Nursing Care for Newborns and Maternal-Newborn Clients, Exams of Nursing

Download Nursing Care for Newborns and Maternal-Newborn Clients and more Exams Nursing in PDF only on Docsity! RN VATI Maternal Newborn Remediation 2019 1. identification (using 2 identifiers) for the newborn is applied ANS - immediatelyafter birth by the nurse -it is an important safety measure to prevent newborn from being given to the wrong parents, switched or abducted 2. how are the client, newborn & client's partner identified during the hospital stay? ANS identified by plastic ID wristbands with permanent locks that must be cut tobe removed 3. identification bands should include what? ANS the newborn's name, sex, date &time of birth & client's health record number 4. how many ID bands should the newborn have? ANS -one band placed on theankle and one on the wrist -in addition, the newborn's footprints & client's thumb prints are taken 5. when should the ID band be checked? ANS each time the newborn is given to theparents, the ID band should be verified against the client's ID band 6. what must a facility member have in order to take the newborn? ANS -all facilitystaff who assist in caring for the newborn are required to wear photo ID badges -the newborn is not given to anyone who does not have a photo ID badge that distinguishes that person as a staff member of the facility maternal-newborn unit 7. many facilities have locked maternal-newborn units that require ANS - staff topermit entrance or exit -some facilities have a sensor device on the ID band or umbilical cord clamp that sounds an alarm if the newborn is removed from the facility 2 / 8 13. nursing actions for endometritis ANS -collect vaginal & blood cultures -administer IV antibiotics -administer analgesics 14. findings to report in third trimester ANS epigastric pain (gestational hyperten-sion) 15. lab tests for gestational hypertension ANS -liver enzymes -blood creatinine, BUN, uric acid -CBC -clotting studies -chemistry profile 16. nursing care for postpartum hemorrhage ANS -assess bladder for distention -insert an indwelling urinary catheter to assess kidney function and obtain an accurate measurement of urinary output 17. nursing care for uterine atony ANS -perform fundal massage if indicated 5 / 8 -if uterus becomes firm, continue assessing hemodynamic status -if uterine atony persists, anticipate surgical intervention, s/a hysterectomy ANS - color changes (pallor, jaundice, petechiae) 19. therapeutic uses of oxytocin ANS -induction of labor (postterm pregnancy, pre-mature ROM, preeclampsia) -enhancement of labor (dysfunctional labor) -delivery of placenta (postpartum, miscarriage) 6 / 8 -management of postpartum hemorrhage -stress testing 20. at the end of the third stage of labor, the uterus should be palpable where? ANS at midline and 2 cm below the umbilicus 21. 1 hr after delivery, the fundus should be where? ANS should rise to the level ofthe umbilicus ANS 1-2cm 23. by the 6th postpartum day, the fundus should be where? ANS halfway betweenthe symphysis pubis & the umbilicus 7 / 8 29. anterior fontanel assessment on newborn ANS -should be palpable -approx. 5 cm on average -diamond shaped 30. posterior fontanel assessment on newborn ANS smaller and triangle- shaped 31. fontanels assessment on newborn ANS -should be soft & flat -can bulge when the newborn cries, coughs or vomits, but should be flat when the newborn is quiet 32. bulging fontanels at rest on newborn can indicate ANS -increased ICP -infection -hemorrhage 33. depressed fontanels on newborn can indicate ANS dehydration 34. cutaneous stimulation strategies for pain management ANS sacral counter- pressure ANS consistent pressure is applied by the support person using the heel of the hand or fist against the client's sacral area to counteract pain in the lower back 35. nursing actions for reflex tachycardia ANS -monitor client's for an increased HR 10 / -administer a beta blocker (metoprolol) to counteract tachycardia 36. terbutaline nursing actions ANS notify provider of HR greater than 130/min, chestpain, cardiac arrhythmias, MI, BP less than 90/60 mmHg, or pulmonary edema 37. intrauterine pressure catheter ANS -insert a sterile solid or fluid-filled IUPC insidethe uterus to measure intrauterine pressure -displays uterine contraction patterns on monitor -requires the membranes to be ruptured and the cervix to sufficiently dilated 38. oxygen therapy for respiratory depression following pain medication administration ANS provide oxygen therapy at lowest flow that will correct hypoxemia 39. respiratory depression nursing actions ANS -monitor VS -stop opioids if client's RR is less than 12/min & notify provider -have naloxone and resuscitation equipment available -avoid use of opioids with CNS depressant medications (barbituates, benzos, consumption of alcohol) 40. causes/complications of late deceleration of FHR ANS -uteroplacental insuffi-ciency causing inadequate fetal oxygenation -maternal hypotension, placenta previa, abruptio placentae, uterine hyperstimula- 11 / and 13 / HR greater than 100/min 44. interventions for stabilization and resuscitation of airway ANS -the newborn isable to clear most secretions in air passages by the cough reflex -routine suctioning of the mouth, then the nasal passages with a bulb syringe is done to remove excess mucus in the respiratory tract 45. nursing action for offsetting maternal hypotension after administration of an epidural block ANS administer a bolus of IV fluids 46. a major nursing priority for maternal-newborn clients ANS -prevention of falls -nurses must evaluate all clients in health care facilities for risk factors for falls and implement preventative measures accordingly 47. danger signs during 1st trimester ANS abdominal cramping and/or vaginalbleeding (miscarriage, ectopic pregnancy) 48. nursing assessment for behaviors that facilitate and indicate parent- in- fant bonding ANS -provides physical care for the infant (feeding, diapering) -responds to the infant's cries 49. normal temperature for a newborn ANS -36.5-37.5 degrees C (97.7-99.5 F) with37 C (98.6 F) being the average 14 / -the newborn is at risk for hypothermia & hyperthermia until thermoregulation stabilizes 15 / and shift the intrauterine contents 53. newborn (metabolic) genetic screening is ANS -mandated in all states -a capillary heel stick should be done 24 hrs following birth -for results to be accurate, the newborn must have received formula or breast milk for at least 24 hrs -if the newborn is discharged before 24 hrs of age, the test should be repeated in 1-2 weeks 54. all states require testing for what in newborns? ANS -phenylketonuria (PKU) -PKU is a defect in protein metabolism in which the accumulation of the amino acid phenylalanine can result in mental retardation -treatment in the first 2 months of life can prevent mental retardation 55. what should nurse do immediately following rupture of membranes? ANS as- sess the FHR for abrupt decelerations, which are indicative of fetal distress to ruleout umbilical cord prolapse 56. what to monitor for in hypoglycemic newborns ANS -jitteriness -twitching -a weak, abnormal cry -irregular respiratory effort 17 / -cyanosis -lethargy -eye rolling -seizures -blood glucose level less than 40 mg/dL by heel stick 57. new ballard score (neuromuscular maturity) for newborn ANS -posture rangingfrom fully extended to fully flexed (0-4) -square window formation with the neonate's wrist (-1-4) -arm recoil, where the neonate's arm is passively extended and spontaneously returns to flexion (0-4) -popliteal angle, which is the degree of the angle to which the newborn's knees can extend (-1-5) -scarf sign, which is crossing the neonate's arm over the chest (-1-4) -heel to ear, which is how far the neonate's heels reach to their ears (-1-4) 58. contraindications for oxytocin administration ANS -fetal factors >immature lungs >cephalopelvic disproportion >fetal malpresentation >prolapsed umbilical cord 18 / >fetal distress >placental abnormalities >threatened spontaneous abortion 59. client preparation for induction of labor ANS initiate oxytocin no sooner than 4hrs after the administration of misoprostol, and 6-12 hrs after dinoprostone gel instillation or removal of a dinoprostone insert 60. excessive weight gain during pregnancy can lead to ANS -macrosomia andlabor complications -inability to gain weight could result in low birth weight of the newborn 61. physiologic jaundice ANS -considered benign(resulting from normal newborn physiology of increased bilirubin production d/t the shortened lifespan and break-down of fetal RBCs and liver immaturity) -the newborn who has physiologic jaundice exhibits an increase in unconjugated bilirubin levels 72-120 hrs after birth, with a rapid decline to 3 mg/dL 5-10 days after birth 62. nursing care for phototherapy for hyperbilirubinemia ANS -keep the newbornundressed -for a male newborn, a surgical mask should be placed (like a bikini) over the 19 /