102 Newborn Assessment Flashcards
Pulse
120-160
Regular rhythm
Respirations
30-60
Irregular but un-labored (no nasal flaring or grunts)
High or low Respirations may indicate ?
High could mean infection
Low could mean sepsis or increased intracranial pressure
Blood pressure
Varies with gestational age/activity
Systolic 50-75
Diastolic 30-45
Arm or leg
Order should take vitals on baby
RR, HR, temp, BP if needed
What peripheral pulses should you check
Brachial, femoral, pedal
Circulation, rate, volume, equality, strength
Normal weight range
2500-4000g (5 lb 8 oz- 8lb 13oz)
How much weight does baby lose first few days and why
10% Bc not constant nutrition from mom, void/bm, activity, calories for warmth
How long to get back to birth weight
10 days
Normal head circumference and length
Head- 33-35.5
Length- 45-53cm
Tremors may indicate
Cold, low blood sugar
Normal baby posture
Extremities flexed, hands clenched, symmetrical movements, slight tremors on crying
acrocyanosis
Blue hands/feet
Normal with pink/tan skin
Mottling
Pink w/ white blotches usually Bc cold
Mongolian spots
May look like bruising
Hemangiomas
Dilated blood vessels- usually fade
Nevi
Birth mark
Cafe au lait spot
Some correlation of neurofibrosis
Depressed fontanel
Dehydration
newborn head fontonel close?
Anterior (diamond) closes 18 months
Posterior (triangle) closes 2-4 months
Newborn temp
97.7-99
Caput succedaneum
Edema of soft tissue in head from delivery trauma; resolved within week; watch for jaundice
Cephalhematoma
Same as caput succedaneum except crosses suture line (edema both sides)
Normal ears position etc
Pin a at level of outer canthus of eye, skin tags common, positive startle reflex to loud noises
two ear issues
Low-set ears may indicate developmental issues
Problem w ears= problem w kidneys maybe Bc develop at same time
Eye assessment
Symmetry Iris- blue/grey Sclera- white Follows object within 12 inches No tears until 2 months Eye color permanent at 6 months
Eye issues
Puffy/bruise from birth trauma
Cross eyed common Bc need to develop muscles
Nasal flaring
Respiratory distress
Epstein pearls
Cysts w epithelial cells on gums, will go away on own
Normal chest
Cylindrical/barrel shaped/symmetrical
Nipples, breast buds/engorgement/drainage due to moms hormones
Crackles within first few hours after birth
Normal abdomen
Round, soft, bowel sounds
Umbilical cord- 3 vessels, whitish/blue, no drainage
Umbilical cord abnormality
Only 2 vessels vs 3 indicates GI/GU issues, and possibly heart issues
Umbilical cord care
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
Hydrocele
Scrotum filled with fluid so swollen
Circumcision care
Petroleum jelly + dressing for 24 hrs for gomco and mogen
No ointment for plastibell instrument
Monitor voiding, bleeding, infection
Gauze dressing
Urination
Void 1-2 times first 24 hrs
Irate crystals on diaper
6-8 wet diapers a day
Mecomiun
Black tarry stool (first infant stool within 24 hrs)
Rooting/babinski reflex
Touch bottom of foot and toes spread
Meds students responsible for (infant)
Vitamin k shot (blood clotting) and erythromycin ointment (antibiotic- put in eyes)
Formula is dr order
Bulb syringe
Gently suction mouth then nose
Feeding
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
Propping bottle
Never prop:
Aspiration
Dental carries
Ear infections
Breast feeding
First hr after birth (.delivery room)
Skin to skin
Supply and demand
Potential illness
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
