INCORRECT A baby born at 39 weeks gestation has minimal lanugo hair, which is the soft prenatal hair that is shed during the last few weeks of pregnancy. B)  Plantar creases covering the entire sole of foot. CORRECT This finding is consistent with a baby born at 39 weeks gestation. C)  Slightly soft, curved pinna with slow recoil. INCORRECT The ear of a baby born at 39 weeks gestation should be well formed and firm with instant recall. D)  Skin is smooth and pink with visible veins. INCORRECT This finding is more consistent for an infant with an earlier gestational age. Continued Transition Care A nursing student is assisting the RN in caring for the infants in the nursery. The RN questions the student  about vitamin  K (Aqua MEPHYTON) as preparations are made for administration. 13. Which response by the student indicates an understanding of the purpose for administering this drug? A)  The purpose of this drug is to prevent hyperbilirubinemia in the newborn. INCORRECT Further teaching is needed because vitamin K does not prevent hyperbilirubinemia. B)  Vitamin K is a fat-soluble vitamin and promotes a positive nutritional status. INCORRECT This is not the primary reason for giving vitamin K. C)  This drug is given to the newborn to prevent and/or treat hemorrhagic disease. CORRECT Because this vitamin does not cross the placenta and there is very little in breast milk, supplemental vitamin K should be given to newborns at birth to help clot the blood. Therefore, this is an accurate response by the student and no further client teaching is needed. D)  Vitamin K is produced and stored in the liver, which is immature in the infant. INCORRECT Vitamin K is produced in the gut, but stored in the liver. The nurse is preparing to give the baby her first bath. 14. Which assessment data indicates that it is safe for the baby to be given her bath at this time? A)  Respiratory rate of 46. INCORRECT This respiratory rate is high-normal and will rise with the activity of bathing. B)  Axillary temperature of 98 ° F. CORRECT A bath may potentially lower the temperature, which will not be harmful because the core temperature is near 99 ° F. C)  Apical heart rate of 160. INCORRECT This heart rate is high-normal and will rise further with the activity of bathing. D)  Pulse oximeter of 90%. INCORRECT This value is below normal and could become lower with the activity of bathing. At 2400 hours the infant is crying, her skin is mottled, and her hands are shaking. 15. Which action should the nurse take first? A)  Assess the infants respiratory efforts. INCORRECT Assessing the respiratory efforts of the infant is unnecessary since the infant is crying, and crying is a good indicator of respiratory effort. B)  Monitor the blood glucose level. CORRECT Since it has been 2 hours since delivery, the infant may be experiencing hypoglycemia. C)  Give the infant some formula. INCORRECT Because this infant is breastfeeding, an attempt should be made to let her nurse before offering the formula. D)  Evaluate for possible seizures. INCORRECT The infant is not exhibiting any signs associated with seizures. Rooming-In The babys vital signs have stabilized by 0100 hours. Upon completion of assessment and documentation, the nurse takes the baby to Ms. Carson who wants to breastfeed and room-in with the baby. After checking the ID bands, the infant is positioned for breastfeeding. The nurse checks on Ms. Carson and the baby at 0200 hours. Both are asleep in the bed, with the baby lying beside Ms. Carson. 16. What should the nurse do next? A)  Pick up the baby and return her to the crib while letting Ms. Carson sleep. INCORRECT Although returning the baby to her crib is the proper response, this action is incomplete. B)  Wake Ms. Carson and remind her that keeping the baby in the bed is unsafe. INCORRECT Although waking Ms. Carson is the proper response, this action is incomplete. C)  Tell Ms. Carson that the baby must be returned to the nursery for safety reasons. INCORRECT Although the baby can be returned to the nursery if Ms. Carson is too tired to care for her, there is a better response in this situation. D)  Remind Ms. Carson about infant safety and assist her to place the infant in the crib. CORRECT This action protects the baby while reinforcing teaching to the mother. When returning the baby to the crib, the nurse notices that the blanket covering the baby is loose, and the cap is off her head. The nurse takes the babys temperature, which is 97. 6 ° F. 17. Which should the nurse do next? A)  Bundle the baby and place the cap on her head. INCORRECT Although this would help the baby, another action is more effective. B)  Cover the baby with a blanket, but leave the cap off. INCORRECT This action is incomplete. C)  Show Ms. Carson how to wrap the baby for warmth and apply the cap to her head. CORRECT This action not only protects the baby, but also involves and teaches the mother. D)  Immediately take the baby and place her under a heat source. INCORRECT Other actions should be done first. The nurse checks on Ms. Carson and her baby every 2 hours throughout the night. The baby is breastfed at 0300 and 0600 hours without difficulty. After the change of shift report at 0700 hours, the day nurse assesses the mother and baby. Ms. Carson states that the baby had a bowel movement after breastfeeding. She tells the nurse that she attempted to change the diaper, but had difficulty doing so. 8. What action should the nurse implement? A)  Reassure Ms. Carson that she will get plenty of practice. INCORRECT Ms. Carsons statement implied a need that should be addressed by the nurse. B)  Observe Ms. Carson as she performs a diaper change. CORRECT This approach helps the nurse evaluate the problems Ms. Carson is experiencing so the most effective teaching can be provided. C)  Pl ace the baby on the bed and demonstrate how to change a diaper. INCORRECT Another action is more effective to meet the clients needs. D)  Tell Ms. Carson that the nurses can change the diapers until they go home. INCORRECT Although the nurses may assist with diaper changing, the mothers involvement in the care of her baby is essential. When Ms. Carson removes the diaper, the nurse notices that the baby has caked powder in the inguinal leg folds and vulva areas. 19. What action should the nurse take? A)  Show Ms. Carson how to remove the caked-on powder. INCORRECT This should be done, but further instruction is needed. B)  Explore with Ms. Carson why powder was used. INCORRECT This may provide some information, but does not correct the problem. C)  Praise Ms. Carson for wanting to keep her baby dry. INCORRECT This response does not teach Ms. Carson about the proper use of powder on her baby. D)  Instruct Ms. Carson to use plain water instead of powder. CORRECT Until the baby is 4 days old, only plain warm water is recommended (after the initial bath) because soaps, ointments, powders, lotions, and baby wipes can disrupt the acid mantle on the skin and provide a medium for bacterial growth. Ointments are prescribed only if a rash develops in the first few days of life. Use of powder also places the infant at risk for fine particle aspiration. While changing the diaper, Ms. Carson notices blood-tinged mucous in the vulva area and asks the nurse what is causing this with her baby. 20. Which explanation should the nurse provide? A)  Your baby probably has the beginning of a urinary tract infection. INCORRECT This finding is not consistent with a urinary tract infection. B)  Apparently your baby had some trauma at birth to cause this. INCORRECT There is usually a much more reasonable explanation for this finding. This response could cause the mother unnecessary anxiety. C)  Withdrawal of maternal hormones is the usual cause of this occurrence. CORRECT This is called pseudomenstruation, which is due to the effects of maternal hormones. D)  This is unusual, and I will notify the pediatrician about the mucous. INCORRECT This is not an unusual occurrence. Preparation for Discharge At two days post birth, Ms. Carson and her baby are doing well and preparing for discharge. The babys weight at birth was 7 lb 15 oz (3600 gms), and today she weighs 7 lb 3 oz (3300 gms). Ms. Carson expresses her concern to the nurse when she realizes that her baby has lost almost a pound since birth. 21. How should the nurse respond? A)  I can tell you are concerned. Would you like to talk with the pediatrician? INCORRECT She can certainly talk with the pediatrician, but the nurse can and should respond to this mothers concern. B)  Yes, this is a concern. The pediatrician may want to keep the baby here for another day. INCORRECT Based on the data regarding the babys weight loss, it would not be necessary to keep the baby another day. C)  Dont worry. Your baby will gain weight in a few days when your milk comes in. INCORRECT This response offers false reassurance. In addition, it may lead the mother to believe that her breast milk is not adequate at this time, which is incorrect. D)  Dont be concerned. Your babys weight loss is in the typical range for all babies. CORRECT Babies may lose up to approximately 10% of their birth weight. Ms. Carson is told that a neonatal screening test needs to be done before they are discharged. 22. When asked the reason for including the PKU test in the screening, which information should the nurse provide? A)  An error in metabolism of the amino acids leucine, isoleucine, and valine can cause death if not detected and treated early. INCORRECT This describes another error in metabolism. B)  A problem converting the protein, phenylalanine, may be present, which can lead to mental retardation if not found and treated early. CORRECT PKU testing is done to detect the level of phenylalanine in the babys blood. C)  Screening for an error in metabolism of the sugars galactose and lactose can prevent liver and brain damage in the newborn. INCORRECT This describes a different error in metabolism. D)  This test detects the level of thyroxin produced by the thyroid. If too little is produced or if treatment is not started early, mental retardation can result. INCORRECT This describes another metabolic disorder, not PKU. 3. How should the nurse collect the blood needed for PKU screening? A)  Clean the heel with alcohol swap, dry with gauze, and collect blood in a capillary tube. INCORRECT A capillary tube is used to collect blood for hemoglobin, not PKU screening. B)  Puncture the lateral heel after warming and collect blood samples on the designated lab form. CORRECT The heel should be warmed, cleaned with alcohol, and dried with gauze. After puncturing the heel with a microlancet, blood is collected on a special neonatal screening form. C)  Collect heel blood using a transfer pipette and place a drop of blood on a reflectance meter. INCORRECT This is the usual technique to collect blood for glucose analysis, not PKU screening. D)  After grasping the babys lower leg and foot, use a microlancet to puncture the middle portion of the heel. INCORRECT The middle portion of the heel should not be used. Case Outcome After discharge teaching is complete and the nurse removes one ID band from the baby to keep with the record, follow-up appointments are made for both mother and baby. Ms. Carson thanks the nurses for their support, care, and teaching. Ms. Carson and baby are taken by wheelchair to a private car, where the baby is secured in a car seat for the drive home.