OB HESI Case Studies-Healthy Newborn

OB HESI Case Studies Healthy Newborn 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 Miss Myers had a spontaneous vaginal delivery of an infant boy. 1. The nurse quickly place is the infant under radiant warmer and starts to dry him. What is the rationale for these actions? a. Convective heat loss from evaporation is reduced. Drying the infant quickly and placing him under a radiant warmer reduces the heat loss through evaporation and radiation 2. Which action should the nurse take prior to drying the infants back? a. Inspect the back for possible neurological defects. To prevent harm on drying the newborn, the back should always be inspected for possible neurological defects, such as spina bifida. 3. At one 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 infants arms and legs are flexed the color of his body is pink and the color of both fee is blue. The nurse continues a physical assessment of the infant looking for normal and abnormal findings. Which APGAR score should the nurse assign? a. Nine 4. Upon inspection of the umbilical cord which finding should the nurse report to the healthcare provider? a. One artery and one vein are present. Two arteries and one vein should be present 5. The Myers baby’s head is molded from the vaginal delivery upon seeing the baby miss Myers says “oh he’s so beautiful but something is wrong with his head”. How should the nurse respond? a. His head has been molded from delivery through the birth canal which is normal. Molding commonly occurs in babies delivered vaginally and the head will become more symmetrical overtime 6. Miss Myers is offered the opportunity to breast feed. After securing a comfortable position for herself and the baby Miss 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 unit. The nurse checked the identification bands for both the baby and the mother upon admission to the nursery. One ID number is incorrect. What action should the nurse take to solve this problem? a. Redo The identification bands with another nurse witnessing the process. Identification bands must be correct to ensure the safety and security of all hospitalized patients, especially newborns 7. Upon admission to the transition care nursery, the Myers babies auxiliary temperature is 97.4°F. what action should the nurse take? This study source was downloaded by from CourseH on 08-30-2021 02:41:30 GMT -05:00 This study resource was shared via CourseH a. Place the infant in a radiant warmer and monitor his temperature. The baby’s temperature is not within normal range. Normal range is 97.5°F to 99°F 8. While examining the infants head the nurse swelling of the scalp that extends across the suture lines of the fetal skull. What action should the nurse taken in response to this finding? a. Document the finding in the record. This finding indicates caput succedaneum, which commonly occurs after a vaginal birth 9. The nurse notes a skin tag on the side of the infant hand. What should the nurse do in response to this finding? a. Document the findings and notify the pediatrician. Skin tags are a common finding on a newborn assessment. They can be harmless, but the pediatrician should be informed 10. Which physical finding, if present, should the nurse report to the HCP? a. Loose natal teeth that are not covered by the gums. Natal teeth, present at birth, are an unusual occurrence that should be reported to the healthcare provider. Loose natal teeth are frequently removed to prevent aspiration 11. While examining the babies gastrointestinal system which finding warrant additional assessment by the nurse? a. No bowel movement in the first 72 hours. The first meconium stool should pass within 48 hours. Abstraction maybe suspected if no bowel movement in the first 72 hours. 12. Which findings are consistent with an infant born at 38 weeks gestation? a. Well defined nipples with a raised areola b. Plantar creases covering 2/3 of the soul of foot 13. The nursing student is assisting the nurse in caring for the infants and the nursery. The nurse questions the student about vitamin K as preparations are made for administration. Which response by the student indicates an understanding of the purpose for administering this drug? a. This drug is given to new born to prevent and or treat hemorrhagic disease. Because this vitamin does not cross the placenta and there is very little and breastmilk, supplemental vitamin K should be given to newborns at birth to help clot the blood. Therefore this is an accurate response by the student. 14. The nurses preparing to give the baby her first bath. Which assessment data indicates that it is safe for the baby to be given the bath at this time? a. Auxiliary temperature of 97.9°F. Correct b. Respiratory rate of 52 breaths per minute. The respiratory rate is slightly high and will rise with activity of bathing c. Apical heart rate of 166 beats/min. This heart rate is slightly high and will rise further with the activity of bathing d. Pulse oximeter of 90%. This value is below normal and could become lower with the activity of bathing 15. At 2400 hrs. infant is crying, his skin is modeled, and his hands are shaking. What action should the nurse take first? This study source was downloaded by from CourseH on 08-30-2021 02:41:30 GMT -05:00 This study resource was shared via CourseH a. Monitor the blood glucose level. Since it has been two hours since delivery that infant maybe experiencing hypoglycemia. 16. The babies vital signs have stabilized bye 0100 hrs. Upon completion of the assessment and documentation, the nurse takes the baby to Miss Myers wants to breast-feed and room in with the baby. After the nurse checks ID bands, the infinite position for breastfeeding. The nurse checks on this Myers and the baby at 0200 hrs. Both are sleep in the bed, with the baby lying beside Miss Myers. What should the nurse do next? a. Remind Miss Myers about infant safety and assist her to place the infant in the crib. This action protects the baby while reinforcing teaching to the mother. 17. When returning the baby to the crib the nurse notices that the blanket covering the baby is wet. The nurse takes the babies temperature which is 97.2°F. What should the nurse do next? a. Show Ms. Myers how to wrap the baby in a dry blanket for warm and apply the cap to his head. This action not only protects the baby but it also involves and teaches the mother 18. The nurse checks on this Myers and her baby every two hours throughout the night. The baby is breast-fed at 0300 and 0600 hrs. without difficulty. After the change of shift report at 0700 hrs., the day nurse assesses the mother and baby. Miss Meyer states that the baby had a bowel movement after breast-feeding. She told the nurse that she attempted to change a diaper but had difficulty doing so. How should the nurse respond to the client? a. Observe Ms. Myers as she performs a diaper change b. Advise Ms. Myers the classes to teach infant care such as diapering are available on the unit 19. When Ms. Myers removes the diaper the nurse notices that the baby has cake powder in the inguinal leg folds. What action should the nurse take? a. instruct Miss Meyer to use clean water instead of powder. Until the baby is four days old, only plain warm water is recommended because soaps, ointments, powders, lotions, and baby wipes can disrupt the acid mantle on the skin and provide a medium for bacterial growth. Ointments are prescribed only if a rash develops in the first few days of life. Use of a powder also places the infant at risk for fine particle aspiration. 20. While changing the infant clothes miss Myers notices the baby startles easily, which explanation should the nurse provide? a. This reflex is a normal response, swaddling the infant should help. 21. At two days post birth, Miss Myers and her baby are doing well and preparing for discharge. The baby’s weight at birth was 7 lbs. 15 oz. (3600gm), and today she weighs 7 lbs. 3 oz. (3300gm). Miss Myers expresses her concerns for the nurse when she realizes that her baby has lost almost a pound since birth. How should the nurse response? a. Don’t be concerned your baby’s weight loss is in the typical range for all babies. Babies may lose up to approximately 10% of their birth weight 22. Miss Meyer was told that a neonatal screening test needs to be done before they’re discharged. When asked the reason for including the PKU testing the screening, which information should the nurse provide? This study source was downloaded by from CourseH on 08-30-2021 02:41:30 GMT -05:00 This study resource was shared via CourseH a. A problem converting the protein phenylalanine maybe present, which can lead to mental retardation if not found and treated early. PKU testing is done to detect the level of phenylalanine and the babies blood. 23. How should the nurse collect the blood needed for PKU screening? a. Puncture the lateral heel after warming collect blood samples on the designated lab form. The heel should be warmed, cleaned with alcohol, and dried with gauze. After the healers punctured with a micro Lancet, blood is collected on a special neonatal screening form This study source was downloaded by from CourseH on 08-30-2021 02:41:30 GMT -05:00 This study resource was shared via CourseH Postpartum Marie Wilson is a 28-year-old client who is gravida 2, Para 2 and is transferred to the postpartum unit one hour after delivery of an 8 lbs. 1 oz. female. She was in labor for 16 hours and forceps were used to assist with the delivery. Marie was given an epidural for anesthesia that was effective. The labor and delivery nurse reported that Marie had a fourth degree laceration and her pain was currently at a 3 out of 10 scale. Her vital signs were stable and she was catheterized for 500 ML of light yellow urine just prior to delivery. Mr. Wilson was at the bedside for delivery and appeared supportive. 1. A 1000mL bag of lactated ringers solution containing 10 units of oxytocin (Pitocin) is infusing via an 18 gauge peripheral IV in the left forearm at 125 mL per hour, with 300mL remaining in the bag. The IV is patent, without redness or swelling, and can be discontinued when this bag’s infusion is complete. Prior to discontinuing the IV oxytocin (Pitocin), which assessment is most important for the nurse to obtain? a. Uterine firmness. Oxytocin is a hormone used to stimulate uterine contractions and prevent hemorrhage from the placental site. Prior to discontinuing the IV, it is most important to ensure that the uterus is contacting by assessing fundal firmness. 2. Marie has minimal sensation in her lower extremities, due to the effect of the epidural anesthesia. What is the priority nursing diagnosis for Marie, who is experiencing residual effects of the epidural anesthesia? a. Risk for injury. Epidural anesthesia causes temporary loss of voluntary movement and muscle strength in the lower extremities. Serious injury can be incurred if Maria tends to get out of bed on her own because her legs will be unable to sustain her weight. Nursing priority is to ensure her safety by implementing the use of two side rails instructing them not to get out of bed for the first time without assistance. 3. What is the priority nursing action to address Marie’s needs related to the repair of her fourth degree perineal laceration? a. Apply perineal icepack consistently for the first 24 to 48 hours. Topical perineal ice packs cause local vasoconstriction, resulting in decreased swelling and tissue congestion, preventing a hematoma, as well as promoting comfort. The application of ice packs as a priority nursing option for the first 24 to 48 hours, which is the period that the tissue is most vulnerable to swelling resulting from the trauma. A hematoma formation could contribute to hypovolemia and needs to be prevented. 4. Early detection of and intervention for postpartum complications promote positive client outcomes. Postpartum protocol requires that the nurse assessed Marie’s vital signs, fundus, perineum, vaginal bleeding, pain, leg movement, and IV every 15 minutes for the first hour and then every hour for the next three hours. The nurse performed the first assessment upon arrival to the postpartum unit. Where when the nurse expect to palpate the fundus? a. 1 cm above umbilicus. For the first 12 hours of fundus should be 1 to 2 cm above the umbilicus. This study source was downloaded by from CourseH on 08-30-2021 02:41:30 GMT -05:00 This study resource was shared via CourseH 5. 15 minutes after the initial assessment the nurse finds Marie disoriented and lying on her back in a pool of vaginal blood, with a sheet beneath her saturated with blood. What action is most important for the nurse to implement it immediately? a. Massage the fundus. Since a boggy fundus is the most likely reason for this clients hemorrhaging, massaging it is the most important intervention. The nurse should also call for assistance due to the amount of blood pooled under the client. 6. What is the best method for the nurse to use to obtain immediate assistance? a. Activate the priority call late from the bedside. The priority call light signals to the entire nursing unit that a client is in crisis. All personnel available will respond to the distress signal. 7. The nurse had requested assistance and personnel are on their way. While waiting for help to arrive what is the next priority action? a. Assess for bladder distention. The client is two hours post delivery with an IV infusion at 125mL/hour, which can contribute to diuresis. A distended bladder impedes uterine contractions and contributes to excessive bleeding. After the fundus is massaged, the bladder should be checked for distention 8. The charge nurse, 2 staff and nurses, and an unlicensed assistant personnel Rush into assist the nurse with Marie. Which task is best delegated to the UAP during this crisis? a. Obtain the vital signs and O2 saturation. The nurse should interpret these findings as indications of hypovolemia due to blood loss and should also report the findings to the healthcare provider 9. The HCP is notified that Marie is hemorrhaging and has an estimated blood loss of 1200mL since delivery. Her BP is 70/40 mmHg, Pulse 120 beats/min, respirations 28breaths/min, and O2 sat is 73%. The HCP prescribes STAT Oxytocin 10 units in each liter of normal saline to infuse @ 40 milliunits/min. The HCP also prescribed methylergonovine maleate IM to be given immediately. The vial of oxytocin is labeled 20units/mL. The vial of methylergonovine is labeled 0.8mg/mL. How many mL of oxytocin should the nurse draw up in the syringe to inject into the 1000mL bag of normal saline? a. 0.5mL 10. How many mL of methylergonovine should the nurse draw up in the syringe to administer to Marie? a. 0.25mL 11. The oxytocin has been infusing at the prescribed rate for 20minutes. Which finding is most indicative that the medication is reaching a therapeutic level? a. Firm Fundus. The desired therapeutic effect of oxytocin is to cause potent and selective stimulation of uterine smooth muscle. A firm fundus indicate to uterine contractions during the postpartum period which is important to prevent further hemorrhage. 12. Postpartum hemorrhage is designated as blood loss in excess of 500mL within the first 24 hours of delivery. Considering the clients history, what etiology is most likely? This study source was downloaded by from CourseH on 08-30-2021 02:41:30 GMT -05:00 This study resource was shared via CourseH a. Uterine atony. The clients history revealed a prolonged labor (muscle fatigue) and a large baby (uterine overdistention), these are both frequent causes of uterine atony. 13. Marie is pale, weak, and anxious, but no longer disoriented. Her fundus is firm and is 1cm above the umbilicus. She is receiving O2 per nasal cannula at 4L/min and has an O2 sat of 88%. Her vitals are BP 74/44mmHg, P 116 beats/min, and RR 26 breaths/min. Her bleeding has slowed considerably. The nurse asks the UAP to bathe Marie and change the linens. Marie tells the nurse that her husband left to get their other child and come back, she states she doesn’t want her children to see her like this and asks the nurse to tell her husband what happened. What intervention should the nurse implement to communicate the situation to Marie’s husband? a. Call Mr. Wilson from the nurses station to inform him of his wife’s status and request that he come to the hospital soon, without the other child. 14. The HCP prescribes two units of packed red blood cells to be transfused as soon as possible. Marie sign the consent form and a blood sample for the type and crossmatch is obtained. What should the nurse due to prepare for Marie’s blood transfusion? a. Start an additional IV using a 16 or 18 gauge Angiocath. Marie needs the current IV site for the continuous infusion of oxytocin. b. Prime a new Y-set blood tubing using a new bag of normal saline. A new blood administration tubing should be set up and primed with a new bag of saline. Than normal saline that is currently infusing has oxytocin added, the oxytocin will react with the blood and cause clotting and hemolysis of the blood cells. c. Obtain a baseline set of vitals. A baseline set of vital signs should be obtained prior to the infusion of blood products 15. Marie’s nurse is getting ready to administer the first unit of blood when the nursery nurse brings in Marie’s infant daughter in state that Marie needs to feed her because it has been four hours since infancy last nursed. The infant is sleeping soundly in the crib. What is the best thing for Marie’s nurse to do? a. Explain Marie’s history and request that the infant is fed with formula in the nursery. Marie’s condition is too unstable for her to feed her infant, even though breast-feeding will stimulate uterine contractions this is not as important as the clients stability. The nursery nurse should be the infant in the nursery until Marie is stable enough to resume breast-feeding. 16. Prior to the blood transfusion, the nurse recorded Marie vital signs as T 97.8F, BP 78/50mmHg, P 110 beats/min, and RR 22 breaths/min. The blood requisition form, client identification bracelet, and blood label are all checked with another nurse, and then the a negative blood transfusion is started at 75mL/hr. 15 minutes after the transfusion begins at another set of vitals are taken, T 98.5°F, BP 76/48mmHg, P 112 beats/min, RR 22 breaths/min. Marie complains of being cold. What should the nurse do you in response to these assessment findings? a. Provide a warm blanket and continue to monitor. The administration of cold blood commonly causes the client to feel cold but it does not constitute chills and fever which are indicative of a febrile nonhemolytic reaction. 17. Skipped bc easy its 580 This study source was downloaded by from CourseH on 08-30-2021 02:41:30 GMT -05:00 This study resource was shared via CourseH 18. The nurse is aware that Marie’s condition is stabilizing. Which nursing intervention would be most appropriate at this time? a. Palpate Marie’s bladder faithfulness and catheterize if indicated. Maries bladder has not been empty since delivery. It is important to evaluate her for two reasons, her kidneys have been stressed by the hemorrhage and urinary output is one parameter used to measure kidney function, along with BUN and serum creatinine levels. In addition if Marie’s bladder is full it will displace the uterus, inhibiting contraction and increasing the risk of further hemorrhage. 19. Marie tell the nurse that she has sensation in her lower extremities, that she can move both her legs and that she needs to use the bathroom. The nurse offers Marie the use of a bedpan or bedside commode. Marie implies that she feels slightly dizzy and would like to set up on the bedpan rather than attempt to get out of the bed right now. Marie is able to void 450 ML on the bedpan and reports that she feel she has emptied her bladder completely. Marie complains that she has developed a headache after she sat upright on the bedpan. She tells the nurse that the headache has lessened to a dull ache after she has leaned back down. The pain intensified when she moves her head. Considering Marie’s history what would be the most likely cause of Maries headache? a. Epidural anesthesia. Postdural puncture headache (PDPH) sometimes occurs after epidural anesthesia. It’s exact pathophysiology is uncertain, but it apparently stems from cerebrospinal fluid leakage at the puncture site which causes a decrease in both CSF volume in intracranial pressure. 20. Considering Marie’s history and acuity level who is the best nurse to reassign into Marie’s care? a. Labor and delivery nurse at 12 years of experience who was called into work for 4 hours until 2300. This nurse is experienced with handling the acute needs of obstetrical clients and would be a great resource for the next four hours and helping stabilize Marie’s condition. When she is more stabilized she could then be reassigned 2300 21. Marie’s nurse gives the shift report and turns Marie’s care over to the nurse who has been assigned to her care. As the nurse is preparing to leave for the evening Marie’s HCP calls returning the page. Who is the best person to speak with Marie HCP? a. Marie’s nurse who has already given the shift report and is preparing to clock out 22. The nurse notified the HCP of Marie’s status including receiving the first unit of blood, current vital signs, voiding 450 mL, and severe headache. The HCP confirms that since the migraine is postural in nature Marie has a postdural puncture headache. The HCP request continuation of IV fluid as previously prescribed for adequate hydration and then prescribes strict reclined bedrest, foley catheter, caffeine and sodium benzoate 0.5g every 6 hours IV, acetaminophen and codeine (Tylenol with Codeine #3) 1 to 1 tabs PO every 4 to 6 hours as needed for pain, and ondansetron (Zofran) 4mg PO every 8 hours as needed for nausea. Marie’s nurse records the new prescriptions and reports them to the nurse with assuming Marie’s care. The UAP approaches Marie’s new nurse and ask if there is anything that she can do to assist. Which task is best for the nurse to delegate to the UAP? a. Obtaining documentaries vital signs This study source was downloaded by from CourseH on 08-30-2021 02:41:30 GMT -05:00 This study resource was shared via CourseH 23. Prior to administering the medications to Marie, which information should the nurse include about caffeine and sodium benzoate? a. Caffeine and sodium benzoate will constrict the cerebral blood vessels and decrease the headache. 24. The nurse stats the second unit of A negative blood, medicates Marie for pain, and encourages her to get some rest while the blood is infusing. Maries vitals anre stable , and her fundus remains firm, located 1 cm below the umbilicus, and no reaction to the second unit of blood is noted. While Marie is resting the blood bank calls and tells the nurse that Maries infants blood type is a positive, and the blood drawn from marie after delivery indicates that she is indirect coombs negative and non-sensitized. Based on this information, what is the correct nursing action? a. Allow Marie to rest during the blood transfusion, and administer the RhoGam as prescribed at a later time. The negative indirect Coombs test indicates that Marie has not yet developed sensitivity to the infants A positive antibodies. RhoGAM prevents sensitization if administered within 72 hours of delivery, since Marie is resting the nursing safely administer at a later time 25. Skipped bc easy This study source was downloaded by from CourseH on 08-30-2021 02:41:30 GMT -05:00 This study resource was shared via CourseH Powered by TCPDF ()