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Childbearing And Reproductive (NUR 344) Quiz 4 HESI Newborn Care

John Marsh
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Quiz 4 HESI Newborn Care

University of Rhode Island

Practicum In Childbearing And Reproductive Health Nursing (NUR 344)

HESI pgs. 267-268: Newborn Care (Delivery Room)
Nursing Assessment in the Delivery Room :
● Maternal history and labor data indicating potential problems with newborn
● Apgar scores
● Findings of brief physical exam performed in delivery room
Nursing Plans & Interventions :
● Immediately dry infant under warmer or skin-to-skin with mother
○ Suction mouth and nose with a bulb syringe
○ Keep head slightly lower than body
○ Assess airway status & for 5 symptoms of respiratory distress:
1. Retractions
2. Tachypnea (rate > 60)
3. Dusky color, circumoral cyanosis
4. Expiratory grunt
5. Flaring nares
○ Do not hyperextend newborn neck at any time (may close
■ Place infant in “ sniff ” position (neck slightly
extended as if sniffing air) to open airway
● Obtain Apgar Score at 1 and 5 minutes
○ Cannot just “eyeball” – must have
○ hands on examination
○ acrocyanotic→ bluish/purplish
○ hands/feet
HESI: do not wait until a 1 minute Apgar is assigned to begin resuscitation of compromised neonate
HESI: Apgar scores of < 6 at 5 min require an additional Apgar assessment at 10 min
● Continue to allow maternal/parent contact if newborn is stable
● Keep neonate’s head covered
● Do quick gestational age assessment: sole creases (before 36 weeks only 1 or 2), breast tissue, breast
bud (larger tissue), skin, vessels, peeling (premature babies may peel less), genitalia, resting posture
(hypertonic flexion in extremities, closely addicted to trunk)
28 Weeks 40 Weeks
No nipple bud
Testes in inguinal canal
OR labia majora widely separated with labia minora
prominent, open, and equal in size
Vernix (cheesy coating) over entire body
Lanugo (fine, downy hair) over entire body
Full extension of extremities in resting posture
Raised nipple with a tissue bud underneath
Descended testes with large rugae (folds) on scrotum
Labia majora large and covering minora
Vernix only in creases
Lanugo perhaps only over shoulders
Hypertonic flexion of extremities in resting posture
● Examine cord for presence of 3 vessels ( 2 arteries and 1 vein ) and document
● Make sure cord blood is collected for analysis and sent to lab: Rh, blood type, hct, possible blood gases
● Document passage of meconium (neonate stool) or urine after delivery
● Place 2 ID bands on neonate and 1 on mother
● Obtain newborn footprints and maternal thumb and fingerprint (follow policy)
● Perform brief physical exam on newborn
○ Check for gross anomalies: spina bifida (spinal cord fails to develop properly), hydrocephalus
(CSF builds up in the ventricles of the brain), cleft lip/palate (opening or splits in lip/palate)
○ Elicit reflexes: moro (startle-spreading out arms, pulling them in, crying) and rooting (suck)
○ Examine cord clamp for closure, absence of blood oozing from cord, recheck presence of 3
● May instill eye prophylaxis in delivery room
Newborn Prophylactic Eye Care: erythromycin ointment



Childbearing And Reproductive (NUR 344) Quiz 4 HESI Newborn Care

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