Next generation case study practice, Lecture notes of Nursing

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NEXT GENERATION

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High Risk Newborn

SCENARIO A 28-year-old client who did not receive prenatal care comes into labor and delivery with cramping. According to her last menstrual period, she is 33 weeks pregnant. When the client arrived at the hospital, her cervix was one centimeter dilated. She was placed on an external fetal monitor and was contracting every two minutes. The fetal heart rate pattern had a baseline of 120 bpm, moderate variability, and accelerations. An hour later, the client’s cervix was two centimeters dilated. She was admitted to labor and delivery. Magnesium sulfate and Betamethasone were ordered and administered. Four hours later, the fetal heart rate tracing showed repetitive late decelerations. Because of the non-reassuring fetal heart rate pattern, the client had a cesarean section with spinal anesthesia. Upon delivery, the newborn has a heart rate of 126, a respiratory rate of 88, is grunting, pale blue, has little grimace, and poor tone. When the nurse performs a gestational age assessment, there are visible veins, ear cartilage is soft, there is a large amount of lanugo, and the testes have not descended.

ITEM #1: MULTIPLE RESPONSE DRAG AND DROP Select the findings that require priority follow-up by the nurse: Multiple Response Drag and Drop A. Heart rate of 126 beats per minute (normal and reassuring finding) B. Respiratory rate of 88 breaths per minute (indicates respiratory distress) C. Grunting (indicates respiratory distress) D. Poor tone (You may think this is indication of prematurity and possible result of lack of oxygen due to current respiratory distress. However, pulse ox of 94% is reassuring. Therefore, likely not due to poor oxygenation as a result of current respiratory distress. Likely, due to prematurity) E. Visible Veins (indication of prematurity) F. Large amount of lanugo (indication of prematurity) G. Soft ear cartilage (indication of prematurity) a. Pulse ox reading of 94% (normal and reassuring finding)

ITEM #2: MULTIPLE RESPONSE FILL IN THE BLANKS Complete the following two-part sentence by selecting one answer from each section: The client’s assessment indicates____________________:

1. Respiratory distress
2. Cold Stress
3. Prematurity
4. Post maturity
5. Fluid volume deficit
6. Risk for impaired skin integrity
7. Risk for infection Therefore, the nurse should monitor_______, _______, _______, _______. (select FOUR): a. Respiratory rate b. Color c. Temperature d. Urine output e. Blood sugar f. Feeding amount and effectiveness

ITEM #3: MULTIPLE RESPONSE The nurse develops the client’s plan of care and includes several nursing diagnoses. One of them is risk for ineffective thermoregulation. Which of the following provide evidence that this nursing diagnosis is relevant to the client? Select all the apply: Findings related to ineffective thermoregulation include: A. Poor tone (non-flexed position) B. Limited brown fatty layer C. Poorly developed suck reflex D. Tachypnea E. Maternal administration of spinal anesthesia F. Maternal administration of magnesium sulfate G. Unknown Group Beta Strep status

ITEM #3: MULTIPLE RESPONSE The nurse develops the client’s plan of care and includes several nursing diagnoses. One of them is risk for ineffective thermoregulation. Which of the following provide evidence that this nursing diagnosis is relevant to the client? Select all the apply: Findings related to ineffective thermoregulation include: A. Poor tone (non-flexed position increases the body surface area, leading to greater heat loss) B. Limited brown fatty layer (brown fat is used for energy to maintain temperature. The assessment indicates the newborn is premature. Premature newborns have not yet developed an adequate amount of brown fat) C. Poorly developed suck reflex D. Tachypnea E. Maternal administration of spinal anesthesia F. Maternal administration of magnesium sulfate G. Unknown Group Beta Strep status

ITEM #4: MULTIPLE RESPONSE FILL IN THE BLANK Priority interventions for the nurse to provide care for this patient are ______, _______, and _____. Select three: A. Dry and stimulate the newborn (drying the newborn helps prevent heat loss) B. Assess temperature (assessing temperature allows the nurse to monitor for potential decrease in temperature) C. Assess blood glucose level (blood glucose levels may decrease because the newborn is working hard and spending energy to breathe fast) D. Monitor output for meconium E. Continue to assess testes for descent F. Notify the healthcare provider of assessment findings G. Continue to monitor lanugo

ITEM #5: MULTIPLE RESPONSE DRAG AND DROP The newborn is admitted to the Neonatal Intensive Care Unit. The nurse is providing education to the parents. The parents ask why temperature, breathing, and blood glucose levels can be related. The nurse explains: Drag and Drop (Three of below are correct) a. “Babies are not able to shiver in order to keep warm and use a brown fatty layer for energy until feeding is well established” b. “Preterm babies have adequate brown fat and use limited glucose stores to stay warm, often decreasing blood sugar levels” c. “Preterm babies may have less developed sucking reflexes and may not feed effectively” d. “In an effort to stay warm, babies may breathe more quickly, adding to respiratory distress” e. “Preterm babies may have less developed lungs, increasing respiratory rate” f. “Magnesium given to the mother may cause the neonate’s respiratory rate to be higher”

ITEM #6: MULTIPLE RESPONSE The nurse conducts a re-assessment of the newborn. What findings show declining status? Select all that apply: A. Temperature 98.8F B. Pulse 88 C. Respiratory rate 62 breaths per minute D. A singing like sound is heard when the baby breathes E. Retracting muscles in between intercostal spaces when the baby breathes F. Respirations appear unlabored G. The baby’s head and core are pink. The hands and feet are blue

ITEM #6: MULTIPLE RESPONSE The nurse conducts a re-assessment of the newborn. What findings show declining status? Select all that apply: A. Temperature 98.8F B. Pulse 88 (normal heart rate for a newborn is about 100- 160. This is a low heart rate and indicates declining status) C. Respiratory rate 62 breaths per minute (improved from previous respiratory rate of

88. Therefore, does not indicate declining status) D. A singing like sound is heard when the baby breathes (indicates the newborn is working hard to breathe and is a sign of respiratory distress) E. Retracting muscles in between intercostal spaces when the baby breathes (indicates the newborn is working hard to breathe and is a sign of respiratory distress) F. Respirations appear unlabored G. The baby’s head and core are pink. The hands and feet are blue (acrocyanosis is expected soon after delivery because oxygen is gong to the brain and core organs. This is also an improvement from the blue color in noted in previous assessments)