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25 Cards in this Set

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What is the immediate assessment that a nurse would do after birth of the neonate?
1) Establish airway: suction, 2) Provide warmth: Dry the infant,
Place on mother’s abdomen; heated blankets,Place beneath radiant heater, Cap 3) Observe respiratory effort: no grunting or retractions or nasal flaring, but 30-60 breath of irregular breathing is normal, 4) color: pink body/blue extremeties, 5) muscle tone: flexing or floppy,
6) irritate them: Stimulate neonate to breathe deeply & cry 7)Assess heart rate: should be at least 100bpm;normal is 120-160; 8) Temperature: 97.6; 9)Note obvious abnormalities 10) Check & record number of umbilical cord vessels:
should be 2 arteries/1 vein; 11) APGAR test: should be done at 1 and 5 minutes, Assesses immediate adaptation, Five categories—each scored 0 to 2
Respiratory effort, Heart rate: has to be 100 at least, Muscle tone: flexing or floppy, Reflex irritability: suctioning to get irritability, Skin color: any blue, not a two, acrocyanosis means they are not a 2, most of the time 0 or 1. Also get weight: should be 2.5-4.3 kg/5.5-9.5lbs or 45-54 cm/17.7-21.5inches.
What is the first immediate nursing care, not to be confused with first immediate nursing assessment, of the neonate?
1) Identification: includes thumbprint, fingerprint and i.d.bracelets, mother's name, baby's gender, name of physician, date and time of birth etc. helps prevent mix-up or abduction; 2) Infection/injury prevention:
Eye prophylaxis: giving erythromyacin to prevent conjuctivitis; Vitamin K injection: to prevent excessive bleeding until they develop it a week after;
Hepatitis B vaccine (parental consent required): because some parents don’t want vaccines given
Assess blood glucose (40-80mg) or symptoms of hypoglycemia; if they don’t have risk factors you wouldn’t stick them unless there were indications, so assess first for risk factors: Hematocrit (48-64%) & hemoglobin (17-18.4); polycythemia: ruddy complexion: (above 7million)-hyperbilirubinemia: jaundice
What is the later neonatal assessment that is done by the nurse?
1) Body positioning: flexed or floppy, hands should be at midline, set the babies free! Means they are neurologically intact.
2) Skin color: checking for cyanosis/hyperbilirubinemia 3)
Body size symmetry,; glucose utilization 4) Level of reactivity: is baby lethargic or acting normal; 5) sleep cycle; is he is acting normal or not 6) Measurements & determination of gestational age
Ballard Gestational Age by Maturity Rating Tool: 574: 18-8: Tests neuromuscular and physical maturity
In the Systems approach to assessment of the normal neonate, what is the skin and integumentary assessment?
1) In a well-lit room, inspect the following: skin, scalp, nails, body hair, skin color, texture, distribution, disruptions, eruptions, & birthmarks,
& Birth injuries. 2) Skin:Smooth & soft; post-term infants—tough, leathery skin,Pre-term– pink, shiny, fragile 3)Pustular melanosis: looks like acne 4) Milia: little bumps on their nose, 5) Erythema toxicum: newborn rash 6) Pigmentation—Mongolian spots, café-au-lait marks Brown nevi—brown skin marks or Nevus flammeus—“port wine stain” , orTelangiectatic nevus—“stork bite”, or Nevus vasculosus—“strawberry mark”.
From the systems assessment of nb what do we assess on the head?
1) Symmetry: can have a broken clavicle if broken during labor 2) Eye shape, size, placement, & coordin- ated lid movement, red reflex, gross vision 3) Ears: shape, size, placement, hearing 4) Movement, color of the lips 5) Chin—appropriate size: FAS can cause this. 6)Estimate head size. Fullness without bulging—normal. Aka soft & flat ,Bulging & tense with large head, circumference, check for increased intracranial pressure: Sunken means dehydration Caput Succedaneum: a cap of fluid covers the head: Diffuse edema, crosses suture lines, disappears in few days. In contrast: Cephalhematoma: involves bleeding; blood. Can be bilateral, but wont cross over. At risk for jaundice because of broken down blood cells.;Subperiosteal hemorrhage Does not cross suture lines. Persists for weeks; 7) Mouth can have Epstein’s pearls (litte pearl-like inclusion cysts taht usally disappear after a few weeks)- Teeth: neonatal teeth are not that common, but have to come out.; 8) Ability to suck
Hard & soft palate-R/O clefts; 9) Neck Torticollis: deviation of neck to one side because of neck spasm muscles, apparent when head points to one side and chin points to the other.;10) Facial features-ear placement: an imaginary line can be drawn from the inner the outer canthus of eye to the ear. 11) Fontanel should be full, but not bulging or sunken. Hydrocephalus is indicated w/bulging fontanel.
What is the simean crease?
2 creases found on the palm that by itself may not indicate anything, but with other symptoms may indicate down syndrome.
what are the signs of respiratory distress?
grunting, nasal flaring, and retractions.
What is important to remember about the pmi on an neonate?
The neonate's pmi can be moved either from wringer effect causing a pnemothorax during birth
How is a bowel obstruction usually first identified?
Absence of bowel sounds.
What are the signals for cause of alarm in the gi inspection of the neonate?
Abdominal distention
Absence of bowel sounds
Discharge from umbilical cord/site: common site of infection, could smell.
Abdominal mass
What things would the nurse do in in the genitourinary assessment of the male neonate?
Hips abducted: leg lengths should be equal; Palpate & inspect scrotum, testes, & penis: head of penis is on the dorsal side look for hypospadius (vertical, rather than central opening on the penis that requires surgery, epispadius (opening located on the dorsal side); testes should drop
Male—retract foreskin, scrotum may be enlarge in breech presentation.
Palpate & inspect female genitalia
Anus & anal wink reflex: anus should be patent (otherwise called imperforate anus).
What are normal findings in the genitourinary system of the female neonate?
Hymenal tags: small piece ot triangular tissue, that is your hymen.
Smegma:Vernix caseosa on labiacheesy white sub. Found in the labia and everywhere and is normal;
Pseudomenstruation
What genitourinary assessment findings would warrant further assessment of the neonate?
Undescended testicles,Micropenis: looks like a button-pituitary gland problem, Ambiguous genitalia
Imperforate hymen, Imperforate anus
How would a nurse carry out a musculoskeletal assessment of the neonate?
1) Observe infant’s movements in crib. Inspect for differences in extremity length & size. Observe initial movements visually. Any compromise might indicate injury or birth trauma; 2) Nurse then places infant in supine and prone positions to check extremity movements or floppiness. She palpates wtarting with the shoulders working down looking for symmetry and full rotation of neck (if not called torticollis) and assess head lag, the natural falling back of the head;3) then hips checking for DDH (developmentatal dysplasia of the hip) by looking for asymmetry of skin folds, noting symmetry of extremities and gentle passive ROM.
What are some common findings that check or indicate DDH or developmental dsyplasia of the hip?
In checking for Developmental dysplasia of the hip the nurse would first assess: Asymmetry of skin folds, then leg length and knee height for eveness and kicking for pain or distress.2) Nurse would then use Barlow maneuver-maintaining hands on infant's thigh w/fingertips around the femur head while the thumb and index finger stabilize knee joint at the same time exerting a dweonward pressure on the head of the femur in attempt to dislodge femur head from the acetabulum.
3) Ortolani maneuver-a circular rotation of the femoral head or inward-outward action that attempts to reposition femur head that was displaced by Barlow maneuver.
4) signs of Crepitus or clicking and 5)
Unusual positions of foot like club foot or pronation.
What are the musculoskeletal findings of the neonate that would warrant further assessment?
Fractured clavicle
Polydactyly: extra digits
Syndactyly : webbed
Simian crease: trisomy babies of down syndrome, hand crease
Name the major and minor reflexes of the neonate?
Major—Gag (should have this reflex in order to eat); Babinski lightly stroking plantar of foot from heel toward toes-infant will incurve toes andthen uncurl and stretch them out; Moro-nurse can mimic a release and infant reflexively extends both arms and flexes both legs., Galant-stroke one side of vertebral column-infant responds by moving buttocks in curving motion toward side that is stroked.
Minor Reflexes: 1) Palmar grasp-infant curls fingers around object; 2) plantar grasp-infant curls toes around an object placed at sole of foot,3) rooting & sucking-stroke infant's cheek to watch baby turn toards object placed in his mouth, 4) head righting, 5)stepping-soles of feet are lightly brushed, infant picks up feet and then places them back down as if stepping 6) tonic neck-extends arm and leg to side and the head andjaw turn while flexing the opposite arm and leg.
What are some neurological findings that would warrant further assessment of the neonate?
Shoulder dystocia: a temporary injury involves brachial plexus and difficulties with shoulder rotation at birth. 2) Erb’s palsy: is also a brachial plexus injury that is identified when positioning baby in supine position both arms and hands are extended anddo not move into a flexed position, also decreased muscle tone and grasp reflex and absence of arm recoil on 1 side called watiers position.
Cerebral palsy: caused by oxygen deprivation which causes multiple motor difficulties like swallowing, breating or moving. Length of time w/out o2 determines severity of brain damage. Spina bifida: Failure of the primitive neural tube to close which causes an open area to fill with fluid or a section of the spinal cord to fill with fluid. In milder cases it can be surgically repaired and will small defects, but more serious closure issues lead to anencepahlies...
What are the first things we as nurses teach mothers about caring for their newborn?
1)Temperature assessment: avoid extremes- and axillary is preferred method of temp, 2) Bathing: Do not submerge until after umbilical falls off-sponge bath only for 2 weeks- and then once a week is sufficient to submerge to prevent heat loss. Never leave unattended and they are slippery little suckers 3) Nail Care: do not trim till after a week so they are separated from skin, and have them wear mittens to prevent scratching, then trim while they sleep, 4) umbilical cord care: cord clamp stays in place for 24 hours, and is cleaned by natural sterile water or neutral ph cleanser.
Clothing:Remember thermoregulation-hat;
Diapering.
Attachment
What are some pertinent issues to discuss and ask before discharge of the newborn?
Circumcision: involves cutting of the prepuce or foreskin on the glans penis. To circumcise or not circumcise-that is the question. Can promote easier cleaning and hygeine; otherwise it is up to the parent no way is wrong or right
Ensuring optimal nutrition: formula needs to be iron-fortified to sub for breast milk. Need 105-108 kcal per kilogram a day.
Discharge planning for the infant & family Ask things like "who will help you with the baby?" ask about carseat that is appropriate for an infant. Child care: Lots of options.
Newborn metabolic screening tests: pku and then some: used to identify newborns w/ genetic, metabolic and or infectious conditions like biotinidase deficiency, hemoglobinopathies, pku (a genetic metabolic disorder a deficiency of enzyme phenylalanine hydroxylase that hte body needs to converts phenylalanine to tyrosine. without it pheylalanine builds up to toxic levels causing cns damage. cystic fibrosis (ca channels) sickle cell.
What is the normal head circumference for the newborn? What is the average wt for a newborn in grams, kg, and lbs?
33-35 cm., 3400 grams, 3.4 kg. or 7lbs/8oz
What increases and decreases when a baby is chilled? What chemical imbalance are they at risk for when they are chilled?
Increases in: O2 consumptions, glucose consumption, utilization of brown fat, more calories consumed.
Ddecrease in: surfactant
Risk for Metabolic Acidosis.
How many hours a day do newborns sleep?
16-20 hours a day.
What are the 5 testing categories of the apgar?
Heart rate, respiratory effort, muscle tone, reflex irritability, and color.
Which of the following vascular blood transfers carries the most oxygenated blood in the fetus? ductus venosus, umbilical artery, pulmonal artery or ductus arteriosis.
Answer is ductus venosus because it is opposite blood gas exchange to the fetus.