Healthy Newborn Case Study

Infant Care at Birth
The nursery RN places the infant under a radiant warmer and starts to dry her quickly.

1.
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.

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

2.
Which action should the nurse take prior to drying the infant’s back?
A) Note if the infant has passed any meconium stool.

B) Observe the sacral area for possible Mongolian spots.

C) Assess the amount and location of vernix caseosa.

D) Inspect the back for possible neurological defects.

D) Inspect the back for possible neurological defects.
CORRECT
To prevent harm while drying the newborn, the back should always be inspected for possible neurological defects, like spinal bifida.
At 1 minute of age, the infant is crying and has a heart rate of 160 and a respiratory rate of 58. Both of the infant’s arms and legs are flexed, and her hands and feet are cyanotic.

3.
Which APGAR score should the nurse assign?

A) 10.

B) 9.

C) 8.

D) 7.

B) 9.
CORRECT
One point is deducted for acrocyanosis.
The nurse conducts a physical assessment of the infant looking for normal as well as abnormal findings.

4.
Upon inspection of the umbilical cord, which finding should the nurse report to the healthcare provider?

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.
CORRECT
Two arteries and one vein should be present.
The Carson baby’s head is molded from the vaginal delivery. Upon seeing the baby, Ms. Carson says, “Oh, she is so beautiful, but something is wrong with her head.”

5.
How should the nurse respond?
A) “No nothing is wrong with her head. She really is a beautiful baby.”

B) “‘Yes, it is misshaped, but we will show you how to change it over time.”

C) “Her 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 midwife?”

C) “Her head has been molded from delivery through the birth canal, which is normal.”
CORRECT
Molding commonly occurs in babies delivered vaginally, and the head will become more symmetrical over time.
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Ms. Carson is offered the opportunity to breastfeed. After securing a comfortable position for herself and the baby, Ms. Carson puts the infant to her breast. The baby latches onto the nipple, and with some encouragement, she begins to nurse. After a time of family interaction, Ms. Carson is taken to the postpartum unit, and the infant is transferred to the transition care nursery.

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.

6.
Which action should the nurse take to solve this problem?
A) Document the presence of the incorrect number on the charts for the baby and the mother.

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

C) Redo the identification bands with another nurse witnessing the process.

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

C) Redo the identification bands with another nurse witnessing the process.
CORRECT
Identification bands must be correct to ensure the safety and security of all hospitalized clients, especially newborns.
Upon admission to the transition care nursery, the Carson baby’s axillary temperature is 97.4° F.

7.
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 her temperature.

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

D) Notify the healthcare provider immediately about the temperature.

B) Place the infant in a radiant warmer and monitor her temperature.
CORRECT
The baby’s temperature is not within normal range (97.5°-99° F). The infant should remain in the radiant heat warmer until her temperature has stabilized.
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.

8.
Which action should the nurse take in response to this finding?
A) Document the finding in the record.

B) Monitor the tension of the anterior fontanel.

C) Report the finding to the healthcare provider.

D) Apply cool compresses to prevent more swelling.

A) Document the finding in the record.
CORRECT
This finding indicates caput succedaneum, which commonly occurs after a vaginal birth.
The nurse notes a bluish discoloration of the skin across the infant’s sacral area.

9.
Which should the nurse do in response to this finding?
A) Assess the infant for cold stress.

B) Refer the parent to the care of a pediatric specialist.

C) Document this finding in the record.

D) Evaluate the infant’s neurological status.

C) Document this finding in the record.
CORRECT
This bluish discoloration of the skin is a birthmark, commonly referred to as Mongolian spots. They are merely a dense collection of normal skin cells deep in the skin. This is a common finding, which should simply be noted in the baby’s record.
10.
Which physical finding, if present, should the nurse report to the healthcare provider?

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.
CORRECT
Natal teeth present at birth is an unusual occurrence that should be reported to the healthcare provider. Loose natal teeth are frequently removed to prevent aspiration.
11.
When examining the baby’s extremities, which finding would warrant additional assessment by the nurse?
A) Toenails blanch with pressure and quickly refill.

B) Feet that turn in, but can be manipulated to midline.

C) Hands are plump and clenched into fists.

D) Limited hip abduction in the supine position.

D) Limited hip abduction in the supine position.
CORRECT
Because this finding could indicate developmental dysplasia of the hip, formerly known as congenital hip dislocation, additional assessment is warranted.
12.
Which finding by the nurse is consistent with an infant born at 39 weeks gestation?
A) Presence of abundant lanugo hair across face and back.

B) Plantar creases covering the entire sole of foot.

C) Slightly soft, curved pinna with slow recoil.

D) Skin is smooth and pink with visible veins.

B) Plantar creases covering the entire sole of foot.
CORRECT
This finding is consistent with a baby born at 39 weeks gestation.
Continued Transition Care
A nursing student is assisting the RN in caring for the infants in the nursery. The RN questions the student about vitamin K (Aqua MEPHYTON) as preparations are made for administration.

13.
Which response by the student indicates an understanding of the purpose for administering this drug?
A) “The purpose of this drug is to prevent hyperbilirubinemia 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.”
CORRECT
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.
The nurse is preparing to give the baby her first bath.

14.
Which assessment data indicates that it is safe for the baby to be given her bath at this time?
A) Respiratory rate of 46.

B) Axillary temperature of 98° F.

C) Apical heart rate of 160.

D) Pulse oximeter of 90%.

B) Axillary temperature of 98° F.
CORRECT
A bath may potentially lower the temperature, which will not be harmful because the core temperature is near 99° F.
At 2400 hours the infant is crying, her skin is mottled, and her hands are shaking.

15.
Which action should the nurse take first?
A) Assess the infant’s respiratory efforts.

B) Monitor the blood glucose level.

C) Give the infant some formula.

D) Evaluate for possible seizures.

B) Monitor the blood glucose level.
CORRECT
Since it has been 2 hours since delivery, the infant may be experiencing hypoglycemia.
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. Carson who wants to breastfeed and ‘room-in’ with the baby. After checking the ID bands, the infant is positioned for breastfeeding.

The nurse checks on Ms. Carson and the baby at 0200 hours. Both are asleep in the bed, with the baby lying beside Ms. Carson.

16.
What should the nurse do next?
A) Pick up the baby and return her to the crib while letting Ms. Carson sleep.

B) Wake Ms. Carson and remind her that keeping the baby in the bed is unsafe.

C) Tell Ms. Carson that the baby must be returned to the nursery for safety reasons.

D) Remind Ms. Carson about infant safety and assist her to place the infant in the crib.

D) Remind Ms. Carson about infant safety and assist her to place the infant in the crib.
CORRECT
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 loose, and the cap is off her head. The nurse takes the baby’s temperature, which is 97.6° F.

17.
Which should the nurse do next?
A) Bundle the baby and place the cap on her head.

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

C) Show Ms. Carson how to wrap the baby for warmth and apply the cap to her head.

D) Immediately take the baby and place her under a heat source.

C) Show Ms. Carson how to wrap the baby for warmth and apply the cap to her head.
CORRECT
This action not only protects the baby, but also involves and teaches the mother.
The nurse checks on Ms. Carson 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. Carson 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.

18.
What action should the nurse implement?
A) Reassure Ms. Carson that she will get plenty of practice.

B) Observe Ms. Carson as she performs a diaper change.

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

D) Tell Ms. Carson that the nurses can change the diapers until they go home.

B) Observe Ms. Carson as she performs a diaper change.
CORRECT
This approach helps the nurse evaluate the problems Ms. Carson is experiencing so the most effective teaching can be provided.
When Ms. Carson removes the diaper, the nurse notices that the baby has caked powder in the inguinal leg folds and vulva areas.

19.
What action should the nurse take?
A) Show Ms. Carson how to remove the caked-on powder.

B) Explore with Ms. Carson why powder was used.

C) Praise Ms. Carson for wanting to keep her baby dry.

D) Instruct Ms. Carson to use plain water instead of powder.

D) Instruct Ms. Carson to use plain water instead of powder.
CORRECT
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 diaper, Ms. Carson notices blood-tinged mucous in the vulva area and asks the nurse what is causing this with her baby.

20.
Which explanation should the nurse provide?
A) “Your baby probably has the beginning of a urinary tract infection.”

B) “Apparently your baby had some trauma at birth to cause this.”

C) “Withdrawal of maternal hormones is the usual cause of this occurrence.”

D) “This is unusual, and I will notify the pediatrician about the mucous.”

C) “Withdrawal of maternal hormones is the usual cause of this occurrence.”
CORRECT
This is called pseudomenstruation, which is due to the effects of maternal hormones.
Preparation for Discharge
At two days post birth, Ms. Carson and her baby are doing well and preparing for discharge. The baby’s weight at birth was 7 lb 15 oz (3600 gms), and today she weighs 7 lb 3 oz (3300 gms).

Ms. Carson 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?
A) “I can tell you are concerned. Would you like to talk with the pediatrician?”

B) “Yes, this is a concern. The pediatrician may want to keep the baby here for another day.”

C) “Don’t worry. Your baby will gain weight in a few days when your milk comes in.”

D) “Don’t be concerned. Your baby’s weight loss is in the typical range for all babies.”

D) “Don’t be concerned. Your baby’s weight loss is in the typical range for all babies.”
CORRECT
Babies may lose up to approximately 10% of their birth weight.
Ms. Carson is told that a neonatal screening test needs to be done before they are discharged.

22.
When asked the reason for including the 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.
CORRECT
PKU testing is done to detect the level of phenylalanine in the baby’s blood.

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 is produced 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.
CORRECT
PKU testing is done to detect the level of phenylalanine in the baby’s blood.
23.
How should the nurse collect the blood needed for PKU screening?
A) Clean the heel with alcohol swap, 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.
CORRECT
The heel should be warmed, cleaned with alcohol, and dried with gauze. After puncturing the heel with a microlancet, blood is collected on a special neonatal screening form.
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