HESI practice case studies

Ms. Stacy Myers is in active labor at 38 weeks gestation with an uncomplicated pregnancy. She is admitted to the birthing center on october 10th at 0830. After 9 hours of labor, Ms. Myers has a spontaneous vaginal delivery of an infant boy. - correct answer The nurse places the infant under a radiant warmer and starts to dry him quickly. What is the rationale for these actions? -heat production is increased through stimulation -convective heat loss from evaporation is reduced -newborns in an incubator are more difficult to access than those in a radiant warmer -bonding is promoted by enhancing the infant's appearance - correct answer convective heat loss from evaporation is reduced explanation: drying the infant quickly and placing him under a radiant warmer reduced heat loss through evaporation and radiation Which action should the nurse take prior to drying the infant's back? -note if the infant has passed an meconium stool -observe the sacral area for possible mongolian spots -assess the amount and location of vernix caseosa -inspect the back for possible neurological defects - correct answer inspect the back for possible neurological defects explanation: to prevent harm while drying the newborn, the back should always be inspected for possible neurological defects, such as spinal bifida APGAR calculation - correct answer Heart rate: 0: absent 1: less than 100 2: over 100 Resp. rate: 0: absent 1: slow, weak cry 2: good cry Muscle tone: 0: flaccid 1: some flexion 2: well flexed Reflex irritability: 0: no response 1: grimace 2: cry Color: 0: blue, pale 1: body pink, extremities blue 2: completely pink At 1 minute of age, the infant is alert and active, and has a strong cry. He has a heart rate of 172 and a respiratory rate of 50. The infant's arms and legs are flexed, the color of his body is pink, and the color of both feet is blue. The nurse continues a physical assessment of the infant looking for normal and abnormal findings. Which APGAR score should the nurse assign? - correct answer 9 not a 10 b/c one point is deducted for acrocyanosis Upon inspection of the umbilical cord, which finding should the nurse report to the healthcare provider? -the cord is covered with Wharton's jelly -pulsations are felt at the base of the cord -one artery and one vein is present -the cord is glistening with a pearl-like color - correct answer one artery and one vein is present explanation: two arteries and one vein should be present The Myer's baby's head is molded from the vaginal delivery. Upon seeing the baby Ms. Myers says, "Oh, he is so beautiful, but something is wrong with his head". How should the nurse respond? -No nothing is wrong with his head. He really is a beautiful boy. -Yes, it is misshaped, but we will should you how to change it over time -His head has been molded from delivery through the birth canal, which is normal. -I know you are concerned. Would you like to talk further with the HCP? - correct answer His head has been molded from delivery through the birth canal, which is normal. explanation: molding commonly occurs in babies delivered vaginally, and the head will become more symmetrical over time Ms. Myers is offered the opportunity to breast feed. After securing a comfortable position for herself and the baby, Ms. Myers puts the infant to her breast. The baby latches onto the nipple, and with some encouragement, he begins to nurse. After a time of family interaction, Ms. Myers is taken to the postpartum unit, and the infant is transferred to the transition care nursery. - correct answer The nurse check the identification bands for both the baby and the mother upon admission to the nursery. One ID number in incorrect. Which action should the nurse take to solve this problem? -Document the presence of the incorrect number on the charts for the baby and the mother -Explain to the mother that there is an incorrect number on one of the bands -Redo the identification bands with another nurse witnessing the process -Mark the incorrect numbers in red to denote the correction made to the bands - correct answer Redo the identification bands with another nurse witnessing the process explanation: 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 Myers' baby's axillary temperature is 97.4F (36.3C). Which action should the nurse take? -continue monitoring and document this finding in the record -place the infant in a radiant warmer and monitor his temp -remover a blanket from the infant and check the temperature again -notify the HCP immediately about the temp - correct answer place the infant in a radiant warmer and monitor his temp explanation: the baby's temp is not within normal range, which is 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 notes soft swelling of the scalp that extends across the suture lines of the fetal skull. Which action should the nurse take in response to this finding? -document the finding in the record -monitor the tension of the anterior fontanel -report the finding to the HCP -apply cool compresses to prevent more swelling - correct answer document the finding in the record explanation: this finding indicated caput succedaneum, which commonly occurs after a vaginal birth The nurse notes a skin tag on the side of the infant's hand. What should the nurse do in response to this finding? -place a string tightly around the skin tag -call rapid response -document the findings and notify the pediatrician -perform a newborn hearing screen - correct answer document the findings and notify the pediatrician explanation: skin tags are a common finding on a newborn assessment. they can be harmless, but the pediatrician should be informed Which physical finding, if present, should the nurse report to the HCP? -presence of unopened sebaceous glands -loose natal teeth that are not covered by the gums -white, cream cheese-like substance on the skin -enlarged breasts secreting a thin, watery discharge - correct answer loose natal teeth that are not covered by the gums explanation: natal teeth, present at birth, are an unusual occurrence that should be reported to the healthcare provider. Loos natal teeth are frequently removed to prevent aspiration. When examining the baby's GI system, which finding warrants additional assessment by the nurse? -greenish black stool -hyperactive bowel sounds -small amount of regurgitation after breastfeeding -no b