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169 Cards in this Set

  • Front
  • Back
Nursing Assessment in Identification of Infection
- Recent exposure to infectious agents
- Prodromal symptoms
- Immunization history
- History of having the disease
How Do you Prevent Spread of Disease?
1. Primary prevention of the disease: Immunization

2. Control spread of disease to others:
- Reduce risk of cross-transmission of organisms
- Infection control policies
- Handwashing
What are prodromal symptoms?
Those symptoms that occur between early manifestation and clinical observation.
What children are immunodeficient?
- Receiving steroid therapy
- Other immunosuppressive therapies (chemo)
- Generalized malignancies (leukemia)
- Immunologic disorder (HIV)
Why use caution with Compromised Children?
- Risk for complications from communicable diseases, especially varicella (chickenpox) and erythema infectiosum (EI)-fifth disease
- Risk for viremia (virus in blood) from varicella zoster virus (VZV)
What intervention is necessary for a fever and uncontrolled rash?
Isolation until diagnosis is confirmed.
- Source: Discharge from mucous membrane of nose, skin, and open lesions
- Transmission: Direct contact with infected person Incubation period: 2-5 days
- Period of communicability:
usually 2 weeks, up to four weeks

Resembles common cold, sore throat, fever, cough, toxemia, shock and death within 6-10 days if untreated
- AGENT: Varicella Zoster Virus
- SOURCE: Respiratory Tract
- TRANSMISSION: Direct Contact, Droplet, Airborne and Contaminated Objects
- PERIOD OF COMMUNICABILITY: Probably 1 day before eruption of lesion to 6 days after first crop of vesicles crusted.

Fever, malaise, highly pruritic rash, begins as macules and then progresses rapidly to vesicles.
Strict isolation precautions in hospital, until vesicles have dried. Isolate high risk children from infected children.
Erythema Infectiosum (Fifth Disease)
AGENT: Human Parvovirus HPV
SOURCE: Infected person
TRANSMISSION: Unknown, possibly respiratory secretions
- INCUBATION PERIOD: 4-14 days, as long as 21 days
- PERIOD OF COMMUNICABILITY: Before onset of symptoms, for a week after onset of symptoms

Three stages…I erythema on face (slapped face)
II maculopapular rash on upper extremities, III rash subsides but reappears with irritation.
AGENT: Human Herpes virus
SOURCE: Unknown
TRANSMISSION: Unknown, virtually limited to children 6 months to 36 months of age

Persistent high fever, rose-pink macules, nonpruritic.
Rubeola (Measles)
- AGENT: Virus
- SOURCE: Respiratory tract secretions, blood, and urine
- TRANSMISSION: Direct contact with droplets
- PERIOD OF COMMUNICABILITY: From 4 days before to 5 days after rash appears

Fever, malaise, cough, conjunctivitis, Koplik spots. Also have photophobia.
What are Koplik spots?
They are small, white spots (often on an reddened background) that occur on the inside of the cheeks early in the course of measles.
- AGENT: Paramyxovirus
- SOURCE: Saliva
- TRANSMISSION: Direct contact or with droplet spread
- PERIOD OF COMMUNICABILITY: Immediately before and after swelling occurs

Fever, headache, parotitis (enlarged parotid glands)
Pertussis (Whooping Cough)
- AGENT: Bordetella pertussis
- SOURCE: Respiratory tract
- TRANSMISSION: Direct contact
- PERIOD OF COMMUNICABILITY: Before onset of paroxysms and up to 4 weeks after

Cough most often occurring at night, whooping sound.
- AGENT: Enterovirus, type 1-3
- SOURCE: Feces and oropharyngeal secretions
- TRANSMISSION: Direct contact
- PERIOD OF COMMUNICABILITY: Not known, up to 1week in throat and 4 weeks in feces.

Fever, sore throat, headache, pain and stiff neck, central nervous system paralysis.
Rubella (German Measles)
- AGENT: Rubella virus
- SOURCE: Nasopharyngeal secretions, blood stool and urine
- TRANSMISSION: Direct contact
PERIOD OF COMMUNICABILITY: 7 days before and 5 days after appearance of rash

Rash appears on face and rapidly spreads , complications are rare. Most benign of all childhood illnesses.
Scarlet Fever
- AGENT: Group A streptococcus
- SOURCE: Nasopharyngeal secretions
- TRANSMISSION: Direct contact
- PERIOD OF COMMUNICABILITY: During incubation and period of illness, approximately 10 days.

Fever, headaches, malaise and lymphadenopathy
swelling of one or more lymph nodes
- In newborns: chlamydia, gonorrhea, or herpes simplex virus
- In infants: may be sign of tear duct obstruction
- In children: causes are bacterial (most common), viral, allergic, or foreign body
Communicable Disease Assessment
- Identification of infectious agent
- Recent exposure to a known case
- prodromal symptoms
- immunization history
- history of having the disease
- NURSING DIAGNOSIS (formulate nursing diagnosis for knowledge deficit)
Communicable Disease Plan of Care & Implementation
- Child will not spread infection
- Child will not experience complications
- Child will have minimal discomfort
- Child and family will receive adequate emotional support/education
NURSING DIAGNOSIS: Risk for infection related to susceptible host and infectious agents.
- Institute infection control practices
- Work with family to ensure adherence to therapeutic regimen
- Report disease of health department to monitor outbreak
- Identify susceptible individuals in community
- Promote public education on prevent/spread of communicable diseases
NURSING DIAGNOSIS: Risk for injury related to disease complications, trauma to skin from scratching
- Involve parent and child in planning and carrying our therapeutic regime
- Monitor vital signs and lab values to detect early signs of potential complications
- Observe skin to detect signs of scratching, trauma, infection
- Institute seizure precautions
- Maintain good body hygiene
- Proper hydration
NURSING DIAGNOSIS: Pain related to skin lesions, malaise
- Use comfort measures such as vaporizer, gargling, lozenges to keep membranes moist
- Use nonpharmacologic techniques for pain reduction
- Adminster analgesics, antipyretics, and antipuritics.
NURSING DIAGNOSIS: Social isolation related to environmentally imposed constraints
- Explain reason for confinement to child
- Enlist child’s assistance with enforcing restrictions to provide increased sense of control
- Allow child to play with isolation supplies
- Encourage parents to stay with child during hospitalization
Atraumatic Care
the provision of therapeutic care in settings, by personnel, and through the use of interventions that eliminates or minimizes the psychologic and physical distress experienced by children and their families in the health care system
What is done to minimize local reaction from a vaccine?
Select adequate needle size(1-inch)
Inject into the vastus lateralis or ventrogluteal muscle. The deltoid may be used in children >18 months.
What is done to minimize pain from a vaccine?
- Apply topical anesthetic
- Distraction techniques
- Never tell a child “It won't hurt”
Immunization Contraindications& Precautions
- Anaphylactic reactions previously
- Moderate to severe illness with or without a fever
Encephalopathy within 7 days of administration or fever of 105
- OPV: infection with HIV or household member of HIV positive
- Known altered immunodeficiency
- MMR: Pregnancy,
Known altered immunodeficiency,
Recent IGG vaccination
- Hib: anaphylactic reaction to bakers yeast
- Varicella: Immunosuppression and
How many periods of reactivity are there?
First period of reactivity
- Lasts up to 30 minutes
- baby's HR increases to 160 - 180bpm (decreases after 30min.)
- Decrease in motor activity after period
Second period of reactivity
- Last between 30 - 120 min.
Third period of reactivity
- Occurs 2 - 6 hrs after birth
- Tachycardia, tachypnea occur
- Meconiuim passed
Physiologic Adaptations: Respiratory system
- Initiation of breathing
- Signs of resp distress
- Maintaining adequate O2 supply
3 ways that breathing is initiated
1. Chemically
2. Cold
3. Chest expands
Physiologic Adaptations: Cardiovascular system
- HR and sounds (averages 120 - 140bpm)
- b/p 60-80/40-50
- blood volume

There is a change in pressure which closes the shunts
Physiologic Adaptations: Hematopoietic system
- RBCs and hemoglobin (physiologic anemia)
- Leukocytes
- Platelets
- Blood Groups
What is acrocyanosis?
Sluggish peripheral circulation in infants
Physiologic Adaptations: Thermogenic system
- Thermogenesis
- Heat Loss
- Temp regulation
Why are newborns given a shot of vitamin K?
They cannot synthesize it.
What is larger, an infants head or chest?
4 Ways that heat can be lost
1. Convection
2. conduction
3. radiation
4. evaporation**
What happens to a baby's heat when there is a problem?
It decreases
What is mottling?
marked with spots or blotches of different shades or colors
When does normal physiological jaundice occur?
Happens after 24 hrs of birth
physiological adaptations: GI
- Digestion: can hold 1-1.5 ounces in stomach.
- stools: meconium passes within 1st 24hrs
- Signs at risk for GI problems: bowel obstruction, meconium ileus, cystic fibrosis
meconium ileus
Obstruction of the intestine (ileus) due to overly thick meconium, the dark sticky stuff that is normally present in the intestine at birth and, after trypsin and other enzymes from the pancreas have acted on it, is normally passed in the feces after birth. Meconium ileus results from a deficiency of trypsin and other digestive enzymes from the pancreas, as in cystic fibrosis (fibrocystic disease of the pancreas, mucoviscidosis).
physiological adaptations: hepatic system
- iron storage
- carbohydrate metabolism
- conjugation of bilirubin
- physiologic jaundice
- breastfeeding and jaundice
- coagulation
- signs of risk for hepatic system problems
physiologic jaundice
Yellowish staining of the skin and whites of the newborn's eyes (sclerae) by pigment of bile (bilirubin). In newborn babies a degree of jaundice is normal. It is due to the breakdown of red blood cells (which release bilirubin into the blood) and to the immaturity of the newborn's liver (which cannot effectively metabolize the bilirubin and prepare it for excretion into the urine). Normal physiologic jaundice of the newborn typically appears between the 2nd and 5th days of life and clears with time.
A type of brain damage associated with athetoid cerebral palsy (uncontrollable movement of the face, body, arms, and legs) and deafness. Kernicterus is due to marked jaundice in the newborn period. The high blood level of the pigment bilirubin results in its deposition in the brain, which damages the brain. >20 bili level
What is the normal range for a bili check?
What must be done if a bili check result is 10-12?
repeat the test
Breastfed baby's stool
yellow and seedy
Bottle-fed baby's stool color
Urates in infant urine
orange/red uric acid crystals
Skin Desquamation
dry skin, 40+ week babies
What is caput succedaneum?
Caput succedaneum is a circular swelling and bruising of the scalp usually seen on top of the head toward the back, which is the part of the scalp most often leading the way through the birth canal. This will fade over a few days.
What is subgaleal hemorrhage?
Bleeding in the potential space between the skull periosteum and the scalp galea aponeurosis.
What is cephalhematoma?
a collection of blood that has seeped under the outer covering membrane of one of the skull bones. This is usually caused during birth by the pressure of the head against the mother's pelvic bones. The lump is confined to one side of the top of the baby's head and, in contrast to caput succedaneum, may take a week or two to disappear.
What is mongolian spot?
smooth blue-gray or slighty brown patches which can be found on the lower back and buttocks area of some East Asian and Native American Infants and babies. It may look somewhat like a bruise or rash. It normally vanishes three to five years after birth and almost always by puberty.
What are pseudo menses?
Exposure to the mother's hormones before birth -- and withdrawal from them at birth -- may cause temporary conditions in a newborn. Maternal hormones are among those chemicals that penetrate the placental barrier and have an influence on the fetus. During pregnancy the hormone estrogen is particularly high. This is the hormone that causes breast enlargement in the mother. Similar influences are commonly found in newborns, both boys and girls, by the third day after birth. Newborn girls may initially have prominent labia as a result of the estrogen exposure. They sometimes also experience a type of vaginal discharge called pseudomenstruation due to the withdrawal of the maternal hormones. The discharge is white and occasionally tinged with blood. This condition is common and should not last beyond the first week of life.
Signs of risk for skeletal problems in an infant
- hip click
- club feet
Newborn reflexes
- rooting
- sucking
- swallowing
- grasp
- babinski
- moro
What is Molding?
an abnormal head shape that results from pressure on the head during childbirth.
newborn respirations
When is an apgar test done?
At 1 and 5 minutes after birth.
When would a 10-minute apgar test be done?
If the infant scored 7 or lower.
What outweighs completing the apgar?
What is the pupose of the apgar test?
For rapid assessment of the newborn during their transition to life outside of the womb.
What 5 things does the apgar test include?
heart rate, respiratory rate, muscle tone, irritability, and color

Activity, Pulse, Grimace, Appearance, Respiration
What do babies usually score on the apgar test and why?
They usually score a 9 because their hands and feet are usually blue.
What is included during the initial physical assessment of the newborn?
- external: skin color, conditon, presence of meconium staining, length of nails and creases on the soles of the feet, check nasal patency.
- Chest: auscultate heart, note rate, rhythm and presence of murmur; respirations note rate and quality of breath sounds.
Abdomen: bowel sounds and the number of vessels in the cord.
- Neuro: check muscle tone, assess reflexes, palpate fontanels and sutures (they should be palpable). In a V-birth sutures usually overlap.
- GU: note external sex characteristics, check anal patency, watch for passage of urine and stool.
- In general: check for symmetry and note any gross structural malformations.
What 2 traits do most newborns have?
Usually a murmur because the foramen ovale hasn't closed completely and some crackles due to fluid being in the lungs.
What else do you check for in an initial newborn assessment?
- Physical injury r/t the birth
- Check skin for erythema, ecchymosis, petechiae, abrasions, lacerations, edema
What are some common injuries r/t the birth?
bruising, dystocia, clavical (intact), hip click
What are some key nursing interventions for a newborn?
- Assess color, cry and activity
- Dry newborn off as much as possible
- Keep newborn warm
- Watch for secretions, bulb syringe as necessary
- Maintain universal precautions
- Promote maternal/child bonding!
- Eye prophylaxis ointment
- Vitamin K IM injection
- Hepatitis B (Brockton Hospital) IM
- Umbilical cord care
- ID Bracelets
When is a baby usually deep suctioned?
After a C-section birth.
After what act can you stop universal precautions with a newborn?
After the first bath (be sure to wear a shield with a boy!)
Why is Eye prophylaxis ointment given?
To kill bacteria (gonorrhea)
Why is vitamin K given?
To help with clotting
What is done for umbilical cord care?
Keeping area clean.
When does the umbilical cord fall off?
takes 7-14 days or 1-2 weeks.
Intrauterine growth restriction (IUGR)
- Applied to fetus whose rate of growth does not meet expected norms
Early onset IUGR, is usually due to what?
During the 1st and 2nd semester due to chromosome abnormality, disease, or severe problems with placenta.
What are some reasons for IUGR?
The baby didn't get the necessary nutrients and oxygen for proper growth and development of the organs. This is related to blood flow.
Low Birth Weight (LBW)
2500g or less
Very Low Birth Weight (VLBW)
1500g or less
Preterm or premature
before completion of 37 weeks
38 to end of 42 weeks
after week 42
after completion of 42 weeks and showing effects of progressive placental insufficiency
What is done from 2 hours after birth until discharge?
- Routine testing: Blood glucose, Urinalysis, Bilirubin levels
Complete blood count (CBC)
- Newborn genetic screening
- Newborn hearing screening
- Collection of specimens: heel stick, Venipuncture, obtaining a urine specimen,
Restraining the infant
What should a newborn's blood glucose be?
Where do you do a heel stick?
on the sides of the foot, not the middle.
What is given for pain during a circumcision?
Tylenol, lidocaine, or emla.
What do you watch for after a circumcision that isn't related to bleeding?
How do you keep the glans from sticking to the diaper?
By applying petrolatum around the glans after each diaper change and by changing the diaper at least every 4 hours.
What happens to the glans penis after circumcision after the first 24 hours?
It's normally dark red during healing and becomes covered with a yellow exudate. This is part of the normal healing process. Do not remove exudate.
Circumcision Care
- Check for bleeding
- Check for urination after the procedure
- Keep area clean
- Check for s/s of infection
- Keep the glans from sticking to the diaper
Newborn Sponge Bath
- Try to minimize heat loss, wash body first, head last
- Wash with warm water and appropriate soap
- Daily bath is not necessary
- Wash cord separately
How often do breastfed babies need to be fed?
every 2 hours
How often do bottlefed babies need to be fed?
every three hours
Personal Liability
the nurse is always accountable for the outcome of his or her actions in carrying out nursing duties. The rule of personal liability requires the professional nurse to assume resp for patient harm that is a result of a nurse's negligent acts.
Personal liability with floating and cross training
Nurse is not allowed to perform tasks, render service when he/she lacks the required knowledge or skill. In any patient care situation, the RN should perform only those acts for which he/she has been prepared and demonstrated skill.
Supervisor Liability
usually involves triage, delegation, supervision, reporting performance deficits, chain of command as well as inadequate training, failure to periodically evaluate staff, failure to discipline or terminate unsafe staff and negligence in developing appropriate policies and procedures. Liability for negligent supervision may be based on improper delegation, improper supervision, negligent judgement.
Types of Employer Negligence
- Vicarious liability
- Respondeat Superior
- Ostensible Authority
Exceptions to Respondeat Superior
- "Borrowed Servant" or "Captain of the Ship"
Vicarious liability (substituted liability)
When one person is liable for the negligent actions of another person, even though the first person was not directly responsible for the injury. For instance, a parent sometimes can be vicariously liable for the harmful acts of a child and an employer sometimes can be vicariously liable for the acts of a worker.
Respondeat Superior
A legal rule that the principal or employer is liable for harms done by agents or employees while acting within the scope of their agency or employment.
Ostensible Authority
The facility is liable for negligence of independent contractor if patient had rational basis to believe that the independent contractor was a facility employee.
Corporate Negligence
Responsibility to hire qualified employees, responsibility to monitor and supervise their performance and act upon substandard performance.
Employer may recover from responsible person, damages paid under doctrine of respondent superior provided the employer is at fault ONLY because of the employee's negligence and the employer incurs monetary damages because of employee's negligence.
Duty to Seek Medical Care
Nurse is expected to exercise good judgement and intervene on behalf of the patient...
What are the most common Medication Errors?
Most common errors reported are: improper dose and quantity, administering wrong medication, omission. Standard of care requires that nurses must understand the medications that they are administering and use judgement in following orders. Medication errors are difficult to defend because they are easily preventable.
Unilateral termination of care and treatment by the health care provider without patient consent and/or adequate notice. Charges of abandonment are usually made against physicians. Failure to adequately monitor patients on inpatient units can lead to charges of abandonment.
Incident Reports
Agency record of accident or unusual occurrence. They are used to make facts available to the agency, contribute statistical data, help prevent future incidents. They are not part of the medical record. NEVER chart that an incident report was filed.
Civil wrong or injury committed by one person against another person or property. Unintentional tort - negligence and malpractice.
Takes place when something untrue is said or written about a person, resulting in injury to that person's good name and reputation.
written defamation
oral defamation
Violation of a controlled substance act
drugs obtained illicitly through work
The four development stages are described in Piaget's theory
1. Sensorimotor stage: from birth to age 2 years (children experience the world through movement and senses and learn object permanence)

2. Preoperational stage: from ages 2 to 7 (acquisition of motor skills)

3. Concrete operational stage: from ages 7 to 11 (children begin to think logically about concrete events)

4. Formal Operational stage: after age 11 (development of abstract reasoning).
What would be a warning sign of ineffective adaptation to extrauterine life if noted when assessing a 24-hour-old breastfed newborn prior to discharge?
Apical heart rate of 90 BPM, slightly irregular, when awake and active. The heart rate of a newborn should range between 120 to 140 beats per minute especially when active. The rate should be regular with sharp, strong sounds.
When caring for a newborn the nurse must be alert for signs of cold stress which would include what?
Increased respiratory rate. Additional signs of cold stress, include increased activity level and crying (increase BMR and heat production) and hypoglycemia as glucose stores are depleted. Newborns are unable to shiver as a means to increase heat production; they increase their activity level instead.
When weighing a newborn, the nurse should...
Weigh the newborn at the same time each day for accuracy. Weigh newborn undressed for accuracy with hand above, not on, the abdomen for safety. Clean scale paper is used.
Babinski reflex
refers to the flaring of the toes when the sole is stroked.
Tonic neck reflex
refers to the "fencing posture" a newborn assumes when he is supine and turns his head to the side.
cremasteric reflex
refers to retraction of testes when chilled.
The nurse must administer erythromycin ophthalmic ointment to a newborn after birth. The nurse should...
Cleanse eyes from inner to outer canthus prior to administration. It should be applied into the conjunctival sac to avoid accidental injury to the eye. It should not be flushed out.
A newborn has just been circumcised. The nurse's first priority would be to...
Assess penis for bleeding
Following circumcision of a newborn, the nurse provides instructions to its parents regarding post-circumcision care. The nurse should tell the parents to...
Expect a yellowish exudate to cover the glans after the first 24 hours
When placing a newborn under a radiant heat warmer to stabilize temperature after birth, the nurse should...
Prewarm the radiant heat warmer and place the undressed newborn under it. The thermistor probe should be placed on the upper abdomen away from the ribs. It should be covered with reflective material. Rectal temperatures should be avoided since rectal thermometers can perforate the intestine, and the temperature may remain normal until cold stress is advanced.
What initiates breathing in a newborn?
It's the result of a reflex triggered by pressure changes, exposure to cool air temp., noise, light, and other sensations. Chemoreceptors in the aorta and carotid bodies initiate neurologic reflexes when arterial O2 pressure (PO2) falls.
When does the respiratory reaction occur?
Within 1 minute of birth.
What are some signs of respiratory distress in a newborn?
Nasal flaring, intercostal or subcostal retractions, or grunting with respirations.
What's the respiratory rate for a newborn?
30-60 breaths per minute.
What can a normal newborn digest?
Simple carbs and proteins, but has a limited ability to digest fats.
At what level does jaundice appear in a newborn?
Until the bilirubin level reaches 5mg/dl.
When does jaundice in a newborn require attention?
If jaundice occurs prior to 24 hrs after birth or beyond 7-10 days after birth.
Trust vs Mistrust
Infant. Needs maximum comfort with minimal uncertainty
to trust himself/herself, others, and the environment
Autonomy vs Shame and Doubt
Toddler. Works to master physical environment while maintaining self-esteem.
Initiative vs Guilt
Preschooler. Begins to initiate, not imitate, activities; develops
conscience and sexual identity.
What happens at approximately 18 months of age nutritionally?
Most toddlers manifest decreased nutritional need with a decrease in appetite, a phenomenon known as physiologic anorexia.
12 to 18 months of age nutritionally
The growth rate slows, decreasing the child's need for calories, protein, and fluid. The need for minerals such as iron, calcium, and phosphorus is still high.
What happens nutritionally at age 4?
The child seems to enter another period of finicky eating.
What does cold do to a newborn?
Cold stress increases the need for O2 and may deplete glucose stores.
What respiratory rates are signs of distress for a newborn?
Respirations less than 30 or greater than 60.
What are some standard lab values for newborns?
Hemoglobin 14-24 g/dl
Hematocrit 44-64%
Glucose 45-65 mg/dl
Leukocytes 9.0-30.0
Bili <2.0 mg/dl
Relating to the use of car seats, what must be done with an infant born less than 37 weeks gestation and with birthweight less than 2500 grams?
They should be observed in a car seat for a period of time before discharge. They are monitored for apnea, bradycardia, and a decrease in O2 saturation.
What can a sore throat signify?
It's most often a symptom of a minor viral infection, although it can signal diphtheria or a strep infection, such as scarlet fever.
What is exanthem?
a widespread rash, usually viral, and usually occurring in children. It represents either a reaction to a toxin produced by the organism, damage to the skin by the organism or an immune response. Exanthems may also be due to a drug, most commonly antibiotics.
What can reduce both morbidity and the mortality rate for children with measles?
Vitamin A.
What increases itching?
What is often given for severe itching?
Antipruritic medication such as diphenhydramine (Benadryl) or hydroxyzine (Atarax).
What is usually given for a sore throat?
With lozenges, saltine rinses, and analgesics.
True or false:
The white blood cell count increases significantly when the newborn develops infection
True or false:
Jitteriness and tremors may indicate that the newborn is experiencing hypoglycemia
True or false:
Abdominal movements are counted when determining the respiratory rate of newborns
True or false:
The wink reflex can be used to test the sphincter
True or false:
Breast tissue in full-term male and female newborns may be swollen and secrete a thin milky-type discharge
What is a generalized, easily identifiable edematous area of the scalp usually over the occiput area?
Caput succedaneum
What is a collection of blood between the skull bone and its periosteum as a result of pressure during birth?
What is a sudden, transient newborn rash characterized by erythematous macules, papules, and small vesicles?
Erythema Toxicum
When assessing a newborn boy at 12 hours of age, the nurse notes a rash on his abdomen and thighs. The rash appears as irregular reddish blotches with pale centers. What should the nurse do?
Document the finding as erythema toxicum.
True or false:
The thermistor probe of a radiant heat panel should be taped to the upper quadrant of the abdomen just below the intercostal margin (ribs) on the right or left side.
True or false:
A newborn whose mother received magnesium sulfate during labor may be lethargic after birth.
True or false:
If bleeding is noted after a circumcision, the nurse should apply gentle pressure to the site of bleeding using a folded sterile gauze pad.
True or false:
When using a bulb syringe, the nose should be suctioned before the mouth.
A newborn male has been designated as large for gestational age. His mother was diagnosed with gestational diabetes late in her pregnancy. The nurse should be alert for signs of hypoglycemia. What assessment finding would be consistent with a diagnosis of hypoglycemia?
Cyanosis. Other signs would include apnea, jitteriness/twitching, irregular respirations, high-pitched cry, difficulty feeding, hunger, lethargy, eye rolling, and seizures.