Test 6

Question 1

1. Cleft palate post op nursing interventions (Slide 13)

Answer 1

 Monitor weight and for dehydration.
 NPO 2 hr post-op, then liquid 3-4 days.
 Encourage parental attachment.
 Suction and Position to facilitate drainage, gentle w/bulb syringe as needed.
 Assist with feeding techniques.
 Elbow restraints

Question 2

2. Identification steps to safeguarding baby (Slide 23)

Answer 2

 VERIFY ID BANDS ON BOTH MOM AND BABY
 VERIFY GENDER
 VERIFY DOB
 VERIFY MOM’S MEDICAL RECORD NUMBER
 VERIFY ANY HEALTH CARE WORKER ID BADGE

Question 3

3. Trisomy 21 manifestations

Answer 3

 Brachycephaly, Short stature, Upward slanted eyes short, flattened bridge of nose
 Thick, hypotonic muscles, protruding tongue, Dry, cracked, fissured skin that may be mottled.
 Small hands with short broad fingers and curved fifth finger. Single deep crease on palm of hand, Wide space between first and second toes
 Lax muscle tone
 Heart and eye anomalies
 Greater susceptibility to leukemia

Question 4

4. Circumcision; health benefits and nursing consideration(Slide 22)

Answer 4

 HEALTH BENEFITS:
• EASIER HYGIENE
• DECREASED RISK OF STIs, PENILE CA AND CERVICAL CA IN PARTNERS

 NURSING CONSIDERATIONS:
• MONITOR FOR S/S INFECTION: DRAINAGE OR REDNESS AT BASE
• AS HEALING OCCURS A YELLOW CRUSTY MATERIAL WILL FORM
• APPLY PETROLEUM JELLY W/ DIAPER CHANGES
• NO BATHS UNTIL HEALED

Question 5

5. Hydrocephalus manifestations (slide 5)

Answer 5

 Rapid head growth with widening cranial sutures
 Dilated scalp veins
 Bulging fontanels
 Sun-setting sign
 Neck muscles fail to develop sufficiently, newborn has difficulty raising or turning head.
 Increasingly helpless, increased intracranial pressure.

Question 6

6. APGAR meaning

Answer 6

 A: APPEARANCE (SKIN COLOR)
• Pale or blue= 0
• Body normal skin tone but extremities blue (cyanotic)= 1
• Normal skin tone= 2

 P: PULSE (HEART RATE)
• Absent= 0
• Less than 100 bpm= 1
• 100 bpm or more= 2

 G: GRIMACE (REFLEX Irritability/ RESPONSE)
• No response to stimulation= 0
• Grimace but no cry to stimulation= 1
• Cry and active movement= 2

 A: ACTIVITY (MUSCLE TONE)
• None, Flaccid= 0
• Some flexions of arms and legs= 1
• Arms and legs flexed and in motion= 2

 R: RESPIRATION (BREATHING ABILITY)
• Absent= 0
• Weak, irregular cry=1
• Strong, vigorous cry= 2

Question 7

6. APGAR interventions.

Answer 7

• SCORE 7-10: NO INTERVENTIONS, BABY DOING GOOD JUST NEEDS ROUTINE POST- CARE

• SCORE 4-6: SOME RESUSCITATION ASSISTANCE REQUIRED. OXYGEN, SUCTION, STIMULATE THE BABY, RUB BABY’S BACK (REASSESS IN 5 MINUTES)

• SCORE 0-3: NEED FULL RESUSCITATION

Question 8

7. Cesarean postop care of newborn

Answer 8

 Worry about the respiratory system.
 MONITOR FOR RESPIRATORY because of retained lung fluid.

Question 9

8. Vitamin K administration location (Slide 5)

Answer 9

 VITAMIN K IS TO STIMULATE APPROPRIATE CLOTTING.
 Decreases risk of infant hemorrhagic disorder
 Not produced in the GI tract of the newborn until around day 7
 Is produced in the colon by bacteria once formula or breast milk is introduced.
 Administer 0.5 to 1mg IM into the vastus lateralis (thigh) within 1 hr. after birth.

Question 10

9. Client education for breastfeeding

Answer 10

 Cleanse with plain water; use of lanolin cream; rub drop of breast milk into each nipple and allow to dry.
 Alternate breasts and empty completely
 Reposition the baby.
 If bottle feeding, do not express milk, will gradually stop producing.
 Encourage early feeding/helps prevent hemorrhage/will help with infant stools 2-3 day.
 Engage a lactation consultant for proper latching.
 Each feeding around 30 minutes
 Assess nipples.

Question 11

10. Jaundice nursing considerations (Slide 4)?

Answer 11

 IF JAUNDICE IS PRESENT BEFORE THE NEWBORN IS 24 HOURS OLD IS A MEDICAL EMERGENCY**
 MONITOR BILIRUBIN LEVEL

Question 12

11. Myelomeningocele nursing priorities

Answer 12

 Maintain the skin integrity and protect it from damage.
 The concerns related to infection, impaired skin integrity, and neuromuscular issues?

Question 13

12. Newborn expected findings r/t vital signs (Slide 2)

Answer 13

RESPIRATORY FUNCTION IS THE NURSE’S PRIORITY: NORMAL RATE IS 30-60 BREATHS/MIN WITH SHORT APNEA LESS THAN 15 SECONDS
 IF SUCTIONING THE NURSE SHOULD SUCTION MOUTH FIRST FOLLOWED BY THE NARES-ASSESS FOR MUCUS AND SUCTIONING NEED.

 (2) KEEPING THE NEWBORN WARM AND PREVENTING COLD STRESS IS THE PRIORITY AFTER RESPIRATORY FUNCTION
 DRYING THE NEWBORN IS THE PRIMARY ACTION TO PREVENT COLD STRESS, FOLLOWED BY KANGAROO CARE

Question 14

13. Transient strabismus nursing consideration

Answer 14

 Binocular vision is maintained through the muscular coordination of eye movements so that a single vision results. (Normal)
 (In strabismus) the visual axes are not parallel, and diplopia (double vision) results.

Question 15

14. Newborn born to a GDM mom nursing considerations (Slide 6)

Answer 15

 NEWBORN HYPOGLYCEMIA IS A BLOOD GLUCOSE LEVEL LESS THAN 50 MG/DL.
 NEWBORNS CAN BE ASYMPTOMATIC OR MAY DEMONSTRATE MULTIPLE SIGNS.
 THE MOST COMMON SIGN FOR HYPOGLYCEMIA IS JITTERINESS AND HIGH PITCH CRYING.
 NEWBORNS BORN TO MOMS WITH GDM ARE AT A HIGHER RISK

Question 16

15. Post dates manifestations

Answer 16

 Wide eyed, hyper alert expression
 Little lanugo or vernix remains.
 Scalp hair is abundant.
 Fingernails are long.
 Skin is dry, cracked, wrinkled, peeling, and whiter than a normal newborn.
 Little subcutaneous fat and appears long and thin.

Question 17

15. Post dates complications

Answer 17

 Neonatal hypoglycemia
 Polycythemia may develop in response to intrauterine hypoxia.
 Polycythemia puts the infant at risk for cerebral ischemia, thrombus formation, and respiratory distress because of hypoviscosity of the blood.
 At birth they may aspirate meconium into the lungs which leads to obstructing the respiratory passage and irritating the lungs and results in meconium aspiration syndrome

Question 18

16. Phototherapy nursing considerations (Slide 4 & page 447)

Answer 18

 A newborn who has mild-to-moderate disease(jaundice) usually receives hydration and phototherapy after birth.
 IF NEWBORN UNDERGOING PHOTOTHERAPY, THE NURSE SHOULD ASSESS FOR DEHYDRATION (25% more fluid) AND ENCOURAGE BREASTFEEDING 1-2 HOURS.

 Place the lights above the isolette at an appropriate height. If the lights are too far away from the newborn, the therapy will not work. If they are too close, the newborn may receive burns.
 The infant is nude, except for a small covering over the genitalia, to maximize the skin surface area exposed to the light. A pad or diaper is placed under the perineal area to collect urine and feces.
 Turn the newborn every 2 hours to rotate the area of exposure. Do not turn off the lights except to feed and to change the diaper.
 Always shield the newborn’s eyes from the ultraviolet light. Carefully apply eye patches to avoid eye irritation. If the eye patch is too loose, it can slip down and obstruct the nares or lead to retinal damage from the light.
 Remove the patches every 4 hours to cleanse the eyes and examine for irritation, inflammation, and dryness. Clean and change the patches daily.

Question 19

17. Nursing actions for bubbling mucus

Answer 19

 Mouth is first followed by the nares.

Question 20

18. Discharge education for new parents (Slide 24)

Answer 20

 STOOL COLOR WILL CHANGE IN 4-5 DAYS
 IF FUSSY CHECK: DIAPER, FEEDING, BURPING
 BABIES SLEEP 16-19 HOURS A DAY
 PLACE INFANT IN SUPINE POSITION WHEN SLEEPING
 SPONGE BATHS UNTIL CORD FALLS OFF
 FLAME-RETARDANT FABRIC
 NEVER LEAVE UNATTENDED WITH PETS OR OTHER SMALL CHILDREN
 CAR SAFETY CHECK

Question 21

19. Types of heat loss in newborn (old study guide Test 1 question 19

Answer 21

 (A) Conductive: Heat loss occurs when the newborn’s skin touches a cold surface, causing body heat to transfer to the colder object. (Ex. This is when the newborn is placed on a cold scale)

 (B) Convection: Happens when air currents blow over the newborn’s body (Ex. When newborn is left in a draft of cool air)

 (C) Evaporative: When the newborn’s skin is wet. (This is why it is important to dry the newborn thoroughly after birth and to bathe the newborn under a radiant warmer. It is also important to change the newborn linens if they become soiled with emesis or urine)

 (D) Radiation: A cold object that is close to but not touching the newborn (Ex. When the newborn is close to a cold windowpane, causing body heat to radiate toward the window and be lost)

Question 22

20. Newborn reflex manifestations (Slide 21)

Answer 22

 MORO: SHARP HAND CLAP NEAR NEWBORN
 GRASPING: PLACE FINGER IN PALM
 TONIC NECK: TURN HEAD QUICKLY TO ONE SIDE
 SUCKING: STROKE CHEEK
 BABINSKI: STOKE OUTER EDGE OF SOLE OF FOOT

Question 23

21. What is acrocyanosis (page 274)

Answer 23

 Blue hands or feet with a natural color trunk, results from poor peripheral circulation and is not a good indicator of oxygenation status.
 Resolves itself within 24 to 48 hours after birth.
 The mucous membranes should be pink, and there should be no central cyanosis. Birthmarks and skin tags may be present.

Question 24

22. Nursing Assessment of the normal newborn (Slide 13)

Answer 24

 THE NEWBORN EXAMINATION IS AN IMPORTANT WAY TO DETERMINE HOW WELL THE NEWBORN IS ADAPTING TO LIFE OUTSIDE THE WOMB.
 THE LEAST DISTURBING ASPECTS OF THE EXAMINATION ARE COMPLETED FIRST.
 RESPIRATORY RATE AND HEART RATE ARE TAKEN FIRST, WHILE THE NEWBORN IS QUIET.
 THEN EXAMINATION PROCEEDS IN A HEAD-TO-TOE MANNER AND INCLUDES PHYSICAL MEASUREMENTS AND INSPECTION OF EACH BODY PART.
 CLEAN GLOVES SHOULD BE USED IF BATH HAS NOT BEEN GIVEN-STANDARD PRECAUTIONS
 EYE MOVEMENTS ARE USUALLY UNCOORDINATED, AND SOME STRABISMUS/NYSTAGMUS (CROSSED EYES) IS EXPECTED.

Question 25

23. Tetralogy of Fallot (Slide 8)

Answer 25

 Cyanotic! Inadequate oxygenation
 Poor feeding or poor weight gain
 Clubbing fingers
 Dyspnea
 Polycythemia: hydration! (Assess for dehydration)
 HGB: over 22 call the provider.
(Give pacifier if crying to reduce cardiac workload)