Maternity Newborn VERIFIED SOLUTIONS 100% GUARANTEE PASS

Maternity Newborn VERIFIED SOLUTIONS 100% GUARANTEE PASS The nurse is caring for a neonate that is 3 hours old and should assess for which signs of cold stress? Select all that apply. 1. Tachycardia 2. Hyperactivity 3. Mottling of skin 4. Increased skin temperature 5. Increased respirations with apnea - ANSWER3, 5 Rationale: Signs of cold stress include decreased skin temperature, increased respiratory rate with periods of apnea, bradycardia, mottling of skin, and lethargy. Recall that neonates are unable to shiver and will use up glucose in an effort to produce heat. The nurse is assisting in providing a class to new mothers on newborn care. In teaching cord care, the nurse makes which suggestion to the new mothers? 1. If triple dye has been applied to the cord, it is not necessary to do anything else to it. 2. All that is necessary is to wash the cord with antibacterial soap, allowing it to air dry once a day. 3. Clean around the cord with plain water as needed until the cord falls off. 4. Gently apply alcohol to the cord, being careful not to move the cord because it will cause the newborn pain. - ANSWER3 Rationale: The cord and base should be cleaned with plain water two or three times a day (per primary health care provider prescription). The steps are to lift the cord, wipe around the cord starting at the top, clean the base of the cord, and fold the diaper below the umbilical cord to allow the cord to air dry. Continuation of cord care is necessary until the cord falls off in 7 to 14 days. The baby does not feel pain in this area. The use of soap is not necessary. Which nursing interventions should be implemented for a newborn receiving phototherapy for hyperbilirubinemia? Select all that apply. 1. Monitor the temperature frequently. 2. Protect the eyes with an opaque mask. 3. Apply lotion generously to the body and extremities. 4. Remove all clothing from the newborn including diapers. 5. Monitor and document the number and consistency of stools. - ANSWER1, 2, 5 Rationale: Phototherapy can cause changes in the newborn's temperature Therefore, the temperature should be closely monitored. The newborn's eyes are protected by an opaque eye mask to prevent overexposure to the light. The number and consistency of stools are monitored. Bilirubin breakdown increases gastric motility, which results in loose stools. Lotion should not be used during phototherapy because it absorbs heat and can cause burns. The newborn is unclothed, but a diaper is left on to protect the genitals. The nurse assisting in the care of a newborn has a standing prescription to administer the hepatitis B vaccine to the infant. The nurse should plan to perform which action when carrying out this prescription? 1. Use the dorsogluteal muscle. 2. Obtain written parental consent. 3. Select a 21-gauge, 1-inch needle. 4. Spread the skin under the injection site. - ANSWER2 Rationale: The nurse must obtain informed consent from the parents before administering the hepatitis B vaccine to the newborn. The vastus lateralis muscle is used because the dorsogluteal muscle is underdeveloped in the newborn and is dangerously close to the sciatic nerve. In addition, the dorsogluteal site is no longer an acceptable injection location even for adults. A 25-gauge, ½-inch needle is used. The nurse pinches up the skin to inject the medication. After birth the nurse prevents hypothermia as a result of evaporation by performing which action? 1. Warming the crib pad 2. Closing the doors of the room 3. Drying the baby with a warm blanket 4. Turning on the overhead radiant warmer - ANSWER2 Rationale: Evaporation occurs when moisture from the newborn's wet body surface dissipates heat along with moisture. By keeping the newborn dry (and by drying the wet newborn at birth), evaporation is prevented. Conduction occurs when the newborn is on a cold surface, such as a cold pad or mattress. Convection occurs as air moves across the newborn's skin from an open door and heat is transferred to the air. Radiation occurs when heat from the newborn radiates to a colder surface. The nurse is reinforcing instructions to the mother of an infant about postcircumcision care. The nurse determines that teaching has been effective when the mother states which? 1. "I will observe for signs of bleeding with each diaper change." 2. "I will gently remove the yellow exudate from my child's penis." 3. "I will use soap to cleanse my child's penis 48 hours after circumcision." 4. "I will wash the penis vigorously with warm water to remove urine and feces." - ANSWER1 Rationale: The glans penis is dark red after circumcision then becomes covered with yellow exudate in 24 hours. This is normal and will persist for 2 to 3 days. The mother should not attempt to remove it. Soap should be used only after the circumcision is healed (5 to 6 days). The circumcision should be checked for bleeding with each diaper change. The penis should be washed gently with warm water to remove urine and feces. The father of a newly delivered full-term newborn is observing admission of the infant to the nursery. He asks the nursing student performing the admission why a cover is being placed on the baby scale to weigh and measure the newborn? The response that the nursing student should make is based on understanding the mechanism of heat loss in the newborn. This nursing intervention is designed to protect the newborn against which heat loss mechanism? 1. Radiation 2. Convection 3. Conduction 4. Evaporation - ANSWER3 Rationale: There are 4 modes of heat loss. Conduction is loss of body heat to cooler surfaces that are in direct contact with the skin. Radiation is loss of body heat to a cooler surface that is not in direct contact with the skin. Convection is loss of heat from the body surface to cooler ambient air. Evaporation is loss of heat when liquid is converted to a gas. The nurse reviews the results of a bilirubin level on a 2-day-old, jaundiced, term newborn. The results indicate a total bilirubin level of 7.2 mg/dL. The newborn's mother verbalizes concern over the bilirubin results. On which interpretation of the bilirubin result does the nurse base a response? 1. Within acceptable ranges 2. Indicative of Rh incompatibility 3. Indicative of a need for phototherapy