ch 24 newborn nursing care Flashcards
adequate neonate heartrate at birth
> 100 bpm
at what bpm do chest compressions start for neonate at birth
<60 bpm
*don’t wait for apgar score
initial care for baby’s airway at birth
-wipe mouth and nose
-maybe suction mouth then nose with bulb syringe
initial care for baby’s thermoregulation at birth
-quickly dry infant
-place skin to skin or under radiant heat
-remove wet linens
when are apgar scores done
1 min
5 min (if >7, repeated q5mins until score of 7 or after 20 mins)
heart rate scoring on apgar
0: absent
1: <100 bpm
2: >100 bpm
resp effort scoring on apgar
0: absent
1: slow, irreg, weak cry
2: good cry
muscle tone scoring on apgar
0: flaccid, limp
1: some flexion of extremities
2: well flexed
reflex irritability scoring on apgar
0: no response
1: grimace
2: cry
what does APGAR stand for
appearance
pulse
grimace
activity
respiration
color scoring on apgar
0: blue or pale
1: body pink, extremities blue
2: all pink
what does apgar score 4-6 mean
moderate distress
what does apgar score 0-3 mean
severe distress
what does apgar score 7-10 mean
minimal to no distress
general appearance of baby at birth
-skin color
-posture
-alert
-active
-head: molding, caput
general assessment of baby’s respiratory system at birth
-airway patent (nasal patency)
-no upper airway congestion
-no retractions or nasal flaring
-RR 30-60/min
-bilateral breath sounds clear and equal (some crackles ok)
-chest expansion symmetrical
general assessment baby’s neurologic system at birth
-moves extremities
-normal tone
-symmetric features and movements
-reflexes present (rooting/sucking, moro, grasp)
-anterior fontanel soft and flat
-spine intact
general assessment baby’s GI system at birth
-abdomen soft, rounded, not distended
-cord attached and clamped securely
-anus appears patent (note meconium passage)
general assessment baby’s eyes, nose, mouth at birth
-eyes clear
-palate intact
-nares patent
general assessment baby’s skin at birth
-no yellow/green staining of skin, nails, cord (meconium)
-no signs birth trauma
-no abrasions/lesions
general assessment baby’s GU at birth
-normal genitalia
-note voiding
general assessment baby’s extremities at birth
10 fingers and 10 toes
initial care interventions at birth
-airway maintenance
-thermoregulation
-promoting attachment
-ID of newborn (bracelet)
-meds
first hour after life
golden hour
meds given at birth (after 1-2 hrs)
-eye ointment
-vitamin K
-hep b vaccine (any time before discharge)
generic name for vitamin k vaccine
phytonadione
what med is given in eye prophylaxis ointment
erythromycin or tetracycline
what does eye prophylaxis prevent?
what STIs cause it?
-prevents ophthalmia neonatorum (blindness)
-chlamydia and gonnorrhea
*TABLE 24.3
2 important considerations when doing neonatal assessment
-normothermic environment (have a heat source)
-sequencing of assessments (depending on how baby reacts)
full physical exam: general appearance
-posture
-color
-resp effort
-activity
-state of alertness
-obvious anomalies
-signs of birth trauma
4 things that affect posture
-position in utero
-oxygenation status
-neurologic status (premature = floppy)
-gestational age
(skin) a lot of color - more red than usual
plethoric
(skin) half is red, half is pale. normal variation. immaturity of vascular system
harlequin sign
types of cyanosis
-generalized
-circumoral (around mouth)
-acrocyanosis (normal)
(skin) red and white splotchy pattern. normal or can be sign of problem
mottling
abnormal colors in skin assessment
-grey
-dark red
-cyanotic
-generalized petechaie
-generalized ecchymoses
-meconium staining
-jaundice (before 24 hrs)
-vesicles
-cafe-au-lait spots (normal unless more than 5-6, >0.5 cm in diameter)
what pulses should be assessed on newborn full assessment
-brachial
-femoral
-popliteal
-posterior tibial
normal temp for baby
36.5-37.5 C
97.7-99.5 F
-axillary
normal weight
2700-4000 g (6-9 lb)
normal length
48-53 cm (19-21 in)
normal head circumference
32.5-37.5 cm
-measure in semi-sitting position at biggest part of head
normal chest circumference
2-3 cm < head
-at nipple line
-may be equal to head if has cone head
full physical exam: assessment of skin
-vernix caseosa (only in creases in term baby)
-plump
-lanugo
-creases in palms and feet
-desquamation (peeling of skin)
-milia (baby acne)
-mongolian spots (blue/brown spot low back in dark-skinned baby)
-telangiectatic nevi “stork bites”
-erythema toxicum/neonatorum “flea bite/newborn rash”
-harlequin sign
-plethora
-petechiae/ecchymoses over presenting part
what could one single crease on palm of hand indicate
genetic disorders
skin assessment abnormals
-jaundice within first 24 hours
-nevus vasculosus “strawberry birth mark”
-nevus flammeus “port wine stain”
-abnormal skin colors
full physical assessment: head
-inspection (size, shape, symmetry, caput succedaneum, molding, cephalohematoma, mark from FSE)
-palpation (fontanels, sutures, hair)
swelling of scalp in newborn
caput succedaneum
collection of blood underneath scalp in periosteum of bone in newborn
cephalomematoma
how to differentiate between caput succedaneum and cephalohematoma
-does it cross the suture line? yes: caput
no: cephalohematoma
consequence from cephalohematoma
jaundice
full physical exam: face
-eyes: placement, movements, blinking, presence of eyeballs, PERRL
-shape and patency of nose
-ears: placement (in relation to eyes), amount of cartilage, open auditory canal
eyes: appears cross eyed, light reflects in same space in eyes
pseudostrabismus
eyes: cross eyed, light does not reflect in same space in eyes
strabismus
what are low set ears associated with
chromosomal anomalies
what can pre-auricular skin tags be associated with
renal insuffiency
(may be normal)
*watch urine output
full physical exam: mouth
-placement, color, configuration, movement
-color of gums
-tongue: attachment, mobility, movement
-palate (soft and hard)
-reflexes: rooting, sucking, extrusion
full physical exam: neck
-inspect and palpate length (short fatty neck)
-evaluate for webbing
-nuchal rigidity
-trachea midline, thyroid nonpalpable
-palpate clavicles
-moro reflex
what is webbed neck associated with
chromosomal anomalies, especially turners syndrome (missing second sex chromosome)
full physical exam: chest
-inspect and palpate: shape, resp movements, ribs, palpate PMI, nipple size number and placement, breast tissue
-auscultate: heart sounds and rate, breath sounds
full physical exam: breasts
-swelling
-supernumery nipple
-nipple size, number, placement
full physical exam: abdomen
-shape: rounded
-note movement w/ resps
-umbilical cord (inspect, palpate, smell)
-auscultate bowel sounds
-palpate abdomen
-note # and character of stools
how many vessels in umbilical cord
1 vein
2 arteries
what is a 2 vessel umbilical cord associated with
renal issues
abdominal abnormality: herniation of abdominal contents into base of umbilical cord, associated with many syndromes and chromosomal disorders
omphalocele
abdominal abnormality: intestines are protruding from abdomen
gastroschisis
full physical exam: genitalia (male)
-general appearance: penis, prepuce (foreskin), location of urinary meatus
-scrotum: rugae, testes descended bilaterally
2 abnormalities of male genitalia in location of urinary meatus
hypospadias
epispadias
2 abnormalities of male genitalia in testes
-cryptochidism
-hydrocele (swelling)
full physical exam: genitalia (female)
-general appearance: maybe edematous (clitoris, labia majora, labia minora)
-vagina: hymenal tag
-discharge: smegma, pseudomenstruation (normal, results from withdrawal of mother’s hormones)
-urinary meatus: difficult to see beneath clitoris
vaginal discharge from baby girl
smegma
normal elimination patterns for newborn
-void within 1st 24 hours
-meconium within 1st 2 days
full physical exam: back
inspect and palpate
-spine: straight, easily flexed, shoulders, scapulae and iliac crests line up
-base of spine and sacrum: tufts of hair
abnormalities of spine during assessment
-masses
-openings
-curving of spine (scoliosis)
-pilonidal dimple (associated with spina bifida)
full physical exam: extremities
-degree of flexion and muscle tone
-range and symmetry of motion
-developmental dysplasia of hips (DDH)
-number of digits, webbing
-creases
S+S dislocated hip (developmental dysplasia of hips)
-nonsymmetrical gluteal folds
-apparent femur length nonsymmetrical
-(dr) ortolani’s maneuver: hip click
too many toes
polydactyly
technical name for club foot, foot rotated inward
talipes equinovarus
*check to make sure not just a positional issue (can straighten)
full physical exam: S+S normal jitteriness/tremors
-transient
-most often during crying
-involves mouth, chin, and hands
-doesn’t occur when infant is quiet
-doesn’t persist > 1 mo
risk factors tremors/jitteriness/irritability of hypoglycemia
-infant of diabetic mother
-large for gestational age (>4000 g)
-small for gestational age (<2500 g)
-premature (<37 wk)
S+S tremors/jitteriness/irritability of hypoglycemia
-high pitched cry
-lethargy
-decreased tone
-poor suck/feed
S+S seizure
-doesn’t stop when holding the body part
-associated with ocular changes (eyes deviated or staring)
full physical exam: neuromuscular system
-normal jitteriness/tremors
-posture and tone
-reflexes
full physical exam: anus
-placement
-number
-patency
-“wink” reflex
gestational age assessment (dubowitz/new ballard scale)
-what is normal for term baby in neuromuscular maturity
neuromuscular maturity
-posture: flexed
-square window: thumb to wrist
-arm recoil: return to flexed position
-popliteal ange: 90 or <90
-scarf sign: arm wraps around front of baby (elbow to first nipple)
-heel to ear: low high kick
gestational age assessment
-what is normal for term baby in physical maturity
physical maturity:
-skin: deep cracking, no vessels
-lanugo: mostly bald
-plantar surface: creases over entire sole
-breast: full areola 5-10 mm bud
-eye/ear: thick cartilage, stiff ear
-genitals (male): pendulous testes, deep rugae
-genitals (female): majora covers clitoris and minora
*gestational age assessment preterm findings
3 classifications of newborns by gestational age and birth weight
-appropriate for gestational age (AGA)
-large for gestational age (LGA)
-small for gestational age (SGA)
what are SGA babies at increased risk for (5)
-perinatal asphyxia
-meconium aspiration syndrome
-excessive heat loss
-hypoglycemia
-infection
what are LGA babies at increased risk for (3)
-meconium aspiration syndrome
-hypoglycemia
-birth trauma
how often are VS taken on newborn baby
T, HR, RR, color, activity, voids/stools:
-q30min x 2 hr
-q1h x 4-5 hr or until stable
-q8h until discontinued (T may be q4-6h)
+daily weights (weigh at same time every day without diaper)
common actual/potential problems in newborns
-impaired gas exchange
-hypothermia
-infection
-hypoglycemia
-hyperbilirubinemia
goals for impaired gas exchange
-color: pink or pink w/ acrocyanosis
-central cap fill time <4 secs
-HR 110-160 bpm
-RR 30-60 breaths/min
-no nasal flaring, grunting, or retractions
risk factors for impaired gas exchange (4)
-inability to clear airway (mucus, MSF, resp malformations)
-cold stress
-ineffective resp transition (preterm, stressful birth, resp malformations)
-cardiovascular complications/anomalies
interventions for impaired gas exchange
-observe infant continuously first 2-4 hours of life
-wipe mouth and nose prn; suction with bulb syringe for obstruction
-keep bulb syringe immediately available (mouth then nose)
-if necessary (turn to stomach/side, pat firmly on back, hold head lower than feet)
risk factors hypothermia
-exposure to heat loss
-SGA, LBW, preterm
-infections
LBW
low birth weight <2500 g
S+S hypothermia
-resp distress
-temp (axillary) <36.5
interventions for hypothermia
-assess axillary temp q1h x 4-6h
-delay bath until temp stable at 36.5-37.5
-protect from heat loss during procedures
-cap
-double wrap in warm blankets
-rewarm hypothermic infant slowly
-keep infant warm and dry
-skin to skin
when would you bathe baby asap (before injections)
-positive/unknown for hep b and HIV
-active infection
where is temp probe placed on baby for monitoring
-RUQ
-never over a bone
risk factors infection
-in utero infections (chorio)
-prolonged ROM (>18h)
-preterm
-complicated birth
-out of facility birth
-active maternal infections
-hospital acquired infections
S+S infections
-temp instability
-resp problems
-tachycardia
-poor feeding
-drainage, redness
-diarrhea
prevention of infection interventions
-handwashing
-avoid borrowing supplies/equipment between infants
-good cord care (clean wet washrag, fold diaper under cord)
-don’t kiss infant or hold close to face
-screen visitors for infections
-circumcision care if applicable
-hep b vaccine (if ordered/consented)
-prophylactic ophthalmic ointment
temporary consequence of erythromycin eye ointment
-blurred vision
-edema, redness
-can wipe away extra ointment after one minute
what baby gets hep b immunoglobulin
Hep B surface antigen positive moms
interventions for umbilical cord care
-remove clamp when cord is dry (24-48 h)
-fold diaper below cord
risk factors hypoglycemia
-birth weight >4000 g
-diabetic mother
-LGA, SGA
-preterm
-stressful labor/birth
-cold stress
S+S hypoglycemia
-jitteriness
-weak, high pitched cry
-*lethargy
-irregular resp efforts
-apnea
-feeding difficulties
-twitching, seizures
classification of hypoglycemia
<40
prevention of hypoglycemia
-protect for intrapartum stress
-early and frequent feedings
-protect from hypothermia
Tx hypoglycemia
-feed
-sometimes IV
risk factors hyperbilirubinemia
-preterm
-delayed/ineffective feeding
-delayed passage meconium
-maternal-fetal blood incompatibility
-enclosed hemorrhage
S+S hyperbilirubinemia
-visual jaundice with blanching
-TcB >12-15
-serum >95% for age (or >1.5-2 mg/dL)
Tx hyperbilirubinemia
-assess feeding once per shift
-early and frequent feedings
-phototherapy
nursing interventions for phototherapy
-dress baby in diaper only
-protect eyes
-avoid ointments, creams, lotions
-monitor temp, urine output and stools
-good diaper care
-maintain hydration with frequent feeds
procedure for heel stick
-warm heel
-cleanse with alcohol
-restrain foot
-puncture site
-wipe away first drop blood with sterile gauze
-obtain sample
-pressure with sterile gauze, bandaid
-comfort baby
where do you do the heel stick on baby
lateral side of heel
(lateral to space between 4th and 5th toe)
or medial (medial to inner half of big toe)
potential complications of heel stick
-necrotizing osteochrondritis
-fibrosis and scarring on walking surface, problems walking
NMC
newborn male circumcision
benefits of circumcision
-decreased UTIs in males <1yo
-decreased risk penile cancer
-decreased risk heterosexual acquisition of STI (especially HIV)
risks of circumcision
-cold stress
-hypoglycemia
-aspiration
-bleeding
-infection
-cutting too much/damaging penis
procedure of circumcision
-NPO up to 2-3 hrs prior
-place in restraint
-drape for warmth and sterile field
-antiseptic prep
-pain management
-gomco (yellen) or mogen clamp or plastibell
benefit of mogen clamp circumcision
clamp minimizes blood loss and protects glans
benefit of plastibell’s circumcision
-provides pressure
-prevents infection
-keeps urine off
-remains in place for one week
pain relief with and after circumcision
-nerve block
-topical EMLA cream
-oral acetaminophen
-sweeties
-swaddling
-breastfeeding after
what should be covering penis after circumcision
sterile vasaline gauze
post-circumcision care
-avoid prepackaged diaper wipes
-cleanse with water
-reapply vaseline gauze
-change diaper atleast q4h
-DONT remove yellow exudate that appears in 24 hrs
-provide comfort
-void before going home
how often do you assess after circumcision (hemorrhage risk)
-q15min x 1 hr
-q30min x 4-6hr
-hourly until 12 hours
must void before going home
for bleeding: gentle pressure with sterile gauze
physiologic S+S acute pain
-increased HR, BP, RR
-pallor or flushing
-diaphoresis
-increased muscle tone
-dilated pupils
behavioral S+S acute pain
-vocalizations
-grimace
-brow furrowed
-chin quiver
-eyes squeezed shut
-limb withdrawal from stimuli
-changes in sleep wake cycles
-changes in feeding patterns
tools for assessing pain
-neonatal infant pain scale (NIPS)
-premature infant pain profile (PIPP)
-neonatal pain agitation and sedation scale (NPASS)
nonpharmacologic management acute pain
-swaddling
-breastfeeding
-oral sucrose
-skin to skin
pharmacologic management acute pain
-local and topical anesthesia
-nonopioid analgesia: acetaminophen drops
-opioid analgesia for surgery (morphine, fentanyl)
what is included in universal newborn screen (3)
-hearing screen
-blood screen
-congenital heart disease
when is dried blood test repeated after birth (mandated by law)
2 weeks
when is critical congenital heart defect test performed
24-48 hours after birth
what is considered a pass in critical congenital heart defect (CCHD) test? what requires immediate evaluation?
-pulse ox on R hand and foot
-O2 >95% in either extremity and <3% difference between extremities
-90-95% requires followup
what needs to be taught to pts for discharge
-temp
-resps
-feeding patterns
-elimination
-sleeping, positioning, and holding: safe sleep, safe crib, SIDS
-rashes (diaper and other)
-clothing
-car seat safety (rear facing)
-nonnutritive sucking (pacifier)
-bathing
-cord care
-skin care
-infant followup care (immunizations and CPR)
*READ PAGES 522-530
consequence of baby powder
risk of irritation of lungs if inhaled
