Ch 21 Care of a Normal Newborn – Flashcards

ANS: A Crust is a normal part of healing. The normal yellowish exudate that forms over the site should be differentiated from the purulent drainage of infection. The only contraindication for petroleum jelly is the use of a PlastiBell. The diaper should be fastened loosely to prevent rubbing or pressure on the incision site.

ANS: D The vastus lateralis muscle is located away from the sciatic nerve and femoral blood vessels. Gluteal muscles are not used until a child has been walking for at least 1 year to develop these muscles. The rectus femoris is used only if absolutely necessary because this muscle is located closer to the sciatic nerve and blood vessels, which poses a greater danger. The deltoid is not a recommended site for newborn injections.

ANS: C The syringe should be inserted into the sides of the mouth rather than the back of the throat to avoid a vagal response and bradycardia. Suction can occur as needed. Vigorous suction of the back of the throat may stimulate the vagal nerve and produce bradycardia. The mouth should be suctioned first to prevent aspiration.

ANS: D Bacterial growth increases in a moist environment, so keeping the umbilical cord dry impedes bacterial growth. Cord care is done to prevent infection and aid in the drying of the cord. No agents are necessary to facilitate drying of the cord. The cord will fall off within 10 to 14 days.

ANS: D Early treatment of disorders will prevent morbidity associated with some common newborn disorders. Keeping state records and documenting the number of births are not the purposes of newborn screening. The number of births is not indicated by the newborn screening test.

ANS: B Infants should be transported in the hallways only in their cribs. Restricting the amount of time infants are out of the nursery will be difficult to monitor and will limit the mother's support system from visiting. Infants need to spend time with the parents to facilitate the bonding process. It is impossible for one nurse to be on call for one mother and baby for the entire shift, so the parents need to be able to identify the nurses who are working on the unit.

ANS: C The mother and infant should have identifying arm bands with matching numbers. The other actions do not adequately verify the identities of mother and infant.

ANS: C Common disorders often included in newborn screening are phenylketonuria (PKU), hypothyroidism, galactosemia, hemoglobinopathies such as sickle cell disease and thalassemia, and congenital adrenal hyperplasia. The parents need further teaching if they say that congenital hypothyroidism is not screened. The newborn screening tests are performed at 24 to 48 hours after birth. Newborn screening requires a blood sample taken from the infant's heel, and only one blood sample is needed for all tests. Tests performed within the first 24 hours of life are less sensitive than those performed after 24 hours. Infants tested before 12 to 24 hours of age should have repeat tests at 1 to 2 weeks of age so that disorders are not missed because of early testing.

ANS: A A glucose level of 40 mg/dL requires an action. Follow agency policy and health care provider orders regarding feeding infants with low glucose levels. A common practice is to feed the newborn if the glucose screening shows a level of 40 to 45 mg/dL or less to prevent further depletion of glucose. Infants with severe hypoglycemia may need intravenous feedings to provide glucose rapidly. A normal temperature for a newborn is 36.5° to 37.5° C (97.7° to 99.5° F). Mild jaundice at 32 hours of age is physiologic jaundice and does not need an action by the nurse, just further monitoring. Some infants develop a mild inflammation a few hours after prophylactic eye treatment.

ANS: A If excessive bleeding occurs after a circumcision, pressure is applied to the site. The nurse notifies the physician, who may apply Gelfoam or epinephrine or suture the small blood vessels. A small amount of blood loss may be significant in an infant, who has a small total blood volume. Continuing to observe could mean additional blood loss. Applying the diaper tightly will not stop the bleeding. Petroleum jelly is applied to keep the diaper from sticking to the circumcised area. It will not stop the bleeding.

ANS: A The American Academy of Pediatrics (AAP) in 2011 recommended that mothers and fathers be taught to place infants on the back for sleep, because this position is associated with the lowest rate of SIDS. The side-lying position is not advised because of the possibility that the infant might roll to the prone position. The newborn should not be placed on the abdomen.

ANS: C Delivery via cesarean section may affect the newborn's ability to remove excess fluid secretions because the infant did not move down the birth canal and thus may be at risk for airway concerns. There is no evidence to support that the equipment is malfunctioning. Although the use of medications may affect the newborn in terms of respiratory, cardiac, and neurologic depression, Apgar scores do not indicate any immediate deficit. The infant is at term based on reported gestational age and therefore is not a risk for ineffective thermoregulation because of this fact.

ANS: D This temperature potentially indicates hypothermia, so the infant should be wrapped securely in a blanket and reassessed after that intervention. Findings should be documented in the EHR, but this is not the priority intervention. Unwrapping the infant would lead to further compromise and additional risk for the core temperature to drop. Feeding the infant with glucose water may eventually be used as an intervention if the infant shows additional signs of hypoglycemia, which may accompany hypothermia.

ANS: B Requiring appropriate identification is the best method of preventing possible infant abduction. Evidenced-based practice has indicated that potentially "family and/or staff or someone representing themselves as such" is more likely to attempt an infant abduction. The unit should be a closed or locked unit and require admittance to maintain security. Limiting the visitors to two per client may cause increased stress to the new family because they want to share this experience. Preventing siblings from visiting by only allowing immediate adult family members may prevent beginning sibling attachment and cause separation and stress anxiety to the mother and children.

ANS: B Temperature instability in the neonate may be caused by a decrease in blood glucose levels. Infants who do not maintain adequate intake will not have adequate energy to maintain temperature; instructing parents on cold stress and increasing the temperature in the room are interventions to maintain a stable temperature but will not correct the underlying problem. A blood sugar level higher than 50 mg/dL is a normal finding.

ANS: B This indication is the reason for vitamin K administration. Vitamin K is given to neonates because they cannot synthesize it in the intestines without bacterial flora. This places them at risk for hemorrhagic disease of the newborn (vitamin K deficiency disease). One dose of vitamin K intramuscularly after birth prevents bleeding problems until the infant is able to produce vitamin K in sufficient amounts. Although the injection is usually given within the first hour after birth, it can be delayed until the infant has finished breastfeeding shortly after birth.

ANS: B The mouth should be suctioned first because the infant may gasp when the nose is suctioned, causing aspiration of mucus or fluid in the mouth. Then the nose is suctioned gently and only if necessary. Suctioning is traumatic to the delicate tissues and may cause edema of the nasal passages. The remaining statements are correct.

ANS: C A temperature of 36.7° C (98° F) or higher is often used to determine when to bathe the infant. The infant can lose heat in the bath through the process of evaporation. Rectal temperatures are avoided because they can traumatize the rectal mucosa. The water temperature should be approximately 38° to 40° C (100.4° to 104° F). The nurse and not the father needs to determine if the bath water is the correct temperature to avoid scalding the newborn. Explain the process of giving a bath during the procedure. Informing the parents before the procedure may result in loss of information.

ANS: B The administration of the vitamin K prevents excessive bleeding. The infant could be at risk for hemorrhage without the vitamin K. Other assessment measures can be used to fulfill the remaining assessments, such as a verbal consent can be obtained, the skin can be palpated to determine temperature, and overall color can give the health care provider information about the infant's heart rate. The only replacement for vitamin K is time to allow for the development of vitamin K in the gastrointestinal (GI) system.