Clinical Judgement Activity- Uncomplicated Newborn PDF

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Clinical Judgement Activity- Uncomplicated Newborn, case study...

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Uncomplicated Newborn Care – Clinical Judgement Activity The nurse is caring for a newborn born at 39 weeks’ gestation 1 hour ago. What evidence-based care will the nurse provide to the newborn during the transitional period? Select all that apply and make a short note beside it why you did or did not choose that answer. __x___ A. Administer hepatitis B vaccine per protocol. ___x_ B. Assess for hypoxia. _____ C. Administer oxygen therapy per protocol. ___x__ D. Perform a gestational assessment. ___x__ E. Administer intramuscular vitamin K per protocol. _____ F. Complete an otoacoustic test. ___x__ G. Encourage skin-to-skin contact with the baby’s mother. _____ H. Complete congenital cardiac heart defect screening. _____ I. Place identification and security safety bands on the newborn.

The nurse completes a routine infant assessment approximately 12 hours after birth. Use an X to indicate whether the assessment findings below are Expected (finding within usual limhepatitis its or parameters), a Common Variation (finding that may or may not indicate an abnormality, usually transitory), or Unexpected (finding that is abnormal and could be harmful) for the infant at this time. Please identify why you chose that answer. Assessment Findings Heart rate = 134 beats/min Pale mucous membranes Bluish tint of fingers and toe Jittery activity Fontanels are soft with edema of soft scalp tissue Cries without tears Positive red reflex

Expected Common Variation x

Unexpected Why Normal VS parameter x

x

Acrocyanosis is normal x

x

x x

Not normal poor circulation

Glucose instability Normal with vaginal birth

Babies don’t have tear initially normal

Ignatavicius, D. D. (2021). Reproduction: Childbearing Families, Uncomplicated Newborn. In Developing clinical judgment for professional nursing and the next-generation NCLEX-RN examination (pp. 118–120). essay, Elsevier.

Large dark bluish areas of pigmentation on lower back Small white bumps along the midline of the hard palate

x

Mongolian spots are not concerning

x

Epstein pearls not concerning

Nursing care for an infant during the first 24 to 48 hours after birth includes frequent assessments. Complete the statements below by selecting from the lists of options provided. And explain why that is the correct answer. To accurately assess the newborn, the nurse will count heart rate and respirations for ____1____ seconds, measure the weight of the baby _____2_____ clothes or diaper at the same time of day daily, and monitor the feeding patterns of the newborn daily. These feeding patterns are then compared with ______3______ intake to identify ____4_____ growth difficulties. Options for 1 5 10 15 30 60

Options for 2, 3, and 4 Potential Without Appropriate for Gestational Age Expected Calories per Kilogram

#1=60 #2=without #3=expected #4=potential The nurse is caring for a maternal/newborn couplet with the following birth delivery data: • Mother’s blood type: O positive • Gestational age: 38 weeks • Spontaneous, precipitous vaginal delivery • Weight 5 9 lb 13 oz (4.46 kg) The nurse identifies screening tests that are needed for newborn infants. Use an X to indicate whether the screening tests below are Anticipated (appropriate or necessary), Contraindicated (could be Ignatavicius, D. D. (2021). Reproduction: Childbearing Families, Uncomplicated Newborn. In Developing clinical judgment for professional nursing and the next-generation NCLEX-RN examination (pp. 118–120). essay, Elsevier.

harmful), or Non-Essential (make no difference or are not necessary) for the newborn at this time. Please also explain Why you chose that answer.

Screening Tests

Anticipated

Type and screen blood Metabolic panel x Bilirubin x Jittery activity Car seat screening Pulse oximetry x Urinalysis Hearing x Fingerprints Blood glucose x

Contraindicated

NonEssential

x

x x x

Why Mothers blood type is given routine Precipitous delivery Not sure on what this means routine Routine No symptoms routine Not really necessary Routine

The nurse is preparing to discharge the client and her newborn following a spontaneous vaginal deliv-ery at 40 weeks’ gestation and evaluates the effectiveness of the newborn’s care. For each assessment finding, use an X to indicate whether the interventions were Effective (helped to meet expected outcomes), Ineffective (did not help to meet expected outcomes), or Unrelated (were not related to the expected outcomes). Please also explain why you chose that answer. Assessment Finding Temperature 5 99.1°F (37.2°C) Heart rate 5 144 beats/min Respirations 5 54 breaths/min Pulse oximetry 5 99% (on room air) Bilirubin 5 14 mg/dL (205 mcmol/L) Birth weight 5 9 lb 13 oz (4.46 kg) Current weight 5 9 lb 6 oz (4.29 kg) Baby has minimal periods of wakefulness

Effective x

Ineffective

Unrelatred

Why Normal VS parameter

x

Normal VS parameter

x

Normal VS parameter

x

Normal VS parameter x

High

x

Normal growth parameter – but a little weight loss

x

Should be more wakeful

Ignatavicius, D. D. (2021). Reproduction: Childbearing Families, Uncomplicated Newborn. In Developing clinical judgment for professional nursing and the next-generation NCLEX-RN examination (pp. 118–120). essay, Elsevier.

Breast-feeding every 2.5–3 hr Urine output = 4 wet diapers in 12 hours Bowel movement 5 dark green, thick, and large amount Baby has had photographs taken Security safety bands are intact

x

Is feeding but not growing

x

Normal

x

normal

x

This is not necessary for d/c

x

Unrelated because of discharge

Ignatavicius, D. D. (2021). Reproduction: Childbearing Families, Uncomplicated Newborn. In Developing clinical judgment for professional nursing and the next-generation NCLEX-RN examination (pp. 118–120). essay, Elsevier....