OB Chapter 24

What should the nurse instruct the parents about traveling with the infant in a car? Secure the infant in a rear-facing car seat in the rear of the car.

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The nurse is providing discharge instructions related to the baby's respiratory system. Which statement should be included as part of discharge teaching? Prevent exposure to people with upper respiratory tract infections Keep the infant away from secondhand smoke Avoid loose bedding, waterbeds, and beanbag chairs

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. Avoid exposure to people with respiratory tract infections. The infant should be laid down to sleep on his or her back for better breathing and to prevent sudden infant death syndrome. Asthma is not a contagious affliction and it wouldn't be a problem for the infant to be around a person with it. Test-Taking Tip: Have confidence in your initial response to an item because it more than likely is the correct answer. p. 589

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 what? Petechiae are benign if they disappear within 48 hours of birth.

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. Test-Taking Tip: Be alert for grammatical inconsistencies. If the response is intended to complete the stem (an incomplete sentence) but makes no grammatical sense to you, it might be a distractor rather than the correct response. Question writers typically try to eliminate these inconsistencies. p. 570

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. What information should be given to the infant's parents based on the knowledge of petechiae? Are benign if they disappear within 48 hours of birth

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. p. 570

Which interventions should the nurse perform to record the respiratory rate of a newborn 12 hours after birth? Count the rise and fall of the abdomen. Observe for symmetry of chest movement. Assess the infant's respiratory rate.

Respiration in a newborn is abdominal in nature and can be counted by observing or slightly feeling the rise and fall of the abdomen. The nurse must observe for symmetry of chest movement and watch for signs of respiratory distress or apnea. The respiratory rate varies with the state of alertness and activity. It is preferable to observe the respiratory rate when the infant is asleep. Respiration should be counted for one full minute to obtain an accurate count. There may be periods of apnea when respiration can cease for about 20 seconds and resume again. The infant may cry and struggle while the nurse determines the axillary temperature. This can affect the respiration rate. Hence, the nurse must assess the respiratory rate before obtaining the temperature.

The nurse is assessing a newborn after 1 hour of delivery and finds that the newborn has chlamydia conjunctivitis. What prescription does the nurse expect from the primary healthcare provider? A 14-day course of oral sulfonamide

A 14-day course of oral sulfonamide is prescribed for chlamydia conjunctivitis. Apart from sulfonamide, oral erythromycin is also prescribed to treat chlamydia conjunctivitis, but only for a 14-day course. A 28-day course will increase the adverse effects in the newborn. Topical tetracycline and topical silver nitrate are ineffective in the treatment of chlamydia conjunctivitis. p. 569

The nurse is counseling the parents of an infant who has physiologic jaundice after birth. At the time of discharge the mother asks, "What care should I take to prevent reoccurrence of jaundice in my baby?" How will the nurse respond to the mother's question? "Breastfeed your baby 10 times a day."

Breastfeeding is one of the best strategies to avoid hyperbilirubinemia, which in turn prevents jaundice in the baby, because it promotes the excretion of bilirubin through stools. Therefore giving the baby breast milk 10 times a day is recommended. Skin-to-skin contact helps promote thermoregulation in a child, but does not affect the bilirubin levels. Cow's milk is not suggested in a newborn, because it has nutrition imbalances. A bulb syringe is used to clear obstructions in the baby's airway, but is not used to reduce bilirubin levels. p. 571

The nurse is counseling the parents of an infant who has physiologic jaundice after birth. At the time of discharge the mother asks, "What care should I take to prevent reoccurrence of jaundice in my baby?" How will the nurse respond to the mother's question? "Breastfeed your baby 10 times a day."

Breastfeeding is one of the best strategies to avoid hyperbilirubinemia, which in turn prevents jaundice in the baby, because it promotes the excretion of bilirubin through stools. Therefore giving the baby breast milk 10 times a day is recommended. Skin-to-skin contact helps promote thermoregulation in a child, but does not affect the bilirubin levels. Cow's milk is not suggested in a newborn, because it has nutrition imbalances. A bulb syringe is used to clear obstructions in the baby's airway, but is not used to reduce bilirubin levels. p. 571

he nurse hands over a newborn to the mother after phototherapy. After some time the mother reports that the child has loose stools. What would account for the infant's loose stools? Bilirubin-induced gastric motility.

The breakdown of bilirubin increases gastric motility, which results in loose stools that can cause skin excoriation and breakdown. The infant's buttocks must be cleaned after each stool to maintain skin integrity. Loose stools are not caused by decreased body fluids; instead the loose stools lead to decreased body fluids and dehydration in the body. Administration of glucose water or plain water perpetuates enterohepatic circulation, but delays the bilirubin excretion from the body. Administration of infant formula after phototherapy is highly beneficial to the infant to combat dehydration due to fluid loss from the body. However, it does not lead to loose stools. p. 563

Which intervention should the nurse perform to determine the baseline measurements of a newborn's physical growth? Measure the circumference of the head just above the eyebrows.

The circumference of the newborn's head is measured at the widest part, which is the occipitofrontal diameter. The tape measure is placed around the head just above the infant's eyebrows. The nurse does not hold the infant while obtaining the weight; instead she places only a hand over the naked newborn to prevent it from falling off the scales. The nurse places the newborn on a flat surface with the head placed against a perpendicular surface with the legs extended until the knee is flat against the surface to measure length. The nurse checks for palmar reflex by placing a finger in the newborn's palm. The plantar reflex is checked by stimulating the base of the toes with a finger. 564

With regard to umbilical cord care, nurses should be aware of what? The stump can easily become infected

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. Test-Taking Tip: Key words or phrases in the stem of the question such as first, primary, early, or best are important. Similarly, words such as only, always, never, and all in the alternatives are frequently evidence of a wrong response. As in life, no real absolutes exist in nursing; however, every rule has its exceptions, so answer with care. p. 565

The nurse reports a neonate's heart rate as 9 beats in 6 seconds. What does the nurse expect the healthcare provider to advise in order to restore the normal heart rate? Provide ventilation support.

The heart rate reported as 9 beats in 6 seconds can be taken as 90 beats/minute. When the heart rate is below 100 beats/minute, the PHP would instruct the nurse to give ventilation support to the infant. Intravenous (IV) epinephrine is administered when the heart rate is still below 60 beats/minute even after providing chest compressions. Infusing normal saline is not indicated for a heart rate of 90 beats/minute. Therefore, the PHP prescribes chest compression if the heart rate is less than 60 beats/minute, but not less than 90 beats/minute. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. Example: If you are being asked to identify a diet that is specific to a certain condition, your knowledge about that condition would help you choose the correct response (e.g., cholecystectomy = low-fat, high-protein, low-calorie diet). p. 567

The nurse is assessing the neurologic activity of a neonate. What observation should the nurse report? The ability to suck

The neurologic assessment of neonates is performed by determining reflex behaviors, such as sucking, rooting, and grasping. The head circumference and the body measurements indicate the physical growth of a neonate. The neonate's abdominal movements are related to the respiratory rate and do not relate to the neonate's neurologic activity. p. 564

The nurse must administer erythromycin ophthalmic ointment to a newborn after birth. What should the nurse do? Cleanse eyes from inner to outer canthus before administration.

The newborn's eyes should be cleansed from the inner to the outer canthus before the administration of erythromycin ointment. 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. 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. pp. 568, 595

A nurse must administer erythromycin ophthalmic ointment to a newborn after birth. How should the nurse do this? Cleanse eyes from inner to outer canthus before administration if necessary

The newborn's eyes should be cleansed if necessary before the administration of erythromycin ointment. Instillation of the ointment can be delayed for up to 2 hours to facilitate eye-to-eye contact between the newborn and parents, an activity that fosters bonding and attachment, especially for fathers. Erythromycin ointment 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 ointment. p. 569

The nurse is caring for a full term infant immediately after birth. The infant is crying and has good muscle tone. What interventions should the nurse perform for this infant? Assess the airway and keep the neck slightly extended. Assess the heart rate by grasping the base of the cord. Place identically numbered bands on the infant and mother.

The nurse must assess the airway and place the infant with the neck slightly extended to ensure a patent airway. The nurse assesses the heart rate quickly by grasping the base of the cord or by auscultating the left chest with a stethoscope. Identically numbered bands are placed on the infant's wrist and ankle, on the mother, and on the father or significant other. The infant is not washed immediately after birth. The naked infant is placed prone on the mother's chest to provide warmth and dried with vigorous rubbing. Vigorous rubbing prevents evaporative heat loss and provides tactile stimulation to stimulate respiratory effort. The infant is footprinted with ink or a scanning device within 2 hours of birth to aid in protection against infant abduction. pp. 549, 551

The nurse is assessing the vital signs of a neonate 12 hours after birth. Which method should the nurse use to check the infant's temperature? Axillary route

The nurse must assess the neonate's temperature using the axillary route. This method is a safe and accurate measurement of temperature. Rectal temperatures should not be obtained for a neonate because there is a risk of perforation. Temperature is not assessed by the temporal artery or tympanic route in the newborn, because the result of this measurement is considered inaccurate. STUDY TIP: Try to decrease your workload and maximize your time by handling items only once. Most of us spend a lot of time picking up things we put down rather than putting them away when we have them in hand. Going straight to the closet with your coat when you come in instead of throwing it on a chair saves you the time of hanging it up later. Discarding junk mail immediately and filing the rest of your bills and mail as they come in rather than creating an ever-growing stack saves time when you need to find something quickly. Filing all items requiring further attention in some fashion helps you remember to take care of things on time rather than being so engrossed in your schoolwork that you forget about them. Many nursing students have had their power or telephone service cut off because the bill simply was forgotten or buried in a pile of old mail. p. 552

The nurse is caring for a newborn with a high bilirubin level. What intervention does the nurse perform while using a fiberoptic blanket and phototherapy light for the newborn? Cover the newborn's eyes with an opaque mask.

The nurse must ensure that the newborn's eyes are closed and covered with an opaque mask to prevent retinal damage. Phototherapy lights can increase the rate of insensible water loss leading to dehydration. The newborn must receive breastfeeding or infant formula rather than glucose water to promote hydration and excretion of bilirubin in the stools. The infant is usually clothed with a diaper to provide maximum skin exposure to the phototherapy light. Although fiberoptic lights do not produce much heat, the nurse should ensure that a covering pad is placed between the newborn's skin and the fiberoptic device to prevent skin burns. p. 572

The nurse is providing information about caring for the infant at home after discharge. What teaching by the nurse is appropriate if the infant has a "common cold?" Hold the infant in an upright position when feeding.

The nurse must teach the parents to hold the infant in an upright position when feeding to relieve the discomfort from accumulated secretions. The nurse must teach the parents to avoid use of a pillow to raise the infant's head. The head of the mattress must be elevated by 30 degrees to raise the infant's head and chest. The nurse must teach the parents not to overdress the infant, but to avoid drafts. The infant must be fed frequently in small amounts to prevent overtiring. p. 590

The nurse is assessing the body temperature of a neonate born 8 hours ago by placing the neonate on the mother's abdomen. The nurse finds that the neonate's body temperature is decreasing gradually. Based on these findings, the nurse concludes the mother's record to be normal. Which maternal condition is responsible for the neonate's decreasing body temperature? The mother has been administered magnesium sulfate.

The nurse places the neonate on the mother's abdomen to maintain thermoregulation. If the mother has been administered magnesium sulfate, the newborn may develop vasoconstriction. This reduces the newborn's ability to conserve heat. Though the birth was through cesarean section, the newborn's temperature should stabilize within 9 hours after the birth in extrauterine life. Neither gestational hyperglycemia nor Ringer's lactate solution would prevent thermoregulation between the neonate and the mother. p.554

A client with a history of gonorrheal infection has just delivered a baby. What immediate intervention should the nurse provide to the newborn to ensure safety? Administer ophthalmic solution.

The nurse should administer erythromycin ophthalmic solution to the newborn within 2 hours of birth to prevent ophthalmia neonatorum caused by gonorrheal infection. Incubation is preferred when a neonate has hypothermia in order to regulate the body temperature. Heelstick puncture is performed to detect abnormalities in blood levels only if the neonate has any infection. Ventilator support is provided if the neonate's heart rate is below 100 beats/minute. However, the heart rate is not decreased due to gonorrheal infection. p. 568

A client with a history of gonorrheal infection has just delivered a baby. What immediate intervention should the nurse provide to the newborn to ensure safety? Administer ophthalmic solution.

The nurse should administer erythromycin ophthalmic solution to the newborn within 2 hours of birth to prevent ophthalmia neonatorum caused by gonorrheal infection. Incubation is preferred when a neonate has hypothermia in order to regulate the body temperature. Heelstick puncture is performed to detect abnormalities in blood levels only if the neonate has any infection. Ventilator support is provided if the neonate's heart rate is below 100 beats/minute. However, the heart rate is not decreased due to gonorrheal infection. p. 568

While reading the medical record of a newborn, the nurse learns that the baby is suspected to have Potter syndrome. What observation from the newborn's assessment sheet validates this suspected condition? Urinary output

The nurse should check the newborn's urinary output to validate Potter syndrome, because a newborn with this condition does not void in the first 24 hours after birth. Therefore Potter syndrome will reduce the urinary output of the neonate. A barrel-shaped chest is a common finding in any newborn. Webbing around the neck region of the neonate is a primary symptom of Turner syndrome, but it is not associated with Potter syndrome. Pinkish coloration of the skin is a normal finding in any healthy neonate, and is not associated with Potter syndrome. p. 561

The nurse is caring for an infant circumcised with the PlastiBell device. What should the nurse teach the parents before discharging the infant from the health care facility? Inspect the circumcision at least every 4 hours. Retain yellow exudate over the glans penis. Report redness, swelling, discharge, or odor.

The nurse should teach the parents to change the diaper and inspect the circumcision at least every 4 hours. The parents should check for bleeding and urination. A yellow exudate covers the glans penis after circumcision. Parents should not wipe this away, because it is normal. Parents should report any redness, swelling, discharge, or odors to the pediatrician, because these are signs of infection. The penis should be washed with warm water without soap until the circumcision is healed in 5 to 6 days. The parents need not apply petrolatum to the circumcision performed with the PlastiBell device. Petrolatum is applied if the clamp technique was used for circumcision. p. 582

The nurse is teaching the parents of a neonate how to use a bulb syringe to suction mucus. Which instruction should the nurse include in the teaching? Insert the tip of the bulb into the side of the mouth.

The nurse should teach the parents to insert the tip of the bulb into the side of the mouth to perform a suction of the mucus. It should not be inserted in the center of the mouth to prevent stimulation of the gag reflex. The bulb syringe should always be kept in the infant's crib so that it can easily be used whenever required. The tip of the bulb should be inserted into the mouth after it is compressed to create a vacuum, which will enable suctioning of the mucus. The mouth should be suctioned first followed by one nostril at a time. p. 567

What care should the nurse take while performing a heelstick for the infant? Warm the heel before taking the sample.

The nurse should warm the heel by applying heat for 5 to 10 minutes. The warmth helps to dilate the vessels in the area. The nurse should puncture the outer aspect of the heel to prevent injury by drawing an imaginary line from between the fourth and fifth toes to the heel and parallel to the lateral aspect of the foot. The puncture should be no deeper than 2.4 mm to prevent bone injury, which may lead to necrotizing osteochondritis. After collection of the blood sample, the nurse should only apply gentle pressure with a dry gauze pad and cover it with an adhesive bandage. p. 576

The nurse observes increased bilirubin levels in the laboratory reports of a newborn. Which complication does the nurse expect in the newborn if this condition is poorly monitored? Kernicterus

Very high levels of bilirubin cause kernicterus. Bilirubin is a yellow pigment that is produced in the body during the normal recycling of old red blood cells (RBCs). High levels of bilirubin in the body can cause the skin to look yellow, a condition known as jaundice. Syndactyly is a condition where two or more digits are fused together. It is not associated with increased bilirubin levels. Rectal fistula is due to the absence of the anal opening in the newborn. Down syndrome is a chromosomal defect and is not associated with increased bilirubin levels. p. 566

The nurse is required to administer vitamin K to a term newborn. How should the nurse administer this injection? Through the vastus lateralis muscle

Vitamin K injection is administered intramuscularly for the term newborn. The preferred injection site for newborns is the vastus lateralis muscle, which is denser than the dorsogluteal and the deltoid muscle. Vitamin K is never administered intravenously to prevent hemorrhagic disease of the newborn. However, intravenous administration may be considered for the preterm infant without adequate muscle mass. In this case, the medication is diluted and administered slowly over 10 to 15 minutes to prevent cardiac arrest. Vitamin K is never administered by the subcutaneous route. The injection is not administered on the dorsogluteal muscle because of inadequate muscle mass. p. 579