Topics: Bilirubin, Plantar reflex, Childbirth Pages: 17 (3008 words) Published: May 24, 2013
Which action should the nursery nurse take first in caring for the infant? A) Dry the infant quickly with warm blankets.
Drying the infant is a priority to prevent evaporative heat loss.

B) Use a scale to immediately weigh the infant.
Weighing the infant can be delayed and another intervention done first.

C) Apply a servomechanism temperature probe.
Applying a temperature probe is a common procedure when using a radiant warmer; however, another action should come first.

D) Cover the infant's head using a soft cap.
Another action should be taken first.

After clearing the airway and drying the infant, the nurse assesses that the infant is breathing and has a heart rate of 100, but remains cyanotic.

What action should the nurse take?
A) Apply temperature probe.
Further action is needed.

B) Prepare to give oxygen.
The infant is breathing and has a heart rate. However, oxygen given during this critical transition can increase oxygenation to the rest of the body. Oxygen is usually given by having the nurse cup her hands around the infant's nose and mouth at the O2 tube.

C) Wrap the infant warmly.
Wrapping the infant is not the best response for this situation.

D) Secure a suction catheter.
Further suctioning is not needed since the infant is breathing on his own. Another response is best.

At 1 minute the infant has a heart rate of 142, a slow weak cry, is grimacing, and is in a flexed position with acrocyanosis.

What Apgar score should the nurse assign?
A) 10.
This score is not correct.

B) 9.
This score is not correct.

C) 7.
One point each is deducted for acrocyanosis (blue hands and feet), a slow weak cry and grimacing.

D) 8.
This score is not correct.

Which action should the nurse take prior to weighing the infant? A) Provide a pacifier.
Pacifiers are not usually provided at delivery.

B) Place a diaper on the infant.
A diaper may add to the infant's initial weight and should not be in place.

C) Place a cover on the scale.
The infant should be weighed nude and covering the scale prevents conductive heat loss.

D) Keep the cap on the infant's head.
Although a cap will prevent heat loss, it may add to the infant's initial weight and should not be in place.

To promote family bonding, which part of infant care should the nurse delay? A) Giving Vitamin K.
This injection can be delayed, but another answer is best.

B) Securing ID bands.
Although this is a safety measure, it does not interfere with bonding.

C) Providing cord care.
This care is usually delayed until after the first bath, but does not interfere with bonding.

D) Giving eye prophylaxis.
The presence of eye ointment or drops can interfere with eye-to-eye parent/infant interaction. Giving eye prophylaxis can be delayed for up to 2 hours after birth.

Transition Care

The infant responded well to oxygen, which was discontinued after 10 minutes. The family is provided time to hold and interact with their infant boy. After a time together, the infant is transferred to the transition care nursery and Mrs. Fuqua is taken to the postpartum unit. The family plans on formula-feeding and rooming-in with the infant.

After receiving the labor and delivery report, which information should direct the nurse to further assessment of the infant's head? A) Fourteen hours of labor.
Fourteen hours of labor is typical for a primigravida and should have minimal effects on the infant's head.

B) Low forceps delivery.
Low forceps delivery is usually done with minimal risk, but there is a potential for head trauma or damage to the facial nerve.

C) Unusual cord length.
A long cord can wrap around the...
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