Author Question: A full-term infant has just been born. Which interventions should the nurse perform first? Note: ... (Read 109 times)

Yolanda · **on:** Jun 27, 2018

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 · **Reply #1 on:** Jun 27, 2018

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.