HESI Case Study: Healthy Newborn

Which response by the mother indicates an understanding of infant safety measures to prevent infant abduction at the hospital?

"The identification bands will be rechecked any time my baby is returned to my room." Identification bands must be verified to ensure the safety and security of all hospitalized newborns.

While changing the infant's clothing, the client notices the baby startles easily. She asks the nurse what is causing this reaction. Which explanation should the nurse provide?

"This reflex is a normal response, swaddling the infant should help." Rationale: The moro reflex is a startling response by the infant as a reaction to a loud noise, sudden touch, or a change in position.

Which responses by the student indicate an understanding of erythromycin administration? (Select all that apply. One, some, or all options may be correct.) Select all that apply

- It is given as a prophylactic eye treatment against ophthalmia neonatorum (Infants receive erythromycin as prophylactic treatment to prevent ophthalmia neonatorum, conjunctivitis that is most often caused by Neisseria gonorrhoeae acquired from the mother's birth canal.) - Erythromycin is given within one to two hours after birth (Infection can cause blindness if not treated promptly, so most states mandate prophylactic treatment within one to two hours of birth, regardless of mode of birth.) - The ointment is applied to the lower conjunctival sac of each eye (A "ribbon" of 0.5% erythromycin ointment, 1 cm (0.4 inch) long, is applied to the lower conjunctival sac of each eye.)

Which findings are consistent with an infant born at 38 weeks' gestation? (Select all that apply. One, some, or all options may be correct.) Select all that apply

- Plantar creases covering 2/3 of the sole of foot (This finding is consistent with a baby born at 38 weeks' gestation.) - Well defined nipples with raised areola (The infant of 38 weeks should have well defined nipples with raised areola.)

The client is told that a neonatal screening test needs to be done before they are discharged. When asked the reason for including the phenylketonuria (PKU) test in the screening, which information should the nurse provide?

A problem converting the protein phenlalanine may be present, which can lead to mental retardation if not found and treated early Rationale: PKU testing is done to detect the level of phenylalanine in the baby's blood.

Case Outcome

After discharge teaching is complete and the nurse removes one ID band from the baby to keep with the record, follow-up appointments are made for both mother and baby. The client thanks the nurses for their support, care, and teaching. They are taken by wheelchair to a private car, where the baby is secured in a car seat for the drive home.

Which assessment data indicates that it is safe for the baby to be given a bath at this time?

Axillary temperature of 98 degrees F - A newborn receives a bath once the temperature is stable, and the temperature should be rechecked within one hour after bath to ensure the infant is maintaining thermoregulation adequately.

At 2400 hours the infant is crying, his skin is mottled, and his hands are shaking. Which action should the nurse take first?

Check the infants blood glucose level with a glucometer (The infant is showing early signs of neonatal hypoglycemia. The nurse should assess the blood glucose.)

The infant's head is molded from the vaginal delivery. Upon seeing the baby, the parent says, "Oh, he is so beautiful, but something is wrong with his head."

How should the nurse respond? Caput succedaneum is an edematous area on the head from pressure against the cervix. It may cross suture lines. "His head has been molded from delivery through the birth canal, which is normal."

The nurse places the infant under a radiant warmer and starts to dry him quickly.

Convective heat loss from evaporation is reduced. Rationale: Drying the infant quickly and placing him under a radiant warmer reduces heat loss through evaporation and radiation.

While examining the infant's head, the nurse notes soft swelling of the scalp that extends across the suture lines of the fetal skull. Which action should the nurse take in response to this finding?

Document the finding in the record - due to molding, this is a normal finding immediately post birth via vaginal delivery. Rationale: This finding indicates caput succedaneum, which commonly occurs after a vaginal birth.

The nurse notes a skin tag on the side of the infant's hand. What should the nurse do in response to this finding?

Document the findings and notify the pediatrician Skin tags are a common finding on a newborn assessment. They can be harmless, but the pediatrician should be informed.

When the client removes the diaper, the nurse notices that the baby has caked powder in the inguinal leg folds. Which action should the nurse take?

Instruct the client to use alcohol free wipes and avoid the use of talc-based powder Rationale: Alcohol and perfume wipes should be avoided because they can cause diaper dermatitis. Talc-based powders should not be used because they can put the infant at risk for pneumonia if the powder gets in the infant's lungs.

Which physical finding, if present, should the nurse report to the healthcare provider (HCP)?

Loose nasal teeth that are not covered by the gums Natal teeth, present at birth, are an unusual occurrence that should be reported to the healthcare provider. They are sometimes found in infants with developmental abnormalities and syndromes, including cleft lip and palate.

When examining the baby's gastrointestinal system, which finding warrants additional assessment by the nurse?

No bowel movement in the first 48 hours The first meconium stool should pass within 48 hours. Obstruction may be suspected if there is no bowel movement in the first 48 hours.

The nurse checks on the client and her baby every two hours throughout the night. The baby is breastfed at 0300 and 0600 hours without difficulty. After the change of shift report at 0700 hours, the day nurse assesses the mother and baby. The client states that the baby had a bowel movement after breastfeeding. She tells the nurse that she attempted to change the diaper but had difficulty doing so. How should the nurse respond to the client?

Observe the client as she performs a diaper change (The nurse should observe parenting behaviors. Involving the mother in the care of the newborn helps her learn successfully.)

Upon inspection of the umbilical cord, which finding should the nurse report to the healthcare provider (HCP)?

One artery and one vein are present Two arteries and one vein should be present.

Upon admission to the transition care nursery, the baby's axillary temperature is 97.4° F (36.3° C). Which action should the nurse take?

Place the infant in a radiant warmer and monitor his temperature Rationale: The baby's temperature is not within normal range, which is 97.7° F to 99.5° F (36.5° C to 37.5° C). The infant should remain in the radiant heat warmer until her temperature has stabilized.

How should the nurse collect the blood needed for PKU screening?

Puncture the lateral heel after warming and collect blood samples on the designated lab form Rationale: The heel should be warmed, cleaned with alcohol, and dried with gauze. After the heel is punctured with a micro lancet, blood is collected on a special neonatal screening form.

Rooming-In The baby's vital signs have stabilized by 0100 hours. Upon completion of assessment and documentation, the nurse takes the baby to the client who wants to breastfeed and room-in with the baby. After the nurse checks the ID bands, the infant is positioned for breastfeeding. The nurse checks on the client and the baby at 0200 hours. Both are asleep in the bed, with the baby lying beside the mother. What should the nurse do next?

Remind the client about infant safety and assist her to place the infant in the crib This action protects the baby while reinforcing teaching to the mother.

When returning the baby to the crib, the nurse notices that the blanket covering the baby is wet. The nurse takes the baby's temperature, which is 97.2° F (36.2° C). Which action should the nurse do next?

Show the client how to wrap the baby in a dry blanket for warmth and apply the cap to his head Rationale: This action not only protects the baby, but also involves and teaches the mother.

At two days post birth, the client and her baby are doing well and preparing for discharge. The baby's weight at birth was 7 lb 15 oz (3600 gm), and today she weighs 7 lb 3 oz (3300 gm). She expresses her concern to the nurse when she realizes that her baby has lost almost a pound since birth. When asked about the infant's weight loss, which information should the nurse provide?

The infant's weight loss is in the typical range for term newborn babies that are formula-fed and breastfed. Rationale: In the first three to four days after birth, the infant loses up to 10% of the birth weight.

A student nurse is assisting the nurse in caring for the infants in the nursery. The nurse questions the student about the newborn medications vitamin K and erythromycin as preparations are made for administration. Which response by the student indicates an understanding of the purpose for administering vitamin K?

This drug is given to the newborn to prevent and/or treat hemorrhagic disease Rationale: Because this vitamin does not cross the placenta and there is very little in breast milk, supplemental vitamin K should be given to newborns at birth to help clot the blood. Therefore, this is an accurate response by the student and no further client teaching is needed.

At 1 minute of age, the infant is alert and active, and has a strong cry. He has a heart rate of 172 and a respiratory rate of 50. The infant's arms and legs are flexed, the color of his body is pink, and the color of both feet is blue. The nurse continues a physical assessment of the infant looking for normal and abnormal findings.

Which APGAR score should the nurse assign? (Enter numeric value only.) One point is deducted for acrocyanosis. The correct score is 9