CH12 Flashcards
what is the normal VS for baby
Resp rate: 30 to 60 per min
report if temp is hgher than 100 F
Pulse: 110 to 160
BP: systolic 65-95 and diastolic 30-60
what is the proper way to suction and when should you suction
mouth first and then nose (we suction the nose to prevent aspiration and inhalation of mucous)
we should suction if there water, gurgling, diff breathing, if you hear noise
what immunization does the baby receiv
hep b immunization (requires consent) and immunoglibulin
what is cord care
check that there 2 arteries and one vein
assess neuro what is an expected finding
head lack is nornal
grasp reflex (tightness of finger is norma)
moro reflex ( startle reflex - clap produce lound sound, extended arms is normal).
startle reflex should be gone after 4 months
what is caput succedameum
-a collection of fluid of baby (usually affects entire head)
-resolves in 3 to 4 fay
-crosses suture line
-usually a cause of vacuum suctioning
what is cephalohematoma
-one side is protruding (collection blood)
-resolves in 2 to 8 weeks
-serious problem
-baby is usually pale
expected finding when assessing eyes
crosseyed for first 6 months
expected finding when assessing ears
-may not pass the first time because of constructions
-if not passed then need follow up
-eye and ears leveled the same, if lower that means DS
what kind of assessment do you use for pain
NIPS (neonatal infant pain scale)
rates facial expression, arm movements, cry, leg, movement, resp, and arousal on scale from 0 to 2, with score 7 indicates worst level of pain
is it reportable to have abnormal respirations
no because apnea, bradycardia, tachypnes is normal at first
how to prevent SID
put baby on back and no toys and pillows on the crib
if warmth is not provided immidietly to the baby, what manifests
hypothermia which leads to cold stress
what is an alarming sign for circumcision
swelling (plastibel slips to the shaft means infection)
nursing care for circumcision care
-do not remove yellow curst
-make sure diaper is lose
-keep clean and dry
-report redness, bleeding, drainage
-make sure that diaper is change 6 to 8 wet diapers (this indicates that they are peeing if not that means urinary obstruction)
how to check hydration of baby
wet diaper ( 6 to 8 diapers)
common skin manifestation
-milia (pearly white spots on face and nose) and Mongolian spots (dark blue or grey discoloration) are common skin findings
-make sure to not touch it because they will go away eventually
lab values for newborn
HgB: 18.5
hematocrit (Hct): 56
WBC: 18,000
bilirubin: 6
lab values 7 day pold
HgB: 17
hematocrit (Hct): 44
WBC: 12,000
bilirubin: 12
lab values 3 moth old
HgB: 11.3
hematocrit (Hct): 35
WBC: 10,800
bilirubin: 1
is acrocyanosis reportable?
no it is normal (extremities are blue and body is pink)
what is the difference between pathologic and physiologic jaundice
pathologic manifest within 24 hrs after delivery (which is reportable), physiologic manifest after 24 hrs after delivery (normal)
hypoglycemia lab finding
30 mg and below for preterm
40 and below for full term
what is abnormal for stool defecation for newborns
-defecation after 24 hrs is abnormal
-meconium should pass within 24 hrs
what is the main cord nursing care
sponge bath until cord falls off usually falls off around 8-14 days
what is the cause of SGA
Intrauterine growth restriction (not enough circulation in placenta, usually cause by gestational DM and gestational HTN)
what the the characteristics for preterm baby
-transparent loose skin*
-superficial vein can be seen*
-lack of fat and fine hair (lanugo) covers the forehead, shoulders, and arms**
-Protruding or sunken chest**
-vernix is abundant
-extremities is short
-sole feet creases
-abdomen protruding
-nails short
-genitalia is small for girls labia majora may be open
what are serious complications for SGA and LGA
resp distress and hypoglycemia
nursing care for premie baby
-give oxygen with humidifier
-betamethasone (2 injections 24 hrs apart at IM route) to the mom
- if baby is out, baby will be given surfactant in endotracheal (slow administration)
s/sx resp distress
cyanosis
grunting
flaring of nostrils
retraction
resp over 60/min
pulse lower than 110/min and higher than 160/min
why are premie baby prone to cold stress and what is nursing care
-lack of fat
-excessive heat loss (head is the largest part)
-inactive muscles, cannot shiver
nursing: kangaroo care
potential complication for premie
hypoglycemia
hypothermia
hypotonia
hypercalcemia
seizure
feeding (poor nutrition)
nursing care for premie baby with jaundice and why does it happen
this happens because immature liver is not able to clears system.
nursing care: phototherapy and this is resolved to prevent permanent brain damamge
nursing goals for preterm newborn
improve sleep
maintain body heat
regulated correct temp (incubator)
conserve energy (cluster work like change diaper, meds, VS)
prevent infectin
provide proper nutrition and hydration
good skin care
observe infant carefully and record observations
support and encourage parents
post mature baby physcical characteristics
dry skin like parchment
wrinkly skin
no vernex because wash off in uterus
nails long and nails stained with meconium
thick hair and looks alert
resp distress and hypoglycemia
