The perinatal nurse wants to contact the pediatrician about a heart murmur that was auscultated during a newborn assessment. During what time frame would hearing the murmur lead the nurse to contact the health-care provider?

Correct Answer: D

Rationale: The correct answer is D) 48 to 72 hours. In the context of a newborn assessment, a heart murmur detected within the first 48 to 72 hours after birth is considered significant and warrants prompt evaluation by a healthcare provider. This timeframe is crucial because certain types of heart murmurs in newborns can indicate underlying congenital heart defects that may require immediate intervention or monitoring. Option A) 8 to 12 hours is too soon to make a definitive assessment of the heart murmur in a newborn. Option B) 12 to 24 hours is also early in the postnatal period and may not allow for a comprehensive evaluation of the murmur. Option C) 24 to 48 hours is closer to the correct timeframe, but it is still within the critical period where a timely assessment is necessary to rule out any serious cardiac issues in the newborn. Understanding the importance of timely detection and evaluation of heart murmurs in newborns is vital for perinatal nurses as they play a crucial role in identifying potential health concerns early and facilitating appropriate interventions. This knowledge ensures the optimal care and outcomes for newborns with cardiac issues, emphasizing the significance of ongoing assessment and communication with healthcare providers in the early postnatal period.

Correct Answer: D

Rationale: In this scenario, the correct answer is option D - "Wraps the baby in a warmed blanket." Placing the baby under a radiant warmer is a common intervention to help maintain the neonate's body temperature. By wrapping the baby in a warmed blanket, the student nurse is assisting in preventing heat loss and promoting thermoregulation, which is crucial for newborns who have difficulty maintaining their body temperature. Option A, assessing the surrounding area for drafts, is not the most immediate or direct action needed to address the neonate's temperature instability. While it is important to ensure a draft-free environment for a newborn, in this case, the priority is to provide direct warmth to the infant. Option B, ensuring the infant is dried off completely, is also important for preventing heat loss. However, the most immediate intervention to address the neonate's temperature regulation issue is to provide direct warmth through a warmed blanket or radiant warmer. Option C, observing the respiratory rate at the same time, is not directly related to the immediate need of addressing the neonate's temperature instability. While monitoring the respiratory rate is essential in newborn care, in this scenario, the primary focus should be on providing warmth to the infant. In educational context, understanding the importance of thermoregulation in newborns and knowing the appropriate interventions to help maintain their body temperature is crucial for nursing students caring for neonates. This scenario highlights the need for prioritizing interventions based on the immediate needs of the patient.

Correct Answer: A

Rationale: Careful and continuous monitoring of infants and proper identification per agency protocol is the best way to ensure a babys safety and well-being. Some institutions may use abduction alarms. Keeping the baby with the mother at all times may not always be possible. Proper identification of visitors is important

Correct Answer: A

Rationale: In the context of pharmacology and nursing care of the newborn, administering vitamin K1 phytonadione (AquaMEPHYTON) is the best way to prevent hemorrhage from injuries in a neonate. This is because vitamin K is essential for the synthesis of clotting factors in the liver, and newborns have lower levels of vitamin K at birth, putting them at risk for bleeding disorders. Option A is correct as it directly addresses the deficiency in newborns and helps prevent hemorrhage. Handling the infant carefully while wearing soft gloves (Option B) is important for infection control but does not directly prevent hemorrhage. Keeping the infant swaddled in several layers of blankets (Option C) and teaching parents how to trim the baby's fingernails (Option D) do not address the underlying physiological issue of vitamin K deficiency leading to hemorrhage. Educationally, understanding the importance of vitamin K administration in newborn care is crucial for nursing students to provide safe and effective care to neonates. It highlights the significance of recognizing and addressing potential bleeding risks in this vulnerable population. This rationale emphasizes the pharmacological aspect of nursing care and underscores the importance of evidence-based practices in neonatal healthcare.

Correct Answer: A

Rationale: The most appropriate action by the nurse in this scenario is to document the finding of the infant's initial blood glucose level of 42 mg/dL in the infant's chart (Option A). This is because the blood glucose level of 42 mg/dL in a term infant is within the normal range for newborns. Term infants typically have lower blood glucose levels in the first few hours after birth due to the transition from intrauterine to extrauterine life. It is crucial for the nurse to document this finding accurately for the infant's medical records and ongoing monitoring. Encouraging the mother to initiate breastfeeding (Option B) is a good practice for promoting bonding and providing essential nutrients to the newborn. However, in this case, immediate breastfeeding may not be necessary as the blood glucose level is within the normal range. Preparing to administer intravenous glucose (Option C) is unnecessary and invasive for a term infant with a blood glucose level of 42 mg/dL. Intravenous glucose administration is usually reserved for newborns with hypoglycemia below the normal range or those who are symptomatic. Rechecking the blood glucose in 2 hours (Option D) is not warranted in this situation since the initial blood glucose level is normal for a term infant. Repeated blood glucose monitoring may cause unnecessary stress to the infant and is not indicated unless the initial levels are abnormal. In an educational context, understanding the normal variations in blood glucose levels in newborns is essential for nurses caring for neonates. It is crucial to differentiate between normal physiological variations and abnormal values to provide appropriate care and interventions. Documenting findings accurately, as in this case, ensures proper communication among healthcare providers and supports the continuity of care for the newborn.