HESI Healthy Newborn Case Study

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.)

9

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? A. Document the finding in the record - due to molding, this is a normal finding immediately post birth via vaginal delivery. B. Monitor the tension of the anterior fontanel. C. Report the finding to the healthcare provider (HCP). D. Apply cool compresses to prevent more swelling.

A. 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; It is not necessary to report this finding to the HCP.

Which responses by the student indicate an understanding of erythromycin administration? (Select all that apply. One, some, or all options may be correct.) A. It is given as a prophylactic eye treatment against ophthalmia neonatorum. B. The medication is given once intramuscularly one hour after birth. C. Erythromycin is given within one to two hours after birth. D. The ointment is applied to the lower conjunctival sac of each eye. E. The medication can be rinsed out of the eyes within one minute of administration.

A. It is given as a prophylactic eye treatment against ophthalmia neonatorum. C. Erythromycin is given within one to two hours after birth. D. The ointment is applied to the lower conjunctival sac of each eye. Rationale: 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. 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. A "ribbon" of 0.5% erythromycin ointment, 1 cm (0.4 inch) long, is applied to the lower conjunctival sac of each eye.

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. An error in metabolism of the amino acids leucine, isoleucine, and valine can cause death if not detected and treated early. B. A problem converting the protein phenylalanine may be present, which can lead to mental retardation if not found and treated early. C. Screening for an error in metabolism of the sugars galactose and lactose can prevent liver and brain damage in the newborn. D. This test detects the level of thyroxin produced by the thyroid. If too little or if treatment is not started early, mental retardation can result.

B. A problem converting the protein phenylalanine 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.

Which assessment data indicates that it is safe for the baby to be given a bath at this time? A. Respiratory rate of 52 breaths/min. B. Axillary temperature of 98.0° F (36.7° C). C. Apical heart rate of 166 beats/min. D. Pulse oximeter of 90%.

B. Axillary temperature of 98.0° F (36.7° C). Rationale: 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.

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? A. No, nothing is wrong with his head. He really is a beautiful baby." B. "Yes, it is misshaped, but we will show you how to change it over time." C. "His head has been molded from delivery through the birth canal, which is normal." D. "I know you are concerned. Would you like to talk further with the healthcare provider (HCP)?"

C. "His head has been molded from delivery through the birth canal, which is normal." Rationale: Molding commonly occurs in babies delivered vaginally, and the head will become more symmetrical over time. Parents can be taught to change an infant's sleeping positions to correct a misshaped head, but this is not the best response; Acknowledging the parent's feelings is a thoughtful response, but referral to the HCP is not necessary.

The nurse notes a skin tag on the side of the infant's hand. What should the nurse do in response to this finding? A. Place a string tightly around the skin tag. B. Call a rapid response. C. Document the findings and notify the pediatrician. D. Perform a newborn hearing screen.

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

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? A. Put a t-shirt on the baby and cap on his head. B. Cover the baby with a dry blanket, but leave the cap off. C. Show the client how to wrap the baby in a dry blanket for warmth and apply the cap to his head. D. Immediately take the baby and place him under a heat source.

C. 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.

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? A. Show the client how to remove the caked-on powder. B. Explore with the client why powder was used. C. Praise the client for wanting to keep her baby dry. D. Instruct the client to use alcohol-free wipes and avoid the use of talc-based powder.

D. 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.

When examining the baby's gastrointestinal system, which finding warrants additional assessment by the nurse? A. Greenish black stool. B. Hyperactive bowel sounds. C. Small amount of regurgitation after breastfeeding. D. No bowel movement in the first 48 hours.

D. No bowel movement in the first 48 hours. Rationale: 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 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? A. Pick up the baby and return him to the crib while letting the client sleep. B. Wake the client and remind her that keeping the baby in the bed is unsafe. C. Tell the client that the baby must be returned to the nursery for safety reasons. D. Remind the client about infant safety and assist her to place the infant in the crib.

D. Remind the client about infant safety and assist her to place the infant in the crib. Rationale: This action protects the baby while reinforcing teaching to 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? A. The infant should gain weight if it is formula-fed for the first 24 hours of life. B. Only breastfed newborns lose weight after the first 48 hours of life. C. The infant should gain five percent of the intial birth weight in the first 48 hours of life. D. The infant's weight loss is in the typical range for term newborn babies that are formula-fed and breastfed.

D. 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. Newborns lose weight the first few days of life, but then regain the weight by 10 days of age.

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? A. "Your baby probably has a neurological deficit." B. "Apparently your baby had some trauma at birth to cause this." C. "This reflex is a normal response, swaddling the infant should help." D. "This is unusual, and I will notify the pediatrician about the reaction."

C. "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.

At 2400 hours the infant is crying, his skin is mottled, and his hands are shaking. Which action should the nurse take first? A. Assess the infant's respiratory efforts. B. Check the infant's blood glucose level with a glucometer. C. Give the infant some formula. D. Evaluate for possible seizures.

B. Check the infant's blood glucose level with a glucometer. Rationale: The infant is showing early signs of neonatal hypoglycemia. The nurse should assess the blood glucose. Assessing the respiratory efforts of the infant is unnecessary since the infant is crying, and crying is a good indicator of respiratory effort.

The nurse places the infant under a radiant warmer and starts to dry him quickly. What is the rationale for these actions? A. Heat production is increased through stimulation. B. Convective heat loss from evaporation is reduced. C. Newborns in an incubator are more difficult to access than those in a radiant warmer. D. Bonding is promoted by enhancing the infant's appearance.

B. 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. Although a radiant warmer allows healthcare personnel easy access to the infant, that is not the reason for its use in this situation.

Which physical finding, if present, should the nurse report to the healthcare provider (HCP)? A. Presence of unopened sebaceous glands. B. Loose natal teeth that are not covered by the gums. C. White, cream cheese-like substance on skin. D. Enlarged breasts secreting a thin, watery discharge.

B. Loose natal teeth that are not covered by the gums. Rationale: 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. This substance is vernix caseosa, which covers and protects the fetus from the amniotic fluid in utero. Because its presence on the infant at birth is normal, this finding does not need to be reported. This temporary condition in the newborn is caused by the influence of the mother's hormones on the fetus prior to birth. The secretion is often referred to as witch's milk. This is a normal finding that does not need to be reported. These pinhead-size whiteheads on the newborn are referred to as milia, and they usually disappear without treatment. Their presence does not need to be reported.

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? A. Reassure the client that she will get plenty of practice. B. Observe the client as she performs a diaper change. C. Place the infant on the bed and demonstrate how to do a diaper change. D. Tell the client that the nurses can change the diapers until they go home.

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

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? A. Continue monitoring and document this finding in the record. B. Place the infant in a radiant warmer and monitor his temperature. C. Remove a blanket from the infant and check the temperature again. D. Notify the healthcare provider (HCP) immediately about the temperature.

B. 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.

Which findings are consistent with an infant born at 38 weeks' gestation? (Select all that apply. One, some, or all options may be correct.) A. Presence of abundant lanugo hair across face and back. B. Plantar creases covering 2/3 of the sole of foot. C. Well defined nipples, with raised areola. D. Slightly soft, curved pinna with slow recoil. E. Skin is smooth and pink with visible veins.

B. Plantar creases covering 2/3 of the sole of foot. C. Well defined nipples, with raised areola. Rationale: The infant of 38 weeks should have well defined nipples with raised areola. A baby born at 38 weeks' gestation has minimal lanugo hair, which is the soft prenatal hair that is shed during the last few weeks of pregnancy. The ear of a baby born at 38 weeks' gestation should be well formed and firm with instant recall.

How should the nurse collect the blood needed for PKU screening? A. Clean the heel with alcohol swab, dry with gauze, and collect blood in a capillary tube. B. Puncture the lateral heel after warming and collect blood samples on the designated lab form. C. Collect heel blood using a transfer pipette, and place a drop of blood on a reflectance meter. D. After grasping the baby's lower leg and foot, use a microlancet to puncture the middle portion of the heel.

B. 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 microlancet, blood is collected on a special neonatal screening form.

The mother is offered the opportunity to breastfeed. After securing a comfortable position for herself and the baby, she puts the infant to her breast. The baby latches onto the nipple, and with some encouragement, he begins to nurse. After a time of family interaction, the client is taken to the postpartum unit, and the infant is transferred to the transition care nursery. The nurse discusses safety issues with the mother to ensure adequate understanding of safety measures to prevent newborn abduction. The identification bands for both the baby and the mother are verified upon admission to the nursery. Which response by the mother indicates an understanding of infant safety measures to prevent infant abduction at the hospital? A. "Anyone with a hospital badge may transport my baby to the nursery." B. "After you bring my baby back to the room, I am going to take a shower and just leave my baby in the crib." C. "The identification bands will be rechecked any time my baby is returned to my room." D. "I am just going to swaddle my baby and carry it to the nursery later today."

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

Upon inspection of the umbilical cord, which finding should the nurse report to the healthcare provider (HCP)? A. The cord is covered with Wharton's jelly. B. Pulsations are felt at the base of the cord. C. One artery and one vein are present. D. The cord is glistening with a pearl-like coloring.

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

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? A. The purpose of this drug is to prevent hypoglycemia in the newborn. B. Vitamin K is a fat-soluble vitamin and promotes a positive nutritional status. C. This drug is given to the newborn to prevent and/or treat hemorrhagic disease. D. Vitamin K is produced and stored in the liver, which is immature in the infant.

C. 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.