CH 28 Care of New Mother and Newborn Evolve

Which instruction would the nurse give to a new mother regarding umbilical cord care?

"Apply alcohol on the cord stump daily to keep it dry until it falls off."

Which statement by the patient indicates that the nurse's instructions about breast-feeing were misunderstood?

"As long as I breast-feed, I can't get pregnant."

What statement made by the mother would indicate further teaching?

"I can let me baby sleep on her belly."

Which statement by the postpartum patient would require the nurse to reinforce teaching about self-care after discharge?

"I can't wait to soak in my Jacuzzi tub."

An African-American father notices a bluish black coloration on the lower back of the newborn. The father asks why his child is bruised. What is the best response?

"I know your are concerned, but this is often seen in darker-skinned patients called Mongolian spots. It is just increased pigmentation in that location that was not caused by trauma."

Which statement by a new moter would warrant a review of the infant's cord care?

"I must place the cord under the diaper."

During teaching the new mother of postpartum follow-up with OGYN, what statement from the patient is correct?

"I need to make a follow-up appointment with my doctor in 6 weeks."

A mother questions why her infant is getting a vitamn K injection. Which is the best statement of the nurse?

"Newborns are born with low prothrombin levels and are at risk for hemorrhaging, and since their colon does not have adequate intestinal flora; they are unable to synthesize the vitamin K."

The new mother asks why she cannot scrub off the vernix of her newborn at bath time? What is the nurses best response?

"The vernix is attached to the upper protective layer of skin and with forced removal can cause damage to the infants skin."

A postpartum nurse is rounding on a patient 3 hours after vaginal delivery. Which statement by the patient would be of concern to the nurse?

"What a disappointment; I thought I was having a girl?"

What is the normal weight loss percentage of newborn in the first week of life?

10%

What is the reqiured approximated calorie intake each day of the newborn?

120 calories per kg

Normal Pulse rate of Newborn:

120-160 bpm

Average head circumference of a newborn:

13-14 inches (33-35.5 cm)

When does the anterior fontanelle close? (Normally large and diamond Shaped)

18 months

When does the posterior fontanelle close? (Smaller and tranular shaped)

2 months

When does the average newborn infant follow-up with HCP occur?

2 weeks

Newborns average length:

20inches (50 cm)

Normal respritory rate of newborn:

30-60 breaths per minute with breif periods of apnea

What is the average length stay after vaginal birth in hospital ? C-Section?

48hr and 72 hrs

Normal blood pressure of newborn:

60-80/40-50 mm Hg

Newborns average weight is:

7 lb 8oz

Which physical sign and symptoms might the postpartum patient experience following delivery? Select all that apply.

A normal bowl movement within 2-3 days, Increased diaphoresis most commonly at night, increased urination beginning 4- 6 hours after delivery

What findings of the newborns palm may indicate a chromosomal disorder, such as Downs Syndrome?

A single crease in the palm of the hand, a simian line will be seen

Hands and feet may appear slightly blue and is caused by poor peripheral circulation (can last for 7-10 days)

Acrocyanosis

Which essential intervention would the nurse perform for an Rh-negative patient that gives birth to an Rh-positive baby?

Administer RhoGAM as prescribed by

Which intervention would the nurse institute for a patient who has a pulse rate of 120 bpm, a 60/80 BP, and cool and clammy skin? Select all that apply.

Administer blood as prescribed, Massage the fundus, Elevate the legs to 30 degrees, Give oxygen, if prescribed, Maintain IV fluids.

A patient with hyperglycemia had a preterm delivery. Which intervention would the nurse plan to prevent complications in the newborn?

Administer glucose solution to the newborn 1 hour after birth.

Adavantages of breast feeding

Antiinfective properties Nutrition Growth and Development Allergy Maternal Benefits

Which nursing concern for a breastfeeding mother is related to lactation issues? Select all that apply

Anxiety related to lactation expectations. Decreased caloric intake because of lactation needs. Potential for infection related to dry, cracked nipples

Which intervention will the nurse expect to be most beneficial for an infant with severe bleeding after circumcision?

Arranging for the ligation of the bleeding blood vessel

A patient reports pain in her right calf, and the LPN notes that the area is reddened and edematous. Which intervention would the nurse perform next?

Assess for a positive or negative Homan's sign.

What method of temperature assessment is recommended for a newborn? Normal Temp?

Axillary: 97.6- 98.7 F

BUBBLE HE

B:Breast U: Uterus B: Bladder B: Bowel L: Lochia E: Episiotomy H: Homan's Sign E: Emotional Status

When would a nurse recommend that mother give her newborn 15mL of water?

Before giving formula

Which physiologic adaptiation will the nurse expect to occur in the newly postpartum patient? Select all that apply

Brusing of the perineum, Sloughing of the urterine lining. Rapid decline of cardiac output

A patient who has had a routine vaginal delivery has a urinary output of 100 mL, 150 mL, and 275 mL recorded for three voiding in 6 hours after delivery. Which nursing action would be best?

Catheterize the patient, if ordered.

Which reason would the nurse give to the mother of a newborn on why not to feed the infant cow's milk?

Causes nausea and skin rashes

Which complication will the nurse expect to find in the newborn who has asummetric gluteal folds

Congenital Hip Dysplasia

Newborns breathing is.....

Diaphramatic and should be effortless with no evidence of respiratory distress

Languo

Downy, fine hair, characteristis of the fetus between 20 weeks of gestation and birth

Which action by the nursing mother will support milk production and promote infant comfort? Select all that apply

Drinking 8-10 glasses of fluids daily. Avoiding spicy foods, chocolate, and onions. Continuing taking prenatal vitamins and minerals until they are gone.

Nursing interventions to prevent evaporation heat loss.

Dry infant thoroughly after delivery and promptly when bathing.

Which intervention would the nurse perform when observing a new mother turning away from her infant and sighing deeply?

Encourage the mother to discuss her feelings by sitting next to her and stating. "Having a baby can be overwhelming."

A patient complains of an uncomfortable fullness of the breast that oocurs when the milk supply comes in. What is this condition called?

Engorgement

The father's behavior when introduced ot his new baby is typically an intense fascination. Which term describes this behavior?

Engrossment

Which medication would the nurse anticipate administering to all newborns admitted to the nursery? Select all that apply.

Erythromycin and Vitamin K

When providing discharge instructions to the family of a newborn infant, which symptoms would the parents be instructed to report to the health care provider? Select all that apply.

Fever, Diarrhea, Vomiting

What are the four most common ways to hold your baby while breast feeding?

Football hold Cradling Lying down Across the lap

Which intervention would the nurse perform FIRST when assessing the new mother's uterus and noting it to be boggy?

Gently massage the fundus to increase contractility

Which Statement made about elimination patters in an infant is incorrect?

Green, watery stoos are normally observed for 3 weeks after birth in infants.

Which nursing intervention would best enable the nurse to assess a postpartum patient for Homan's Sign?

Have the patient lie flat and point the toes toward the ankles.

A new mother reports feeling weak, lightheaded, and sick to her stomach. The LPN also notes that the patient's perineal pad is soaked since she last checked it 15 minutes ago. The patient's skin is cool and clammy, her pulse 110 bpm, and blood pressure is 80/60. Which complication do these symptoms indicate?

Hypovolemic shock

Which statement indicates that a mother fully understands care of her son's penis after circumcision? Select all that apply.

I will try not to touch the penis too much because it will be painful to the baby. I should put petroleum jelly on the penis with each diaper change. Some yellow discharge may be seen on the penis after a few days.

Dance or Stepping Reflex

If infant is held so that sole of foot touches a hard surface, there will be a reciprocal flexion and extension of the leg, stimulating walking.

How do you teach the patient who complains of engorgement to gain relief?

If patient is breast feeding they manually express the milk with warm, moist heat. If the patient is not breast feeding they compress the breats with a firm bra, wrapped in ice packs, and analgesics Both can place a clean cabbage leaf inside the bra over breasts and Supportive bra

Babinski Reflex

Infant reflex where if its foot is stroked, the baby's toes fan out with dorsiflexion of the big toe

Which intervention would the nurse perform for a postpartum patient with an anterior rectal laceration? Select all that apply.

Instructing the patient to drink a lot of fluids. Administering stool softeners to the patient. Assessing the fecal continence of the patient.

A mother calls for the nurse when she notices a raised hivelike rash, that has some small white vesicles on her newborn infant. Which phrase do you say to ease mothers concern?

It is called a Newborn rash. This is not contagious and nothing that is harmful. It will disappear without treatment.

Nursing intervention to prevent radiation heat loss of newborn?

Keep body well wrapped to prevent radiant loss. Work quickly to avoid excessive time with skin exposed. Use radiant warmer to minimize loss. Locate crib away from outside

The nurse would primarily monitor for symptoms of which condition in the neonate after administereing 1 mg of vitamin K intramuscularly? Select all that apply.

Kernicterus, Hyperbilirubinemia, and Hemolytic anemia

Attachment of the infant to the breast for feeding

Latch-on

Tingling or prickling sensation when feeding time approaches

Let-down reflex

Conduction Heat Loss

Loss of heat to a coller surface via direct skin contact

Convection Heat Loss

Loss of heat to cooler air currents

Evaporation Heat loss

Loss when water is converted into a vapor

A new mother expresses concern that she is going back to work and does not want to stop breast feeding her baby. What information do you teach the patient?

Manual pumping of the breast every 2- 3hours to maintain milk supply

The nurse palpates the uterus of a postpartum patient for involution and observes that the uterine fundus is soft and distended. Which medication will the nurse expect the health care provider to prescribe to the patient?

Methylergonovine maleate (Methergine)

Calculating fluid intake for newborn based on weight.

Minimum fluid intake is 140-160 mL per kg/daily is recommended. EX: Baby weighs 3 kg x 140 = 420 mL/daily

Which occurrence would be prevented by folding the baby's diaper down such that the plastic side is facing outside for proper umbilical cord care?

Moistue retention in the umbilicus

Which intervention would the nurse perform to provide effective care to a newly postpartum patient who reports feeling weak and "seeing stars"? Select all that apply.

Monitor the patient's vital signs. Gently message the patient's uterus. Notify the health care provider.

What are the reflexes that are assessed of newborn?

Moro, Tonic Neck, Dance or Stepping, Rooting, Sucking, Babinski's, Grasp (Plantar and Palmer) and Pull to Sit

Which medication will the nurse expect the health care provider to prescribe for the newborn with a white patchy coating on the oral mucous membrane that cannot be wiped off?

Nystatin (Mycostatin)

Nursing interventions to prevent conduction heat loss.

Pad surfaces under infant, including tables and scales. Warm other equipment, such as stethoscopes before use.

When jaundice that occurs sooner than 48 hours after birth is termed what? Is it normal?

Pathologic Jaundice; not normal d/t the possiblity of a maternal-fetal blood incompatibility

When jaundice that occurs after 48 hours after birth is termed what? Is it normal?

Physiologic Jaundice. Yes, it is normal and should disappear by the 7-10th day.

Which reflex is being demonstrated when the newborn curls the toes downward?

Planter Grasp

Why is the body temperature of the newbown such a concer for the newborn?

Prolonged exposure to a cold enviornment can results in increased oxygen consumption and depleted oxygen reserves

Pull to Sit Reflex

Pull newborn up from wrist while in supine position Head will lag until newborn is in upright position, then will level with chest, then fall forward; infant attempts to right head.

The vital signs of a newborn are as follows: T 97.9, P 140 bpm, RR 34 with brief periods of apnea, and BP 80/40 with an increase in systolic pressure when crying. Which nursing action would be best?

Realize that these vital signs are normal for a newborn, and document the data on the flow sheet.

Nursing interventions to prevent convection heat loss.

Reduce drafts from open doors, windows, or air conditioning; wrap newborn to protect from cold

Sucking Reflex

Reflex that causes a newborn to make sucking motions when a finger or nipple if placed in the mouth

What is another word for fontanelles?

Soft spot

What teaching do does the nurse include with umbilical cord care?

Sponge infant until umbilical cord falls off. The cord will turn brownish-blakc in 2-3 days and fall off in 10-14 days. Fold the diaper below cord to keep it dry and free from contamination of urine

In which order would the nurse perform a disposable type of sitz bath for a postpartum patient with severe lacerations and hemorrhage?

Step1. Clamp the tubing and fill the bag with water. Step 2. Fill the bad with required amount of water. Step 3. Toliet seat is raised and the bath is placed in the bowl. Step 4. The container is placed above the toilet bowl Step5. The tube is attached into the groove at the front side of bath Step 6. The tube clamp is loosened to regulate the rate of flow and fill the bath to halfway full.

Moro (startle) reflex

Sudden noises or jarring movements cause the newborn to throw out the arms and to draw up the legs and infant may cry

Which intervention would the nurse provide to the non-breastfeeding postpartum patient to provide relief from swollen, firm, and painful breast? Select all that apply.

Suggest that the patient take lukewarm showers. Suggest that the patient wear a good supportive bra. Apply ice bags on the patient's breasts four times daily.

Which behavior by a new breastfeeding mother would call for immediate corrective action?

Swiftly removing the breast from the infant's mouth

A patient who had a cesarean section due to be discharged home. Which data obtained during an assessment would be of concern to the nurse?

The abdominal incision is red and warm, and the edges are nonapproximated, with moderate exudate.

Which date on the nursing documentation would indicate a potential complication in a patient 8 hours after cesarean delivery?

The apical pulse is 25 bpm above predelivery baseline.

What does it mean when the newborn infant has Harlequin's Sign?

The condition is normal and it is not harmful. Half of the newborn's body appears deep red and the other half appears pale (results of vasomotor disturbance, some vessels contricting while others dialate)

Which inference will the nurse conclude when the infant is passing very water and green stools after the transition stools?

The infant has GI irritation.

Which statement regarding jaundice is accurate?

The jaundice s likely related to maternal-fetal blood incompatibility

The nurse is reviewing the lab reports of a postpartum patient and the newborn and expect the health care provider to prescribe RhoGAM to the patient. Which finding enabled the nurse ot reach this conclusion?

The patient is Rh positive and the newborn is Rh negative.

Which reason explains why the patient hold her breast away from the infant's nostrils when breastfeeding the infant?

The patient is trying to promote proper respiration in the infant.

Which ESSENTIAL information would the nurse include as part of the teaching process when administering the rubella vaccine to a recently delivered mother?

The patient should avoid conceiving for a least 3 months.

Which inference would the nurse make when observing a Vietnamese mother changing her newborn's diaper and providing basic care but failing to cuddle, kiss, or talk to the infant?

This behavior is normal for a mother of this culture.

A nurse is observing a newborn's skin and notices small white spots across the nose and chin. What do you tell the mother when she ask?

This is called, Milia. It is a results of occluded sebaceous glands and it does disappear in a few weeks.

The nurse finds that the glucose level in a neonate is 45 mg/dL and advises the parents to avoid giving glucose supplements to the neonate before breastfeeding. Which reason explains why the nurse gives this advice to the parents?

To ensure that the neonate takes interest in breastfeeding.

The nurse is caring for a patient who had cesarean delivery and was administered general anesthesia. Which reason would the nurse have for suggesting that the patient walk at frequent intervals and avoid continuous bed rest?

To help promote bowl function

For which reason would the nurse advise a postpartum patient to place the newborn on the right side after feeding?

To prevent regurgitation.

While caring for a lactating patient, the nurse suggests that the patient place the infant or her shoulder after feeding. Which reason for this suggestion is best?

To promote burping in the infant.

For which reason would a lactating mother lightly brush the infant's lips with the nipple?

To promote rooting reflex

Why would the nurse place an ice pack on the patient's perineum 4 hours after delivery?

To provide pain relief

Which symptom would the nurse monitor for in the postpartum patient to ensure safe administration of oxytocin? Select all that apply.

Water intoxication, irregular heartbeat, decreased blood pressure

Which reason explains why a postpartum patient with significant bleeding would be prescribed an IV infusion of lactated Ringer's solution?

Weakness and frequent vomiting.

Which sign and symptom would indicate to the nurse that a newly postpartum patient may be in shock? Select all that apply.

Weakness, tachycardia, gray skin tone

Which actions by the other indicate that the teaching of nipple care after breast-feeding was not effective?

Wiping each nipple thoroughly with an alcohol pad after feeding

Rooting Reflex

a baby's tendency, when touched on the cheek, to turn toward the touch, open the mouth, and search for the nipple to attempt sucking

Cephalhematoma

collection of blood between periosteum and skull bone that it covers does not cross suture line that appear 1-2 post delivery results from trauma during birth. Normally absorbed without treatment

Polydactyl

extra digits

When does engorgement of the breast occur?

first 24-48hrs pt has colostrum. 48-72hrs, breast milk will come in. rapid filling may cause swelling & pain.

Radiation Heat loss

loss that occurs when heat transfers from the body to coller surgaces and objects not in contact with the body

Epstein Pearls

multiple small, white, epithelial inclusion cysts found in the midline of the palate in newborn infants that disappear within a few weeks

Plantar Grasp Reflex

reaction to stimulation of the sole of the foot that causes the toes of the feet to "grasp"

Palmer Grasp Reflex

reflexive curling of the infant's fingers around an object that touches its palm

caput succedaneum

results of edma in soft tissue of scalp feels spungy and may be felt over the suture lines and disappears without treatment

Tonic Neck Reflex

turning the head to one side, extending the arm and leg on that side, and flexing the limbs on the opposite side; posture resembles a fencing position

Syndactyl

two or more digits (fingers or toes) joined together or webbed together

cyptorchidism

undescended testes

What is Jaundice?

yellow discoloration caused by deposits of bile pigments (also known as icterus neonatorum) This is the first detected over bony prominences on the face and mucous membranes

Vernix Caseosa

yellowish-white cream cheese like substance covering the skin at birth