HESI case study: Healthy Newborn Stacy Myers

Which findings are consistent with an infant born at 38 weeks' gestation? (select all the apply)

- Plantar creases covering 2/3 of the sole foot. - Well defined nipples, with raised areola.

While changing the infant's clothing, Ms. Myers notices the baby startle easily. Ms. Myers ask the nurse what is causing this reaction. 20. Which explanation should the nurse provide?

"This reflex is a normal response, swaddling the infant should help"

At 2 days post birth, Ms. Myers 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 (3300gm) Ms. Myers expresses her concern to the nurse when she realizes that her baby has lost almost a pound since birth. 21. How should the nurse respond?

"Don't be concerned. Your baby's weight loss is in the typical range for all babies" (babies may lose up to approzimately 10% of their birth weight)

The nurse is preparing to give the baby her first bath. 14. Which assessment date indicates that it is safe for the baby to be given a bath at this time?

Axillary temperature of 97.9 F (36.61 C) (A bath may potentially lower the temperature, which will not be harmful because the core temperature is near 99 F (37.22 C)

When returning the baby to the crib, the nurse notices that the blanket covering the baby is wet. The nurse takes the baby's temp, which is 97.2 F (36.22 C)

Show Ms. Myers how to wrap the baby in a dry blanket for warmth and apply the cap to his head.

The nurse checks on Ms. Myers and her baby every 2 hrs. throughout the night. The baby is breastfeed at 0300 and 0600 hrs without difficulty. After the change of shift report at 0700 hours, the day nurse assesses the mother and baby. Ms. Myers states that the baby had a bowel movement after breastfeeding. She tell the nurse that she attempted to change the diaper but had difficulty doing so. 18. How should the nurse respond to the client? Select all that apply.

-Observe Ms. Myers as she performs a diaper change. -Advise Ms. Myers that classes to teach infant care, such as diapering, are available on the units.

22. When asked the reason for including the PKU test in the screening, which information should the nurse provide?

A problem converting the protein pheynylalanine may be present, which can lead to mental retardation if not found and treated early. (PKU testing is done to detect the level of phenylalanine in the babys blood)

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. 3. Which APGAR score should the nurse assign?

9 One point is deducted for acrocyanosis Heart Rate: absent = 0, slow (<100) = 1, Over 100 = 2 Resp Rate: absent = 0, slow/irregular = 1, good/crying = 2 Muscle Tone: flaccid = 0, some flexion of the extremeties = 1, active motion = 2 Reflex Irritability: no response = 0, grimace = 1, cry = 2 Color: blue/pale = 0, body pink/extremeties blue = 1, completely pink = 2

2. Which action should the nurser take prior to drying the infact's back?

Inspect the back for possible neurological defects . (To prevent harm while drying the newborn, the back should always be inspected for possible neurological defects, such as spinal bifida)

When Ms. Myers removes the diaper, the nurse notices that the baby has caked powder in the inguinal leg folds.

Instruct Ms. Myers to use plain water instead of powder. (Until the baby is 4 days old, only plain warm water is recommended after the initial bath because soaps, ointments, powders, lotions, and baby wipes can disrupt the acid matle on the skin and provide a medium for bacterial growth. Ointments are prescribed only if a rash develops in the first few days of life. Use of powder also places also infant at risk for fine particle aspiration.

10. Which physical finding, if present, shoulde the nurse report to the HCP?

Loose natal teeth that are not covered by the gum.

At 2400 hours the infant is crying, his skin is mottled, and his hands are shaking. 15. Which action should the nurse take first?

Monitor the blood glucose level. (Since it has been 2 hours since delivery, the infant may be experiencing hypoglucemia)

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

No bowel movement in the first 72 hours.

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 nursey, the Myers' baby axiallary tem is 97.4F (36.3 C) 7. Which action should the nurse take?

Place the infant in a radiant warmer and monitor his temperature. ( The baby's temp is not within normal range, which is 97.5 F to 99 F ( 36.39 C to 37.22 C). The infant should remain in the radiant heat warmer until her temperature has stablized.

The Nurse place the infant under a radiant warmer and starts to dry him quickly. 1. What is the rationale for theses actions?

Convective heat loss from evaporation is reduced. (drying the infant quickly and placing him under a radiant warmer reduces heat)

While examining the infant's head, the nurse notes soft swelling of the scalp that extend across the suture line of the feral skull. 8. Which action should the nurse take in response to this finding?

Document the finding in the record.

The nurse notes a skin tag on the side of the infant's hand. 9. What should the nurse do in response to this finding?

Document the findings and notify the pediatrician.

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

His head has been molded from delivery through the birth canal, which is normal. (Molding commonly occurs in babies delivered vaginally, and the head will become more symmetrical over time.

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

Puncture the lateral heel after warming and collect blood sample on the designated. (the heel should be warmed, cleaned with alcohol, and dired with gauze. After the heel is puncture with a microlance, blood is collected on a special neonatal screening form .

The nurse checks the identification bands for both the baby and the mother upon admission to the nursery. One ID number is incorrect. 6. Which action should the nurse take to solve this problem?

Redo the identification band with another nurse witnessing the process. (Identification bands much be correct to ensure the safety and security of all hospitalizes clients, especially newborns)

The baby vital sign have stabilized by 0100 hours. Upon completion of assessment and documentation, the nurse takes the baby to Ms. Myers who want to breastfeed and room-in with the baby. After the nurse check the ID bands, the infant is positioned for breastfeeding. The nurse check on Ms. Myers and the baby at 0200 hours. Both are asleep in the bed, with the baby lying beside Ms. Myers. 16. What should the nurse do next?

Remind Ms. Myers about infant safety and assist her to place the infant in the crib.

A nursing student is assisting the nurse in caring for the infants in the nursery. The nurse questions the student about vitamin K (Aquea MEPHYTON) as preparation are made for administration. 13. Which response by the student indicates an understanding of the purpose for administering this drug?

The drug is given to the newborn to prevent any/or treat hemorrhagic disease.