HESI Case Studies–Obstetric/Maternity-Newborn with Jaundice (The Fuqua family)
1. Which action should the nursery nurse take first in caring for the infant?
Dry the infant quickly with warm blankets
Drying the infant is a priority to prevent evaporative heat loss
2. After cleaning the airway and drying the infant, the nurse assesses that the infant is breathing and has a heart rate of 100 but remains cyanotic
Prepare to give oxygen
The infant is breathing and has a heart rate. However, O2 given during this critical transition can increase oxygenation to the rest of the body. Oxygen is usually given by having the nurse cup her hands around the infants nose and mouth at the O2 tube.
3. At 1 minute the infant has a heart rate of 142, has a slow weak cry, is grimacing, and is in a flexed position with acrocyanosis. What Apgar score should the nurse assign?
one point each deducted for acrocyanosis (blue hands and feet), a slow weak cry and grimacing
4. Which action should the nurse take prior to weighing the infant?
Place a cover on the scale
the infant should be weighted nude, and covering the scale prevents conductive heat loss
5. To promote family bonding, which part of infant care should the nurse delay
Giving eye prophylaxis
the presence of eye ointment or drops can interfere with eye to eye parent/infant interaction. giving eye prophylaxis can be delayed for up to 2 hours after birth
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6. After receiving the labor and delivery report, which information should direct the nurse to further assessment of the infant’s head?
Low forceps delivery
low forceps delivery is usually done with minimal risk, but there is a potential for head trauma or damage to the facial nerve
7. The infant’s vital signs are as follows: temp 97.8F; HR 136, irregular with soft murmur; and RR 36. Which action should the nurse take?
Place the infant under a radiant heat source
the infant should be place under a radiant heat source to prevent further heat loss during the transition period. the temperature usually stabalizes within 4 hours of birth
8. What action should the nurse take when finding that the head measures 35 cm and the chest circumference measures 33 cm?
Document the findings in record
the head and chest circumference are within normal limits
9. Upon examining the chest, which finding should the nurse report to the healthcare provider?
Crepitus across right clavicle
crepitus could indicate a fractured clavicle that may have occurred at delivery
10. The infant exhibits a positive Babinski reflex. Which action should the nurse take to elicit a Babinski reflex?
Stroke side of the sole of the foot from heel upward toward toes
this will elicit the babinski reflex with the newborn flexing the great toe and extending other toes, which is a normal response in an infant
11. When the nurse conducts a gestational age assessment, which finding(s) may indicate post-maturity? (Select all)
-Low reading on blood glucose testing
post-mature infants are at risk of hypoglycemia due to rapid use of glycogen stores
-Peeling, parchment-like skin
this is one indicator of postmaturity because vernix caseosa disappears
-Thin with loose skin and little subcutaneous fat
subcutaneous fat, which had been used for nourishment, is lost prior to birth. This results in the infant’s low temperature
-Deep creases at the base of the toes extending to the heels.
post-term infants develop deep creases on the foot extending from the base of the toes to the heels
12. While administering the vitamin K to the infant, which action should the nurse take?
Select the middle part of the vastus lateralis for use.
this muscle is the preferred site in infants for administration of injections
13. The nurse next prepares to administer the erythromycin ointment (Ilotycin ophthalmaic ointment). Which approach should the nurse use to administer the ointment?
Cover entire lower conjunctiva with ointment after gently retracting the lid.
the eye needs to be opened gently using two hands and a ribbon of ointment is applied
14. While the nurse is discussing care with Mrs. Fuqua, the infant starts gagging. What action should the nurse implement first?
Use a bulb syringe to clear the mouth and nose
gagging due to excessive mucous is a typical response during the transition period. Suctioning the mouth and nose shold be done first
15. The mother asks how often the infant should be burped. How should the nurse respond?
He needs burping at the start and after each ounce of formula
this gives specific guildelines to the parents
16. When Mrs. Fuqua starts feeding the infant, large bubbles are seen in the bottle. Mr. Fuqua expresses concern. What explanation should the nurse give to the family?
Too much formula is flowing through the nipple
the bottle cap should be tightened. Small bubbles should be seen with feeding. large bubbles indicate that the cap is too loose and should be tightened
17. Upon entering the Fuquas’ room, the nurse finds Mrs. Fuqua in the bathroom and the infant in the crib with a bottle propped on a towel. What action should the nurse take?
Remove the bottle from the infant’s mouth
the primary concern is for the safety of the infant. propping a bottle places the infant at risk for choking as well as ear infections
18. Which finding by the nurse is consistent with a cephalhemotoma?
Well-outlined swelling that does not cross suture lines
Cephalhematoma is caused by blood collecting beneath the periosteum of the bone and therefore does not cross the suture line
19. The infant has a reddish papular rash across his face. How should the nurse respond when Mrs. Fuqua asks about the rash?
A newborn rash is very common, but it will disappear soon
the infant rash, erythema toxicum, is very common and usually disappears by the 3rd day of life
20. Which factor should alert the nurse to assess for the risk of jaundice
Presence of cephalhematoma
the presence of cephalhematoma indicates that bleeding has occured. as the red blood cells break down, increased amounts of bilirubin are released into the general circulation
21. The nurse observes that the infant is jaundiced on his face, head, and chest. What action should the nurse take next?
Obtain blood for laboratory analysis
blood drawn for serum bilirubin provides additional data and the basis for treatment of hyperbilirubinemia, which may be physiologic or nonphysiologic
22. The nurse prepares the infant for placement under a bilirubin light. Which action(s) the nurse should implement? (Select all)
-Remove the infant’s clothing
although some agencies will leave a diaper in place, it is important to expose as much of the skin as possible
-Place eye patches on the infant
eye covering is important during phototheraphy to prevent retinal injury from the phototherapy lights
-Turn off lights and allow parents to hold infant for feedings
removing the infant from phototherapy for feedings and interactions with parents for perionds up to an hour at a time does not decrease effectiveness of phototherapy. This also provides needed sensory stimulation for the infant
23. While the infant is receiving phototherapy, his stools become loose and green. What action should the nurse take?
Document the findings in the record
the loose green stools are a typical response to phototherapy, so stools should continue to be monitored and results documented
24. The parents ask about why they have a phototherapy blanket instead of lights. How should the nurse respond?
Holding the infant does not interrupt the phototherapy process
the phototherapy blanket allows the infant to be held while the process is continued
25. Mrs. Fuqua asks how she will know the phototherapy is working. How should the nurse respond?
Serum bilirubin level decreases
decreasing bilirubin levels are the best indicator of phototherapy effectiveness