Thermoregulation and Care of a Newborn
1. Nurse Jackie is preparing the labor room for Ms. Bottelli's delivery. Which of the following equipment should
... [Show More] Jackie have available for the delivery? (Select all that apply.)
a. Suction apparatus
b. Stethoscope
c. Radiant warmer
d. Phototherapy lights
e. Bag and mask respirator
f. Bath kit
Using the ABC priority-setting framework, the nurse should have a bag and mask respirator, suction apparatus, and stethoscope available in the labor room to assess the newborn and maintain airway and breathing. The nurse needs a radiant warmer to promote circulation by providing warmth and preventing cold stress. The nurse does not need phototherapy lights or a bath kit at this time.
2. Nurse Jackie completes the newborn's initial assessment and Apgar scoring. Based on Jackie's assessment, what is the expected Apgar score?
6
Apgar scoring consists of heart rate, respiratory rate, muscle tone, reflex irritability, and color. The nurse assigns a score of 0 to 2 for each category 1 min and 5 min after birth. The newborn's heart rate was 130/min, which is a score of 2. The respiratory rate was a weak cry that sounded like whimpering with slow and irregular breathing, which is a score of 1. The nurse noted some flexion of the extremities for tone, which is a score of 1. The nurse noted grimacing, which is a score of 1. The newborn had good color in the body with some blue color in the hands and feet, which is a score of 1. The total Apgar score for the newborn totals 6 points.
3. Nurse Jackie assesses Ms. Bottelli's newborn. After placing the newborn under the radiant warmer, which of the following actions should Jackie take?
a. Dry the newborn
The nurse should dry and wrap the newborn immediately after birth to prevent cold stress.
b. Perform a head-to-toe assessment
c. Administer Vitamin K (AquaMEPHYTON)
d. Administer eye prophylaxis
4. Nurse Jackie observes the newborn's lack of respiratory effort. Which of the following is the priority nursing action at this time?
a. Perform deep suctioning using a nasopharyngeal suction catheter
b. Suction the newborn’s mouth using a bulb syringe
Gentle oropharyngeal suctioning using a bulb syringe is the priority action at this time. [Show Less]