1. A nurse is caring for a newborn immediately following birth.

Exhibit 1

Medical History

Vacuum-assisted vaginal birth

Maternal history of positive group B streptococcus 8-hemolytic Mother received two doses of ampicillin IV bolus during labor

Exhibit 2

Vital Signs

Apgar:

Heart rate 96/min

Weak cry

Muscle tone: some flexion

Reflex: grimace

Color: acrocyanosis

Axillary temperature 36.9° C (98.5° F)

Exhibit 3

Medications

Erythromycin ophthalmic ointment once 1 to 2 hr after birth Hepatitis B vaccine 10 mcg/0.5 mL IM once within 24 hr after birth

Phytonadione 1 mg IM once 1 to 2 hr after birth

Exhibit 4

Laboratory Findings

WBC count 15,000mm (9,000 to 30,000/mm)

Hgb 19 g/dl (15 to 24 g/dL)

HCt 57% (44% to 70%)

Blood glucose 44 mg/dl (40 to 60 mg/dL)

The nurse is assessing the newborn 24 hr later. How should the nurse interpret the findings?

For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication that the client's condition is improving, or indication that the client's condition is worsening

Explanation:

A. Airborne precautions:

Airborne precautions are used for pathogens that are transmitted through the air over long distances. This includes pathogens such as Mycobacterium tuberculosis (TB) or varicella-zoster virus (chickenpox). However, Clostridium difficile (C. difficile) infection is not transmitted through the airborne route. Therefore, airborne precautions are not appropriate for managing C. difficile infection.

B. Droplet precautions:

Droplet precautions are used for pathogens that are transmitted through respiratory droplets, typically over short distances (usually within about 3 feet). This includes pathogens such as influenza virus or Bordetella pertussis (whooping cough). However, C. difficile infection is primarily transmitted through the fecal-oral route and contact with contaminated surfaces or objects, rather than through respiratory droplets. Therefore, droplet precautions are not appropriate for managing C. difficile infection.

C. Protective environment:

Protective environment, also known as reverse isolation, is used to protect immunocompromised clients from pathogens in the environment. This includes clients who have undergone bone marrow transplantation or chemotherapy. However, protective environment precautions are not appropriate for managing C. difficile infection. C. difficile infection control measures primarily focus on preventing the spread of the infection to others, rather than protecting the client from external pathogens.

D. Contact precautions:

Contact precautions are used for pathogens that are transmitted through direct or indirect contact with the client or their environment. This includes pathogens such as methicillin-resistant Staphylococcus aureus (MRSA) or C. difficile. C. difficile infection is primarily transmitted through contact with contaminated surfaces or objects. Therefore, contact precautions, which involve measures to prevent the transmission of infectious agents via contact, including wearing gloves and a gown, performing hand hygiene, and ensuring environmental cleaning and disinfection, are appropriate for managing C. difficile infection.

A. The client puts their personal needs aside:

This option is not characteristic of the taking-in phase. During this phase, the mother tends to focus on her own needs and may rely on others for assistance with caregiving tasks.

B. The client takes charge of all mothering tasks:

Taking charge of all mothering tasks is more characteristic of the maternal role attainment phase, which occurs later in the postpartum period. During the taking-in phase, the mother may be less assertive in assuming full responsibility for caregiving tasks.

C. The client desires privacy with their newborn:

Incorrect. While privacy is important, it is not a specific indicator of the taking-in phase.

D. The client reviews their birth experience with others:

The client reviews their birth experience with others:This is correct. During the taking in phase, the client has a great need to talk about the labour and birth experience.