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
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
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?
7
4. Which action should the nurse take prior to weighing the infant?
Place a cover on the scale
5. To promote family bonding, which part of infant care should the nurse delay
Giving eye prophylaxis

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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
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
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
9. Upon examining the chest, which finding should the nurse report to the healthcare provider?
Crepitus across right clavicle
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
11. When the nurse conducts a gestational age assessment, which finding(s) may indicate post-maturity? (Select all)
-Low reading on blood glucose testing
-Peeling, parchment-like skin
-Thin with loose skin and little subcutaneous fat
-Deep creases at the base of the toes extending 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.
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.
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
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
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
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
18. Which finding by the nurse is consistent with a cephalhemotoma?
Well-outlined swelling that does not cross suture lines
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
20. Which factor should alert the nurse to assess for the risk of jaundice
Presence of cephalhematoma
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
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
-Place eye patches on the infant
-Turn off lights and allow parents to hold infant for feedings
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
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
25. Mrs. Fuqua asks how she will know the phototherapy is working. How should the nurse respond?
Serum bilirubin level decreases
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