OB ATI: Chapter 26 - Nursing Care and Discharge Teaching

A nurse is reviewing care of the umbilical cord with the parent of a newborn. Which of the following should be included 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.

D

bleeding disorders

family history contraindication for circumcision, disorder

how far apart should the slats of a crib be?

less than 5.1 cm

true or false: never leave a newborn unattended with pets or other small children

true

true or false: never place newborn on their stomach to sleep during first few months, back lying position is best, but can be placed on abdomen when awake and supervised

true

sticking to specific timings for feeding

what do parents need to avoid when feeding a newborn?

cord clamp

what is removed from the newborn before discharged?

dry and fold diaper

what to do to prevent cord infection?

tub baths or submersion

what type of bath is not given during the first few days (10 to 14 days) of the newborn?

right after birth and frequently

when is the newborn offered breast milk and how often?

6 to 48 hours old

when will the mother and the newborn usually get discharged?

level of vitamin K is low, risk bleeding

why is circumcision not done right after birth?

A nurse is reviewing car seat safety with the parents of a newborn. The nurse instructs the parents to restrain the newborn in a car seat in the A. front seat, rear-facing position. B. front seat, forward-facing position. C. back seat, rear-facing position. D. back seat, forward-facing position.

C

discharge teaching

bathing the baby, umbilical cord care, circumcision, car seat safety, environmental safety, newborn behaviors, feeding, elimination and signs of illness to report

parent teaching-cleaning post op

change diaper q 4 h, with warm water each time, if clamped procedure: apply petroleum jelly with each diaper change for at least 24 hours after circumcision to keep diaper from adhering to penis, do not wrap tight gauze, no tub baths until healed, only warm water trickled gently over, notify for redness, discharge, swelling, strong odor, tenderness, decrease in urination, excessive crying, film of yellowish mucus by day 2-do not wash it off, avoid premoistened towlettes (alcohol), may be fussy or may sleep several hours after, acetaminophen as Rx, heals within couple weeks

cold stress/hypoglycemia

complication circumcision, monitor for excessive loss of heat resulting in increased respirations and lowered body temp, swaddle and feed as soon as procedure is over

cradle hold

head in bend of elbow, permits eye to eye contact, good position for feeding

assessments preprocedure circumcision

history of bleeding, hypospadias or epispadias, ambiguous genitalia (male/female characteristics), illness, infection

3 to 4 stools

how many stools per day for a newborn?

8 to 12 times

how many times do you have to feed a newborn in a 24 hour period?

6 to 8 wet diapers

how many wet diapers per day for a newborn who had adequate feeding?

36.6 to 38 C (97.9 to 100.4)

instruct parents to report when temperature is outside of this range

reasons for circumcision

it's a personal choice made by newborn's family for hygiene purposes, religious conviction (Jewish male on 8th day after birth), tradition, culture, or social norms, consult the provider to help parents make well-informed decision

Yellen, Mogen, Gomco clamp

surgeon applies one of these to loosen foreskin and inserts cone under foreskin to provide cutting surface for removal and to protect penis, wound covered with sterile petroleum gauze to prevent infection and control bleeding

A nurse is reviewing contraindications for circumcision with a newly hired nurse. Which of the following are contraindications? (Select all that apply.) A. Hypospadias B. Hydrocele C. Familiar history of hemophilia D. Hyperbilirubinemia E. Epispadias

A, C, E

immunizations

diptheria, tetanus, pertussis, hepatitis B, Heamophilius influenzae, polio, measles, mumps, rubella, influenza, rotavirus, pneumococcal, varicella

sleep-wake cycle

◯ Reinforce to the parents that placing the newborn in the supine position for sleeping greatly decreases the risk of sudden infant death syndrome. ◯ Most newborns sleep 17 out of every 24 hr with periods of wakefulness increasing. By 4 weeks of age, the newborn may remain awake from one feeding to the next. ◯ Many parents believe that adding solid food to the newborn's diet will help with sleep patterns. During the first 6 months of life, the American Academy of Pediatrics recommends only breastfeeding. Most newborns will sleep through the night without a feeding by 4 to 5 months of age. The provider will instruct the parents when to add solid food to the newborn's diet. ◯ Keep the newborn's environment quiet and dark at night. ◯ Place the newborn in a crib or bassinet to sleep. The newborn should never sleep in the parents' bed due to the risk of suffocation. ◯ Most newborns get their days and nights mixed up. Provide basic suggestions for helping the parents develop a predictable routine. Bring the newborn out into the center of the action in the afternoon, and keep him there for the rest of the evening. Bathe him right before bedtime so that he feels soothed. Give him his last feeding around 2300, and then place him into a crib or bassinet. ◯ When awake, the newborn can be placed on his abdomen to promote muscle development for crawling. The infant should be supervised. ◯ For nighttime feedings and diaper changes, keep a small night-light on to avoid having to turn on bright lights. Speak softly, and handle the newborn gently so that he goes back to sleep easily.

A nurse is caring for a newborn immediately following a circumcision using a Gomco procedure. Which of the following is an appropriate nursing intervention? 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.

C

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 a need for further clarification? A. "His circumcision will heal within a couple of weeks." B. "I do not need to 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."

D

Plastibell device

surgeon slides this between foreskin and glas, suture tightly around foreskin at coronal edge of glans, this applies pressure as the excess foreskin is removed from penis, after 5 to 7 days this device drops off, leaving clean, healed circumcision, no petroleum is used with this device

Yellen, Mogen, Gomco clamps, Plastibell

surgical methods of removing the foreskin,

Complications stemming from improper understanding of discharge instructions may include:

◯ An infected cord or circumcision from improper care or tub bathing too soon. ◯ Falls; suffocation; strangulation; burns resulting in injuries, fractures, aspiration; or even death due to improper safety precautions. ◯ Respiratory infections due to passive smoke or inhaled powders. ◯ Improper or no use of a car seat resulting in injuries or death. ◯ Serious infections due to lack of noncompliance with immunization schedule.

bathing

◯ After the initial bath, the newborn's face, diaper area, and skin folds are cleansed daily. Complete bathing is performed 2 to 3 times a week using a mild soap that does not contain hexachlorophene. ◯ Bathing by immersion is not done until the newborn's umbilical cord has fallen off and the circumcision has healed on males. Wash the area around the cord, taking care not to get the cord wet. 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; and wash the groin area last. ◯ Teach the parents proper newborn bathing techniques by a demonstration. Have the parents return the demonstration. ◯ Bathing should take place at the convenience of the parents, but not immediately after feeding to prevent spitting up and vomiting. ◯ Organize all equipment so that the newborn is not left unattended. Never leave the newborn alone in the tub or sink. ◯ Make sure the hot water heater is set at 49° C (120.2° F) or less. The room should be warm, and the bath water should be 36.6° to 37.2° C (98° to 99° F). Test the water for comfort on inner wrist prior to bathing the newborn. ◯ Avoid drafts or chilling of the newborn. Expose only the body part being bathed, and dry the newborn thoroughly to prevent chilling and heat loss. ◯ 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. ◯ Each area of the newborn's body should be washed, rinsed, and dried, with no soap left on the skin. ◯ Wrap the newborn in a towel, and swaddle him in a football hold to shampoo his head. Rinse shampoo from the newborn's head, and dry to avoid chilling. ◯ 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 may result. ◯ In female newborns, wash the vulva by wiping from front to back to prevent contamination of the vagina or urethra from rectal bacteria. ◯ Do not use lotions, oils, or powders, because they can alter a newborn's skin and provide a medium for bacterial growth or cause an allergic reaction. Powder should be avoided because it can cause respiratory problems if inhaled by the newborn.

epispadias

contraindication for circumcision, urethral canal terminates on dorsum penis

check ups

during 2 to 6 weeks of age, then every 2 months until newborn is 6 months old, weight check on day 2 after discharge, immunization schedule is reviewed with parents

assessment of readiness to care

experience and knowledge, parent-newborn attachment, adjustment to parental role, social support, educational needs, sibling rivalry, educational needs, readiness to accommodate, ability to verbalize and demonstrate

upright position

facing toward holder with head, upper back, and buttocks support

true or false: small objects such as coins can be left in the crib or near newborns

false

true or false: you can leave a newborn alone on a bed, couch, or table as long as they are in the middle

false

true or false: you can provide a newborn with soft pillows and place them on soft surfaces surrounded by toys, bumper pads, loose blankets

false

true or false: you can tie anything around a newborn's neck

false

signs of cord infection

moist, red, foul odor, purulent drainage, notify MD STAT

colic hold

newborn faced down along holder's forearm with hand firmly between newborn's legs, newborn's cheek should be by the holder's elbow, good position for quieting fussy newborn

prior to circumcision

oral sucrose, acetaminophen, swaddling, pacifier

interventions preprocedure circumcision

parent teaching, consent, will not be able to bottle feed for up to 4 hours prior to prevent vomiting and aspiration, breastfeeding ok up until procedure, restraint used during procedure, supplies, meds, place newborn on restraining board, radiant heat source to prevent cold stress, do not leave unattended, bulb syringe, comfort, document: time, type, bleeding, voiding

reasoning of advocates for circumcision

promotes penis with clean glans, minimizes risk of phimosis, penile cancer, cervical cancer in sexual partners

interventions postprocedure circumcision

remove from restraint, swaddle, monitor for bleeding and voiding, gauze lightly to penis of bleeding or oozing, fan fold diapers to prevent pressure on area

anesthesias before circumcision

ring block, dorsal-penile nerve block, topical anesthetic (eutectic mixture of local anesthetics-EMLA)

what is the best clothing for a newborn?

soft cotton

football hold

support half of newborn's body in forearm with head and neck resting in palm of hand, this is good position for breastfeeding and shampooing

quieting techniques

swaddling, close skin contact, nonnutritive sucking-pacifier, rhythmic noises to stimulate utero sounds, movement, placing newborn on stomach on lap while gently bouncing legs, en face position of eye contact, stimulation

circumcision

the surgical removal of the foreskin of the penis

what is the proper length of the space between the mattress and the sides of the crib?

2 fingerbreadths or less

hemorrhage

complication circumcision, monitor and provide gentle pressure on penis using small gauze square, gelfoam powder or sponge may be applied to stop the...if it persists, notify MD ...vessel may need to be ligated, continue to hold pressure until MD arrives while another nurse prepare tray and suture materials

hypospadias

contraindication for circumcision, abnormal positioning of urethra on ventral undersurface of the penis

past experience and knowledge of parents

a nurse should inquire about these along with anticipating learning needs of parents and assessing readiness to learn

car seat safety

approved rear-facing in back preferably in the middle, until age 2 or reaches maximum height and weight for the seat, do not use hand me downs

where should the crib be placed in a room?

away from window blinds or drapes, heaters, radiators, heat vents, on an inner wall

crying

babies do this when they are hungry, need to be burped, overstimulated, wet, cold, hot, tired, bored, assure mom that in time, she will know what her newborn's ....means, instruct not to feed every time the baby does this, overfeeding can cause stomach upset, it is ok to let them....for short periods of time

assessments postprocedure circumcision

check for bleeding q 15 min first hour then hourly for at least 12 hours, first voiding