HESI Case Study: Healthy Newborn
The nursery RN places the infant under a radiant warmer and starts to dry her quickly. What is the rationale for these actions?
Convective heat loss from evaporation is reduced. [Drying the infant quickly and placing her under a radiant warmer reduces heat loss through evaporation and radiation.]
Which action should the nurse take prior to drying the infant’s 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.]
Heart Rate: absent = 0, slow (<100) = 1, Over 100 = 2
Resp Rate: absent = 0, slow/irregular = 1, good/crying = 2
Muscle Tone: flaccid = 0, some flexion of the extremeties = 1, active motion = 2
Reflex Irritability: no response = 0, grimace = 1, cry = 2
Color: blue/pale = 0, body pink/extremeties blue = 1, completely pink = 2
Upon inspection o the umbilical cord, which finding should the nurse report to the healthcare provider?
One artery and one vein are present. [Two arteries and one vein should be present.]
The Carson’s 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.” How should the nurse respond?
Her head has been molded from delivery through the birth canal, which is normal. [Molding commonly curs in babies delivered vaginally, and the head will become more symmetrical over time.]
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The nurse checks the identification bands for both the baby and the mother upon admission to the nursery. One ID number is incorrect. Which action should the nurse take to solve this 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.]
Upon admission to the transition care nursery, the Carson’s baby’s auxiliary temperature is 97.4 F. WHich action should the nurse take?
Place the infant in a radiant warmer and monitor her temperature. [The baby’s temperature is not within normal range (97.5-99F). The infant should remain in the radiant heat warmer until her temperature has stabilized.]
While examining the infant’s head, the nurse note soft swelling of the scalp that extends across the suture lines if the fetal skull. What action should the urge take in response to this finding?
Document the finding in the record. [This finding indicates capet sucedaneum (swelling, or edema, of a newborn’s scalp soon after delivery; appears as a lump or bump; caused by prolonged pressure from the dilated cervix or vaginal walls during delivery; usually goes away on its own in a couple days), which commonly occurs after a vaginal birth.]
The nurse notes a bluish discoloration of the skin across the infant’s sacral area. Which should the nurse do in response to this finding?
Document this finding in the record. [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.]
Which physical finding, if present, should the nurse report to the healthcare provider?
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.]
When examining the baby’s extremities, which finding would warrant additional assessment by the nurse?
Limited hip abduction in the supine position. [Because this finding could indicate developmental dysphasia (enlargement of an organ or tissue by the proliferation of cells of an ad normal type) of the hip, formerly known as congenital hip dislocation, additional assessment is warranted.]
Which finding(s) are consistent with an infant born at 39 weeks gestation?
Head and neck is 25% of bdy’s surface. [The head of a term baby is large in proportion to the rest of the body. The head and neck comprise 25% of the body surface.]
Plantar creases covering the entire sole of foot. [This finding is consistent with a baby born at 39 weeks gestation.]
Which response by the student indicates an understanding of the purpose for administering vitamin K (Aqua MEPHYTON)?
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, supplements 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.]
Which assessment data indicates that it is safe for the baby to be given her bath at this time?
Axillary temperature of 98F. [A bath may potentially lower the temperature, which will not be harmful because the core temperature is near 99F.]
At 2400 hours the infant is crying, her skin is mottled, and her hands are shaking. Which action should the nurse take first?
Monitor the blood glucose level. [SInce it has been 2 hours since delivery, the infant may be experiencing hypoglycemia.]
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. What should the nurse do next?
Remind Ms. Carson 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 loose, and the cap is off her head. The nurse takes the baby’s temperature, which is 976f. Which should the nurse do next?
Show Ms. Carson how to wrap the baby for warmth and apply the cap to her head. [This action not only protects the baby, but also involves and teaches the mother.]
Ms. Carson tells the nurse that she attempted to change the diaper bu had difficulty doing so. How should the nurse respond to the client?
Observe Ms. Carson as she performs a diaper change. [This approach helps the nurse evaluate the problems Ms. Carson is experiencing so the most effective teaching can be provided.]
Advise Ms. Carson 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. Carson removes the diaper, the nurse notice that the baby has caked powder in the inguinal leg folds and vulva areas. What action should the nurse take?
Instruct Ms. Carson to use plain water instead of powder. [Until the baby is 4 days old, only plain water is recommended 9after the initial bath0 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-tingles mucous in the vuvla area and asks the nurse what is causing this with her baby. Which explanation should the nurse provide?
“Withdrawal of maternal hormones is the usual cause of this occurrence.” [This is called psuedomenstruation, which is due to the effects of maternal hormones.]
Ms. Carson expresses her concern to the nurse when she realizes that her baby has lost almost a pound since birth. How should the nurse respond?
“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. Carson is told that a neonatal screening test needs to be done before they are discharged. When asked the reason for including the PKU test in the screening, which information should the nurse provide?
A problem converting the protein phenylalanine may be present, which can lead to mental reardation if not found and treated early. [PKU testing is done to detect the level of phenylalanine in the baby’s blood.]
How should the nurse collect the blood needed for PKU screening?
Puncture the paternal 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.]