CH 26: Nursing Care and Discharge Teaching
When would you not want to bathe a baby?
*Bathing shouldn't be done immediately after feeding to prevent spitting up and vomiting*.
*What medication can be administered post-procedure?*
*Liquid acetaminophen* 10 to 15 mg/kg can be administered orally after the procedure and repeated every 4 to 6 hr as prescribed for a maximum of 30 to 45 mg/kg/day.
*How should the newborn be placed while sleeping to prevent SIDS?*
*Supine position*
2. a nurse is reviewing contraindications for circumcision with a newly hired nurse. Which of the following conditions are contraindications? (select all that apply.) a. hypospadias B. hydrocele C. Family history of hemophilia d. hyperbilirubinemia e. epispadias
*a. CORRECT: hypospadias involves a defect in the location of the urethral opening and is a contraindication to circumcision. * B. hydrocele, a collection of fluid in the scrotal sac, is not a contraindication to circumcision. *C. CORRECT: a family history of hemophilia is a contraindication for circumcision. * d. hyperbilirubinemia is not a contraindication for circumcision. *e. CORRECT: epispadias involves a defect in the location of the urethral opening and is a contraindication to circumcision.*
When are you allowed to bath the baby by immersion?
Bathing by immersion is not done until the newborn's umbilical cord has fallen off and the circumcision has healed, if applicable.
When is it not appropriate to initiate circumcision?
Circumcision should not be done immediately *following birth because the newborn's level of vitamin K is at a low point, and the newborn would be at risk for hemorrhage*
What should you not do to a newborn's neck?
Do not tie anything around the newborn's neck.
What are examples of instruments used to perform a circumcision?
Gomco (Yellen) or Mogen clamp, or Plastibell device
How to cleanse a female newborn's perineum?
In female newborns, wash the vulva by wiping from *front to back* to prevent contamination of the vagina or urethra from rectal bacteria.
How to cleanse & care for an *uncircumcised* penis?
In male newborns, to cleanse an uncircumcised penis, wash with soap and water and rinse the penis. *The foreskin should not be forced back or constriction can result.*
What is the proper way of cleansing a baby?
Move from the cleanest to dirtiest part of the newborn's body beginning with his eyes, face, and head; proceed to the chest, arms, and legs; wash the groin area last.
What are the restrictions in terms of feeding the baby before the circumcision?
Newborn will not be able to be bottle feed for up to 2-3 hr prior to the procedure to prevent vomiting and aspiration based on the preferences of the provider. Newborns who are breastfed can nurse up until the procedure.
What are some Nonpharmacologic methods that can be used to enhance pain management?
Swaddling and Nonnutritive sucking (sucrose pacifier)
What should parents avoid using to clean the penis?
Teach the parents to avoid using premoistened towelettes to clean the penis because they contain alcohol.
*What can form over the glans by day two & what should the parents be told not to do?*
Tell the parents that a film of *yellowish mucus (expected finding) can form over the glans by day two, and it is important not to wash it off.*
How can you clean a baby's eyes?
The newborn's eyes should be cleaned using a clean portion of the wash cloth. Clear water should be used to clean each eye, moving from the inner to the outer canthus.
1. a nurse is reviewing care of the umbilical cord with the parent of a newborn. Which of the following instructions should the nurse include in the teaching? a. Cover the cord with a small gauze square. B. Trickle clean water over the cord with each diaper change. C. apply hydrogen peroxide to the cord twice a day. d. Keep the diaper folded below the cord.
a. Covering the cord with a gauze square prevents the cord from drying and encourages infection. B. Water should not be applied to the cord. C. The cord should be kept clean and dry. hydrogen peroxide is not applied to the cord site. *d. CORRECT: Folding the diaper below the cord prevents urine from the diaper penetrating the cord site.*
3. a nurse is providing discharge teaching to the parents of a newborn regarding circumcision care. Which of the following statements made by a parent indicates an understanding of the teaching? a. "his circumcision will heal within a couple of days." B. "i should remove the yellow mucus that will form." C. "i will clean his penis with each diaper change." d. "i will give him a tub bath within a couple of days."
a. The circumcision will heal within a couple of weeks. B. The yellow mucus should remain in place as part of the healing process. *C. CORRECT: The penis should be cleaned with warm water with each diaper change.* d. a tub bath should not be given until the circumcision is healed.
5. a nurse is reviewing car seat safety with the parents of a newborn. Which of the following instructions should the nurse include in the teaching regarding car seat position? a. Front seat, rear‑facing B. Front seat, forward‑facing C. Back seat, rear‑facing d. Back seat, forward‑facing
a. This is not an appropriate position for the car seat. B. This is not an appropriate position for the car seat. *C. CORRECT: The newborn should be restrained in a car seat in a rear‑facing position in the back seat until 2 years of age. * d. This is not an appropriate position for the car seat.
4. a nurse is caring for a newborn immediately following a circumcision using a gomco procedure. Which of the following actions should the nurse implement? a. apply gelfoam powder to the site. B. Place the newborn in the prone position. C. apply petroleum gauze to the site. d. avoid changing the diaper until the first voiding.
a. gelfoam powder is used to control bleeding when there is a risk for hemorrhage. B. Newborns should not be placed in the prone position. *C. CORRECT: Petroleum gauze is applied to the site for 24 hr to prevent the skin edges from sticking to the diaper.* d. diapers are changed more frequently to inspect the site.
*Review on # stools & voids for both breastfed/formula babies!*
● *Breastfed* newborns should have *3 or more bowel movements* per day ● *Formula* (bottle) fed newborns are *less frequent* ● Breastfed newborns should have *six or more wet diapers per day* ● Formula-fed infants have a similar number of voids.
*Car seat safety*
● *Rear-facing car seat in the back seat* ● *Preferably in the middle (away from air bags and side impact)* ● Put car seat at a *45 degree angle* ● Keep infants in rear-facing car seats until age 2 or until the child reaches the maximum height and weight for the seat.
*Cord care*
● Before discharge, the cord clamp is removed. ● *Prevent cord infection by keeping the cord dry, and keep the top of the diaper folded underneath it* ● *Sponge baths are given until the cord falls off, which occurs around 10 to 14 days* after birth. Tub bathing and submersion can follow. ● Cord infection (a complication of improper cord care) can result if the cord is not kept clean and dry. ◯ *Monitor for manifestations of a cord that is moist and red, has a foul odor, or has purulent drainage*. ◯ Notify the provider immediately if findings of cord infection are present.
Nursing interventions: Hemorrhage
● Monitor the newborn for bleeding. ● Provide gentle pressure on the penis using a small gauze square. ●Gelfoam powder or sponge can be applied to stop bleeding. ●If bleeding persists, notify the provider that a blood vessel can need to be ligated. ●Have a nurse continue to hold pressure until the provider arrives while another nurse prepares the circumcision tray and suture material.
Nursing interventions: Cold stress/hypoglycemia
● Monitor the newborn for excessive loss of heat resulting in increased respirations and lowered body temperature. ● Swaddle and feed the newborn as soon as the procedure is over.
How should the newborn's be made up & what should not be placed inside the crib?
● NEVER provide a newborn with a soft surface to sleep on (pillows or water bed). ● The *newborn's mattress should be firm*. ●*NEVER put pillows, toys, bumper pads, or loose blankets in a crib*. ●*Crib linens should be tight-fitting*.
How should a newborn be placed while sleeping & how can it be placed while awake?
● Never place the newborn on his stomach to sleep during the first few months of life. ●*The back-lying position is the position of choice. * ●The newborn can be *placed on his abdomen when awake and being supervised*.
Contraindications for Circumcision
● Newborns born with hypospadias (abnormal positioning of urethra on ventral under-surface of the penis) and epispadias (urethral canal terminates on dorsum of penis) because the prepuce skin can be needed for surgical repair of the defect ● Familiar history of bleeding disorders: Hemophilia ● *Newborns who are circumcised and whose parents decline vitamin K can be more likely to experience bleeding at the circumcision site, especially if they are breastfed.*
*What adverse effects should be reported to the doctor after the circumcision?*
● Redness ●Discharge ●Swelling ●Strong odor ●Tenderness ●Decrease in urination ●Excessive crying from the newborn ●Frank bleeding
What are some quieting techniques?
● Swaddling ● Close skin contact ● Nonnutritive sucking with pacifier ● Rhythmic noises to simulate utero sounds ● Movement (a car ride, vibrating chair, infant swing, rocking newborn) ● Placing the newborn on his stomach across a holder's lap while gently bouncing legs ● En face position for eye contact (when parents and newborns faces are about 30 cm (12 in) apart and on the same plane ● Stimulation
Instruction to provide the parents on how to properly clothe their newborn?
● The best clothing is soft and made of cotton. ● Clothes should be washed separately with mild detergent and hot water. ● Dress lightly for indoors and on hot days. Too many layers of clothing or blankets can make the newborn too hot. ● On cold days, cover the newborn's head when outdoors. ● A general rule is to dress the newborn as the parents would dress themselves.
*Review on feeding a baby!*
● The newborn is *offered the breast immediately after birth* and frequently thereafter. ● Newborns need to be breastfed at least *8 to 12 times in a 24-hr period*. ● Newborns who are breastfed will average *15 to 20 min per breast* and 30 to 40 min for the total feeding. ● Feeding for a newborn who is *breastfeeding* should be on demand or every *2 to 3 hr* ● Newborns who are *formula-fed* should also be fed on demand or every *3 to 4 hr*. ● Parents should *awaken the newborn* to feed at least *every 3 hr during the day* and at least *every 4 hr at night*. ● Once the newborn is feeding well and gaining weight adequately, going to demand feeding is appropriate.
Where should and should not a crib be placed?
● The newborn's crib or playpen should be away from window blinds and drapery cords. Newborns can become strangled in them. ● The bassinet or crib should be placed on an inner wall, not next to a window, to prevent cold stress by radiation.
Gomco (Yellen) or Mogen clamp *What can you cover the wound with to prevent infection & control bleeding?*
● The provider applies the Gomco (Yellen) or Mogen clamp to the penis, loosens the foreskin, and inserts the cone under the foreskin to provide a cutting surface for removal of the foreskin and to protect the penis. ● *The wound is covered with sterile petroleum gauze to prevent infection and control bleeding.* -Keeps the penis from sticking to the diaper
Plastibell device *What should you avoid using w/ circumcision w/ a Plastibell?*
● The provider slides the Plastibell device between the foreskin and the glans of the penis. ●The provider ties a suture tightly around the foreskin at the coronal edge of the glans. ●This applies pressure as the excess foreskin is removed from the penis. ●After 5 to 7 days, the Plastibell drops off, leaving a clean, healed excision. ●*No petroleum is used for circumcision with the Plastibell*
What are some reasons why a newborn would cry? Why shouldn't try to feed your baby each time that it cries?
●Inform the parents that newborns cry when they are hungry, overstimulated, wet, cold, hot, tired, bored, or need to be burped. ●Instruct the mother not to feed her newborn every time he cries. Overfeeding can lead to stomach aches and diarrhea. ●After checking the newborn, it is okay to let her cry for short periods of time.
What instructions to provide on how to care and clean the penis after the circumcision?
●Teach the parents to keep the area clean. ●Change the newborn's diaper at least every 4 hr, ●Clean the penis with warm water with each diaper change. ●With clamp procedures, apply petroleum jelly with each diaper change for at least 24 hr after the circumcision to keep the diaper from adhering to the penis. ● Avoid wrapping the penis in tight gauze, which can impair circulation to the glans. ● A tub bath should not be given until the circumcision is healed. Until then, warm water should be trickled gently over the penis.
What should be considered to maintain the safety of a crib?
●The space between the mattress and sides of the crib should be less than 2 fingerbreadths. ●The slats on the crib should be no more than 5.7 cm (2.25 in) apart.
