*NURSING > Solutions Guide > NURS 3620 HCD Final (Latest) (All)

NURS 3620 HCD Final (Latest)

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Reproduction ● Teaching the pregnant client and family (anything discussed in voice-overs or class): ● Assessments of newborn, including vital signs, reflexes: ○ Vital Signs: ■ Temp: 97 ... .6 - 99 ■ HR: 110 - 160 ■ RR: 30 - 60 ■ BP: 65-80 / 30 - 40 ■ SPO2: 90% or > after first 10 minutes of birth ○ Reflexes: ■ Suck: stick finger in mouth (disappears by 4-7 months) ■ Babinski: toes flex out, run finger from heel up to toes (reverts to normal (toes in) at 12 months) ■ Moro (Startle): when dropped slightly, quickly ABducts extremities (disappear after 3-4 months) ■ Rooting: turns mouth to same side of cheek being stroked ■ Tonic-Neck (Fencing): head turned, neck over shoulder, arm/leg same side extended ■ Stepping: stimulates walking when held upright and sole of foot touches flat surface (fades 4-5 months) ■ Palmar Grasp: wraps fingers around finger when placed in palm (fades by 3-4 months) ■ Plantar Grasp: curls toes downward in response to pressure on sole of foot (lessens by 8 months) ● Interventions to promote thermoregulation in the newborn: ○ Incubator or radiant warmer ○ Warm surfaces ○ Keep skin dry and head covered ○ Warm humidified oxygen ○ Warm ambient humidity ○ Warm feedings ● Education to parents about infant care: ○ Erythromycin eye ointment: ■ Tell family it's done for every baby, but not the specific reason to prevent problems ■ Done to prevent Ophthalmia Neonatorum that is caused by Chlamydia/Gonorrhea exposure ○ Vitamin K: ■ Given I'M in middle third of vastus lateralis ● ⅝ inch or ½ inch ■ Because stomach is sterile and not making it's own Vitamin K until day 7. ■ Vitamin K is essential in blood clotting ○ Umbilical Cord Care: ■ Report bleeding, drainage, foul smell ■ Don't submerge in bath tub until falls off ■ Keep clean and dry, clean with warm water ■ Fold upper edge of front of diaper down below ■ Will fall off between 10 - 14 days after birth ○ Suctioning of Nose: ■ Bulb syringe and 1 nostril at a time ■ Only if something is in nose, it can cause irritation ○ Swaddling: ■ Not required, but helps infant feel safe and helps with temperature regulation ■ Lay blanket in diamond shape with top folded down, pull 1 side across baby’s chest, fold bottom up and tuck behind shoulder, and then fold other side across chest ○ Safe Sleep Practices: ■ Nothing loose in crim, firm mattress covered with a fitted sheet ■ Supine, sleep sack, no blankets, swaddling is ok ○ Immunizations: ■ Hep. B before leaving hospital [Show More]

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