Hesi CS: Healthy Newborn – Flashcards
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The nursery nurse places the infant under the radiant warmer and start to dry the infant quickly. What is the rationale for this action?
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Convective heat loss from evaporation is reduced.
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Which action should the nurse take prior to drying the infant's back?
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Inspect the back for possible neurological defects. rationale: To prevent harm while drying the newborn, the back should always be inspected for possible neurological defects, like spinal bifida.
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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 infant's arms and legs are flexed, and her hands and feet are cyanotic.
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9. rationale: One point is deducted for acrocyanosis.
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Upon inspection of the umbilical cord, which finding should the nurse report to the healthcare provider?
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One artery and one vein are present. Rationale: two arteries and one vein should be present
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The Carson baby's 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." How should the nurse respond?
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"Her head has been molded from delivery through the birth canal, which is normal." Rationale: Molding commonly occurs in babies delivered vaginally, and the head will become more symmetrical over time.
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The nurse checks the identification bands for both the baby and the mother upon admission to the nursery. One ID number is incorrect. What should the nurse do?
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Redo the identification bands with another nurse witnessing the process Rationale: Identification bands must be correct to ensure the safety and security of all hospitalized clients, especially newborns.
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Upon admission to the transition care nursery, the Carson baby's axillary temperature is 97.4° F What action should the nurse take?
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Place the infant in a radiant warmer and monitor her temperature. Rationale: The baby's temperature is not within normal range (97.5°-99° F). The infant should remain in the radiant heat warmer until her temperature has stabilized.
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While examining the infant's head, the nurse notes soft swelling of the scalp that extends across the suture lines of the fetal skull. What action should the nurse take?
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Document the finding in the record. Rationale: This finding indicates caput succedaneum, which commonly occurs after a vaginal birth.
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The nurse notes a bluish discoloration of the skin across the infant's sacral area. What action should the nurse take?
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Document this finding Rationale: 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 baby's record
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Which physical finding, if present, should the nurse report to the healthcare provider?
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Loose natal teeth that are not covered by the gums. Rationale: 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.
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When examining the baby's extremities, which finding would warrant additional assessment by the nurse?
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Limited hip abduction in the supine position. Rationale: Because this finding could indicate developmental dysplasia of the hip, formerly known as congenital hip dislocation, additional assessment is warranted.
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Which finding by the nurse is consistent with an infant born at 39 weeks gestation? Select all that apply
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Plantar creases covering the entire sole of foot Head and neck are 25% of body's surface Incorrect: Presence of abundant lanugo hair across face and back. Slightly soft, curved pinna with slow recoil Skin is smooth and pink with visible veins.
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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 Which response by the student indicates an understanding of the purpose for administering this drug?
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"This drug is given to the newborn to prevent and/or treat hemorrhagic disease." Rationale: 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.
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The nurse is preparing to give the infant her first bath. Which assessment data indicates that it is safe for the baby to be given her bath at this time?
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Axillary temperature of 98. Rationale: A bath may potentially lower the temperature, which will not be harmful because the core temperature is near 99° F.
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At 2400 hours the infant is crying, her skin is mottled, and her hands are shaking. What action should the nurse take first?
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Monitor the blood glucose level. Rationale: Since it has been 2 hours since delivery, the infant may be experiencing hypoglycemia.
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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. What action should the nurse take?
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Remind Ms. Carson about infant safety and assist her to place the infant in the crib. Rationale: This action protects the baby while reinforcing teaching to the mother
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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 baby's temperature, which is 97.6° F. What action should the nurse take?
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Show Ms. Carson how to wrap the baby for warmth and apply the cap to her head. Rationale: This action not only protects the baby, but also involves and teaches the mother.
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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. What action should the nurse take?
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Observe Ms. Carson as she performs a diaper change. *This approach helps the nurse evaluate the problems Ms. Carson is experiencing so the most effective teaching can be provided. Advise Mrs. Carson that classes to teach infant care are available on the unit.
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When Ms. Carson removes the diaper, the nurse notices that the baby has caked powder in the inguinal leg folds and vulva areas.
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Instruct Ms. Carson to use plain water instead of powder. Rationale: 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.
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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. What explanation should the nurse give?
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Withdrawal of maternal hormones is the usual cause of this occurrence." Rationale: This is called pseudomenstruation, which is due to the effects of maternal hormones.
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At two days post birth, Ms. Carson and her baby are doing well and preparing for discharge. The baby's 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. How should the nurse respond?
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"Don't be concerned. Your baby's weight loss is in the typical range for all babies." Rationale: Babies may lose up to approximately 10% of their birth weight.
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Ms. Carson is told that a neonatal screening test needs to be done before they are discharged When asked the reason for including the PKU test in the screening, which information should the nurse provide?
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A problem converting the protein, phenylalanine, may be present, which can lead to mental retardation if not found and treated early. Rationale: PKU testing is done to detect the level of phenylalanine in the baby's blood.
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How should the nurse collect the blood needed for PKU screening?
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Puncture the lateral heel after warming and collect blood samples on the designated lab form. Rationale: 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.
