NURS 4325 Maternal-Child Nursing: SECTIONS COVERED IN Q&A. Healthy Newborn, Infant Care at Birth, Tr

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Meet the Client Meet the Client: Stacey Myers Ms. Stacey Myers is in active labor at 38 weeks' gestation with an uncomplicated pregnancy. She is admitted to the birthing center on October 10th at 0830. After 9 hours of labor, Ms. Myers has a spontaneous vaginal delivery of an infant boy.

Section 1 Infant Care at Birth The nurse places the infant under a radiant warmer and starts to dry him quickly.

Question 1 of 23 What is the rationale for these actions?

Heat production is increased through stimulation.

Convective heat loss from evaporation is reduced.

Newborns in an incubator are more difficult to access than those in a radiant warmer.

Bonding is promoted by enhancing the infant's appearance.

Heat production is increased through stimulation.

Drying the infant may increase heat production, but this is not the best method to correct the newborn's body temperature.

Convective heat loss from evaporation is reduced.

Drying the infant quickly and placing him under a radiant warmer reduces heat loss through evaporation and radiation.

Newborns in an incubator are more difficult to access than those in a radiant warmer.

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

Bonding is promoted by enhancing the infant's appearance.

Drying and warming do not necessarily enhance the infant's appearance or promote bonding.

Question 2 of 23 Which action should the nurse take prior to drying the infant's back?

Note if the infant has passed any meconium stool.

Observe the sacral area for possible Mongolian spots.

Assess the amount and location of vernix caseosa.

Inspect the back for possible neurological defects.

Note if the infant has passed any meconium stool.

Although this observation is important, it is not related to drying the back.

Observe the sacral area for possible Mongolian spots.

Mongolian spots are normal variations in the pigment of the skin, and they do not hinder drying the back.

Assess the amount and location of vernix caseosa.

The amount of vernix caseosa is related to gestational age, but is not related to drying the 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.

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.

Question 3 of 23 Fill in the blank Which APGAR score should the nurse assign? (Enter numeric value only.) 9 One point is deducted for acrocyanosis.

Question 4 of 23 Upon inspection of the umbilical cord, which finding should the nurse report to the healthcare provider (HCP)?

The cord is covered with Wharton's jelly.

Pulsations are felt at the base of the cord.

One artery and one vein are present.

The cord is glistening with a pearl-like coloring.

The cord is covered with Wharton's jelly.

This is a normal finding.

Pulsations are felt at the base of the cord.

This is a normal finding.

One artery and one vein are present.

Two arteries and one vein should be present.

The cord is glistening with a pearl-like coloring.

This is a normal finding.

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 his head."

Healthy Newborn

Caput succedaneum is an edematous area on the head from pressure against the cervix. It may cross suture lines.

Question 5 of 23 How should the nurse respond?

No nothing is wrong with his head. He really is a beautiful baby.

Yes, it is misshaped, but we will show you how to change it over time.

His head has been molded from delivery through the birth canal, which is normal.

I know you are concerned. Would you like to talk further with the HCP? No nothing is wrong with his head. He really is a beautiful baby.

This response does not fully address the mother's concern.

Yes, it is misshaped, but we will show you how to change it 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.

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.

I know you are concerned. Would you like to talk further with the HCP? Acknowledging Ms. Myers' feelings is a thoughtful response, but referral to the HCP is not necessary.

Ms. Myers is offered the opportunity to breastfeed. After securing a comfortable position for herself and the baby, Ms. Myers 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, Ms. Myers is taken to the postpartum unit, and the infant is transferred to the transition care nursery.

Section 2 Transition Care The nurse checks the identification bands for both the baby and the mother upon admission to the nursery. One ID number is incorrect.

Question 6 of 23 Which action should the nurse take to solve this problem?

Document the presence of the incorrect number on the charts for the baby and the mother.

Although the nurse should probably document the discrepancy, it does not solve the problem.

Explain to the mother that there is an incorrect number on one of the bands.

Although an explanation should be given to the mother, that will not solve the problem.

Redo the identification bands with another nurse witnessing the process.

Identification bands must be correct to ensure the safety and security of all hospitalized clients, especially newborns.

Mark the incorrect numbers in red to denote the correction made to the bands.

This is not the proper action for the nurse to take to solve this problem.

Submit Upon admission to the transition care nursery, the Myers' baby's axillary temperature is 97.4° F (36.3° C).

Question 7 of 23 Which action should the nurse take?

Continue monitoring and document this finding in the record.

Place the infant in a radiant warmer and monitor his temperature.

Remove a blanket from the infant and check the temperature again.

Notify the HCP immediately about the temperature.

Continue monitoring and document this finding in the record.

Another action should be taken in this situation.

Place the infant in a radiant warmer and monitor his temperature.

The baby's temperature 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 stabilized.

Remove a blanket from the infant and check the temperature again.

This action will make the situation worse, not improve it.

Notify the HCP immediately about the temperature.

The nurse is capable of providing care to remedy this situation. It is not necessary to notify the HCP.

Section 3 Newborn Assessment While examining the infant's head, the nurse notes soft swelling of the scalp that extends across the suture lines of the fetal skull.

Question 8 of 23 Which action should the nurse take in response to this finding?

Document the finding in the record.

Monitor the tension of the anterior fontanel.

Report the finding to the HCP. Apply cool compresses to prevent more swelling.

Document the finding in the record.

This finding indicates caput succedaneum, which commonly occurs after a vaginal birth.

Monitor the tension of the anterior fontanel.

Although the anterior fontanel should be monitored, it is not related to this finding.

Report the finding to the HCP. It is not necessary to report this finding to the HCP. Apply cool compresses to prevent more swelling.

Applying cool compresses is not the proper action for the nurse to take.

The nurse notes a skin tag on the side of the infant's hand.

Question 9 of 23 What should the nurse do in response to this finding?

Place a string tightly around the skin tag.

Call a rapid response.

Document the findings and notify the pediatrician.

Perform a newborn hearing screen.

Place a string tightly around the skin tag.

This is not an appropriate nursing intervention.

Call a rapid response.

This is not an emergency situation.

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.

Perform a newborn hearing screen.

If a skin tag is found close to the ear, it can indicate hearing damage.

Question 10 of 23 Which physical finding, if present, should the nurse report to the HCP? Presence of unopened sebaceous glands.

Loose natal teeth that are not covered by the gums.

White, cream cheese-like substance on skin.

Enlarged breasts secreting a thin, watery discharge.

Presence of unopened sebaceous glands.

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.

Loose natal 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. Loose natal teeth are frequently removed to prevent aspiration.

White, cream cheese-like substance on skin.

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.

Enlarged breasts secreting a thin, watery discharge.

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.

Question 11 of 23 When examining the baby's gastrointestinal system, which finding warrants additional assessment by the nurse?

Greenish black stool.

Hyperactive bowel sounds.

Small amount of regurgitation after breastfeeding.

No bowel movement in the first 72 hours.

Greenish black stool.

This is meconium and is a normal response that does not require additional assessment.

Hyperactive bowel sounds.

This is a normal finding that does not require additional assessment.

Small amount of regurgitation after breastfeeding.

This is a normal finding and does not require additional assessment.

No bowel movement in the first 72 hours.

The first meconium stool should pass within 48 hours. Obstruction may be suspected if no bowel movement in the first 72 hours.

Question 12 of 23 Which findings are consistent with an infant born at 38 weeks' gestation?

Select all that apply Presence of abundant lanugo hair across face and back.

Plantar creases covering 2/3 of the sole of foot.

Well defined nipples, with raised areola.

Slightly soft, curved pinna with slow recoil.

Skin is smooth and pink with visible veins.

Presence of abundant lanugo hair across face and back.

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.

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.

Slightly soft, curved pinna with slow recoil.

The ear of a baby born at 38 weeks' gestation should be well formed and firm with instant recall.

Skin is smooth and pink with visible veins.

This finding is more consistent for an infant with an earlier gestational age.

Section 4 Continued Transition Care A nursing student is assisting the nurse in caring for the infants in the nursery. The nurse questions the student about vitamin K (Aqua MEPHYTON) as preparations are made for administration.

Question 13 of 23 Which response by the student indicates an understanding of the purpose for administering this drug?

The purpose of this drug is to prevent hypoglycemia in the newborn.

Vitamin K is a fat-soluble vitamin and promotes a positive nutritional status.

This drug is given to the newborn to prevent and/or treat hemorrhagic disease.

Vitamin K is produced and stored in the liver, which is immature in the infant.

The purpose of this drug is to prevent hypoglycemia in the newborn.

Further teaching is needed because vitamin K does not prevent hypoglycemia.

Vitamin K is a fat-soluble vitamin and promotes a positive nutritional status.

This is not the primary reason for giving vitamin K. This drug is given to the newborn to prevent and/or treat hemorrhagic disease.

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.

Vitamin K is produced and stored in the liver, which is immature in the infant.

Vitamin K is produced in the gut but stored in the liver.

The nurse is preparing to give the baby her first bath.

Question 14 of 23 Which assessment data indicates that it is safe for the baby to be given a bath at this time?

Respiratory rate of 52 breaths/min.

Axillary temperature of 97.9° F (36.61° C).

Apical heart rate of 166 beats/min.

Pulse oximeter of 90%.

Respiratory rate of 52 breaths/min.

This respiratory rate is high-normal and will rise with the activity of bathing.

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).

Apical heart rate of 166 beats/min.

This heart rate is high-normal and will rise further with the activity of bathing.

Pulse oximeter of 90%.

This value is below normal and could become lower with the activity of bathing.

At 2400 hours the infant is crying, his skin is mottled, and his hands are shaking.

Question 15 of 23 Which action should the nurse take first?

Assess the infant's respiratory efforts.

Monitor the blood glucose level.

Give the infant some formula.

Evaluate for possible seizures.

Assess the infant's respiratory efforts.

Assessing the respiratory efforts of the infant is unnecessary since the infant is crying, and crying is a good indicator of respiratory effort.

Monitor the blood glucose level.

Since it has been 2 hours since delivery, the infant may be experiencing hypoglycemia.

Give the infant some formula.

Because this infant is breastfeeding, an attempt should be made to let him nurse before offering the formula.

Evaluate for possible seizures.

The infant is not exhibiting any signs associated with seizures.

Section 5

Rooming-In The baby's vital signs have stabilized by 0100 hours. Upon completion of assessment and documentation, the nurse takes the baby to Ms. Myers 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 Ms. Myers and the baby at 0200 hours. Both are asleep in the bed, with the baby lying beside Ms. Myers.

Question 16 of 23 What should the nurse do next?

Pick up the baby and return her to the crib while letting Ms. Myers sleep.

Wake Ms. Myers and remind her that keeping the baby in the bed is unsafe.

Tell Ms. Myers that the baby must be returned to the nursery for safety reasons.

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

Pick up the baby and return her to the crib while letting Ms. Myers sleep.

Although returning the baby to her crib is the proper response, this action is incomplete.

Wake Ms. Myers and remind her that keeping the baby in the bed is unsafe.

Although waking Ms. Myers is the proper response, this action is incomplete.

Tell Ms. Myers that the baby must be returned to the nursery for safety reasons.

Although the baby can be returned to the nursery if Ms. Myers is too tired to care for him, there is a better response in this situation.

Remind Ms. Myers 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 (36.22° C).

Question 17 of 23 Which should the nurse do next?

Put a t-shirt on the baby and cap on his head.

Cover the baby with a dry blanket, but leave the cap off.

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

Immediately take the baby and place him under a heat source.

Put a t-shirt on the baby and cap on his head.

Although this would help the baby, another action is more effective.

Cover the baby with a dry blanket, but leave the cap off.

This action is incomplete.

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

This action not only protects the baby, but also involves and teaches the mother.

Immediately take the baby and place him under a heat source.

Other actions should be done first.

The nurse checks on Ms. Myers and her baby every 2 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. Ms. Myers 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.

Question 18 of 23 How should the nurse respond to the client?

Select all that apply Reassure Ms. Myers that she will get plenty of practice.

Observe Ms. Myers as she performs a diaper change.

Place the baby on the bed and demonstrate how to change a diaper.

Tell Ms. Myers that the nurses can change the diapers until they go home.

Advise Ms. Myers that classes to teach infant care, such as diapering, are available on the unit.

Reassure Ms. Myers that she will get plenty of practice.

Ms. Myers's statement implied a need that should be addressed by the nurse.

Observe Ms. Myers as she performs a diaper change.

This approach helps the nurse evaluate the problems Ms. Myers is experiencing so the most effective teaching can be provided.

Place the baby on the bed and demonstrate how to change a diaper.

Another action is more effective to meet the client's needs.

Tell Ms. Myers that the nurses can change the diapers until they go home.

Although the nurses may assist with diaper changing, the mother's involvement in the care of her baby is essential.

Advise Ms. Myers that classes to teach infant care, such as diapering, are available on the unit.

It is appropriate to address the need for teaching at this time.

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

Question 19 of 23 What action should the nurse take?

Show Ms. Myers how to remove the caked-on powder.

Explore with Ms. Myers why powder was used.

Praise Ms. Myers for wanting to keep her baby dry.

Instruct Ms. Myers to use plain water instead of powder.

Show Ms. Myers how to remove the caked-on powder.

This should be done, but further instruction is needed.

Explore with Ms. Myers why powder was used.

This may provide some information, but it does not correct the problem.

Praise Ms. Myers for wanting to keep her baby dry.

This response does not teach Ms. Myers about the proper use of powder on her baby.

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 mantle 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 the infant at risk for fine particle aspiration.

While changing the infant's clothing, Ms. Myers notices the baby startles easily. Ms. Myers asks the nurse what is causing this reaction.

Question 20 of 23 Which explanation should the nurse provide?

"Your baby probably has a neurological deficit."

"Apparently your baby had some trauma at birth to cause this."

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

"This is unusual, and I will notify the pediatrician about the reaction."

"Your baby probably has a neurological deficit."

This finding is normal response in a 38 week gestational newborn. This response is inappropriate "Apparently your baby had some trauma at birth to cause this."

There is usually a much more reasonable explanation for this finding. This response could cause the mother unnecessary anxiety.

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

The moro reflex is a startling response by the infant as a reaction to a loud noise, sudden touch, or a change in position.

"This is unusual, and I will notify the pediatrician about the reaction."

This is not an unusual occurrence.

Section 6 Preparation for Discharge 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 (3300 gm). Ms. Myers expresses her concern to the nurse when she realizes that her baby has lost almost a pound since birth.

Question 21 of 23 How should the nurse respond?

"I can tell you are concerned. Would you like to talk with the pediatrician?"

"Yes, this is a concern. The pediatrician may want to keep the baby here for another day."

"Don't worry. Your baby will gain weight in a few days when your milk comes in."

"Don't be concerned. Your baby's weight loss is in the typical range for all babies."

"I can tell you are concerned. Would you like to talk with the pediatrician?"

She can certainly talk with the pediatrician, but the nurse can and should respond to this mother's concern.

"Yes, this is a concern. The pediatrician may want to keep the baby here for another day."

Based on the data regarding the baby's weight loss, it would not be necessary to keep the baby another day.

"Don't worry. Your baby will gain weight in a few days when your milk comes in."

This response offers false reassurance. In addition, it may lead the mother to believe that her breast milk is not adequate at this time, which is incorrect.

"Don't be concerned. Your baby's weight loss is in the typical range for all babies."

Babies may lose up to approximately 10% of their birth weight.

Ms. Myers is told that a neonatal screening test needs to be done before they are discharged.

Question 22 of 23 When asked the reason for including the PKU test in the screening, which information should the nurse provide?

An error in metabolism of the amino acids leucine, isoleucine, and valine can cause death if not detected and treated early.

A problem converting the protein phenylalanine may be present, which can lead to mental retardation if not found and treated early.

Screening for an error in metabolism of the sugars galactose and lactose can prevent liver and brain damage in the newborn.

This test detects the level of thyroxin produced by the thyroid. If too little is produced or if treatment is not started early, mental retardation can result.

An error in metabolism of the amino acids leucine, isoleucine, and valine can cause death if not detected and treated early.

This describes another error in metabolism.

A problem converting the protein phenylalanine 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 baby's blood.

Screening for an error in metabolism of the sugars galactose and lactose can prevent liver and brain damage in the newborn.

This describes a different error in metabolism.

This test detects the level of thyroxin produced by the thyroid. If too little is produced or if treatment is not started early, mental retardation can result.

This describes another metabolic disorder, not PKU. Question 23 of 23 How should the nurse collect the blood needed for PKU screening?

Clean the heel with alcohol swap, dry with gauze, and collect blood in a capillary tube.

Puncture the lateral heel after warming and collect blood samples on the designated lab form.

Collect heel blood using a transfer pipette, and place a drop of blood on a reflectance meter.

After grasping the baby's lower leg and foot, use a microlancet to puncture the middle portion of the heel.

Clean the heel with alcohol swap, dry with gauze, and collect blood in a capillary tube.

A capillary tube is used to collect blood for hemoglobin, not PKU screening.

Puncture the lateral heel after warming and collect blood samples on the designated lab form.

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.

Collect heel blood using a transfer pipette, and place a drop of blood on a reflectance meter.

This is the usual technique to collect blood for glucose analysis, not PKU screening.

After grasping the baby's lower leg and foot, use a microlancet to puncture the middle portion of the heel.

The middle portion of the heel should not be used.

Section 7 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.

Ms. Myers thanks the nurses for their support, care, and teaching. Ms. Myers and baby are taken by wheelchair to a private car, where the baby is secured in a car seat for the drive home.

Healthy Newborn Rear-facing infant seat in rear seat of car