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OB > ch 24 newborn nursing care > Flashcards

ch 24 newborn nursing care Flashcards

1
Q

adequate neonate heartrate at birth

A

> 100 bpm

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2
Q

at what bpm do chest compressions start for neonate at birth

A

<60 bpm
*don’t wait for apgar score

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3
Q

initial care for baby’s airway at birth

A

-wipe mouth and nose
-maybe suction mouth then nose with bulb syringe

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4
Q

initial care for baby’s thermoregulation at birth

A

-quickly dry infant
-place skin to skin or under radiant heat
-remove wet linens

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5
Q

when are apgar scores done

A

1 min
5 min (if >7, repeated q5mins until score of 7 or after 20 mins)

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6
Q

heart rate scoring on apgar

A

0: absent
1: <100 bpm
2: >100 bpm

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7
Q

resp effort scoring on apgar

A

0: absent
1: slow, irreg, weak cry
2: good cry

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8
Q

muscle tone scoring on apgar

A

0: flaccid, limp
1: some flexion of extremities
2: well flexed

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9
Q

reflex irritability scoring on apgar

A

0: no response
1: grimace
2: cry

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10
Q

what does APGAR stand for

A

appearance
pulse
grimace
activity
respiration

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11
Q

color scoring on apgar

A

0: blue or pale
1: body pink, extremities blue
2: all pink

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12
Q

what does apgar score 4-6 mean

A

moderate distress

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13
Q

what does apgar score 0-3 mean

A

severe distress

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14
Q

what does apgar score 7-10 mean

A

minimal to no distress

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15
Q

general appearance of baby at birth

A

-skin color
-posture
-alert
-active
-head: molding, caput

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16
Q

general assessment of baby’s respiratory system at birth

A

-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

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17
Q

general assessment baby’s neurologic system at birth

A

-moves extremities
-normal tone
-symmetric features and movements
-reflexes present (rooting/sucking, moro, grasp)
-anterior fontanel soft and flat
-spine intact

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18
Q

general assessment baby’s GI system at birth

A

-abdomen soft, rounded, not distended
-cord attached and clamped securely
-anus appears patent (note meconium passage)

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19
Q

general assessment baby’s eyes, nose, mouth at birth

A

-eyes clear
-palate intact
-nares patent

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20
Q

general assessment baby’s skin at birth

A

-no yellow/green staining of skin, nails, cord (meconium)
-no signs birth trauma
-no abrasions/lesions

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21
Q

general assessment baby’s GU at birth

A

-normal genitalia
-note voiding

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22
Q

general assessment baby’s extremities at birth

A

10 fingers and 10 toes

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23
Q

initial care interventions at birth

A

-airway maintenance
-thermoregulation
-promoting attachment
-ID of newborn (bracelet)
-meds

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24
Q

first hour after life

A

golden hour

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25
Q

meds given at birth (after 1-2 hrs)

A

-eye ointment
-vitamin K
-hep b vaccine (any time before discharge)

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26
Q

generic name for vitamin k vaccine

A

phytonadione

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27
Q

what med is given in eye prophylaxis ointment

A

erythromycin or tetracycline

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28
Q

what does eye prophylaxis prevent?
what STIs cause it?

A

-prevents ophthalmia neonatorum (blindness)
-chlamydia and gonnorrhea

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29
Q

*TABLE 24.3

A
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30
Q

2 important considerations when doing neonatal assessment

A

-normothermic environment (have a heat source)
-sequencing of assessments (depending on how baby reacts)

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31
Q

full physical exam: general appearance

A

-posture
-color
-resp effort
-activity
-state of alertness
-obvious anomalies
-signs of birth trauma

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32
Q

4 things that affect posture

A

-position in utero
-oxygenation status
-neurologic status (premature = floppy)
-gestational age

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33
Q

(skin) a lot of color - more red than usual

A

plethoric

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34
Q

(skin) half is red, half is pale. normal variation. immaturity of vascular system

A

harlequin sign

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35
Q

types of cyanosis

A

-generalized
-circumoral (around mouth)
-acrocyanosis (normal)

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36
Q

(skin) red and white splotchy pattern. normal or can be sign of problem

A

mottling

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37
Q

abnormal colors in skin assessment

A

-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)

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38
Q

what pulses should be assessed on newborn full assessment

A

-brachial
-femoral
-popliteal
-posterior tibial

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39
Q

normal temp for baby

A

36.5-37.5 C
97.7-99.5 F
-axillary

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40
Q

normal weight

A

2700-4000 g (6-9 lb)

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41
Q

normal length

A

48-53 cm (19-21 in)

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42
Q

normal head circumference

A

32.5-37.5 cm
-measure in semi-sitting position at biggest part of head

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43
Q

normal chest circumference

A

2-3 cm < head
-at nipple line
-may be equal to head if has cone head

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44
Q

full physical exam: assessment of skin

A

-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

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45
Q

what could one single crease on palm of hand indicate

A

genetic disorders

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46
Q

skin assessment abnormals

A

-jaundice within first 24 hours
-nevus vasculosus “strawberry birth mark”
-nevus flammeus “port wine stain”
-abnormal skin colors

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47
Q

full physical assessment: head

A

-inspection (size, shape, symmetry, caput succedaneum, molding, cephalohematoma, mark from FSE)
-palpation (fontanels, sutures, hair)

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48
Q

swelling of scalp in newborn

A

caput succedaneum

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49
Q

collection of blood underneath scalp in periosteum of bone in newborn

A

cephalomematoma

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50
Q

how to differentiate between caput succedaneum and cephalohematoma

A

-does it cross the suture line? yes: caput
no: cephalohematoma

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51
Q

consequence from cephalohematoma

A

jaundice

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52
Q

full physical exam: face

A

-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

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53
Q

eyes: appears cross eyed, light reflects in same space in eyes

A

pseudostrabismus

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54
Q

eyes: cross eyed, light does not reflect in same space in eyes

A

strabismus

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55
Q

what are low set ears associated with

A

chromosomal anomalies

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56
Q

what can pre-auricular skin tags be associated with

A

renal insuffiency
(may be normal)
*watch urine output

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57
Q

full physical exam: mouth

A

-placement, color, configuration, movement
-color of gums
-tongue: attachment, mobility, movement
-palate (soft and hard)
-reflexes: rooting, sucking, extrusion

58
Q

full physical exam: neck

A

-inspect and palpate length (short fatty neck)
-evaluate for webbing
-nuchal rigidity
-trachea midline, thyroid nonpalpable
-palpate clavicles
-moro reflex

59
Q

what is webbed neck associated with

A

chromosomal anomalies, especially turners syndrome (missing second sex chromosome)

60
Q

full physical exam: chest

A

-inspect and palpate: shape, resp movements, ribs, palpate PMI, nipple size number and placement, breast tissue
-auscultate: heart sounds and rate, breath sounds

61
Q

full physical exam: breasts

A

-swelling
-supernumery nipple
-nipple size, number, placement

62
Q

full physical exam: abdomen

A

-shape: rounded
-note movement w/ resps
-umbilical cord (inspect, palpate, smell)
-auscultate bowel sounds
-palpate abdomen
-note # and character of stools

63
Q

how many vessels in umbilical cord

A

1 vein
2 arteries

64
Q

what is a 2 vessel umbilical cord associated with

A

renal issues

65
Q

abdominal abnormality: herniation of abdominal contents into base of umbilical cord, associated with many syndromes and chromosomal disorders

A

omphalocele

66
Q

abdominal abnormality: intestines are protruding from abdomen

A

gastroschisis

67
Q

full physical exam: genitalia (male)

A

-general appearance: penis, prepuce (foreskin), location of urinary meatus
-scrotum: rugae, testes descended bilaterally

68
Q

2 abnormalities of male genitalia in location of urinary meatus

A

hypospadias
epispadias

69
Q

2 abnormalities of male genitalia in testes

A

-cryptochidism
-hydrocele (swelling)

70
Q

full physical exam: genitalia (female)

A

-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

71
Q

vaginal discharge from baby girl

A

smegma

72
Q

normal elimination patterns for newborn

A

-void within 1st 24 hours
-meconium within 1st 2 days

73
Q

full physical exam: back

A

inspect and palpate
-spine: straight, easily flexed, shoulders, scapulae and iliac crests line up
-base of spine and sacrum: tufts of hair

74
Q

abnormalities of spine during assessment

A

-masses
-openings
-curving of spine (scoliosis)
-pilonidal dimple (associated with spina bifida)

75
Q

full physical exam: extremities

A

-degree of flexion and muscle tone
-range and symmetry of motion
-developmental dysplasia of hips (DDH)
-number of digits, webbing
-creases

76
Q

S+S dislocated hip (developmental dysplasia of hips)

A

-nonsymmetrical gluteal folds
-apparent femur length nonsymmetrical
-(dr) ortolani’s maneuver: hip click

77
Q

too many toes

A

polydactyly

78
Q

technical name for club foot, foot rotated inward

A

talipes equinovarus
*check to make sure not just a positional issue (can straighten)

79
Q

full physical exam: S+S normal jitteriness/tremors

A

-transient
-most often during crying
-involves mouth, chin, and hands
-doesn’t occur when infant is quiet
-doesn’t persist > 1 mo

80
Q

risk factors tremors/jitteriness/irritability of hypoglycemia

A

-infant of diabetic mother
-large for gestational age (>4000 g)
-small for gestational age (<2500 g)
-premature (<37 wk)

81
Q

S+S tremors/jitteriness/irritability of hypoglycemia

A

-high pitched cry
-lethargy
-decreased tone
-poor suck/feed

82
Q

S+S seizure

A

-doesn’t stop when holding the body part
-associated with ocular changes (eyes deviated or staring)

83
Q

full physical exam: neuromuscular system

A

-normal jitteriness/tremors
-posture and tone
-reflexes

84
Q

full physical exam: anus

A

-placement
-number
-patency
-“wink” reflex

85
Q

gestational age assessment (dubowitz/new ballard scale)
-what is normal for term baby in neuromuscular maturity

A

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

86
Q

gestational age assessment
-what is normal for term baby in physical maturity

A

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

87
Q

*gestational age assessment preterm findings

A
88
Q

3 classifications of newborns by gestational age and birth weight

A

-appropriate for gestational age (AGA)
-large for gestational age (LGA)
-small for gestational age (SGA)

89
Q

what are SGA babies at increased risk for (5)

A

-perinatal asphyxia
-meconium aspiration syndrome
-excessive heat loss
-hypoglycemia
-infection

90
Q

what are LGA babies at increased risk for (3)

A

-meconium aspiration syndrome
-hypoglycemia
-birth trauma

91
Q

how often are VS taken on newborn baby

A

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)

92
Q

common actual/potential problems in newborns

A

-impaired gas exchange
-hypothermia
-infection
-hypoglycemia
-hyperbilirubinemia

93
Q

goals for impaired gas exchange

A

-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

94
Q

risk factors for impaired gas exchange (4)

A

-inability to clear airway (mucus, MSF, resp malformations)
-cold stress
-ineffective resp transition (preterm, stressful birth, resp malformations)
-cardiovascular complications/anomalies

95
Q

interventions for impaired gas exchange

A

-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)

96
Q

risk factors hypothermia

A

-exposure to heat loss
-SGA, LBW, preterm
-infections

97
Q

LBW

A

low birth weight <2500 g

98
Q

S+S hypothermia

A

-resp distress
-temp (axillary) <36.5

99
Q

interventions for hypothermia

A

-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

100
Q

when would you bathe baby asap (before injections)

A

-positive/unknown for hep b and HIV
-active infection

101
Q

where is temp probe placed on baby for monitoring

A

-RUQ
-never over a bone

102
Q

risk factors infection

A

-in utero infections (chorio)
-prolonged ROM (>18h)
-preterm
-complicated birth
-out of facility birth
-active maternal infections
-hospital acquired infections

103
Q

S+S infections

A

-temp instability
-resp problems
-tachycardia
-poor feeding
-drainage, redness
-diarrhea

104
Q

prevention of infection interventions

A

-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

105
Q

temporary consequence of erythromycin eye ointment

A

-blurred vision
-edema, redness

-can wipe away extra ointment after one minute

106
Q

what baby gets hep b immunoglobulin

A

Hep B surface antigen positive moms

107
Q

interventions for umbilical cord care

A

-remove clamp when cord is dry (24-48 h)
-fold diaper below cord

108
Q

risk factors hypoglycemia

A

-birth weight >4000 g
-diabetic mother
-LGA, SGA
-preterm
-stressful labor/birth
-cold stress

109
Q

S+S hypoglycemia

A

-jitteriness
-weak, high pitched cry
-*lethargy
-irregular resp efforts
-apnea
-feeding difficulties
-twitching, seizures

110
Q

classification of hypoglycemia

A

<40

111
Q

prevention of hypoglycemia

A

-protect for intrapartum stress
-early and frequent feedings
-protect from hypothermia

112
Q

Tx hypoglycemia

A

-feed
-sometimes IV

113
Q

risk factors hyperbilirubinemia

A

-preterm
-delayed/ineffective feeding
-delayed passage meconium
-maternal-fetal blood incompatibility
-enclosed hemorrhage

114
Q

S+S hyperbilirubinemia

A

-visual jaundice with blanching
-TcB >12-15
-serum >95% for age (or >1.5-2 mg/dL)

115
Q

Tx hyperbilirubinemia

A

-assess feeding once per shift
-early and frequent feedings
-phototherapy

116
Q

nursing interventions for phototherapy

A

-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

117
Q

procedure for heel stick

A

-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

118
Q

where do you do the heel stick on baby

A

lateral side of heel
(lateral to space between 4th and 5th toe)

or medial (medial to inner half of big toe)

119
Q

potential complications of heel stick

A

-necrotizing osteochrondritis
-fibrosis and scarring on walking surface, problems walking

120
Q

NMC

A

newborn male circumcision

121
Q

benefits of circumcision

A

-decreased UTIs in males <1yo
-decreased risk penile cancer
-decreased risk heterosexual acquisition of STI (especially HIV)

122
Q

risks of circumcision

A

-cold stress
-hypoglycemia
-aspiration
-bleeding
-infection
-cutting too much/damaging penis

123
Q

procedure of circumcision

A

-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

124
Q

benefit of mogen clamp circumcision

A

clamp minimizes blood loss and protects glans

125
Q

benefit of plastibell’s circumcision

A

-provides pressure
-prevents infection
-keeps urine off
-remains in place for one week

126
Q

pain relief with and after circumcision

A

-nerve block
-topical EMLA cream
-oral acetaminophen
-sweeties
-swaddling
-breastfeeding after

127
Q

what should be covering penis after circumcision

A

sterile vasaline gauze

128
Q

post-circumcision care

A

-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

129
Q

how often do you assess after circumcision (hemorrhage risk)

A

-q15min x 1 hr
-q30min x 4-6hr
-hourly until 12 hours

must void before going home
for bleeding: gentle pressure with sterile gauze

130
Q

physiologic S+S acute pain

A

-increased HR, BP, RR
-pallor or flushing
-diaphoresis
-increased muscle tone
-dilated pupils

131
Q

behavioral S+S acute pain

A

-vocalizations
-grimace
-brow furrowed
-chin quiver
-eyes squeezed shut
-limb withdrawal from stimuli
-changes in sleep wake cycles
-changes in feeding patterns

132
Q

tools for assessing pain

A

-neonatal infant pain scale (NIPS)
-premature infant pain profile (PIPP)
-neonatal pain agitation and sedation scale (NPASS)

133
Q

nonpharmacologic management acute pain

A

-swaddling
-breastfeeding
-oral sucrose
-skin to skin

134
Q

pharmacologic management acute pain

A

-local and topical anesthesia
-nonopioid analgesia: acetaminophen drops
-opioid analgesia for surgery (morphine, fentanyl)

135
Q

what is included in universal newborn screen (3)

A

-hearing screen
-blood screen
-congenital heart disease

136
Q

when is dried blood test repeated after birth (mandated by law)

A

2 weeks

137
Q

when is critical congenital heart defect test performed

A

24-48 hours after birth

138
Q

what is considered a pass in critical congenital heart defect (CCHD) test? what requires immediate evaluation?

A

-pulse ox on R hand and foot
-O2 >95% in either extremity and <3% difference between extremities
-90-95% requires followup

139
Q

what needs to be taught to pts for discharge

A

-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)

140
Q

*READ PAGES 522-530

A
141
Q

consequence of baby powder

A

risk of irritation of lungs if inhaled

OB (21 decks)

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