ch 23 OB NCLEX
A 3.8-kg infant was delivered vaginally at 39 weeks after a 30-minute second stage. There was a nuchal cord. After birth the infant is noted to have petechiae over the face and upper back. Information given to the infant's parents should be based on the knowledge that petechiae: are benign if they disappear within 48 hours of birth Correct result from increased blood volume should always be further investigated usually occur with forceps delivery
Petechiae, or pinpoint hemorrhagic areas, acquired during birth may extend over the upper portion of the trunk and face. These lesions are benign if they disappear within 2 days of birth and no new lesions appear. Petechiae may result from decreased platelet formation. In this situation the presence of petechiae is most likely a soft-tissue injury resulting from the nuchal cord at birth. Unless they do not dissipate in 2 days, there is no reason to alarm the family. Petechiae usually occur with a breech presentation vaginal birth.
At 1 minute following birth, the newborn exhibited the following: heart rate of 155; loud, vigorous crying with active movement of all extremities; sneezing when nose is stimulated with a catheter; hands and feet bluish and cool to the touch. The Apgar score of this newborn should be recorded as________.
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As part of their teaching function at discharge, nurses should tell parents that the baby's respiratory status should be protected by the following procedures: (Select all that apply.) Prevent exposure to people with upper respiratory tract infections Correct Keep the infant away from secondhand smoke Correct Avoid loose bedding, waterbeds, and beanbag chairs Correct Do not let the infant sleep on his or her back Keep a bulb suction available at home. Correct
Infants are vulnerable to respiratory infections; infected people must be kept away. Secondhand smoke can damage lungs. Infants can suffocate in loose bedding and furniture that can trap them. The infant should be laid down to sleep on his or her back for better breathing and to prevent sudden infant death syndrome. A bulb syringe will be useful if the baby needs suctioning of the mouth and nose at home to protect the airway.
The nurse must administer erythromycin ophthalmic ointment to a newborn after birth. The nurse should: instill within 15 minutes of birth for maximum effectiveness. cleanse eyes from inner to outer canthus before administration. Correct apply directly over the cornea. flush eyes 10 minutes after instillation to reduce irritation.
Instillation of the ointment can be delayed for up to 1 hour to facilitate eye-to-eye contact between the newborn and parents, an activity that fosters bonding and attachment, especially for fathers. The newborn's eyes should be cleansed from the inner to the outer canthus before the administration of erythromycin ointment. Erythromycin should be applied into the conjunctival sac to avoid accidental injury to the eye. The eyes should not be flushed after instillation of the erythromycin.
With regard to umbilical cord care, nurses should be aware that: the stump can easily become infected. Correct a nurse noting bleeding from the vessels of the cord should immediately call for assistance. the cord clamp is removed at cord separation. the average cord separation time is 5 to 7 days.
The cord stump is an excellent medium for bacterial growth. The nurse should first check the clamp (or tie) and apply a second one. If the bleeding does not stop, then the nurse calls for assistance. The cord clamp is removed after 24 hours when it is dry. The average cord separation time is 10 to 14 days.
Newborns are at high risk for injury if appropriate safety precautions are not implemented. Parents should be taught to: place the newborn on the abdomen (prone) after feeding and for sleep. avoid use of pacifiers. use a rear-facing car seat. Correct use a crib with side rail slats that are no more than 3 inches apart.
The prone position is no longer recommended since it may interfere with chest expansion and lead to sudden infant death syndrome. Approved pacifiers are safe to use and fulfill a newborn's need to suck. If the newborn is breastfed, the use of pacifiers should be delayed until breastfeeding is well established to avoid the development of nipple confusion. Your baby should be in a rear-facing infant car safety seat from birth until age 2 years or until exceeding the car seat's limits for height and weight. Slats in a crib should be no more than 2 inches apart.
When placing a newborn under a radiant heat warmer to stabilize the temperature after birth, the nurse should: place the thermistor probe on the left side of the chest. cover the probe with a nonreflective material. recheck the temperature by periodically taking a rectal temperature. prewarm the radiant heat warmer and place the undressed newborn under it. Correct
The thermistor probe should be placed on the upper abdomen away from the ribs. It should be covered with reflective material. Rectal temperatures should be avoided since rectal thermometers can perforate the intestine, and the temperature may remain normal until cold stress is advanced. The radiant warmer should be prewarmed so the infant does not experience more cold stress.
Following circumcision of a newborn, the nurse provides instructions to his or her parents regarding postcircumcision care. The nurse should tell the parents to: apply topical anesthetics with each diaper change. expect a yellowish exudate to cover the glans after the first 24 hours. Correct change the diaper every 2 hours and cleanse the site with soap and water or baby wipes. apply constant pressure to the site if bleeding occurs and call the physician.
Topical anesthetics are applied before the circumcision. Infant-comforting techniques are generally sufficient following the procedure. Parents should be taught that a yellow exudate will develop over the glans and should not be removed. The diaper is changed frequently, but the site is cleansed with warm water only since soap and baby wipes can cause pain/burning and irritation at the site. Intermittent pressure is applied if bleeding occurs.
A mother expresses fear about changing her infant's diaper after he is circumcised. What does the woman need to be taught to take care of the infant when she gets home? Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours. Apply constant, firm pressure by squeezing the penis with the fingers for at least 5 minutes if bleeding occurs. Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change. Correct Wash off the yellow exudate that forms on the glans at least once every day to prevent infection.
With each diaper change, the penis should be washed off with warm water to remove any urine or feces. If bleeding occurs, the nurse should apply gentle pressure to the site of the bleeding with a sterile gauze square. This action is appropriate when caring for an infant who has had a circumcision. Yellow exudate covers the glans penis in 24 hours after the circumcision. This is part of normal healing and not an infective process. The exudate should not be removed.
Which of these statements are helpful and accurate nursing advice concerning bathing the new baby. (Select all that apply.) Newborns should be bathed every day, for the bonding as well as the cleaning Tub baths may be given before the infant's umbilical cord falls off and the umbilicus is healed. Correct Only plain warm water can be used to preserve the skin's acid mantle. Powders are not recommended because the infant can inhale powder. Correct Bathe immediately after feeding while baby is calm and relaxed.
Newborns do not need a bath every day, even if the parents enjoy it. The diaper area and creases under the arms and neck need more attention. Tub baths may be given as soon as an infant's temperature has stabilized. Unscented mild soap is appropriate to use to wash the infant. Powder is not recommended due to the risk of inhalation. Should a parent elect to use baby powder, it should never be sprinkled directly onto the baby's skin. The parent can apply a small amount of powder to his or her own hand and then apply to the infant. Do not bathe immediately after a feeding period because the increased handling may cause regurgitation.
