Jeremy is a 1-day-old male born via frank breech position. His mother is concerned he may have brain damage due to his legs being stiffly bent. On physical exam, Jeremy's legs remain sharply bent at the hips and knees with difficulty flexing. This is likely due to his breech position. The nurse evaluates Jeremy's signs and symptoms as normal for a newborn and teaches the mother techniques to care for him, including skin-to-skin contact for warmth. The nurse also explains that newborns can hear from birth as eustachian tube fluid is absorbed and that Jeremy's exam findings are normal.
Jeremy is a 1-day-old male born via frank breech position. His mother is concerned he may have brain damage due to his legs being stiffly bent. On physical exam, Jeremy's legs remain sharply bent at the hips and knees with difficulty flexing. This is likely due to his breech position. The nurse evaluates Jeremy's signs and symptoms as normal for a newborn and teaches the mother techniques to care for him, including skin-to-skin contact for warmth. The nurse also explains that newborns can hear from birth as eustachian tube fluid is absorbed and that Jeremy's exam findings are normal.
Jeremy is a 1-day-old male born via frank breech position. His mother is concerned he may have brain damage due to his legs being stiffly bent. On physical exam, Jeremy's legs remain sharply bent at the hips and knees with difficulty flexing. This is likely due to his breech position. The nurse evaluates Jeremy's signs and symptoms as normal for a newborn and teaches the mother techniques to care for him, including skin-to-skin contact for warmth. The nurse also explains that newborns can hear from birth as eustachian tube fluid is absorbed and that Jeremy's exam findings are normal.
Jeremy is a 1-day-old male born via frank breech position. His mother is concerned he may have brain damage due to his legs being stiffly bent. On physical exam, Jeremy's legs remain sharply bent at the hips and knees with difficulty flexing. This is likely due to his breech position. The nurse evaluates Jeremy's signs and symptoms as normal for a newborn and teaches the mother techniques to care for him, including skin-to-skin contact for warmth. The nurse also explains that newborns can hear from birth as eustachian tube fluid is absorbed and that Jeremy's exam findings are normal.
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Case Scenario #9:
Nursing Care of a Family with A
Newborn Mondelo, Ara Mae Medina, Doneva Lyn Hakima, Hadji Daud A FAMILY WITH AN INFANT BORN BREECH: Jeremy is a 1-day-old male who was born from a frank breech position. Types of Breech Presentation CHIEF CONCERN: “He looks funny. Could he have brain damage?” HISTORY OF CHIEF CONCERN: Labor began with ruptured membranes; amniotic fluid was stained “dark green.” When Mrs. Farmer arrived at the hospital, an ultrasound revealed her baby was presenting breech; because dilatation was already at 8 cm, she was allowed to give birth vaginally. The infant was born with aid of Piper forceps and was intubated immediately to assess for meconium. None visualized beyond vocal cords; Apgar scores of 9 and 9. The infant retains in intrauterine position (legs extended at knee; sharply bent at hip). FAMILY PROFILE: The family lives in a two-bedroom condominium next to national park. The father works as a park ranger; the mother works part time as a paralegal in lawyer’s office. They have one other child: 1-year-old Margo. Finances are “adequate.” The mother is concerned something is wrong with baby because he was born breech; points to stiffness of legs as indication some neurological problem must be present. PREGNANCY HISTORY:
The mother is G2P2. Pregnancy was unintended because
older child is only 1 year old (mother had not begun on a contraceptive as yet following first birth). The mother’s hemoglobin was low at beginning of pregnancy (10 g/dl) so she was prescribed an iron supplement. There are no other complications with pregnancy other than breech presentation. The mother states as long as children are so close together, she would have preferred a second female, not a boy. PHYSICAL EXAMINATION: Weight: 8.1 lb (3.6 kg); height: 20 in. (51 cm); head circumference: 35 cm
Temperature: 98.6°F (37°C)
General appearance: Well-proportioned, alert, male newborn who assumes a frank breech position
Head: Normocephalic; no molding; ant. fontanelle: 3 cm × 3 cm; posterior fontanelle: 1 cm
Eyes: Red reflex present; follows to midline without difficulty
Ears: Normal alignment; canal patent
Nose: Midline septum; no drainage
Mouth: No teeth; palate intact; midline uvula
Neck: No lymph nodes palpable; midline trachea
Chest: Occasional rhonchi present; no rales; respiratory rate: 20 breaths/min
Heart: No murmurs; heart rate: 145 beats/min
Abdomen: Soft; no masses; liver palpable 1 cm
Genitalia: Normal male; testes palpable in scrotum bilaterally; midline meatus
Extremities: Full range of motion in upper extremities; lower extremities are
positioned sharply bent at the hip with extended knees; knees flex but with difficulty; no fractures in long bones palpable; unable to flex and abduct hips to assess for subluxated hip; buttocks have large ecchymotic areas
Neuro: Moro, sucking, and rooting reflexes present; step-in-place, crossed
extension, tonic neck poorly demonstrated because of stiffness of legs LABORATORY FINDINGS:
Hemoglobin: 18.0 g/dl
Hematocrit: 56% Jeremy was administered AquaMEPHYTON (vitamin K) and erythromycin eye ointment in the birthing room. He was scored as a term 39-week infant by a Ballard scale. STUDY QUESTIONS:
1. Jeremy’s temperature at 1 hour after birth was 98.6°F
(37°C). The temperature of the average newborn immediately after birth is: (2 pts)
A. 96°F (35.6°C) B. 99°F (37.2°C) C. 101°F (38.4°C) D. 105°F (40.6°C) B. 99°F (37.2°C)
Rationale: The temperature of newborns is about 99°F (37.2°C) at birth because they have been confined in their mother’s warm and supportive uterus. (Maternal and Child Health Nursing Care of the Childbearing and Childrearing Family 8th edition Volume 1 (p. 428) 2. A major way that Jeremy can lose heat is by radiation. This type of heat loss involves which of the following? (2 pts)
A. Loss of heat from a draft in the room
B. Shift of body heat from trunk to extremities C. Loss of heat to a cold surface that Jeremy is laying upon D. Heat lost to a distant cold surface like a window D. Heat lost to a distant cold surface like a window
Rationale: Radiation is the transfer of body heat to a cooler solid object not in contact with the baby, such as a cold window or air conditioner. Moving an infant as far from the cold surface as possible helps reduce this type of heat loss. (Maternal and Child Health Nursing Care of the Childbearing and Childrearing Family 8th edition Volume 1 (p. 429) 3. Jeremy’s hemoglobin is 18 g/100 mL. You should recognize that the usual hemoglobin value of newborns is: (2 pts)
A. 7 to 11 g/100 mL B. 11 to 12 g/100 mL C. 17 to 18 g/100 mL D. 19 to 21 g/100 mL C. 17 to 18 g/100 mL
Rationale: A newborn has more red blood cells than the average adult, the hemoglobin level averages 17 to 18 g/100 mL of blood. (Maternal and Child Health Nursing Care of the Childbearing and Childrearing Family 8th edition Volume 1 (p. 431) 4. Jeremy weighed 8.1 lb at birth. Suppose on the third day of life, he weighs 7.5 lb. You would assess this as which of the following? (2 pts)
A. Excessive newborn weight loss
B. An average weight loss for a newborn C. A loss still normal but becoming dangerous D. A loss not consistent with breastfeeding B. An average weight loss for a newborn
Rationale: During the first few days after birth, a newborn loses 5% to 10% of birth weight (6 to 10 oz). This weight loss occurs because a newborn is no longer under the influence of salt and fluid-retaining maternal hormones. In addition, the newborn voids and passes stool. (Maternal and Child Health Nursing Care of the Childbearing and Childrearing Family 8th edition Volume 1 (p. 428) 5. You have taught Jeremy’s mother to provide skin-to-skin care. This type of care will primarily involve what practice? (2 pts)
A. Frequently walking with the infant to decrease conduction
B. Keeping the newborn covered with baby oil to seal in heat C. Holding the infant against her chest or abdomen for warmth D. Covering the infant with clothes so completely no skin shows C. Holding the infant against her chest or abdomen for warmth
Rationale: Newborns are wet when born, so they can lose a great deal of heat as the amniotic fluid on their skin evaporates. To prevent this type of heat loss, a newborn is placed in the mother’s abdomen immediately after birth and cover with a warm blanket for skin-to-skin contact. (Maternal and Child Health Nursing Care of the Childbearing and Childrearing Family 8th edition Volume 1 (p. 429) 6. Jeremy was administered vitamin K in the birthing room. What rationale for this intervention should you explain to Mrs. Farmer? (2 pts)
A. Breast milk does not contain vitamin K.
B. His mother’s hemoglobin was 10.5 g/dl. C. He was scored as only a 39-week infant. D. Newborns cannot produce vitamin K. D. Newborns cannot produce vitamin K.
Rationale: A newborn’s intestine is sterile at birth, unless membranes were ruptured more than 24 hours, it will take about 24 hours for flora to accumulate and for ongoing vitamin K to be synthesized. This causes most newborns to be born with a lower than usual level of vitamin K, leading to a prolonged coagulation or prothrombin time. (Maternal and Child Health Nursing Care of the Childbearing and Childrearing Family 8th edition Volume 1 (p. 431) 7. Jeremy’s first stool was black and sticky. Knowing the importance of the QSEN competency of safety, you would evaluate this as: (2 pts)
A. A normal newborn meconium stool.
B. He must have swallowed blood at birth. C. He may have some internal bleeding. D. He may be allergic to breast milk. A. A normal newborn meconium stool.
Rationale: The first stool of a newborn is usually passed wiyhin 24 hours after birth. It consists of meconium, a sticky, tar-like, blackish- green, odorless material formed from mucus, vernix, lanugo, hormones, and carbohydrates that accumalated in the bowel during intrauterine life. (Maternal and Child Health Nursing Care of the Childbearing and Childrearing Family 8th edition Volume 1 (p. 432) 8. At 20 hours after birth, Jeremy still has not voided. How would you appraise this assessment finding? (2 pts)
A. He needs a referral for both kidney and bladder structure.
B. This is within normal parameters for a breastfed newborn. C. This is an emergency situation requiring catheterization. D. Jeremy likely needs his breast milk intake supplemented. A. He needs a referral for both kidney and bladder structure.
Rationale: The average newborn voids within 24 hours after birth. A newborn who does not take in much fluid for the first 24 hours may void later than this, but the 24- hour point is a general ruel. Newborns who do not void within this time need to be assessed for the possibility of urethral stenosis or absent kidneys or ureters. (Maternal and Child Health Nursing Care of the Childbearing and Childrearing Family 8th edition Volume 1 (p. 432) 9. Jeremy was assessed for a tonic neck reflex. In a typical tonic neck reflex: (2 pts)
A. One arm extends on the side to which he turns his head when he is supine. B. The infant throws out his hands and legs and then “curls back” again. C. The infant takes a few pacing steps forward when he is held upright. D. On his stomach, the newborn lifts up his head and nods expectantly. A. One arm extends on the side to which he turns his head when he is supine.
Rationale: When the arm and leg on the side toward which the head is turned extend, and the opposite arm and leg contract. (Maternal and Child Health Nursing Care of the Childbearing and Childrearing Family 8th edition Volume 1 (p. 434) 10. You notice Jeremy’s mother sings to him. How soon after birth can newborns hear? (2 pts)
A. At 3 to 4 weeks of age B. As soon as vernix is wiped from the ear pinna C. As soon as eustachian tube fluid is absorbed D. When the infant yawns and opens the ear canal C. As soon as eustachian tube fluid is absorbed
Rationale: As soon as amniotic fluid drains or is absorbed from the middle ear by way of the euthachian tube within hours after birth, hearing becomes acute. (Maternal and Child Health Nursing Care of the Childbearing and Childrearing Family 8th edition Volume 1 (p. 435) 11. Jeremy’s skin is described as having slight physiologic jaundice. What factor is involved in the etiology of this problem? (2 pts)
A. Shunting of blood from the extremities to the body core
B. A reaction from the vitamin K administered at birth C. An allergy to the protein in either formula or in breast milk D. The breakdown of hemoglobin which occurs in newborns D. The breakdown of hemoglobin which occurs in newborns
Rationale: Infants who are prone to to extensive bruising ( large, breech, or preterm babies) for jaundice because bruising leads to to hemorrage of blood into the subcutaneous tissie or skin; this blood then ahs to be broken down so can add to the amount of indirect bilirubin accumulating. (Maternal and Child Health Nursing Care of the Childbearing and Childrearing Family 8th edition Volume 1 (p. 441) 12. Which finding in Jeremy’s history puts him at higher risk for an increased serum bilirubin level than other infants?
A. He has bruising on his buttocks from birth.
B. His mother had a low hemoglobin during pregnancy. C. He was born within 1 year of a sibling. D. He was a full-term infant. A. He has bruising on his buttocks from birth.
Rationale: Infants who are prone to to extensive bruising ( large, breech, or preterm babies) for jaundice because bruising leads to to hemorrage of blood into the subcutaneous tissie or skin; this blood then ahs to be broken down so can add to the amount of indirect bilirubin accumulating. (Maternal and Child Health Nursing Care of the Childbearing and Childrearing Family 8th edition Volume 1 (p. 441) 13. Jeremy’s Apgar score at 5 minutes was 9. How should you evaluate this assessment finding?
A. He was having trouble breathing at 5
minutes of age. B. He must have been hyperventilating at this time period. C. His heart must have been beating too fast to be accurately assessed. D. He is adjusting well to intrauterine life. D. He is adjusting well to intrauterine life.
Rationale: Using the apgar test, the nurse assesses heart rate, respiratory effort, muscle tone, reflex irritability, and color. (Maternal and Child Health Nursing Care of the Childbearing and Childrearing Family 8th edition Volume 1 (p. 437) 14. A heel stick blood sample from Jeremy at 12 hours of age revealed a glucose level of 50 mg/100 ml. You would interpret this as: (2 pts)
A. Severe hypoglycemia. B. Mild hypoglycemia. C. Normal for a newborn. D. Hyperglycemia. C. Normal for a newborn.
Rationale: A serum glucose reading that is less than 40 mg/100 ml of blood indicates hypoglycemia. Newborn symptoms of hypoglycemia include jitteriness, lethargy seizures, and intravenous glucose may be prescribed. A continuous intravenous infusion of glucose may be necessary if the newborn is unable to maintain glucose levels higher than 40 mg/100 ml. (p. 450-451) (Maternal and Child Health Nursing Care of the Childbearing and Childrearing Family 8th edition Volume 1 (p. 450-451) 15. Jeremy was scored as a term newborn on a Ballard scale. In a term newborn, you would expect which of the following assessment findings? (2 pts)
A. No creases on the sole of the foot
B. Creases covering the entire sole C. Rounded or “rocker-bottom” feet D. Toes held in a splayed position B. Creases covering the entire sole
Rationale: The sole of the foot is flat because of an extra pad of fat in the longitudinal arch. The foot of a term newborn has many crisscrossed lines on the sole, covering approximately two thirds of the foot. If these creases cover less than two thirds of the foot or are absent, it suggests the infant is preterm. (Maternal and Child Health Nursing Care of the Childbearing and Childrearing Family 8th edition Volume 1 (p. 450) 16. You inspect Jeremy’s head, mouth, and ears closely. What finding would you consider to be normal if discovered at birth? (2 pts)
A. Craniotabes B. Protruding eye globes C. Swollen tongue D. Yellow-tinged sclera A. Craniotabes
Rationale: Craniotabes is an example of a condition that is normal if seen in a newborn but would be pathologic in an older child or adult. (Maternal and Child Health Nursing Care of the Childbearing and Childrearing Family 8th edition Volume 1 (p. 445) 18. While Jeremy’s mother takes a shower, you place Jeremy in his bassinette. Which would be the best position in which to place him? (2 pts)
A. On his back B. On his abdomen C. On his right side D. On his left side A. On his back
Rationale: Sudden Infant death syndrome (SIDS) is the sudden, unexplained death of an infant younger than 1 year of age. Although the specific cause of SIDS cannot be explained, these interventions have been shown to decrease the incidence of the syndrome: place infant on the back to sleep; use a firm sleep surface; and avoid soft bedding. (Maternal and Child Health Nursing Care of the Childbearing and Childrearing Family 8th edition Volume 1(p. 456-457) 19. Jeremy’s parents have chosen to have him circumcised. What would you teach his parents? (2 pts)
A. Do not feed him for 12 hours postprocedure.
B. Using local anesthesia will help control pain. C. He will need to receive IV heparin afterward. D. Bleeding of about 100 ml can be expected B. Using local anesthesia will help control pain.
Rationale: For the procedure, an infant is placed in a supine position and restrained either manually or with a commercial swaddling board. Application of EMLA cream (a eutectic mixture of local anesthetics) or a similar compound is a popular choice for local anesthesia. Regional block anesthesia may also be used if an anesthetist is involved. (Maternal and Child Health Nursing Care of the Childbearing and Childrearing Family 8th edition Volume 1(p. 457) 20. Mr. Farmer is preparing to take Jeremy and Mrs. Farmer home. In the interests of safety, what would you teach him? (2 pts)
A. His mother should hold him securely on her lap during the trip home. B. Newborns do not necessarily need car seats until they are 2 weeks old. C. Newborn seats should be placed in the back seat facing forward. D. In the back seat, facing backward, is the safest position for newborn car seats. D. In the back seat, facing backward, is the safest position for newborn car seats.
Rationale: Automobile accidents are a safety problem all during childhood, beginning with the newborn period. For protection while in automobiles, newborns should always be transported in rear facing car seats placed in the backseat. (Maternal and Child Health Nursing Care of the Childbearing and Childrearing Family 8th edition Volume 1(p. 459)
