chapter 15: nursing care of the newborn

Question 1

physical examination of the newborn

Answer 1

• 1 minute and 5 minute APGAR scores
• before stimulating w/ touch, nurse should observe infant for position, sleep or wake cycle, skin color, respiratory pattern
• vital signs
• measurements: length, head, and chest circumference

Question 2

acrocyanosis

Answer 2

bluish color of hands and feet due to immature peripheral circulation
first 24-48 hours after birth

Question 3

lanugo

Answer 3

fine, downy hair

Question 4

vernix caseosa

Answer 4

white protective coating on skin

Question 5

hemangioa

Answer 5

newly formed capillaries in dermal and subdermal layers of skin

Question 6

nevus flammeus

Answer 6

dilated skin capillaries

Question 7

nevus simplex

Answer 7

stork bite, angel kiss

Question 8

melanocytic nevi

Answer 8

mole; uncommon in newborn

Question 9

erythema toxicum neonatorum

Answer 9

newborn rash; macules, papules, or vesicles on body

Question 10

acne neonaorum

Answer 10

clogged hair follicles

Question 11

milia

Answer 11

occluded sebaceous glands

Question 12

dermal melanosis

Answer 12

mongolian spot; trapped melanocytes

Question 13

head assessment

Answer 13

• note appearance, shape, circumference, suture lines

Question 14

cephalohematoma

Answer 14

swelling on head, does not cross suture line

Question 15

caput succedaneum

Answer 15

swelling of scalp

Question 16

fontanel

Answer 16

soft spot; fibrous membrane that lies between bones of cranium

Question 17

eye assessment

Answer 17

• examine eyes and eyelids for symmetry
• abnormal eye assessment findings

Question 18

ear assessment

Answer 18

• note ear size, shape, and location
• abnormal ear assessment findings

Question 19

nose

Answer 19

• should be midline w/ symmetrical nares
• clear nasal drainage is expected
• abnormal nose assessment findings

Question 20

mouth assessment

Answer 20

• inspect lips, mouth, tongue, palate, and gums

Question 21

chest assessment

Answer 21

• observe for shape and symmetry of movement

Question 22

gynecomastia

Answer 22

breast enlargement from maternal hormones

Question 23

respiratory system assessment

Answer 23

• breathing effort, chest movement, auscultation of lungs
• periodic breathing
• retractions
• apnea

Question 24

retractions

Answer 24

skin pulling around ribs and sternum w/ difficult inhalation

Question 25

apnea

Answer 25

cessation of breathing >20 seconds

Question 26

cardiovascular system assessment

Answer 26

• heart sounds: APTM
• assess peripheral pulses for quality and equality
• capillary refill

Question 27

abdomen and gi assessment

Answer 27

• observe shape, contour, and movement
• bowel sounds
• stool

Question 28

genitourinary system assessment

Answer 28

• inspect female genitalia for placement of labia and urinary meatus
• pseudomenstruation
• inspect male penis: midline and straight, urethral opening midline
• urinary output
• ambiguous genitalia

Question 29

neurologic system assessment

Answer 29

• immature at birth: jerking, twitching is normal
• reflexes

Question 30

musculoskeletal system assessment

Answer 30

• resting posture
• hips: assess for dysplasia —> ortolani and barlow maneuvers
• spinal cord and back for curvatures and asymmetry

Question 31

pain

Answer 31

neonatal infants pain scale

Question 32

nursing care of the newborn: medications

Answer 32

• vitamin k
• erythromycin ointment
• hepatitis b vaccin

Question 33

estimate gestational age

Answer 33

• completed on preterm babies, postterm babies, babies of diabetic mother, babies of mothers w/ no prnatal care, and babies weighing <2500g or >4000g
• preterm: born before 27 weeks
• postterm: born after 42 weeks
• ballard tool

Question 34

bath

Answer 34

• removes blood and body fluids
• sponge bathing, small tub bathing, large tub or immersion bathing, swaddling immersion bathing

Question 35

newborn screening

Answer 35

• conducted for genetic, metabolic, endocrine disorders, infectious diseases, hearing loss, and congenital heart disease
• technique to obtain blood specimens

Question 36

congenital heart defect screening

Answer 36

• critical congenital heart defect
• 24 hour or older infant
• uses pulse ox probes

Question 37

hearing screen

Answer 37

• automated otoacoustic emission test
• automated auditory brainstem response
• brainstem auditory evoked response