A full-term infant has just been born. Which interventions should ...

[Yolanda]

A full-term infant has just been born. Which interventions should the nurse perform first? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.
 
  1. Placing the infant in a radiant-heated unit
  2. Suctioning the infant with a bulb syringe
  3. Wrapping the infant in a blanket
  4. Evaluating the newborn using the Apgar system
  5. Offering a feeding of 5 glucose water

Question 2

Which assessment findings would lead the nurse to suspect that a newborn might have a congenital heart defect? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.
 
  1. Cyanosis
  2. Heart murmur
  3. Bradycardia
  4. Diaphoresis
  5. Tachypnea

[ntsoane kedibone]

Answer to Question 1

1,2,4
Rationale 1: The body temperature of the newborn does not stabilize for 810 hours after birth.
Rationale 2: Newborns are suctioned with a bulb syringe to remove excess mucus as needed to maintain respiration.
Rationale 3: Infants should be left uncovered in a radiant warmer.
Rationale 4: The purpose of the Apgar system is to evaluate the physical condition of the newborn at birth.
Rationale 5: The nurse would first assist the mother to breastfeed if she desires. It is not necessary to give glucose water.

Answer to Question 2

1,2,4,5
Rationale 1: Reduced oxygenation saturation, related to unoxygenated blood entering the systemic circulation without entering the lungs, accounts for the cyanosis or blue coloration of the skin. Cyanosis indicates a possible cardiac defect.
Rationale 2: Heart murmur is abnormal extra heart sounds caused by shunting of the blood.
Rationale 3: The signs of congestive heart failure include tachycardia, not bradycardia.
Rationale 4: The signs of congestive heart failure include diaphoresis, which is often seen on the head during exertion.
Rationale 5: The signs of congestive heart failure include tachypnea, which is a respiratory rate greater than 60 breaths/min and which occurs in response to decreased lung compliance.

[Yolanda]

Excellent

[xiazhe]

TYSM