Postpartum 2

juniperk's version from 2017-12-02 02:36


Question Answer
A full-term newborn was just born. Which nursing intervention is important for the nurse to perform first? 1. Remove wet blankets. 2. Assess Apgar score. 3. Insert eye prophylaxis. 4. Elicit the Moro reflex.1. When newborns are wet they can become hypothermic from heat loss resulting from evaporation. They may then develop cold stress syndrome.
To reduce the risk of hypoglycemia in a full-term newborn weighing 2900 grams, what should the nurse do? Maintain the infant’s temperature above 97.7ºF. Hypothermia in the neonate is de- fined as a temperature below 97.7ºF. Cold stress syndrome may develop if the baby’s temperature is below that level
A mother, 1 day postpartum from a 3-hour labor and a spontaneous vaginal delivery, questions the nurse because her baby’s face is “purple.” Upon examination, the nurse notes petechiae over the scalp, forehead, and cheeks of the baby. The nurse’s response should be based on which of the following?Rapid deliveries can injure the neonatal presenting part. When neonates speed through the birth canal during rapid deliveries, the presenting parts become bruised. The bruising often takes the form of petechial hemorrhages.
A 2-day-old breastfeeding baby born via normal spontaneous vaginal delivery has just been weighed in the newborn nursery. The nurse determines that the baby has lost 3.5% of the birth weight. What should the nurse do?Do nothing. The baby has lost less than 4% of its birth weight. The normal weight loss for babies is 5% to 10%.
A nurse is doing a newborn assessment on a new admission to the nursery. Which of the following actions should the nurse make when evaluating the baby for developmental dysplasia of the hip (DDH)? Ortolani- (a) the nurse places the baby on its back; (b) the nurse grasps the baby’s thighs with a thumb on the inner aspect and forefingers over the trochanter; (c) with the hips the knees flexed at 90º angles, the hips are abducted; (d) the nurse palpates the trochanter to assess for hip laxity.
A nurse notes that a 6-hour-old neonate has cyanotic hands and feet. Which of the following actions by the nurse is appropriate? 1. Place child in isolette. 2. Administer oxygen. 3. Swaddle baby in blanket. 4. Apply pulse oximeter.Swaddle baby in blanket.Acrocyanosis, bluish/cyanotic hands and feet, is normal in the very young neonate resulting from its immature circulation to the extremities.
The nurse is assessing a newborn on admission to the newborn nursery. Which of the following findings should the nurse report to the neonatalogist? 1. Intracostal retractions. 2. Caput succedaneum. 3. Epstein’s pearls. 4. Harlequin signIntracostal retractions.
A mother calls the nurse to her room because “My baby’s eyes are bleeding.” The nurse notes bright red hemorrhages in the sclerae of both of the baby’s eyes. What should the nurse do?Reassure the mother that the trauma resulted from pressure changes at birth and the hemorrhages will slowly disappear. Subconjunctival hemorrhages are a normal finding and are not pathological.
The nurse is about to elicit the Moro reflex. Which of the following responses should the nurse expect to see?When the baby is suddenly lowered or startled, the neonate’s arms straighten outward and the knees flex.
A 40-week-gestation neonate is in the first period of reactivity. Which actions should the nurse take at this time?Encourage the parents to bond with their baby. Babies are awake and alert for approximately 30 minutes to 1 hour immediately after birth
The nurse notes that a newborn, who is 5 minutes old, exhibits the following characteristics: heart rate 108 bpm, respiratory rate 29 rpm with lusty cry, pink body with bluish hands and feet, some flexion. What does the nurse determine the baby’s Apgar score is? The baby’s Apgar is 8.
The mother notes that her baby has a “bulge” on the back of one side of the head. She calls the nurse into the room to ask what the bulge is. The nurse notes that the bulge covers the right parietal bone but does not cross the suture lines. The nurse explains to the mother that the bulge results from what? Small blood vessels that broke under the baby’s scalp during birth. Cephalhematomas are subcutaneous swellings of accumulated blood from the trauma of delivery. The bulges may be one sided or bilateral and the swellings do not cross suture lines.
A nurse is providing discharge teaching to the parents of a newborn. What should be included when teaching the parents how to care for the baby’s umbilical cord? Call the doctor if greenish drainage appears.
A nurse is advising a mother of a neonate being discharged from the hospital regarding car seat safety. What should be included in the teaching plan?Put the car seat facing forward only after the baby reaches twenty pounds.
A baby has just been admitted into the neonatal nursery. Before taking the newborn’s vital signs, the nurse should warm his or her hands and the stethoscope in order to prevent heat loss resulting from which of the following? 1. Evaporation. 2. Conduction. 3. Radiation. 4. Convection.Conduction. Heat loss resulting from conduction occurs when the baby comes in contact with cold objects (hands or stethoscope).
A 4-day-old breastfeeding neonate whose birth weight was 2678 grams has lost 100 grams since the cesarean birth. Which of the following actions should the nurse take?Nothing because this is an acceptable weight loss.
A physician writes in a breastfeeding mother’s chart, “Ampicillin 500 mg q 6 h po. Baby should be bottlefed until medication is discontinued.” What should be the nurse’s next action?Refer to a text to see whether the antibiotic is safe while breastfeeding.
A client asks whether or not there are any foods that she must avoid eating while breastfeeding. What response by the nurse is appropriate?There are no foods that are absolutely contraindicated during lactation. Some babies may react to certain foods, but this must be determined on a case-by-case basis.
A full-term neonate, Apgar 9/9, has just been admitted to the nursery after a cesarean delivery, fetal position LMA, under epidural anesthesia. Which of the following physiological findings would the nurse expect to see? 1. Soft pulmonary rales. 2. Absent bowel sounds. 3. Depressed Moro reflex. 4. Positive Ortolani sign.. Soft rales are expected because babies born via cesarean section do not have the advantage of having the amniotic fluid squeezed from the pulmonary system as occurs during a vaginal birth.
A full-term neonate has brown adipose fat tissue (BAT) stores that were deposited during the latter part of the third trimester. What does the nurse understand is the function of BAT stores? BAT is metabolized during hypothermic episodes to maintain body temperature. Unfortunately, this can lead to metabolic acidosis.
A neonate has an elevated bilirubin and is slightly jaundiced on day 3 of life. What is the probable reason for these changes? With lung oxygenation, the neonate no longer needs large numbers of red blood cells. As a result, excess RBCs are destroyed. Jaundice often results on days 2 to 4. Pathological before 24 hours. Physiological after 24 hours.
The nurse informs the parents of a breastfed baby that the American Academy of Pediatrics advises that babies be supplemented with which vitamins?Vitamin D.
Four babies with the following conditions are in the well-baby nursery. The baby with which of the conditions is high risk for physiological jaundice? 1. Cephalhematoma. 2. Caput succedaneum. 3. Harlequin coloring. 4. Mongolian spotting.Cephalhematoma. Red blood cells in the cephalhematoma will have to be broken down and excreted. risk for physiological jaundice
A full-term baby’s bilirubin level is 15 on day 3. What neonatal behaviors would the nurse expect to see?Lethargy is one of the most common early symptoms of hyperbilirubinemia.
A 2-day-old baby’s blood values are: blood type—O(negative). direct Coombs—(negative). hematocrit—50%. bilirubin—1.5 mg/dL. The mother’s blood type is A. What should the nurse do?Do nothing because the results are within normal limits.
A 4-day-old baby born via cesarean section is slightly jaundiced. The laboratory reports a bilirubin assessment of 6.0 mg/dL. What would the nurse expect the neonatalogist to order for the baby at this time?Since peak bilirubin levels are seen between days 3 and 5, and since the level is well within normal range, the nurse should expect that the baby will be discharged home with parents

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