VN 34 Test 6

Question 1

1. Cleft palate post op nursing interventions (PP slide 13)

Answer 1

 Suction & Position to facilitate drainage, gentle w/bulb syringe as needed
 Encourage parental attachment
 Assist w/feeding techniques
 Monitor weight & for dehydration
 Elbow restraints(because they want to touch & pull)
 NPO 2hr post op, then liquid 3-4 days

Question 2

2. Identification steps to safeguarding baby (CH.13 PP slide 22)

Answer 2

 Verify ID bands on both mom & baby
 Verify Gender
 Verify DOB
 Verify mom’s medical record number
 Verify any health care worker ID badges

Question 3

3. Trisomy 21 manifestations (PP slide 30)

Answer 3

 Brachycephaly (deformity in skull), short stature, flattened bridge of nose
 Thick hypotonic muscles, protruding tongue, dry cracked , fissure skin that may be mottled
 Small hands w/short broad fingers & curved 5th finger, single deep crease on palm of hand, wide space between 1st & 2nd toes
 Lax muscle tone
 Heart & eye anomalies, upward slanted eyes
 Greater susceptibility to leukemia

Question 4

4. Client education/considerations & health benefits for circumscision (CH.13 pp slide 22)

Answer 4

 Monitor for S/S of infection (drainage or redness @ base)
 As healing occurs a yellow crusty material will form
 Apply petroleum jelly w/diaper changes
 No baths until healed

Health benefits
 Easier hygiene
 Decreased risk of STIs, penile cancer & cervical cancer in partners

Question 5

5. Hydrocephalus manifestations (PP slide 5)

Answer 5

 Rapid head growth w/widening cranial sutures
 Bulging fontanels
 Increasingly helpless, increased intracranial pressure (PRIORITY)
 Neck muscles fail to develop sufficiently, newborn has difficulty raising or turning head
 Dilated scalp veins
 Sun-setting signs

Question 6

6. APGAR meaning (CH.13 PP slide 8-11)–Appearance–

Answer 6

A-appearance (skin color)

Pale or blue = 0
Body normal skin tone but extremities blue = 1
Normal skin tone = 2

Question 7

APGAR meaning (CH.13 PP slide 8-11)–Pulse–

Answer 7

Absent = 0
Less than 100bpm = 1
100bpm or more = 2

Question 8

APGAR meaning (CH.13 PP slide 8-11)–Grimace—

Answer 8

G- grimace (reflex irritability/response)
No response to stimulation = 0
Grimace but no cry to stimulation = 1
Cry & active movement = 2

Question 9

APGAR meaning (CH.13 PP slide 8-11)–Activity–

Answer 9

A-Activity (Muscle Tone)
None, flaccid = 0
Some flexion of arms & legs =1
Arms & legs flexed & in motion = 2

Question 10

APGAR meaning (CH.13 PP slide 8-11)–Respiration–

Answer 10

Absent = 0
Weak, irregular cry = 1
Strong, vigorous cry = 2

Question 11

APGAR interventions (CH.13 pp slide 8-11)

Answer 11

 Score 7-10: no interventions, baby doing good just needs routine post care
 Score 4-6: some resuscitation assistance required. Oxygen, suction, stimulate the baby, rub baby’s back (reassess in 5 mins after performing intervention)
 Score 0-3: need full resuscitation

Question 12

7. Cesarean postop care of newborn (pg. 224)

Answer 12

 Monitor newborn for respiratory distress because of retained lung fluid.

Question 13

8. Vitamin K administration location(CH.13 PP slide 5, ATI pg.133)

Answer 13

 Administer 0.5- 1mg into vastus lateralis to stimulate appropriate clotting w/in 1hr of newborns birth(decreases risk of infant hemorrhagic disorders)
 Not produced in the GI tract of newborn until around day 7
 Is produced in the colon by bacteria once formula or breastmilk is introduced

Question 14

9. Client education for breastfeeding (CH.12 pp slide 8 & 14)

Answer 14

 Early feeding helps prevent hemorrhage (infant will have 2-3 stools/day)
 Engage lactation consultant for proper latching
 Each feeding around 30 mins
 Assess nipples & apply milk on nipple prior to feeding
 Change infant position & rotate breasts in the beginning
 Cleanse w/plain water, use of lanolin cream
 Empty breasts completely

Question 15

10. Jaundice nursing considerations (CH.13 slide 4, pg.270)

Answer 15

 If Jaundice is present before the newborn is 24hrs old (medical emergency)
 Monitor bilirubin level

Question 16

11. Myelomeningocele nursing priorities (pg.458)

Answer 16

 Maintain integrity of myelomeningocele (protect from damage)
 Concerns related to infection, impaired skin integrity, and neuromuscular issues are included.

Question 17

12. Newborn expected findings r/t vital signs (CH.13 pp slide 2)

Answer 17

 Drying the newborn is the primary action to prevent cold stress, followed by kangaroo care
 If suctioning the nurse should suction mouth 1st followed by the nares (assess for mucus & suctioning need)
 Respiratory function is the nurse’s priority: Normal RR 30-60min w/short apnea less than 15 secs
 Keeping the newborn warm & preventing cold stress is the priority after respiration function

Question 18

13. Transient strabismus nursing consideration (pg.712)

Answer 18

 Lack of muscular coordination of eye movements
 The visual axes are not parallel, and diplopia (double vision) results.
-place eye patch on unaffected side, so affected side can try to adjust

Question 19

14. Newborn born to a GDM mom nursing considerations (CH.13 pp slide 6)

Answer 19

 Newborn hypoglycemia is a blood glucose level less than 50mg/dL
 Newborns can be asymptomatic or may demonstrate multiple signs
 The most common sign is jitteriness & high pitched crying
 Newborns born to moms w/GDM are at a higher risk

Question 20

15. Post dates manifestations

Answer 20

 Wide eyed, hyper alert expression
 Little lanugo or vernix remains
 Scalp hair is abundant
 Fingernails are long
 Skin is dry, cracked, wrinkled, peeling & wither than a normal newborn
 Little subcutaneous fat appears long & thin

Question 21

15. post dates complications

Answer 21

 Neonatal hypoglycemia
 Polycythemia may develop in response to intrauterine hypoxia
 Polycythemia puts the infant @ risk for cerebral ischemia, thrombus formation & respiratory distress because of viscosity of the blood
 At birth they may aspirate meconium into the lungs & results in meconium aspiration syndrome

Question 22

16. Phototherapy nursing considerations (CH.13 PP slide 4, pg.447)

Answer 22

 A newborn who has mild-to-moderate disease (jaundice) usually receives hydration and phototherapy after birth.
 If newborn undergoing phototherapy, the nurse should assess for dehydration & encourage breastfeeding 1-2hrs (Infants undergoing phototherapy need as much as 25% more fluids to prevent dehydration.)
 Don’t place the lights too close, can cause burns (too far, therapy wont work)
 Only place covering over genitalia to maximize the skin surge area exposed to light (turn newborn q 2hrs)
 Always shield the newborn’s eyes from the UV light
 Remove eye patches q4hrs to cleanse the eyes & examine for irritation, inflammation & dryness, clean & change the patches daily.
 Monitor the serum bilirubin levels routinely when the infant is receiving phototherapy.

Question 23

17. Nursing actions for bubbling mucus

Answer 23

 Suction w/bulb syringe (mouth first then nares)

Question 24

18. Discharge education for new parents (CH.13 pp slide 24)

Answer 24

 Stool color will change in 4-5 days
 If fussy check: diaper, feeding, burping
 Babies sleep 16-19hrs/day
 Place infant in supine position when sleeping
 Sponge baths until cord falls off
 Flame-retardant fabric
 Never leave unattended w/peds or other small children
 Car safety check

Question 25

19. Types of heat loss in newborn (PG.269)

Answer 25

Conduction: when the newborns skin touches a cold surface causing body heat to transfer to the colder object.

Convection: when air currents blow over the newborn’s body.

Evaporation: happens when the newborn’s skin is wet. As the moisture evaporates from the body surface, the newborn loses body heat along with the moisture.

Radiation: a cold object that is close to but not touching the newborn.

Question 26

20. Newborn reflex manifestations (CH.13 PP slide 21)

Answer 26

 Moro: sharp hand clap near newborn
 Grasping: place finger in palm
 Tonic neck: turn head quickly to one side
 Sucking: stroke cheek
 Babinski: stoke outer edge of sole of foot

Question 27

21. Acrocyanosis (CH.13 PP slide 15, PG.274)

Answer 27

 Torso looks good but extremities are cyanotic (usually resolves itself w/in 24-48hrs)

Question 28

22. Nursing assessment of the normal newborn (CH.13 pp slide 13)

Answer 28

 Important way to determine how well the newborn is adapting to life outside the womb
 The least disturbing aspects of the examination are completed 1st
 RR & HR are taken 1st, while the newborn is quiet
 Then examination proceeds in a head-to-toe manner & includes physical measurements & inspection of each body part
 Clean gloves should be used if bath has not been given (standard precautions)
 Eye movements are usually uncoordinated & some strabismus/nystagmus (crossed eyes) is expected.

Question 29

23. Teratology of Fallout manifestations (pp slide 8)

Answer 29

 Cyanotic! (Inadequate oxygenation)
 Clubbing fingers
 Poor feeding or poor weight gain
 Polycythemia: hydration!
 Dyspnea

Question 30

23. Teratology of Fallout nursing interventions (pp slide 8)

Answer 30

 Hydration for risk of clots
 High risk of CHF after surgery
 During spells: young baby knee to chest, older squat
 If hemoglobin is over 22 call provider!
 Provide pacifier when crying, small frequent feedings