Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
256 Cards in this Set
- Front
- Back
|
Infants with CHD are at risk for delayed growth and development. Why? |
CHD ➡ inadequacy of oxygenation ➡ poorer perfusion ➡ increased difficulty of obtaining adequate calories for continued growth ➡ increased risk of delays in growth and development |
|
|
Assessing __, __, __, and __ provides basic but essential assessment data points of how well the heart can perfuse the tissues. |
HR, pulses, CRT, and BP |
|
|
The level of __ and quantity of __ output can also indicate the cardiac output of blood to key organ systems. |
level of mentation (i.e. mental status and alertness) quantity of urine output |
|
|
What are signs of hypoperfusion that require immediate intervention and notification of healthcare providers? |
CRT >3 sec Weak or absent pulses Pale or cyanosis in nail beds, mucosa, and circumoral (around the mouth) area Decreased mental status Decreased urine output (<1 to 2 ml per kg per hour) Cool extremities Tachycardia Hypotension or near normals (initially) |
|
|
What are the physiological adaptations a fetus does to prepare for extra uterine life? |
Fetal lungs develop and mature Surfactant is produced
Glycogen is stored in the liver Brown fat is deposited Adrenal glands catecholamines |
|
|
True or false: Fetal lungs are filled with fluid. |
True |
|
|
true or false: Fetuses make respiratory movements but aren't really using their lungs. |
True |
|
|
What is surfactant? |
It is a mix of phospholipids and lipoproteins that is produced in the lungs. |
|
|
When does production of surfactant begin? |
34 weeks gestation |
|
|
What does surfactant do? |
It prevents the alveoli from sticking together, making it easier for gas exchange to occur. |
|
|
Where does a fetus have brown fat? |
Suprarenal, pericardial and periaortic, interscapular, supraclavicular, laterally in the axillary area, around the pancreas, around the trachea |
|
|
When is brown fat deposited? |
During the last few weeks of pregnancy; beginning at about 32 weeks gestation |
|
|
Why is glycogen stored in the liver? |
For energy |
|
|
What are catecholamines? |
Hormones |
|
|
The fetal adrenal glands produce catecholamines during ___. |
labor |
|
|
The catecholamines produced during labor include |
dopamine, norepinephrine, and epinephrine |
|
|
The catecholamines that are produced during labor help the newborn by causing |
⬆surfactant ⬆blood flow to the heart, lungs, and brain ⬆energy Stimulate WBC production |
|
|
It is important for the nurse to identify infants who may need support for the initial transition to extrauterine life. Examples of these infants include |
Premature infants Infants with a non reassuring FHR pattern in labor Infants with shoulder dystocia Those who went through assisted deliveries Those with the presence of meconium |
|
|
Explain the mechanism of heat loss through evaporation. |
It is the loss of heat as the amniotic fluid evaporates. |
|
|
Explain the mechanism of heat loss through conduction. |
It is the transfer of heat from the infant's body to cooler services, such as towels or the cold base of a warming unit. |
|
|
Explain the mechanism of heat loss through convection. |
It is the transfer of the infant's body heat to the surrounding cool air. |
|
|
Explain the mechanism of heat loss through radiation. |
It is the transfer of the infant's body heat to a cooler object that the infant is not in contact with, such as a window. |
|
|
It can take up to ___ hours for a newborn's temperature to stabilize. |
4 |
|
|
If additional heat is needed, to produce heat, the infant begins to metabolize the brown fat, also known as ___. |
Nonshivering thermogenesis |
|
|
The consequences of an increased metabolic rate in the newborn, like that which occurs due to cold stress, include |
❄ increased need for oxygen ❄ increased use of stored glycogen, which can lead to hypoglycemia ❄ decrease in surfactant production ❄ rapid metabolism of brown fat, leading to metabolic acidosis |
|
|
What nursing interventions should be conducted immediately after birth to maintain thermoregulation? |
The infant should be dried immediately and the wet towels should be removed. The infant should be placed skin-to-skin with the mother as soon as possible. Their head should be covered with a hat as soon as possible. |
|
|
A newborn's temperature should be monitored every __ for the __. |
15 minutes for the first hour |
|
|
Brown fat breaks down into ___, which can lead to ___. |
fatty acids; metabolic acidosis |
|
|
During procedures, avoid ___ the infant's entire body to help maintain thermoregulation. |
uncovering/exposing |
|
|
A newborn should not be bathed until the temperature has been stable for at least __. |
2 hours |
|
|
If unable to maintain skin to skin contact with the mother, the infant should be ___ for procedures. |
placed under a preheated radiant warmer |
|
|
Although heat loss is a major concern in newborns, it's also important to prevent ___. |
overheating |
|
|
Parents should be cautioned that over dressing for bundling the newborn excessively can make the baby __ and cause ___ such as ___. It's also linked to ___. |
uncomfortable; problems such as heat rash; SIDS |
|
|
What causes the newborn's inability to conserve heat? |
A large surface area relative to body mass and limited subcutaneous fat for insulation |
|
|
The ___, ___, and ___ close to redirect the blood flow through the newborn's body. |
Ductus arteriosus, ductus venosus, and foramen ovale |
|
|
The newborns kidneys are immature and do not concentrate urine while for about __. The urine should be __ and __. |
6 weeks; odorless and a light color or clear |
|
|
Bacteria begin entering the GI tract shortly after birth through |
Vaginal secretions Hospital Linens Contact at the breast The environment in general |
|
|
The bacteria that enter the GI tract shortly after birth aid in __ and __. |
digestion and synthesis of Vitamin K |
|
|
What is meconium like? |
It is a sticky, blackish green material. |
|
|
What is meconium made from? |
Mucus, vernix, lanugo, hormones, carbohydrates that accumulated in the bowel during fetal development. |
|
|
When should meconium be expelled? |
Within 24 to 48 hours of birth. |
|
|
The immature liver is unable to change bilirubin from the breakdown of __ into a form that can be excreted by the body. |
RBCs |
|
|
When bilirubin deposits in the skin, __ occurs. |
jaundice |
|
|
A newborn is born with passive antibodies passed to him or her from the mother through the ___. |
placenta |
|
|
A newborn cannot produce their own antibodies until about __. |
2 months of age |
|
|
The first period of reactivity occurs within the __ after birth so this is an excellent time to __ and ___. |
first 30 to 60 minutes; introduce breastfeeding and encourage bonding |
|
|
The second period of reactivity begins when __. This is a good time to encourage __ and __. |
baby wakes up from their long sleep and is alert and active again; family interaction with the baby and educate about hunger cues |
|
|
What are the external stimuli that helped the prepare to take their first breath? |
Pressure on the chest causes squeezing out of the lung secretions in amniotic fluid inside the lungs then the chest recoils when it fully emerges from the birth canal causing an intake of air to fill the lungs. |
|
|
External stimuli that take effect after the first breath include |
Surfactant opens the alveoli, then stimulation of the sensors in the skin, which further encourages the respiratory Center to begin the first sequences of breathing |
|
|
The internal stimuli are the chemical factors that influence a newborn to breathe. What is the major internal stimuli for this? |
The Cutting of the umbilical cord, which decreases the oxygen concentration, increases the carbon dioxide, and causes a drop in the pH of the blood, which triggers the medulla to stimulate the respiratory Center in the brain to begin functioning. |
|
|
What are the nursing interventions for assisting the newborn with the respiratory transition after birth? |
Counting the respiratory rate Suctioning the mouth and nose Monitoring respiratory effort Observing the abdomen (newborn breathing involves the diaphragm and abdominal muscles) |
|
|
Short bursts of crying causes __ and aids in __, but prolonged crying is unsafe due to __. |
an increase in depth of respirations; opening the alveoli at birth; excessive use of glycogen stores |
|
|
True or false: A newborn has more RBCs than the average adult. |
True; the blood cells are produced to provide extra oxygenation during the stress of labor |
|
|
A newborn's hemoglobin averages __ to __g/100 ml. |
17 to 18 |
|
|
A newborn's blood volume is __ to __ ml/kg. |
80 to 110 |
|
|
A newborn's hematocrit is between __ and __. |
45% and 50% |
|
|
A newborn's WBC count ranges from __ to __ cells/mm3. This is an elevation which indicates __. |
15,000 to 30,000; stress of birth |
|
|
Vitamin K is essential for the formation of factors __, __, and __. These are known respectively as __, __, and __. |
II, VII, and IX; prothrombin, plasma thromboplastin component, Stuart-Prower factor |
|
|
What are the nursing interventions for assisting the newborn with their cardiovascular transition after birth? |
Monitor heart rate (if <100, stimulate to breathe; if ineffective, use positive pressure ventilation of room air at a low pressure to increase oxygenation which will increase HR) If HR is <60, begin chest compressions. |
|
|
Urine volume for the first day of life should be about __. |
15 ml |
|
|
For the first two days of Life, the total daily urine output should be about __ to __. |
30 to 60 ml |
|
|
By the end of the first week, the volume of urine should rise to __ per day. |
300 ml |
|
|
A baby should have a wet diaper equal to the number of days of life until one week of age at which point they should start having __ to __ wet diapers a day. |
6 to 8 |
|
|
What are the nursing interventions for assisting newborns with renal and Gi transitions after birth? |
Monitoring for the first void and meconium stool Weigh diapers if concerned about urinary output Encourage frequent breastfeeding to increase fluid intake Teach parents not to over feed the newborn as well as help them be aware of the immature cardiac sphincter which can cause regurgitation |
|
|
What is the difference between indirect/unconjugated bilirubin and direct/conjugated bilirubin? |
Indirect bilirubin is what causes the yellow discoloration of the skin. The liver changes it into direct bilirubin which is excreted in the stool and urine. |
|
|
An expected total bilirubin value for a newborn is less than __ mg/dL. This level will rise and peak at about day __. It should be below __ to be considered normal. |
5.8; 5; 11.7 |
|
|
What are the nursing interventions for assisting the newborn with immune system transition? |
Maintaining strict hand-washing for everyone who cares for the newborn, screen Healthcare personnel and visitors for illness, encourage parents to begin immunizations at 2 months of age |
|
|
What behaviors indicate that a newborn likes something? |
Focusing their eyes to track an object or person moving around the room |
|
|
What behaviors does a newborn demonstrate that indicate they dislike something? |
Turning away, crying, yawning |
|
|
A newborn will fall into a deep sleep that can last __ to __, which is called the ___. |
2 to 4 hours or longer; the period of relative inactivity |
|
|
What are the nursing interventions for assisting the newborn with the hepatic transition? |
Monitor for jaundice Teach parents about normal physiological jaundice |
|
|
Hyperbilirubinemia causes issues when it goes to the __. |
brain |
|
|
What does deep sleep look like in a newborn? |
Baby lays very still, no eye movement, difficult to wake |
|
|
What times are good to wake a baby for feeding? |
During light sleep, when drowsy, or are active and alert |
|
|
What does light sleep look like in a newborn? |
Rapid eye movements |
|
|
What does a drowsy state look like in a newborn? |
Their Eyes Are Open, not fully awake or asleep |
|
|
What does an alert State look like in a newborn? |
They're breathing is regular, Eyes Are Open, baby is attentive |
|
|
What does an active Alert state look like in a newborn? |
They're more active, may chew on hands, may try to get in a position to eat |
|
|
What does crying indicate in a newborn? |
Something is bothering them, they initiate interaction by crying |
|
|
Vital signs for newborn include |
Heart rate, respiratory rate, temperature, and blood pressure; blood pressure is not routinely assess a newborn unless they are suspicious of congenital cardiac anomalies; Hospital procedure can differ for timing for newborn vital signs, but are usually taken every 30 minutes for the first 2 hours after birth then every hour for 3 hours, then every 48 hours for 24 hours |
|
|
Each newborn should be weighed and measured for __, __, and __. |
Length, head circumference, chest circumference |
|
|
When weighing the baby, __ should be removed. |
Clothing, including their diaper |
|
|
Length should be measured from __ to __. |
Head to heel, with the leg fully extended |
|
|
Chest circumference is measured by placing the tape measure around the infant's chest at the __ and noting the number at midway between __ and __. |
nipple line; inspiration and expiration |
|
|
Head circumference is measured by placing the tape measure just above the __ and __. |
ears and eyebrows |
|
|
A skin assessment in a newborn should include |
Skin color, mucous membranes, nail beds, petechiae, turgor, creases in the palms and soles, lanugo, vernix, and birthmarks |
|
|
What is a hemangioma? |
Also known as a nevus vascularis, it consists of newly-formed capillaries in the dermal and subdermal layers of the skin. It is raised and dark red. Usually no intervention is required unless it is larger than 5 cm. It's gradually Fades away over a few years. (50% are gone by age 5, 70% are gone by age 7) |
|
|
What is a nevus flammeus? |
Also known as a port wine stain, it is usually present at birth and grows with the child. It is made of dilated skin capillaries. Frequently located on the face and is red to purple in color. This birthmark is not raised and does not blanch when pressure is applied. This lesion will not fade on its own, laser surgery is the treatment of choice if parents desire to have it removed. |
|
|
What is nevus simplex? |
Also known as stork bites, angel kisses, or salmon patches. They appear in 40% of all newborns. Typically on the forehead or nape of the neck. Pink in color and does blanch when pressure is applied. No treatment is required and it usually Fades by 18 months |
|
|
What is melanocytic nevi? |
Also known as moles, uncommon in newborn, potential for malignancy, may be flat or raised, hair may be present and if it is, if it is noted along the base of this mind it could indicate a spina bifida congenital abnormality, do not fade on their own, can be removed surgically for cosmetic considerations / concerned about malignancy later in life |
|
|
What is erythema toxicum neonatorum? |
Also known as newborn rash, appears on any part of the body except the palms and Soles, appears suddenly, disappears quickly really lasting more than 7 days, does not cause any discomfort for the newborn, does not require medical treatment |
|
|
What is acne neonatorum? |
Clogged hair follicles or pores, will resolve without treatment, causes no scarring |
|
|
What are milia? |
Sebaceous glands occluded with keratin, tiny white papules about 1 mm in size, usually disappear within 4 weeks, no special care |
|
|
What is dermal melanosis? |
Also known as Mongolian spots, common finding in infants have darker skin, flat and bluish gray or brown, located on the back or buttocks, most Disappear by 2 years of age but some finally fade away at adolescence |
|
|
What should a nurse assess when examining a newborn's head? |
Shape, circumference, suture lines, and fontanelles |
|
|
The molding or "cone head" appearance resolves within __ to __. |
3 to 5 days |
|
|
What is a cephalohematoma? |
A swelling on the head that does not cross the suture line; May worsen at first, but will resolve over days or weeks as the blood is reabsorbed |
|
|
What is caput succedaneum? |
It is the swelling of the scalp of a newborn caused by pressure from the uterus or vaginal wall during delivery; soft and spongelike with possible bruising; crosses suture lines; no treatment is needed and swelling will decrease over a few days |
|
|
What is the anterior fontanelle? |
Known as the soft spot, it is a diamond shaped area between the coronal and sagittal suture lines; and does a fibrous membrane that lies between the bones of the cranium that closes by 18 months |
|
|
What is the posterior fontanel? |
It is located midline on the back of the head between the sagittal and lambdoid suture; it should close by 2 months of age |
|
|
Fontanelles should be __. Bulging fontanelles may indicate __ whereas sunken fontanelles are associated with __. Missing or small fontanelles indicate __, which can interfere with ___. |
Flat; increased intracranial pressure; dehydration and decreased intracranial pressure; fused cranial bones; brain growth |
|
|
The eyes and eyelids should be examined for __ in __ and __. |
symmetry in size and location |
|
|
What abnormal findings during an eye assessment should be reported by the nurse? |
Yellow or red sclera Any exudate noted Drooping eyelids |
|
|
The nurse should note the ear __, __, and __. |
Size, shape, location |
|
|
True or false: A mature infant will have softer ear cartilage than a premature infant. |
False, immature infant will have firmer ear cartilage |
|
|
What abnormal findings during an ear assessment should be reported by the nurse? |
Abnormal folds, discharge, or irregularities of the pinna, or a lack of response to loud noises |
|
|
What is the typical placement of the ear in a neonate? |
In a horizontal line from the inner canthus of the eye |
|
|
What may low set ears indicate? |
A chromosomal abnormality |
|
|
An infant's nose should be __ with __. |
Midline with symmetrical nares |
|
|
True or false: A small amount of clear nasal discharge is expected in the newborn. |
True |
|
|
True or false: Newborns are obligatory mouth breathers, which means that the newborn breathes through the mouth much easier than the nose. |
False, they are obligatory nose breathers |
|
|
What does nasal flaring indicate? |
Difficulty breathing |
|
|
What abnormal findings should the nurse report from a nose assessment? |
Obstructed nasal passages, discharge from the nose that is not clear, anatomical abnormalities, nasal flaring |
|
|
The nurse should know any asymmetrical movement of the mouth or tongue, which could indicate __. |
Nerve injury from birth trauma |
|
|
If there is a large amount of bubbly saliva, the health care provider should be noted to evaluate the __. |
patency of the esophagus |
|
|
What are Epstein's pearls? |
White papules on the roof of the mouth or gums, sometimes appear as little emerging teeth but are really cysts, typically found on the midline of the palate and formed when the palate fused during early fetal development, not painful, usually disappear within a few weeks |
|
|
What abnormal findings should the nurse report from the mouth assessment? |
Asymmetrical movement of the lips or tongue, mucous membranes that are not pink, excessive bubbly saliva, absent suck reflex, hole in the palate |
|
|
What should the nurse assess when examining the infant's chest? |
Shape, size, and symmetry of movement, the size, shape of nipple formation, nipple placement |
|
|
What is gynecomastia? |
An enlargement of breast tissue due to maternal hormones, present in both genders |
|
|
What is galactorrhea? |
Also known as witches milk, it is a Milky appearing discharge from the nipples that resolves on its own as a hormone levels in the Infant drops, associated with neonatal gynecomastia |
|
|
What abnormal findings should the nurse report when conducting a chest assessment? |
Variation in chest size from the norm, any abnormalities in the placement or size of the nipples, pirulent or bloody discharge from the nipples |
|
|
What should the nurse assess in a respiratory assessment of a newborn? |
Breathing effort, chest movement, auscultation of the lung fields, presence of retractions, nasal flaring, and/or see saw movements of the chest and abdomen, respiratory rate |
|
|
True or false: A newborn's lung fields should sound clear at all times. |
False, the normal newborn will have wet sounds, such as crackles, for the first 24 hours after birth |
|
|
What abnormal findings should the nurse report when conducting a respiratory assessment? |
Respiratory rate less than 30 or more than 60 breaths per minute, apnea of more than 20 seconds, any abnormal sound other than crackles in the first 24 hours, increased work of breathing, seesaw chest movements, retraction of the skin around the ribs and sternum |
|
|
How can a nurse listen to the aortic valve area? |
Placing the stethoscope at the second intercostal space at the right of the sternum |
|
|
How can a nurse assess the pulmonic valve area? |
Placing the stethoscope at the second intercostal space to the left of the sternum |
|
|
What is Erb's point and what can a nurse assess there? |
It is the left lower sternal border located at the third intercostal space and does not reflect a particular valve sound but is a good location to evaluate the S2 heart sound |
|
|
How can a nurse assess the tricuspid valve area? |
Placing the stethoscope at the fifth intercostal space at both the left and right side of the sternum |
|
|
How can a nurse assess the mitral valve area? |
Placing the stethoscope at the fourth intercostal space at the left of the midclavicular line |
|
|
An infant's pulse rate and Rhythm should match the __. |
Apical pulse |
|
|
The test for CRT in the newborn is controversial because the refill time can be affected by ___, ___, and ___. |
decreased peripheral circulation, temperature of the foot, environmental temperature |
|
|
What abnormal findings should be reported by the nurse during a cardiovascular assessment? |
A heart rate below 110 beats per minute or above 160 beats per minute at rest, any extra heart sounds other than the normal S1 and S2 heart sounds, any abnormal heart sounds such as blowing, clicking, or mechanical sounds, which could indicate a murmur, any discrepancy between the peripheral pulses side to side or with the apical heart rate, a CRT greater than 3 seconds |
|
|
What should the nurse assess during an abdominal and gastrointestinal assessment? |
The abdomen's shape, contour, and movement, the umbilical stump, presence of bulging around the umbilicus, patency of the anus, auscultation of the abdominal bowel sounds, stool assessment |
|
|
Umbilical stump should be __ and __, with 2 __ and 1 __. |
white and gelatinous; arteries; vein |
|
|
Bulging around the umbilicus could indicate __, which could result in __. |
failure of the umbilical ring closure; an umbilical hernia |
|
|
There should be a bowel sounds present within __ to __ of birth. |
1 to 2 hours |
|
|
Meconium is made up of bile __ and __, ___ cells, lanugo, and debris shed from the __ during intrauterine life. |
salts and acids, epithelial cells, intestinal mucosa |
|
|
Meconium should be passed Within __. |
24 hours of birth |
|
|
What is Transitional stool? |
Stool by the second or third day which will have a greenish or yellowish seedy appearance |
|
|
After a few days, the breastfed infant's stool will have the appearance of __. |
mustard |
|
|
After a few days, the bottle fed infant's stool will have a __, __, or __ appearance. |
Tan, yellow, greenish |
|
|
True or false: A flat abdomen is an expected finding in a neonate. |
False, they should have a domed appearance due to immature abdominal muscles; a flat abdomen should be reported |
|
|
What abnormal findings should be reported by the nurse during an abdominal / GI assessment? |
Failure to pass a meconium stool within 24 hours, a closed anus, absence of bowel sounds after 2 hours, a flat abdomen |
|
|
True or false: In a healthy newborn, the labia will cover the clitoris. |
True |
|
|
True or false: Swollen labia or darker labia is an abnormal finding that must be reported. |
False, maternal hormones may cause this to happen |
|
|
True or false: Muscous and blood-tinged vaginal discharge in an infant needs to be reported right away. |
False, this is called pseudomenstruation and may be present for a few days until maternal hormone levels in the newborn decreases |
|
|
The male infant's penis should be __ and __, with the urethral opening __ at the __ of the penis. |
midline and straight; midline at the top |
|
|
The female genitalia should be inspected for placement of the __ and __. |
Labia and urinary meatus |
|
|
True or false: Until three to four years of age, the foreskin is usually tight. |
True |
|
|
True or false: Swelling and darkened appearance of the scrotum is a typical finding. |
True, this is due to maternal hormones |
|
|
Testes usually descend by the __ trimester and are approximately __ at birth. |
3rd; 1 cm |
|
|
What abnormal findings during a GU assessments need to be reported by the nurse? |
Lack of or decrease in urinary output, structural abnormalities of the genitals, undescended testicles |
|
|
The newborn should urinate Within ___. |
24 hours of birth |
|
|
Normal urine output for a neonate is __/kg/hr. |
1 to 2 ml |
|
|
True or false: Periodic jerking or twitching in a newborn is considered normal. |
True, however tremors are not considered a normal finding |
|
|
A high-pitched cry can indicate ___. |
an increase in intracranial pressure |
|
|
True or false: In infants who were premature, reflexes will be the same as more mature infants. |
False, premature infants will have a reduced response to reflex evaluation |
|
|
What abnormal findings during a neurological assessment of a newborn should the nurse report? |
Tremors, a high-pitched cry, abnormal pupillary responses, hypertonic or hypotonic positions, absent newborn reflexes |
|
|
True or false: The typical resting posture for newborn is flexed with good muscle tone. |
True |
|
|
When evaluating a newborn's limbs, they should be inspected for __, __, __, __, and __. |
symmetry, length, ROM, webbing, and number of digits |
|
|
True or false: It is typical to find that the feet are turned inward in a newborn. |
True, uterine position can sometimes cause this, but the nurse can gently try to straighten the foot and if it can't be straightened, you just caused by uterine position and will straighten out over time usually, but if the foot cannot be straightened because of resistance it should not be forced and the findings need to be reported |
|
|
Two tests are recommended to determine hip instability in the newborn. What are they and how are they done? |
Ortolani's maneuver--The infant is in a Supine position, The Examiner holds the infant's thigh with a thumb and places the index finger of the same hand over the greater trochanter. The hip is gently lifted and abducted while pushing gently down on the knee. If the hip is not stable, a clunk sound will be heard or felt. Barlow's test--The examiner places a thumb on the infant's thigh and uses the Palm in the same hand to press down on the knee. Apply gentle pressure, feeling for a just location with the middle finger of the same hand. These tests are considered positive for congenital hip dislocation if a click is observed. |
|
|
The newborn's spinal cord and back should be observed for __ and __. |
Curvatures and asymmetry |
|
|
Any nevi, dimples, or skin tags that appear on the midline of the back along the spine could indicate __. |
a spinal cord condition |
|
|
What abnormal findings in a musculoskeletal assessment should a nurse report? |
The absence of limbs are digits, structural abnormalities of any bones or muscles, lack of movement in a limb, asymmetrical thigh creases, unusual length of Limbs, positive ortolani's or Barlow's tests, the presence of any nevi, skin tags, or dimples on the spinal cord |
|
|
Some hospitals require a newborn pain assessment to be done ___ and ___, ___, and ___ a painful procedure. |
once a day; before, during, and after |
|
|
A commonly used Pain Scale for newborns is the ___. It can be used for infants less than __. |
NIPS (Neonatal Infant Pain Scale); 1 year |
|
|
Common medications a nursery nurse will administer to a newborn if they have not already received them include __, __, and in some cases __. |
Vitamin K, erythromycin ointment, first hepatitis B vaccine |
|
|
If the mother has Hepatitis B, an additional medication called ___ is given within 12 hours of birth to protect the baby against catching hepatitis B. |
Hepatitis B immune globulin |
|
|
A gestational age assessment may be indicated if the newborn appears __, __, __, or __. |
Preterm, post-term, small for gestational age, or large for gestational age |
|
|
The most widely used clinical tool for assessing gestational age is the ___. |
Ballard's tool |
|
|
The purpose of the initial bath is to ___. |
remove blood and other bodily fluids that could contaminate healthcare workers. |
|
|
The risks of bathing the newborn are __, __, and __. |
hypothermia, respiratory distress, and an increased oxygen need |
|
|
The Association of Women's Health, Obstetric, and Neonatal Nurses recommends that the newborn be bathed between __ and __ hours of birth if their temperature is at least __. |
2 to 4 hours; 36.8°C |
|
|
The WHO recommends waiting __ hours after birth to avoid interfering with __ and __. |
6 hours; bonding and the initiation of breastfeeding |
|
|
Though a variety of methods can be used for bathing an infant, a __ cleanser is used. |
pH neutral |
|
|
Newborn screening tests for a variety of __, __, and __ disorders, __ diseases, __ loss, and congenital __ disease. |
genetic, metabolic, and endocrine disorders; infectious diseases; hearing loss; congenital heart disease |
|
|
The four most commonly diagnosed conditions through newborn screening in the United States are: |
Hearing loss, congenital hypothyroidism, cystic fibrosis, and sickle cell disease |
|
|
How is a congenital heart defect screening conducted? |
It is connected on a 24 hour or older infant with pulse oximeter probes placed on the right hand and right foot. If there is a difference of more than 5% between the hand and foot, the test is considered positive and the healthcare provider must be notified so further testing can be ordered. |
|
|
The otoacoustic emission test measures a response produced in the __ by placing a probe __. |
inner ear; into the ear |
|
|
The auditory brainstem response measures the hearing from the __ to the __. Information is obtained by placing __ on the infant's __. |
ear; brainstem; electrodes; head |
|
|
True or false: Infants sometimes fail the first hearing screen due to fluid in the ears from birth. |
True, if it happens most hospitals repeat the test another time before discharge. The healthcare provider must be notified if the infant failed the hearing screen on the second attempt. Infants who failed the newborn screen should be retested in one month. |
|
|
To promote safety, parents need to be instructed about the use of the __, __ positions, holding and positioning, trimming of __, bathing, __ safety, and __ care. |
bulb syringe, sleeping positions, nails, car seat safety, and skin care |
|
|
Discharge teaching for newborn care should include __ and __ care, __ schedules, and elimination. |
umbillicus and circumcision care, feeding |
|
|
True or false: If parents accidentally draw blood during nail trims, they should apply pressure and a bandage. |
False, they should apply pressure with a sterile gauze pad. They should be instructed to never applying adhesive bandage because babies can dislodge the bandage and choke on it. |
|
|
What is the recommendation if a baby develops diaper rash? |
Change diapers frequently, clean the skin with warm water and avoid pre-moistened cleaning cloths, apply a barrier of zinc oxide to the skin, keep the diaper area open to air as long as possible before applying a clean diaper. |
|
|
True or false: The umbilical cord will turn from a whitish-blue to Black over a period of several days. |
True |
|
|
What is the average time frame for the umbilical stump to fall off? |
10 to 21 days |
|
|
True or false: the baby should be sponge bathed until the cord falls off. |
True |
|
|
True or false: the umbilical stump should be kept clean and moist. |
False, the umbilical stump should be kept clean and dry |
|
|
True or false: parents should be instructed to avoid pulling on the cord to dislodge it. When the cord falls off, small amount and bleeding may be noticed. |
True |
|
|
In Mexican culture, a coin may be placed over the umbilicus. This tradition is not harmful. The nurse should encourage the mother to __ the coin with __ before placing it over the umbillicus. |
clean the coin with alcohol |
|
|
True or false: After a circumcision, a small amount of blood tinged drainage maybe noticed in the diaper after the procedure. |
True |
|
|
true or false: A yellow crust may form on the circumcision site. |
True, this is normal |
|
|
The nurse needs to document the first time the newborn __ after a circumcision. |
urinates |
|
|
For a few days, a newly circumcised penis should be wrapped in a small amount of __ with a dab of __ to keep the penis from sticking to the diaper. |
gauze; petroleum jelly |
|
|
A newly circumcised penis needs to be kept __ and __. |
Clean and dry |
|
|
Parents of a newly circumcised baby should call if there is |
Discoloration of the penis, discharge from the penis or surgical site that includes pus, a spot of blood in the diaper larger than 2 inch, the baby does not urinate, a fever greater than 37.8 degrees Celsius, parents are able to calm or soothe the baby |
|
|
How can a parent prevent flat spots on the newborn's head? |
Arranging for supervised tummy time |
|
|
What is tummy time? |
Placing the belly on his or her tummy on a blanket on a clean floor for several minutes each day; this will help prevent flat spots as well as help the neck and shoulder muscles grow stronger so the baby can start to sit up and crawl |
|
|
What does feeding "on demand" mean? |
When the baby show signs of hunger such as crying, rooting, enjoying on hands, the baby should be fed. |
|
|
The general guideline for a breastfed baby is that they should be nursing every __ to __ hours. |
2 to 2.5 |
|
|
The general guideline for a bottle fed baby is it they should be fed every __ to __ hours. |
3 to 3.5 |
|
|
True or false: Unless recommended by the pediatrician, the baby does not need to be awakened at night for a feeding. |
True |
|
|
The breastfed newborn should be passing __ to __ seedy yellow bowel movements a day by day 5. |
4 to 5 |
|
|
Whether breast or bottle-fed, an infant should have __ to __ wet diapers a day. |
6 to 8 |
|
|
The bottle fed infant should have at least __ __ tan or yellow bowel movement per day. |
one large |
|
|
Typically, the healthy newborn requires about __ layer(s) of clothing more than the parent. |
one |
|
|
Parents should be encouraged to put a __ on the baby to prevent heat loss. |
hat/cap |
|
|
Some commercial baby wipes can be irritating to the skin. If that is the case, __ can be used in its place for the diaper area. |
Plain water with cotton squares |
|
|
True or false: It's suggested to use baby powder each day. |
False, talcum powder is not used for babies because of the risk of inhaling the talcum into the lungs. |
|
|
Most pediatrician schedule a follow-up appointment at __ for newborns. Those who lost 10% or more of the birth weight will probably be scheduled for an appointment __ after discharge for a weight check. |
2 weeks; 2 days |
|
|
Do not give a child with a cardiac condition oxygen without consulting a pediatric cardiology team. The indiscriminate use of oxygen can place a child at risk for __ and __. |
complications associated with cardiac stunts and subsequent perfusion |
|
|
Cyanotic heart defects or group of heart malformations or lesions that have __. |
Right to left blood flow shunts |
|
|
Normal oxygen saturations typically are greater than __. |
92% |
|
|
Cyanotic heart defects include |
Transposition of the great arteries Tetralogy of Fallot Hypoplastic left heart syndrome Tricuspid atresia |
|
|
Acyanotic heart defects are malformations or lesions that have a __. |
Left to right blood flow shunt |
|
|
Acyanotic heart defects can flood the lungs with excess blood flow, leading to ___. |
CHF |
|
|
Acyanotic heart defects include |
Patent ductus arteriosus Ventricular septal defect Atrial septal defect Aortic stenosis Pulmonary stenosis Coarctation of the aorta |
|
|
If CHF develops before __, it is because of a congenital defect. If CHF develops after __, the etiology is most likely from an acquired cause. |
One year of age; one year of age |
|
|
What are the cardinal signs of CHF? |
Tachycardia Cardiomegaly Tachypnea Hepatomegaly |
|
|
Kawasaki disease is one of the only conditions in which a child receives __ therapy. |
aspirin |
|
|
A 22 month toddler squats intermittently when walking. She is irritable, cyanotic, and is now appearing listless and progressively more unresponsive. The most likely cardiac malformation is |
Tetralogy of Fallot |
|
|
Oxygenated blood mixes in the fetal heart through a shunt between the pulmonary artery and the aorta. What is the name of the shunt? |
Ductus arteriosus |
|
|
What disease state increases the risk of delivering a baby with a congenital heart defect? |
diabetes |
|
|
What causes transposition of the great arteries? |
A malformation in the fetal development of the heart |
|
|
After a cardiac catheterization, postoperative nursing interventions for a child include |
Assessing pulses for Symmetry and strength Assuring continuous cardiac monitoring and pulse oximetry to monitor for dysrhythmias, bradycardia, hypotension, hypoxia and hypoxemia Maintaining the affected extremity in a flat position for 4 to 8 hours to prevent post-procedure bleeding Assessing I&O closely for sufficient urinary output, dehydration, or hypovolemia Assessing for the pain level using a developmentally appropriate tool for that child |
|
|
A term newborn is diagnosed with transposition of the great arteries. What is the priority nursing intervention to be instituted immediately? Why is this critical? |
Establishing IV access and initiating a PGE1 drip, which maintains the patency of the ductus arteriosus by dilating vessels and inhibiting clotting. This allows blood flow through the ductus arteriosus and maintains perfusion before a surgical intervention is performed to reroute the blood flow and repair the PDA. |
|
|
When assessing the conduction system of the heart by looking at an EKG strip, the P wave indicates that which area in the heart has fired an electrical impulse? |
The SA node |
|
|
Pediatric heart failure is most common in infants with CHD, but can present in older children due to |
Myocarditis |
|
|
Subacute bacterial endocarditis is a(n) __ in the __. |
infection in the lining of the heart |
|
|
Risk factors for Subacute bacterial endocarditis include |
Congenital cyanotic heart disease The presence of central venous catheters IV medication use Rheumatic fever Residual post-operative defect or cardiac catheterization |
|
|
The primary symptoms of Subacute bacterial endocarditis are __ that last more than __. |
flu-like symptoms; 2 weeks |
|
|
It is imperative to reinforce teaching for parents about ___ before dental procedures. |
Prophylactic oral antibiotic therapy |
|
|
After a diagnosis of Kawasaki disease, follow-up care with an echocardiogram every __ to __ is recommended. |
1 to 2 years |
|
|
After a diagnosis of rheumatic fever, follow up appointments are held every __. |
5 years |
|
|
Digoxin is to be administered every __ unless __. |
12 hours unless their HR is below the specified number |
|
|
What are signs of digoxin toxicity? |
Decreased heart rate Nausea and vomiting loss of appetite |
|
|
If a dose of digoxin is missed, what should be done? |
Do not give an extra dose or increase the dose. |
|
|
What should a parent do if a digoxin dose is vomited? |
Do not repeat the dose. |
|
|
Following digoxin administration, __ should be given to prevent __. |
water; tooth decay |
|
|
The nurse notes that the newborn's respiratory rate is 42 breaths per minute, the pulse is 140 beats per minute, and the CRT is less than 3 seconds. The nurse should: |
Document the findings as normal. |
|
|
The nurse is most concerned about which of the following assessment findings? 1. Gynocomastia 2. Positive ortolani's test 3. Pseudomenstruation 4. Dermal melanosis |
2. Positive ortolani's test |
|
|
A sponge bath should not be given to the newborn until |
The umbilical cord falls off and the circumcision is healed. |
|
|
Which of the following assessment findings should be reported? 1. Undescended testicles 2. Periodic mild twitching 3. Yellowish skin color 4. Stork bites on the forehead 5. Bulging anterior fontanelle 6. Absent Moro reflex 7. Irregular breathing pattern |
Undescended testicles Yellowish skin color Bulging anterior fontanelle Absent Moro reflex |
|
|
What is the purpose of starting the hepatitis B vaccine series shortly after birth? |
To prevent the infant from contracting hepatitis B from family members. |
|
|
A new mother asks the nurse if she should get her baby circumcised. The best response by the nurse is: |
What are your questions or concerns about it? |
|
|
The newborn shows signs of hunger in which state? |
Active alert |
|
|
A term newborn has just been born. Which intervention should receive the highest priority? 1. Conducting the five-minute apgar score 2. Injecting vitamin K 3. Removing wet blankets 4. Applying the identification band |
3. Removing wet blankets |
|
|
A newborn is in the first period of reactivity. What action should the nurse take at this time? |
Encourage bonding and breastfeeding. |
|
|
A newborn has just been delivered. Which of the following physiological changes is of the highest priority? 1. Passing meconium stool 2. Closure of the ductus venosus 3. Spontaneous respirations 4. Thermoregulation |
3. Spontaneous respirations |
|
|
A baby can lose heat by evaporation if which of the following situations occurs? 1. The mother unwraps the baby to show a visitor. 2. The nurse places the baby crib near the air conditioner vent. 3. The baby is placed in a cold crib. 4. The baby is wet from amniotic fluid. |
4. The baby is wet from amniotic fluid. |
|
|
Which of the following changes occur in the cardiovascular system when the newborn transitions from the uterus to extrauterine life? 1. The right ventricle has increased pressure. 2. There is increased blood flow through the lungs. 3. Blood is shunted from the pulmonary artery to the aorta. 4. The ductus arteriosus closes. 5. Blood flow to the liver increases. |
2. There is increased blood flow through the lungs. 4. The ductus arteriosus closes. 5. Blood flow to the liver increases. |
|
|
A breastfeeding mother is complaining that she has sore nipples. The nurse should: 1. Observe her latch on technique with the infant. 2. Suggest that she only breastfeed for 5 minutes on each side. 3. Suggest that she changed breastfeeding positions. 4. Suggest that she give the baby a bottle for a couple of feedings. 5. Suggest that she switch to bottle-feeding. |
1. Observe her latch on technique with the infant. 3. Suggest that she change breastfeeding positions. |
|
|
A new father states, "As soon as we take the baby home, I am going to be feeding him a little bit of cereal between feedings." The best response by the nurse is: |
Babies don't need solid food until about 6 months of age. |
|
|
A new father states, "As soon as we take the baby home, I am going to be feeding him a little bit of cereal between feedings." The best response by the nurse is: |
Babies don't need solid food until about 6 months of age. |
