OB HESI Case Studies
Healthy Newborn
Ms. Stacy Myers is in active labor at 38 weeks gestation with an uncomplicated pregnancy. She
is admitted to the birthing center on October 10th at 0830. After 9 hours of labor Miss Myers
had a spontaneous vaginal delivery of an infant boy.
1. The nurse q...
ob hesi case studies healthy newborn ms stacy myers is in active labor at 38 weeks gestation with an uncomplicated pregnancy she is admitted to the birthing cen
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OB HESI Case Studies
Healthy Newborn
Ms. Stacy Myers is in active labor at 38 weeks gestation with an uncomplicated pregnancy. She
is admitted to the birthing center on October 10th at 0830. After 9 hours of labor Miss Myers
had a spontaneous vaginal delivery of an infant boy.
1. The nurse quickly place is the infant under radiant warmer and starts to dry him. What is
the rationale for these actions?
a. Convective heat loss from evaporation is reduced. Drying the infant quickly and
placing him under a radiant warmer reduces the heat loss through evaporation
and radiation
2. Which action should the nurse take prior to drying the infants back?
a. Inspect the back for possible neurological defects. To prevent harm on drying the
newborn, the back should always be inspected for possible neurological defects,
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such as spina bifida.
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3. At one minute of age the infant is alert and active and has a strong cry. He has a heart
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rate of 172 and a respiratory rate of 50. The infants arms and legs are flexed the color of
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his body is pink and the color of both fee is blue. The nurse continues a physical
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assessment of the infant looking for normal and abnormal findings. Which APGAR score
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should the nurse assign?
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a. Nine
4. Upon inspection of the umbilical cord which finding should the nurse report to the
healthcare provider?
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a. One artery and one vein are present. Two arteries and one vein should be
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present
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5. The Myers baby’s head is molded from the vaginal delivery upon seeing the baby miss
Myers says “oh he’s so beautiful but something is wrong with his head”. How should the
nurse respond?
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a. His head has been molded from delivery through the birth canal which is normal.
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Molding commonly occurs in babies delivered vaginally and the head will
become more symmetrical overtime
6. Miss Myers is offered the opportunity to breast feed. After securing a comfortable
position for herself and the baby Miss Myers puts the infant to her breast. The baby
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latches onto the nipple and with some encouragement he begins to nurse. After a time
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of family interaction Ms. Myers is taken to the postpartum unit and the infant is
transferred to the transition care unit. The nurse checked the identification bands for
both the baby and the mother upon admission to the nursery. One ID number is
incorrect. What action should the nurse take to solve this problem?
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a. Redo The identification bands with another nurse witnessing the process.
Identification bands must be correct to ensure the safety and security of all
hospitalized patients, especially newborns
7. Upon admission to the transition care nursery, the Myers babies auxiliary temperature is
97.4°F. what action should the nurse take?
This study source was downloaded by 100000829874104 from CourseHero.com on 08-30-2021 02:41:30 GMT -05:00
, a. Place the infant in a radiant warmer and monitor his temperature. The baby’s
temperature is not within normal range. Normal range is 97.5°F to 99°F
8. While examining the infants head the nurse swelling of the scalp that extends across the
suture lines of the fetal skull. What action should the nurse taken in response to this
finding?
a. Document the finding in the record. This finding indicates caput succedaneum,
which commonly occurs after a vaginal birth
9. The nurse notes a skin tag on the side of the infant hand. What should the nurse do in
response to this finding?
a. Document the findings and notify the pediatrician. Skin tags are a common
finding on a newborn assessment. They can be harmless, but the pediatrician
should be informed
10. Which physical finding, if present, should the nurse report to the HCP?
a. Loose natal teeth that are not covered by the gums. Natal teeth, present at birth,
are an unusual occurrence that should be reported to the healthcare provider.
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Loose natal teeth are frequently removed to prevent aspiration
11. While examining the babies gastrointestinal system which finding warrant additional
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assessment by the nurse?
a. No bowel movement in the first 72 hours. The first meconium stool should pass
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within 48 hours. Abstraction maybe suspected if no bowel movement in the first
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72 hours.
12. Which findings are consistent with an infant born at 38 weeks gestation?
a. Well defined nipples with a raised areola
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b. Plantar creases covering 2/3 of the soul of foot
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13. The nursing student is assisting the nurse in caring for the infants and the nursery. The
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nurse questions the student about vitamin K as preparations are made for
administration. Which response by the student indicates an understanding of the
purpose for administering this drug?
a. This drug is given to new born to prevent and or treat hemorrhagic disease.
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Because this vitamin does not cross the placenta and there is very little and
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breastmilk, supplemental vitamin K should be given to newborns at birth to help
clot the blood. Therefore this is an accurate response by the student.
14. The nurses preparing to give the baby her first bath. Which assessment data indicates
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that it is safe for the baby to be given the bath at this time?
a. Auxiliary temperature of 97.9°F. Correct
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b. Respiratory rate of 52 breaths per minute. The respiratory rate is slightly high and
will rise with activity of bathing
c. Apical heart rate of 166 beats/min. This heart rate is slightly high and will rise
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further with the activity of bathing
d. Pulse oximeter of 90%. This value is below normal and could become lower with
the activity of bathing
15. At 2400 hrs. infant is crying, his skin is modeled, and his hands are shaking. What action
should the nurse take first?
This study source was downloaded by 100000829874104 from CourseHero.com on 08-30-2021 02:41:30 GMT -05:00
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