HESI Case Studies–Obstetric/Maternity-Newborn with Jaundice (The Fuqua family) – Flashcards
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1. Which action should the nursery nurse take first in caring for the infant?
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Dry the infant quickly with warm blankets
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2. After cleaning the airway and drying the infant, the nurse assesses that the infant is breathing and has a heart rate of 100 but remains cyanotic
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Prepare to give oxygen
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3. At 1 minute the infant has a heart rate of 142, has a slow weak cry, is grimacing, and is in a flexed position with acrocyanosis. What Apgar score should the nurse assign?
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7
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4. Which action should the nurse take prior to weighing the infant?
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Place a cover on the scale
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5. To promote family bonding, which part of infant care should the nurse delay
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Giving eye prophylaxis
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6. After receiving the labor and delivery report, which information should direct the nurse to further assessment of the infant's head?
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Low forceps delivery
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7. The infant's vital signs are as follows: temp 97.8F; HR 136, irregular with soft murmur; and RR 36. Which action should the nurse take?
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Place the infant under a radiant heat source
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8. What action should the nurse take when finding that the head measures 35 cm and the chest circumference measures 33 cm?
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Document the findings in record
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9. Upon examining the chest, which finding should the nurse report to the healthcare provider?
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Crepitus across right clavicle
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10. The infant exhibits a positive Babinski reflex. Which action should the nurse take to elicit a Babinski reflex?
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Stroke side of the sole of the foot from heel upward toward toes
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11. When the nurse conducts a gestational age assessment, which finding(s) may indicate post-maturity? (Select all)
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-Low reading on blood glucose testing -Peeling, parchment-like skin -Thin with loose skin and little subcutaneous fat -Deep creases at the base of the toes extending to the heels.
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12. While administering the vitamin K to the infant, which action should the nurse take?
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Select the middle part of the vastus lateralis for use.
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13. The nurse next prepares to administer the erythromycin ointment (Ilotycin ophthalmaic ointment). Which approach should the nurse use to administer the ointment?
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Cover entire lower conjunctiva with ointment after gently retracting the lid.
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14. While the nurse is discussing care with Mrs. Fuqua, the infant starts gagging. What action should the nurse implement first?
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Use a bulb syringe to clear the mouth and nose
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15. The mother asks how often the infant should be burped. How should the nurse respond?
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He needs burping at the start and after each ounce of formula
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16. When Mrs. Fuqua starts feeding the infant, large bubbles are seen in the bottle. Mr. Fuqua expresses concern. What explanation should the nurse give to the family?
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Too much formula is flowing through the nipple
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17. Upon entering the Fuquas' room, the nurse finds Mrs. Fuqua in the bathroom and the infant in the crib with a bottle propped on a towel. What action should the nurse take?
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Remove the bottle from the infant's mouth
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18. Which finding by the nurse is consistent with a cephalhemotoma?
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Well-outlined swelling that does not cross suture lines
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19. The infant has a reddish papular rash across his face. How should the nurse respond when Mrs. Fuqua asks about the rash?
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A newborn rash is very common, but it will disappear soon
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20. Which factor should alert the nurse to assess for the risk of jaundice
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Presence of cephalhematoma
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21. The nurse observes that the infant is jaundiced on his face, head, and chest. What action should the nurse take next?
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Obtain blood for laboratory analysis
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22. The nurse prepares the infant for placement under a bilirubin light. Which action(s) the nurse should implement? (Select all)
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-Remove the infant's clothing -Place eye patches on the infant -Turn off lights and allow parents to hold infant for feedings
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23. While the infant is receiving phototherapy, his stools become loose and green. What action should the nurse take?
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Document the findings in the record
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24. The parents ask about why they have a phototherapy blanket instead of lights. How should the nurse respond?
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Holding the infant does not interrupt the phototherapy process
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25. Mrs. Fuqua asks how she will know the phototherapy is working. How should the nurse respond?
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Serum bilirubin level decreases
