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nursing > 102 Newborn Assessment > Flashcards

102 Newborn Assessment Flashcards

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1
Q

Pulse

A

120-160

Regular rhythm

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2
Q

Respirations

A

30-60

Irregular but un-labored (no nasal flaring or grunts)

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3
Q

High or low Respirations may indicate ?

A

High could mean infection

Low could mean sepsis or increased intracranial pressure

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4
Q

Blood pressure

A

Varies with gestational age/activity

Systolic 50-75
Diastolic 30-45

Arm or leg

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5
Q

Order should take vitals on baby

A

RR, HR, temp, BP if needed

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6
Q

What peripheral pulses should you check

A

Brachial, femoral, pedal

Circulation, rate, volume, equality, strength

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7
Q

Normal weight range

A

2500-4000g (5 lb 8 oz- 8lb 13oz)

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8
Q

How much weight does baby lose first few days and why

A

10% Bc not constant nutrition from mom, void/bm, activity, calories for warmth

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9
Q

How long to get back to birth weight

A

10 days

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10
Q

Normal head circumference and length

A

Head- 33-35.5

Length- 45-53cm

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11
Q

Tremors may indicate

A

Cold, low blood sugar

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12
Q

Normal baby posture

A

Extremities flexed, hands clenched, symmetrical movements, slight tremors on crying

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13
Q

acrocyanosis

A

Blue hands/feet

Normal with pink/tan skin

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14
Q

Mottling

A

Pink w/ white blotches usually Bc cold

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15
Q

Mongolian spots

A

May look like bruising

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16
Q

Hemangiomas

A

Dilated blood vessels- usually fade

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17
Q

Nevi

A

Birth mark

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18
Q

Cafe au lait spot

A

Some correlation of neurofibrosis

19
Q

Depressed fontanel

A

Dehydration

20
Q

newborn head fontonel close?

A

Anterior (diamond) closes 18 months

Posterior (triangle) closes 2-4 months

21
Q

Newborn temp

A

97.7-99

22
Q

Caput succedaneum

A

Edema of soft tissue in head from delivery trauma; resolved within week; watch for jaundice

23
Q

Cephalhematoma

A

Same as caput succedaneum except crosses suture line (edema both sides)

24
Q

Normal ears position etc

A

Pin a at level of outer canthus of eye, skin tags common, positive startle reflex to loud noises

25
Q

two ear issues

A

Low-set ears may indicate developmental issues

Problem w ears= problem w kidneys maybe Bc develop at same time

26
Q

Eye assessment

A 
Symmetry 
Iris- blue/grey 
Sclera- white 
Follows object within 12 inches 
No tears until 2 months
Eye color permanent at 6 months
27
Q

Eye issues

A

Puffy/bruise from birth trauma

Cross eyed common Bc need to develop muscles

28
Q

Nasal flaring

A

Respiratory distress

29
Q

Epstein pearls

A

Cysts w epithelial cells on gums, will go away on own

30
Q

Normal chest

A

Cylindrical/barrel shaped/symmetrical

Nipples, breast buds/engorgement/drainage due to moms hormones

Crackles within first few hours after birth

31
Q

Normal abdomen

A

Round, soft, bowel sounds

Umbilical cord- 3 vessels, whitish/blue, no drainage

32
Q

Umbilical cord abnormality

A

Only 2 vessels vs 3 indicates GI/GU issues, and possibly heart issues

33
Q

Umbilical cord care

A

Clamp for 24 hrs for bleeding; clamp off when looks dry

Falls off at about 2 weeks

Shouldn’t bathe until no cord Bc infection

Keep CLEAN and DRY

34
Q

Hydrocele

A

Scrotum filled with fluid so swollen

35
Q

Circumcision care

A

Petroleum jelly + dressing for 24 hrs for gomco and mogen

No ointment for plastibell instrument

Monitor voiding, bleeding, infection

Gauze dressing

36
Q

Urination

A

Void 1-2 times first 24 hrs
Irate crystals on diaper
6-8 wet diapers a day

37
Q

Mecomiun

A

Black tarry stool (first infant stool within 24 hrs)

38
Q

Rooting/babinski reflex

A

Touch bottom of foot and toes spread

39
Q

Meds students responsible for (infant)

A

Vitamin k shot (blood clotting) and erythromycin ointment (antibiotic- put in eyes)

Formula is dr order

40
Q

Bulb syringe

A

Gently suction mouth then nose

41
Q

Feeding

A 
Never microwave formula 
Feed every 3-4 hours 
Burp half way (10ml) and at end 
New bottle every feed 
HOB elevated 20-30 mins after
42
Q

Propping bottle

A

Never prop:

Aspiration
Dental carries
Ear infections

43
Q

Breast feeding

A

First hr after birth (.delivery room)
Skin to skin
Supply and demand

44
Q

Potential illness

A

Change behavior, floppy arms/legs, loss appetite, decrease wet diaper #, temp > 99.3, fontanels sunken or bulging, jaundice, skin rash, bleeding/odor from circumcision or cord, congestion, lethargy, watery/green stool, vomit, blue lip/blue and pale skin

nursing (14 decks)

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