ATI Maternal Newborn 2 Questions And Answers Rated A+

A nurse is assessing a 4 hr old newborn who is to breastfeed and notes hands and feet that are cool and slightly blue What action should the nurse take? a. check the newborns temp using temporal thermometer b. place the naked newborn on the mothers bare chest and cover both with a blanket c. apply an o2 hood over the newborns head and neck d. give the newborn glucose water between feedings - b. place the naked newborn on the mothers bare chest and cover both with a blanket Exposure to a cool environment causes vasoconstriction, which results in cool extremities with a bluish discoloration. Placing the newborn skin-to-skin with his mother helps stabilize his temperature and promotes bonding. Apply an oxygen hood over the newborn's head and neck. Blue lips and mucus membranes can indicate central cyanosis and respiratory distress, which might require supplemental oxygen. Check the newborn's temperature using a temporal thermometer. Temporal and intraauricular thermometers are not effective tools to measure a newborn's temperature. The nurse should use an axillary thermometer. Place the naked newborn on the mother's bare chest and cover both with a blanket. MY ANSWER Exposure to a cool environment causes vasoconstriction, which results in cool extremities with a bluish discoloration. Placing the newborn skin-to-skin with his mother helps stabilize his temperature and promotes bonding. Give the newborn glucose water between feedings. The nurse should not give the newborn glucose water between feedings because this can cause the newborn to become full and not suck enough to ensure adequate milk production. A nurse is caring for a newborn immediately following delivery. What actions should the nurse take first? a. place the newborn directly on the client's chest b. administer erythromycin ophthalmic ointment c. give the newborn vit K IM d. perform a detailed physical assessment - a. place the newborn directly on the client's chest The nurse should apply the safety and risk reduction priority-setting framework when caring for this client. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, the greatest risk to the newborn is cold stress, which increases the need for oxygen and glucose. Placing the newborn directly on the client's chest will help maintain the newborn's temperature. Perform a detailed physical assessment. The nurse should perform a detailed physical assessment of the newborn to detect birth anomalies or injuries within 12 to 18 hr. However, there is another action the nurse should take first. Give the newborn vitamin K IM. The newborn is at risk for coagulation deficits and the nurse should administer vitamin K within the first 2 hr of life. However, there is another action the nurse should take first. Administer erythromycin ophthalmic ointment. The newborn is at risk for ophthalmia neonatorum and the nurse should administer erythromycin ophthalmic ointment within the first 2 hr of life. However, there is another action the nurse should take first. A nurse is planning care for a newborn who is receiving phototherapy for an elevated bilirubin level. What action should the nurse take? a. apply barrier ointment to the newborn's perianal region b. offer the newborn glucose water between feedings c. use photometer to monitor the lamp's energy d. keep the newborn's eye patches on during feedings - c. use photometer to monitor the lamp's energy the nurse should monitor the lamp's energy throughout the therapy to ensure the newborn is receiving the appropriate amount to be effective Offer the newborn glucose water between feedings. The nurse should provide breast milk or infant formula to maintain the newborn's hydration, which promotes the excretion of bilirubin in the stool. Supplemental feedings of glucose water or plain water can increase circulation to the liver and impede bilirubin excretion. Keep the newborn's eye patches on during feedings. The nurse should apply eye patches so the light does not damage the newborn's eyes. The nurse should remove the patches during feedings to observe the eyes and clean them. The parents can make direct eye contact with the newborn during this time. Apply barrier ointment to the newborn's perianal region. The nurse should avoid applying any type of topical substance to the newborn's skin because these substances can absorb heat and cause burns. A nurse is providing teaching to the parents of a newborn about home safety. What statement by the parents indicates an understanding of the teaching? a. I will use an infant carrier when I drive to places close to the house b. I will tie my baby's pacifier around his neck with a piece of yarn c. I will place my baby on his back when it is time for him to sleep d. I will keep my babys crib close to heat vents to keep him warm - c. I will place my baby on his back when it is time for him to sleep The newborn should always sleep on his back to prevent sudden infant death syndrome. "I will keep my baby's crib close to the heat vents to keep him warm." The parents should not place the newborn's crib close to a heat source due to the risk of the crib linen catching on fire. "I will use an infant carrier when I drive to places close to my house." The parents should always place the newborn in an approved car seat whenever driving with the newborn. Infant carriers are not approved safety seats for motor vehicles. "I will tie my baby's pacifier around his neck with a piece of yarn." The parent should never tie any type of string around the newborn's neck due to the risk of strangulation. A nurse is assessing a newborn 1 min after birth andnotes a hr of 136/min, resp 36, well flexed extremities, responding to stimuli with a cry, blue hands and feet. What Apgar score should the nurse assign to the newborn? a. 10 b. 9 c. 8 d. 7 - b. 9 The nurse should use the Apgar scoring system to perform a quick assessment of the newborn at 1 min and 5 min after birth. The nurse should assign a score of 0, 1, or 2 to each of five categories. The nurse should assign a score of 2 for a heart rate greater than 100/min; a score of 2 for a good, strong cry, which shows normal respiratory effort; a score of 2 for well flexed extremities, which shows expected normal muscle tone; a score of 2 for responding to stimulation with a cry, cough, or sneeze; and a score of 1 for blue hands and feet, known as acrocyanosis. A nurse is assessing a client who is 14 hr postpartum and has a 3rd degree perineal laceration. The client's temp is 37.8 C (100F), her fundus is firm and slightly deviated to the right. The client reports a gush of blood when she ambulates and no bm since delivery. What action should the nurse take? a. notify the provider about the elevated temp b. massage the client's fundus c. administer bisacodyl supp d. assist the client to empty her bladder - d. assist the client to empty her bladder When the client's fundus is deviated to the right or left it can indicate that her bladder is full. The nurse should assist the client to empty her bladder to prevent uterine atony and excessive lochia.