N144 Week 2 Case Study - Newborn with Jaundice

Question 3 of 25 At 1 minute the infant has a heart rate of 130 beats/min, has a slow weak cry, is grimacing, and has sluggish movements with acrocyanosis. Which Apgar score should the nurse assign? 10. 9. 8. 6.

6. One point each is deducted for acrocyanosis (blue hands and feet), sluggish movement, a slow weak cry, and grimacing.

Question 19 of 25 The infant has a reddish papular rash across his face. How should the nurse respond when the client asks about the rash? Don't worry about it. This rash will go away in a couple of days. I see you are concerned, so I will call your pediatrician. A newborn rash is very common, but it will disappear soon. Good question. Let me take the infant's vital signs and examine him.

A newborn rash is very common, but it will disappear soon. The infant rash, erythema toxicum, is very common and usually disappears by the third day of life. It is not necessary to call the pediatrician to respond to the mother's question.

Question 13 of 25 The nurse next prepares to administer the erythromycin ointment. Which approach should the nurse use to administer the ointment? Apply ointment across the closed eyelids and rub the eye gently. Open the eye using two fingers and apply ointment to the upper lid. Apply gentle pressure to the inner canthus after applying ointment to eyes. Cover entire lower conjunctiva with ointment after gently retracting the lid.

Cover entire lower conjunctiva with ointment after gently retracting the lid. To instill medication, the thumb and forefinger are used to open the eye. A ribbon of ointment is applied in the lower conjunctiva from the inner to the outer canthus. Typically the infant's eyes are tightly closed and ointment may not reach inside the eyelid as required.

Question 9 of 25 Upon examining the infant's extremities, which finding should the nurse report to the HCP? Bilateral legs flexed. Diminished movement in one arm. The infant's arms resist extension. Equal movement in extremities in a random manner.

Diminished movement in one arm Diminished movement in an extremity may indicate nerve damage. The infant's legs should be flexed; this is a normal finding.

Question 8 of 25 Which action should the nurse take when finding that the head measures 36 cm and the chest circumference measures 35 cm? Notify the HCP. Document the findings in the EMR. Monitor for excessively wide sutures. Verify the findings with another nurse.

Document the findings in the EMR. The head and chest circumference are within normal limits.

Question 23 of 25 While the infant receives phototherapy, his stools become loose and green. Which action should the nurse take? Change from formula to electrolyte solution. Document the findings in the EMR. Send a stool specimen to the laboratory. Reduce the amount of formula feedings.

Document the findings in the EMR. The loose green stools are a typical response to phototherapy, so stools should continue to be monitored and results documented. The amount of fluids should be increased, not decreased, at this time.

Question 7 of 25 Which action should the nurse take? Document the findings in the electronic medical record (EMR). Stimulate the infant to breathe by stroking his feet. Notify the healthcare provider about the findings. Provide oxygen by tube or mask close to infant's nose.

Document the findings in the electronic medical record (EMR). The infant's vital signs are within normal parameters and the soft murmur is an expected finding with the infant. The respiratory rate is within normal limits, and stimulation is not needed.

Section 1 Infant Care at Birth Question 1 of 25 Which action should the nursery nurse take first in caring for the infant? Dry the infant quickly with warm blankets. Use a scale to immediately weigh the infant. Apply a temperature probe. Cover the infant's head using a soft cap.

Dry the infant quickly with warm blankets. Drying the infant is a priority to prevent evaporative heat loss. Weighing the infant can be delayed and another intervention done first. Applying a temperature probe is a common procedure when a radiant warmer is used; however, another action should come first. A cap should be placed on the infant's dry head to further prevent heat loss; however, another action should be taken first.

Question 6 of 25 To promote family bonding, which part of infant care should the nurse delay? Giving Vitamin K. Securing ID bands. Providing cord care. Giving eye prophylaxis.

Giving eye prophylaxis. The presence of eye ointment or drops can interfere with eye-to-eye parent/infant interaction. Giving eye prophylaxis can be delayed until the end of the first hour after birth or after the first breastfeeding. This injection can be delayed, but another answer is best. Although this is a safety measure, it does not interfere with bonding. This care is usually delayed until after the first bath, but it does not interfere with bonding.

Question 15 of 25 The nurse instructs the family about feeding the infant. The mother asks how often the infant should be burped. Which is the best response by the nurse for how often the infant should be burped? Click for Image Click for Image It is a good time to burp the infant when he stops sucking. The infant should be burped before and after each feeding. Burping should be done when the infant begins to get sleepy. He needs burping after 1 to 1.5 ounces (30-45 mL) of formula and at the end of the feeding.

He needs burping after 1 to 1.5 ounces (30-45 mL) of formula and at the end of the feeding. This gives specific guidelines to the parents.

Question 24 of 25 Which instructions should the nurse include in the discharge planning? The phototherapy blanket is placed over the infant's clothing. Holding the infant does not interrupt the phototherapy process. A phototherapy blanket is more effective than the overhead lights. The length of time required for phototherapy intervention is decreased.

Holding the infant does not interrupt the phototherapy process. The phototherapy blanket allows the infant to be held while the process is continued. Although diapers can be worn, the blanket is placed next to the skin on the trunk of the body to expose as much skin as possible to the light. Both are equally effective. The length of time is not decreased by the blanket.

Question 4 of 25 After receiving the labor and delivery report, which information should direct the nurse to further assessment of the infant's head? Thirteen hours of labor. Low forceps delivery. Unusual cord length. Vaginal delivery.

Low forceps delivery. Low forceps delivery is usually done with minimal risk, but there is a potential for head trauma or damage to the facial nerve. Thirteen hours of labor is typical for a primigravida and should have minimal effects on the infant's head. A long cord can wrap around the neck (nuchal cord) and can possibly cause asphyxia, but further assessment of the head is not needed. An infant delivered vaginally may have some molding, but another piece of reported information is more important.

Question 21 of 25 The nurse observes that the infant is jaundiced on his face, head, and chest. Which action should the nurse take next? Obtain blood for laboratory analysis. Monitor the infant for increasing jaundice. Give the infant water to promote bowel movements. Anticipate changing from milk to soy-based formula.

Obtain blood for laboratory analysis. Blood drawn for serum bilirubin provides additional data and the basis for treatment of hyperbilirubinemia, which may be physiologic or nonphysiologic. Although the nurse should monitor the infant, another action should be done first. Typically, feedings are increased for formula-fed and breastfed infants. Although water may be given later, another action should be done first. Jaundice is not related to milk or soy-based formula but is usually related to a decreased ability of the liver to conjugate bilirubin.

Question 11 of 25 When the nurse conducts a gestational age assessment, which findings may indicate postmaturity? (Select all that apply. One, some, or all options may be correct.) Select all that apply Testes descended, good rugae. Formed ears with instant recall. Peeling, parchment-like skin. Thin with loose skin and little subcutaneous fat. Deep creases at the base of the toes extending to the heels.

Peeling, parchment-like skin. Thin with loose skin and little subcutaneous fat. Deep creases at the base of the toes extending to the heels. This is one indicator of postmaturity because vernix caseosa disappears. Subcutaneous fat, which had been used for nourishment, is lost prior to birth. This results in the infant's low temperature. Postterm infants develop deep creases on the feet, extending from the base of the toes to the heels. This finding occurs as early as 38 weeks' gestation. This finding is not related to postmaturity.

Question 5 of 25 Which action should the nurse take prior to weighing the infant? Provide a pacifier. Place a diaper on the infant. Place a cover on the scale. Keep the cap on the infant's head.

Place a cover on the scale. The infant should be weighed nude, and covering the scale prevents conductive heat loss. Pacifiers are not usually provided at delivery and a pacifier may add to the infant's weight. A diaper may add to the infant's initial weight and should not be in place. Although a cap will prevent heat loss, it may add to the infant's initial weight and should not be in place.

Question 2 of 25 After clearing the airway with a bulb syringe and drying the infant with warm blankets, the nurse assesses that the infant is breathing and has a heart rate of 124 beats/min, but remains cyanotic. Which action should the nurse take? Click for Image Apply temperature probe. Prepare to give oxygen. Wrap the infant warmly. Secure a suction catheter.

Prepare to give oxygen. The infant is breathing and has a heart rate. However, oxygen given during this critical transition can increase oxygenation to the rest of the body. Further suctioning is not needed since the infant is breathing on his own. Another response is best.

Question 17 of 25 Which action should the nurse take? Remove the bottle from the infant's mouth. Refer the family to social services for further evaluation. Instruct the client not to leave the bottle propped on the towel. Take the infant to the newborn nursery.

Remove the bottle from the infant's mouth. The primary concern is for the safety of the infant. Propping a bottle places the infant at risk for choking as well as ear infections.

Question 22 of 25 The bilirubin serum level comes back at 8 mg/dL. The infant is diagnosed with pathologic hyperbilirubinemia. The nurse prepares the infant for placement under a bilirubin light. Which actions should the nurse implement? (Select all that apply. One, some, or all options may be correct.) Click for Image Select all that apply Remove the infant's clothing. Anticipate starting IV fluids. Keep the infant in one position. Place eye patches on the infant. Turn off the lights and allow parents to hold infant for feedings.

Remove the infant's clothing. Place eye patches on the infant. Turn off the lights and allow parents to hold infant for feedings. Although some agencies will leave a diaper in place, it is important to expose as much of the skin as possible. Eye covering is important during phototherapy to prevent retinal injury from the phototherapy lights. Removing the infant from phototherapy for feedings and interactions with parents for periods up to one hour at a time does not decrease effectiveness of phototherapy. This also provides needed sensory stimulation for the infant. IV fluids are not needed at this time. It is important to change the infant's position every 1 to 2 hours to expose as much skin as possible.

Question 12 of 25 While administering the vitamin K to the infant, which action should the nurse take? Select the middle third of the vastus lateralis for use. Place the infant on the abdomen for better visualization. Use the V technique after cleaning the ventral gluteal area. Administer the medication using a 22 gauge, ½ inch needle.

Select the middle third of the vastus lateralis for use. This muscle is the preferred site in infants for administration of injections. V technique is used for the ventral gluteal area, but injections are not given in this area for infants. This needle selection is too large for an infant.

Question 25 of 25 The client asks how she will know the phototherapy is working. How should the nurse respond? Stools are loose and bright green. Formula feedings increase. Serum bilirubin level decreases. Skin is resilient with no indications of jaundice.

Serum bilirubin level decreases. Decreasing bilirubin levels are the best indicator of phototherapy effectiveness. Although this occurs, it is not the best indicator of phototherapy effectiveness. The appetite will not be changed. This is not the best indicator of effectiveness.

Question 10 of 25 The nurse performs a newborn assessment and evaluates the infant's reflexes. How does the nurse perform the Moro reflex? Hold the infant upright with his feet touching a solid surface. Place a finger in the infant's palm and assess whether the infant's hand closes in a fist. Slightly raise the infant's head and trunk and allow the infant to drop back 30 degrees. Stroke the lateral side of the sole of the infant's foot from the heel to the ball of the foot.

Slightly raise the infant's head and trunk and allow the infant to drop back 30 degrees. This would elicit the infant's arms and legs to extend and abduct, with fingers fanning open. This would elicit the infant's arms and legs to extend and abduct, with fingers fanning open. Holding the infant upright with his feet touching a solid surface would elicit the stepping reflex. This is the palmar grasp reflex. This is done to elicit the Babinski reflex.

Question 16 of 25 When the client finishes feeding the infant, she checks the diaper and it is dry. The client's partner expresses concern that the infant is becoming dehydrated. In view of the partner's concern, how should the nurse respond? Click for Image The infant should have at least 6 voids per day. The infant should have urine that appears dark orange. The infant should have pink-tinged urine. The infant should have 1 or 2 voids per day.

The infant should have 1 or 2 voids per day. To maintain fluid balance, infants in the first 3 to 5 days of life should have 1 or 2 voids per day. By the fourth day of life, the infant should void at least six times daily. The urine should be yellow in color. The newborn's urine may contain uric acid crystals that can cause a pink stain on the diaper, but this is not related to dehydration.

Question 20 of 25 Which factor should alert the nurse to assess for the risk of jaundice? Post-mature gestational age. Providing formula feedings. Passage of meconium stools. Trauma at birth.

Trauma at birth. The presence of a cephalhematoma indicates trauma during birth and bleeding has occurred. As the red blood cells break down, increased amounts of bilirubin are released into the general circulation. Post-maturity does not necessarily contribute to jaundice. Diminished frequency of feedings may contribute to jaundice, but not formula feeding itself. Passage of meconium stools decreases the risk for jaundice.

Question 14 of 25 Which action should the nurse implement first? Support the infant in side-lying position. Place the infant supine in the crib. Use a bulb syringe to clear the mouth and nose. Secure a delee catheter to wall suction for use.

Use a bulb syringe to clear the mouth and nose. Gagging due to excessive mucus is a typical response during the transition period. Suctioning the mouth and nose should be done first.

Question 18 of 25 The nurse conducts the change of shift assessment of the infant. Which finding by the nurse is consistent with a cephalohematoma? Head shaped into the appearance of a dunce cap. Swelling of the scalp that crosses the suture line. Well-outlined swelling that does not cross suture lines. Softening of the cranial bones that indent with pressure.

Well-outlined swelling that does not cross suture lines. Cephalhematoma is caused by increased pressure or trauma at birth from blood collecting beneath the periosteum of the bone and therefore does not cross the suture line. This describes molding. This describes caput succedaneum. This describes craniotabes.