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27 Cards in this Set
- Front
- Back
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Wash Hands and Identify Client
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Check armband and Crib Card
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Provide for warm environment
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Radiant warmer if indicated and keep away from drafts
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Color - Need to assess for:
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Normal Findings/Variations:
pink, acrocyanosis , mottled Deviations from Normal: Ruddy, pale, cyanosis |
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Skin - Need to assess for:
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Normal Findings/Variations: warm/cool to the touch, forceps marks present, stork bites present, peeling noted age of NB, and where, vernix location amount, age of NB, petechiae over presenting part, bruising with breech births, mongolian spot-location
Deviations from Normal generalized petechiae, general ecchymosis |
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Tone - Need to assess for:
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Normal Findings/Variations:
normal/flexed, legs straighter and stiff, if breech Deviations from Normal: flaccid - is preterm or term, arched - is baby crying or in pain, hypertonia |
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Cry - Need to assess for:
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Normal findings/Variations:
Vigorous sound Deviations from Normal: weak sound, absent, hoarse sounding cry , high pitched cry noted |
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Activity - at time of assessment:
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Normal findings/Variations:
crying, quiet/alert Deviations from Normal: tremors - Need to check BS, Hyperactive - drug addicted NB, Hypoactive |
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Head - Need to assess for:
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Normal Findings/Variations: molded - determine if Small/Moderate
Caput present and location, Fontanels - need to palpate and note: Anterior Soft/flat/open Posterior Open/nonpalpable Palpate sutures and note: well approximated open overlapping/overriding Deviations from Normal: cephalhematoma - location R or L and size large amount of molding present Fontanels - sunken, small, bulging |
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Eyes - Need to assess for:
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Normal Findings/Variations: appear clear
assess for drainage from silver nitrate red reflex present Deviations from Normal: opaque lens noted purulent drainage chemical conjunctivitis |
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Nose - Need to assess for:
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Normal Findings/Variations:
nares patent Deviations from Normal: nares obstructed secretions present: small/medium/large amount noted of secretions Possible Interventions: suctioned as needed |
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Mouth - Need to assess for:
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Normal Findings/Variations: check if normal - put on gloves to palpate - if intact or open
Deviations from Normal: cleft palate present cleft lip present facial palsy noted excessive saliva Possible Interventions: need suctioning |
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Ears - Need to assess for:
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Normal Findings/Variations: normal - measure with imaginary line
Deviations from Normal: Low set ears present |
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Respirations - Need to assess for:
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Normal Findings/Variations: unlabored breathing present
bilateral and equal on auscultation clear on auscultation Deviations from Normal: diminished on auscultation crackles on auscultation rhonchi on auscultation apnea present nasal flaring noted grunting noted tachypnea - rate of respirations >60/min distress retractions noted, location Types are: intercostal, substernal, and subcostal Possible Interventions O2 - need to be given CXR to be done ABG's need to be drawn |
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Chest - Need to assess for:
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Normal findings/Variations:
symetrical appearence Deviations from Normal: barreled appearence Fx clavicle on palpatation location of fx Right/Left |
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Breast Tissue - Need to assess for:
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Mature when measured or palpated
Immature when measured or palpated |
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Heart - Need to assess for:
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Normal findings/Variations:
regular (120 - 160 BPM) murmur - as base or left 3 - 4 intercostal Deviations from Normal Murmur possibly functional |
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Cord - Need to assess for:
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Normal Findings/Variations:
3 vessels - two arteries and one vein Deviations from Normal: bleeding 2 vessels - one artery one vein |
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Abdomen - Need to assess for:
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Normal findings/Variations:
bowel sounds present soft to touch Deviations from Normal: scaphoid appearence distended appearence Possible Interventions: Need lavage Note amount of air Note amount of secretions |
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Extremities - Need to assess for:
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Normal findings/Variations:
normal range of motion Deviations from Normal: hip click present erb palsy's noted and location R/L extra digit present on: finger toe syndactomy - webbing Club foot noted and location R/L |
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Reflexes - Need to assess for:
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Need to demonstrate how to perform the following reflexes:
moro +/- (Present or absent) grasp - good/fair/poor sucking - good/fair/poor demonstrated |
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Male Genitalia - Need to assess for:
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Normal Findings/Variations:
testes descends on plapation voided since delivery Deviations from Normal: hydrocele noted with pen light undescended R/L noted on palpatation |
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Femals Genitalia - Need to assess for:
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Normal Findings/Variations:
Mature appearence vaginal tag present secretions noted Deviations from normal: immature appearence |
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Anus - Need to assess for:
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Normal findings/Variations:
Patent Stool since delivery Deviations from Normal: Imperfoate present |
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Spine - Need to assess for:
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Normal findings/Variations:
normal alignments on palpation Deviations from Normal: Scoliosis noted Dimple present and closed |
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Measurements - Must know how to take measurements and normal ranges:
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Head - demonstrate and give measurement (around head above eyebrows) Avg. 32 cm - 36.8 cm (12.4 - 14.5")
Chest - demonstrate and give measurement 30 - 34 cm (around chest at nipple - same as head never bigger than head) Length-measure (Paper tape mark at head, mark at feet Avg. 45 cm - 55 cm (17.7 - 21.6")), Weight (2500 - 4000 g (5.5 lbs. - 8.8 lbs) |
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VS - Vital Signs (Must show where to take VS and know normal ranges)
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Temp - demonstrate axillary (do last) Average (36.5 C - 37.2 C ( 97.7 F - 98.9 F))
Pulse - demonstrate how to take apical (120 - 160 Count 1 full min) Respirations - how to measure (30 - 60 min - place hand on stomach, 1 full minute) BP x 4 extremities - how to apply cuff |
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Medications - Must show sites for
each med |
Hep B - must explain purpose (Right Leg)
Erythromycin must explain purpose (Gonherra, Eye inside out in conjuctive) Aquamephyton must explain purpose (Vitamn K Left Leg - Coagulation GI/digestion) Triple dye must explain purpose (Prevent infection) |
