Newborn with Jaundice

Newborn with Jaundice RN Case Study The laboring client is admitted to the labor and delivery unit. Her pregnancy is uncomplicated and she has received routine prenatal care starting at 8 weeks' gestation. After 14 hours of intense labor, she is physically and emotionally too exhausted to continue unassisted. The healthcare provider (HCP) uses low forceps to assist with the delivery of the infant. The client is relieved to have a vaginal delivery of an infant boy at 38 weeks' gestation who weighs 8 lbs 5 oz (3.78 kg). The client’s partner attends the birth and is very supportive during the labor process. Which action should the nursery nurse take first in caring for the infant? Dry the infant quickly with warm blankets After clearing the airway with a bulb syringe and drying the infant with warming blankets, the nurse assesses that the infant is breathing and has a HR of 124, but remains cyanotic. What action should the nurse take? Prepare to give oxygen At 1 minute the infant has a heart rate of 130, has a slow weak cry, is grimacing, and has sluggish movements with acrocyanosis. What Apgar score should the nurse assign? 6 Transition Care The infant responds well to oxygen, which is discontinued after 10 minutes The family is provided time to hold and interact with their infant boy. After a time together, the infant is transferred to the transition care nursery and Mrs. Ivy is taken to the postpartum unit. The family plans on formula feeding and rooming in with the infant. The infant is immediately placed on the scale prior to being placed on the radiant warmer. After receiving the labor and delivery report, which information should direct the nurse to further assessment of the infant's head? Low forceps delivery Which action should the nurse take prior to weighing the infant? Place a cover on the scale Which part of infant care should the nurse delay? Giving eye prophylaxis The infant's vitals include: T 96.8; HR 136 irregular w/ soft murmur; RR 42. Which action should the nurse take? Document the finding in the electronic medical record (EMR) What action should the nurse take when finding that the head measures 36cm and the chest measures 35? Document the findings in the EMR Upon examining the infant's extremities, which finding should the nurse report to the HCP? Diminished movement in one arm The nurse performs a newborn assessment and evaluates the infant's reflexes. How does the nurse perform the Moro reflex? Slightly raise the infant's head and trunk and allow the infant to drop back 30 degrees When the nurse conducts a gestational age assessment, which findings may indicate post-maturity? Peeling, parchment-like skin Thin with loose skin and little subcutaneous fat Deep creases at the base of the toes extending to the heels. Medication Administration In the transitional care nursery, the nurse reviews the infant's prescriptions for vitamin K (Aquamephyton) 0.5 mg IM x one dose and erythromycin (Ilotycin Ophthalmic Ointment) x one dose in each eye. While administering Vitamin K to infant, which action should the nurse take? Select the middle part of the vastus lateralis for use. The nurse next prepares to administer the erythromycin ointment (Ilotycin ophthalmic ointment). Which approach should the nurse use to administer the ointment? Cover entire lower conjunctiva with the ointment after gently retracting the lid Rooming-In Five hours after delivery, the infant's vital signs are stable and he is taken to his family. While the nurse discusses care with Mrs. Ivy, the infant starts gagging. Which action should the nurse implement first? Use bulb syringe to clear the mouth and nose The nurse instructs the family about feeding the infant. The mother asks how often the infant should be burped. Which is the best response by the nurse for how often the infant should be burped? He needs burping at the start of the feeding and after each ounce (30 mL) of formula When Mrs. Ivy finishes feeding the infant, she checks the diaper and it is dry. Mr. Ivy expresses concern that he thinks the infant is becoming dehydrated. In view of Mr. Ivy's concern, how should the nurse respond? The infant should have 1 or 2 voids per day After receiving report from the day shift, the night nurse begins making rounds. Upon entering the Ivy's room, the nurse finds Mrs. Ivy 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 nurse conduct the change of shift assessment of the infant. Which finding by the nurse is consistent with a cephalhematoma? Well-outlined swelling that does not cross suture lines The infant has a reddish papular rash across his face. How should the nurse respond when Mrs. Ivy asks about the rash? A newborn rash is very common, but it will disappear soon One the second day, the nurse assesses the infant for jaundice. Which factor should alert the nurse to assess for the risk of jaundice? Trauma at birth 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 The nurse prepares infant for placement under a bilirubin light. Which actions should the nurse implement? -Remove the infant's clothing -Turn off the lights and allow parents to hold infant for feedings -Place eye patches on the infant While infant receives phototherapy, his stools become loose and green. What action should the nurse take? Document the findings in the EMR Discharge Home with Phototherapy Blanket. The Ivy family is preparing to go home with their infant. The HCP prescribes a home phototherapy blanket since the infant's hyperbilirubinemia has not resolved. The parents appear confused and scared of using the phototherapy blanket Which instructions should the nurse include in the discharge planning? Holding the infant does not interrupt the phototherapy process Mrs. Ivy asks how she will know the phototherapy is working. How should the nurse respond? Serum bilirubin level decreases Family Outcome The Ivy family is discharged home with instructions for infant care and phototherapy use. The family returns for two follow-up visits at which the infant's blood is drawn to evaluate his response to the phototherapy. By the second visit, the bilirubin levels are diminished and phototherapy is discontinued.