Case Scenario #9:

Nursing Care of a Family with A

Newborn
Mondelo, Ara Mae
Medina, Doneva Lyn
Hakima, Hadji Daud
A FAMILY WITH AN INFANT BORN BREECH:
Jeremy is a 1-day-old male
who was born from a frank breech position.
Types of Breech Presentation
CHIEF CONCERN:
“He looks funny. Could he
have brain damage?”
HISTORY OF CHIEF CONCERN:
Labor began with ruptured membranes; amniotic fluid was
stained “dark green.” When Mrs. Farmer arrived at the
hospital, an ultrasound revealed her baby was presenting
breech; because dilatation was already at 8 cm, she was
allowed to give birth vaginally. The infant was born with aid
of Piper forceps and was intubated immediately to assess for
meconium. None visualized beyond vocal cords; Apgar
scores of 9 and 9. The infant retains in intrauterine position
(legs extended at knee; sharply bent at hip).
FAMILY PROFILE:
The family lives in a two-bedroom condominium next to
national park. The father works as a park ranger; the mother
works part time as a paralegal in lawyer’s office. They have
one other child: 1-year-old Margo. Finances are “adequate.”
The mother is concerned something is wrong with baby
because he was born breech; points to stiffness of legs as
indication some neurological problem must be present.
PREGNANCY HISTORY:

The mother is G2P2. Pregnancy was unintended because

older child is only 1 year old (mother had not begun on a
contraceptive as yet following first birth). The mother’s
hemoglobin was low at beginning of pregnancy (10 g/dl) so
she was prescribed an iron supplement. There are no other
complications with pregnancy other than breech
presentation. The mother states as long as children are so
close together, she would have preferred a second female,
not a boy.
PHYSICAL EXAMINATION:
Weight: 8.1 lb (3.6 kg); height: 20 in. (51 cm); head circumference: 35 cm

Temperature: 98.6°F (37°C)

General appearance: Well-proportioned, alert, male newborn who assumes a frank breech
position

Head: Normocephalic; no molding; ant. fontanelle: 3 cm × 3 cm; posterior fontanelle: 1 cm

Eyes: Red reflex present; follows to midline without difficulty

Ears: Normal alignment; canal patent

Nose: Midline septum; no drainage

Mouth: No teeth; palate intact; midline uvula

Neck: No lymph nodes palpable; midline trachea

Chest: Occasional rhonchi present; no rales; respiratory rate: 20 breaths/min

Heart: No murmurs; heart rate: 145 beats/min

Abdomen: Soft; no masses; liver palpable 1 cm

Genitalia: Normal male; testes palpable in scrotum bilaterally; midline meatus

Extremities: Full range of motion in upper extremities; lower extremities are

positioned sharply bent at the hip with extended knees; knees flex but with
difficulty; no fractures in long bones palpable; unable to flex and abduct hips to
assess for subluxated hip; buttocks have large ecchymotic areas

Neuro: Moro, sucking, and rooting reflexes present; step-in-place, crossed

extension, tonic neck poorly demonstrated because of stiffness of legs
LABORATORY FINDINGS:

Hemoglobin: 18.0 g/dl

Hematocrit: 56%
Jeremy was administered
AquaMEPHYTON (vitamin K) and
erythromycin eye ointment in the
birthing room. He was scored as a
term 39-week infant by a Ballard
scale.
STUDY QUESTIONS:

1. Jeremy’s temperature at 1 hour after birth was 98.6°F

(37°C). The temperature of the average newborn
immediately after birth is: (2 pts)

A. 96°F (35.6°C)
B. 99°F (37.2°C)
C. 101°F (38.4°C)
D. 105°F (40.6°C)
B. 99°F (37.2°C)

Rationale:
The temperature of newborns is about 99°F (37.2°C) at birth
because they have been confined in their mother’s warm and
supportive uterus.
(Maternal and Child Health Nursing Care of the
Childbearing and Childrearing Family 8th edition
Volume 1 (p. 428)
2. A major way that Jeremy can lose heat is by radiation.
This type of heat loss involves which of the following? (2
pts)

A. Loss of heat from a draft in the room

B. Shift of body heat from trunk to extremities
C. Loss of heat to a cold surface that Jeremy is laying
upon
D. Heat lost to a distant cold surface like a window
D. Heat lost to a distant cold surface like a
window

Rationale:
Radiation is the transfer of body heat to a cooler solid object not
in contact with the baby, such as a cold window or air conditioner.
Moving an infant as far from the cold surface as possible helps
reduce this type of heat loss.
(Maternal and Child Health Nursing Care of the Childbearing
and Childrearing Family 8th edition Volume 1 (p. 429)
3. Jeremy’s hemoglobin is 18 g/100 mL. You should
recognize that the usual hemoglobin value of newborns
is: (2 pts)

A. 7 to 11 g/100 mL
B. 11 to 12 g/100 mL
C. 17 to 18 g/100 mL
D. 19 to 21 g/100 mL
C. 17 to 18 g/100 mL

Rationale:
A newborn has more red blood cells than the average adult, the
hemoglobin level averages 17 to 18 g/100 mL of blood.
(Maternal and Child Health Nursing Care of the Childbearing
and Childrearing Family 8th edition Volume 1 (p. 431)
4. Jeremy weighed 8.1 lb at birth. Suppose on the third
day of life, he weighs 7.5 lb. You would assess this as
which of the following? (2 pts)

A. Excessive newborn weight loss

B. An average weight loss for a newborn
C. A loss still normal but becoming dangerous
D. A loss not consistent with breastfeeding
B. An average weight loss for a newborn

Rationale:
During the first few days after birth, a newborn loses 5% to 10% of
birth weight (6 to 10 oz). This weight loss occurs because a newborn
is no longer under the influence of salt and fluid-retaining maternal
hormones. In addition, the newborn voids and passes stool.
(Maternal and Child Health Nursing Care of the Childbearing
and Childrearing Family 8th edition Volume 1 (p. 428)
5. You have taught Jeremy’s mother to provide skin-to-skin care. This
type of care will primarily involve what practice? (2 pts)

A. Frequently walking with the infant to decrease conduction

B. Keeping the newborn covered with baby oil to seal in heat
C. Holding the infant against her chest or abdomen for warmth
D. Covering the infant with clothes so completely no skin shows
C. Holding the infant against her chest or abdomen for
warmth

Rationale:
Newborns are wet when born, so they can lose a great deal of heat as
the amniotic fluid on their skin evaporates. To prevent this type of
heat loss, a newborn is placed in the mother’s abdomen immediately
after birth and cover with a warm blanket for skin-to-skin contact.
(Maternal and Child Health Nursing Care of the Childbearing
and Childrearing Family 8th edition Volume 1 (p. 429)
6. Jeremy was administered vitamin K in the birthing
room. What rationale for this intervention should you
explain to Mrs. Farmer? (2 pts)

A. Breast milk does not contain vitamin K.

B. His mother’s hemoglobin was 10.5 g/dl.
C. He was scored as only a 39-week infant.
D. Newborns cannot produce vitamin K.
D. Newborns cannot produce vitamin K.

Rationale:
A newborn’s intestine is sterile at birth, unless membranes were
ruptured more than 24 hours, it will take about 24 hours for flora to
accumulate and for ongoing vitamin K to be synthesized. This causes
most newborns to be born with a lower than usual level of vitamin K,
leading to a prolonged coagulation or prothrombin time.
(Maternal and Child Health Nursing Care of the Childbearing
and Childrearing Family 8th edition Volume 1 (p. 431)
7. Jeremy’s first stool was black and sticky. Knowing the
importance of the QSEN competency of safety, you
would evaluate this as: (2 pts)

A. A normal newborn meconium stool.

B. He must have swallowed blood at birth.
C. He may have some internal bleeding.
D. He may be allergic to breast milk.
A. A normal newborn meconium stool.

Rationale:
The first stool of a newborn is usually passed wiyhin 24 hours
after birth. It consists of meconium, a sticky, tar-like, blackish-
green, odorless material formed from mucus, vernix, lanugo,
hormones, and carbohydrates that accumalated in the bowel
during intrauterine life.
(Maternal and Child Health Nursing Care of the
Childbearing and Childrearing Family 8th edition
Volume 1 (p. 432)
8. At 20 hours after birth, Jeremy still has not voided. How would you
appraise this assessment finding? (2 pts)

A. He needs a referral for both kidney and bladder structure.

B. This is within normal parameters for a breastfed newborn.
C. This is an emergency situation requiring catheterization.
D. Jeremy likely needs his breast milk intake supplemented.
A. He needs a referral for both kidney and bladder
structure.

Rationale:
The average newborn voids within 24 hours after birth. A
newborn who does not take in much fluid for the first 24 hours
may void later than this, but the 24- hour point is a general ruel.
Newborns who do not void within this time need to be assessed for
the possibility of urethral stenosis or absent kidneys or ureters.
(Maternal and Child Health Nursing Care of the Childbearing
and Childrearing Family 8th edition Volume 1 (p. 432)
9. Jeremy was assessed for a tonic neck reflex. In a typical tonic
neck reflex: (2 pts)

A. One arm extends on the side to which he turns his head when
he is supine.
B. The infant throws out his hands and legs and then “curls back”
again.
C. The infant takes a few pacing steps forward when he is held
upright.
D. On his stomach, the newborn lifts up his head and nods
expectantly.
A. One arm extends on the side to which he turns his
head when he is supine.

Rationale:
When the arm and leg on the side toward which the head is
turned extend, and the opposite arm and leg contract.
(Maternal and Child Health Nursing Care of the Childbearing
and Childrearing Family 8th edition Volume 1 (p. 434)
10. You notice Jeremy’s mother sings to him. How soon
after birth can newborns hear? (2 pts)

A. At 3 to 4 weeks of age
B. As soon as vernix is wiped from the ear pinna
C. As soon as eustachian tube fluid is absorbed
D. When the infant yawns and opens the ear canal
C. As soon as eustachian tube fluid is absorbed

Rationale:
As soon as amniotic fluid drains or is absorbed from the middle
ear by way of the euthachian tube within hours after birth,
hearing becomes acute.
(Maternal and Child Health Nursing Care of the
Childbearing and Childrearing Family 8th edition
Volume 1 (p. 435)
11. Jeremy’s skin is described as having slight physiologic jaundice.
What factor is involved in the etiology of this problem? (2 pts)

A. Shunting of blood from the extremities to the body core

B. A reaction from the vitamin K administered at birth
C. An allergy to the protein in either formula or in breast milk
D. The breakdown of hemoglobin which occurs in newborns
D. The breakdown of hemoglobin which occurs in
newborns

Rationale:
Infants who are prone to to extensive bruising ( large, breech, or
preterm babies) for jaundice because bruising leads to to
hemorrage of blood into the subcutaneous tissie or skin; this blood
then ahs to be broken down so can add to the amount of indirect
bilirubin accumulating.
(Maternal and Child Health Nursing Care of the Childbearing
and Childrearing Family 8th edition Volume 1 (p. 441)
12. Which finding in Jeremy’s history puts him at higher
risk for an increased serum bilirubin level than other
infants?

A. He has bruising on his buttocks from birth.

B. His mother had a low hemoglobin during pregnancy.
C. He was born within 1 year of a sibling.
D. He was a full-term infant.
A. He has bruising on his buttocks from birth.

Rationale:
Infants who are prone to to extensive bruising ( large, breech, or
preterm babies) for jaundice because bruising leads to to
hemorrage of blood into the subcutaneous tissie or skin; this blood
then ahs to be broken down so can add to the amount of indirect
bilirubin accumulating.
(Maternal and Child Health Nursing Care of the
Childbearing and Childrearing Family 8th edition
Volume 1 (p. 441)
13. Jeremy’s Apgar score at 5 minutes was 9.
How should you evaluate this assessment
finding?

A. He was having trouble breathing at 5

minutes of age.
B. He must have been hyperventilating at this
time period.
C. His heart must have been beating too fast
to be accurately assessed.
D. He is adjusting well to intrauterine life.
D. He is adjusting well to intrauterine life.

Rationale:
Using the apgar test, the nurse assesses heart rate, respiratory
effort, muscle tone, reflex irritability, and color.
(Maternal and Child Health Nursing Care of the
Childbearing and Childrearing Family 8th edition
Volume 1 (p. 437)
14. A heel stick blood sample from Jeremy at 12 hours of
age revealed a glucose level of 50 mg/100 ml. You would
interpret this as: (2 pts)

A. Severe hypoglycemia.
B. Mild hypoglycemia.
C. Normal for a newborn.
D. Hyperglycemia.
C. Normal for a newborn.

Rationale:
A serum glucose reading that is less than 40 mg/100 ml of blood
indicates hypoglycemia. Newborn symptoms of hypoglycemia include
jitteriness, lethargy seizures, and intravenous glucose may be
prescribed. A continuous intravenous infusion of glucose may be
necessary if the newborn is unable to maintain glucose levels higher
than 40 mg/100 ml. (p. 450-451)
(Maternal and Child Health Nursing Care of the Childbearing
and Childrearing Family 8th edition Volume 1 (p. 450-451)
15. Jeremy was scored as a term newborn on a Ballard
scale. In a term newborn, you would expect which of the
following assessment findings? (2 pts)

A. No creases on the sole of the foot

B. Creases covering the entire sole
C. Rounded or “rocker-bottom” feet
D. Toes held in a splayed position
B. Creases covering the entire sole

Rationale:
The sole of the foot is flat because of an extra pad of fat in the
longitudinal arch. The foot of a term newborn has many
crisscrossed lines on the sole, covering approximately two thirds
of the foot. If these creases cover less than two thirds of the foot or
are absent, it suggests the infant is preterm.
(Maternal and Child Health Nursing Care of the Childbearing
and Childrearing Family 8th edition Volume 1 (p. 450)
16. You inspect Jeremy’s head, mouth, and ears closely.
What finding would you consider to be normal if
discovered at birth? (2 pts)

A. Craniotabes
B. Protruding eye globes
C. Swollen tongue
D. Yellow-tinged sclera
A. Craniotabes

Rationale:
Craniotabes is an example of a condition that is normal if seen in
a newborn but would be pathologic in an older child or adult.
(Maternal and Child Health Nursing Care of the Childbearing
and Childrearing Family 8th edition Volume 1 (p. 445)
18. While Jeremy’s mother takes a shower, you place
Jeremy in his bassinette. Which would be the best
position in which to place him? (2 pts)

A. On his back
B. On his abdomen
C. On his right side
D. On his left side
A. On his back

Rationale:
Sudden Infant death syndrome (SIDS) is the sudden, unexplained
death of an infant younger than 1 year of age. Although the specific
cause of SIDS cannot be explained, these interventions have been
shown to decrease the incidence of the syndrome: place infant on the
back to sleep; use a firm sleep surface; and avoid soft bedding.
(Maternal and Child Health Nursing Care of the Childbearing
and Childrearing Family 8th edition Volume 1(p. 456-457)
19. Jeremy’s parents have chosen to have him
circumcised. What would you teach his parents? (2 pts)

A. Do not feed him for 12 hours postprocedure.

B. Using local anesthesia will help control pain.
C. He will need to receive IV heparin afterward.
D. Bleeding of about 100 ml can be expected
B. Using local anesthesia will help control pain.

Rationale:
For the procedure, an infant is placed in a supine position and
restrained either manually or with a commercial swaddling board.
Application of EMLA cream (a eutectic mixture of local
anesthetics) or a similar compound is a popular choice for local
anesthesia. Regional block anesthesia may also be used if an
anesthetist is involved.
(Maternal and Child Health Nursing Care of the Childbearing
and Childrearing Family 8th edition Volume 1(p. 457)
20. Mr. Farmer is preparing to take Jeremy and Mrs. Farmer home. In the
interests of safety, what would you teach him?
(2 pts)

A. His mother should hold him securely on her lap during the trip home.
B. Newborns do not necessarily need car seats until they are 2 weeks old.
C. Newborn seats should be placed in the back seat facing forward.
D. In the back seat, facing backward, is the safest position for newborn car
seats.
D. In the back seat, facing backward, is the safest
position for newborn car seats.

Rationale:
Automobile accidents are a safety problem all during childhood,
beginning with the newborn period. For protection while in
automobiles, newborns should always be transported in rear
facing car seats placed in the backseat.
(Maternal and Child Health Nursing Care of the Childbearing
and Childrearing Family 8th edition Volume 1(p. 459)