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Maternal Exam 2 ATI Chamberlain Nursing with complete solution
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Maternal Exam 2 ATI Chamberlain Nursing with complete solution
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Maternal Exam 2 ATI Chamberlain Nursingwith complete solution
Collecting blood samples from newborn steps - ANSWER- 1. Warm heel
2. Cleanse with antiseptic, allow to air dry
3. Prick at OUTTER aspect of heel
4. Apply pressure with gauze; not using alcohol
5. Cuddle and comfort
Bradypnea - ANSWER- less that 30
tachypnea - ANSWER- more that 60
abnormal breathing sounds - ANSWER- grunting
crackles
wheezes
s/s of respiratory distress - ANSWER- nasal flaring
retractions
grunting
gasping
labored breathing
Stabilizing airway - ANSWER- Routine suction of mouth THEN nose.
Cesarean births more likely to have fluid remain in lungs vs vaginal deliveries
Using Bulb syringe - ANSWER- Compress bulb before insertion (to side of mouth)
Avoid center of the mouth (causes gag)
Aspirate mouth first, one nostril, then second
s/s of hypothermia - ANSWER- ax temp less than 97.7F
cyanosis
increased resp rate
, T or F: becoming chilled increases newborns oxygen demand - ANSWER- True:
when chill or hyperthermic newborn will need 02
Bathing - ANSWER- done only when temp is stable; at least 97.7
given within 1-2 hrs under radiant heat
gloves should be worn until after bath (mom's body secretions)
Elimination - ANSWER- void 6 to 8 times per day
Meconium within first 24 hrs
Stool 3-4 times per day
Umbilical Cord Care - ANSWER- goal: decrease infection and hemorrhage
Cord clamp stays in place for 24 to 48 Hrs
Clean cord with water initially
Assess stump for: redness, edema and drainage at base of cord
ensure diaper is folded down and away from umbilical stump
DON'T submerge in water until cord has fallen out
When does cord fall off? - ANSWER- 10-14 days
Erythromycin Ointment - ANSWER- prevents opthalmia neonatorum
caused by gonorrhoeae or chlamydia
done once only
apply at lower conjuctival sac of each eye
start INNER canthus moving outward
must be givin within 1st hour
Vitamin K (phytonadione) - ANSWER- Prevent hemorrhagic disorders
IM
Vastus Lateralis
Give within 1st hr
Hep B Immunization - ANSWER- protects against hep B
need informed consent
birth, 1mos, 6mos
-if mom infected: give hep B immunoglobulin + hep B vaccine within 12 hr
do NOT give hep B and Vit K injection in same thigh! - ANSWER- sites should be
altered
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