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HESI case study: Healthy Newborn Stacy Myers
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HESI case study: Healthy Newborn Stacy Myers
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HESI case study: Healthy Newborn Stacy MyersThe Nurse place the infant under a radiant warmer and starts to
dry him quickly.
1. What is the rationale for theses actions? Correct Answers
Convective heat loss from evaporation is reduced. (drying the
infant quickly and placing him under a radiant warmer reduces
heat)
2. Which action should the nurser take prior to drying the
infact's back? Correct Answers Inspect the back for possible
neurological defects . (To prevent harm while drying the
newborn, the back should always be inspected for possible
neurological defects, such as spinal bifida)
At 1 minute of age, the infant is alert and active, and has a
strong cry. He has a heart rate of 172 and a respiratory rate of
50. The infant's arms and legs are flexed, the color of his body is
pink, and the color of both feet is blue. The nurse continues a
physical assessment of the infant looking for normal and
abnormal findings.
3. Which APGAR score should the nurse assign? Correct
Answers 9
One point is deducted for acrocyanosis
, Heart Rate: absent = 0, slow (<100) = 1, Over 100 = 2
Resp Rate: absent = 0, slow/irregular = 1, good/crying = 2
Muscle Tone: flaccid = 0, some flexion of the extremeties = 1,
active motion = 2
Reflex Irritability: no response = 0, grimace = 1, cry = 2
Color: blue/pale = 0, body pink/extremeties blue = 1, completely
pink = 2
Upon inspection of the umbilical cord, which finding should the
nurse report to the healthcare provider (HCP) Correct Answers
One artery and one vein are present. ( Two arteries and one vein
should be present)
The Myers' baby's head is molded from the vaginal delivery.
Upon seeing the baby, Ms. Myers says "Oh, he is so beautiful,
but something is wrong with this head" Correct Answers His
head has been molded from delivery through the birth canal,
which is normal.
(Molding commonly occurs in babies delivered vaginally, and
the head will become more symmetrical over time.
The nurse checks the identification bands for both the baby and
the mother upon admission to the nursery. One ID number is
incorrect.
6. Which action should the nurse take to solve this problem?
Correct Answers Redo the identification band with another
nurse witnessing the process.
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