chapter 15: nursing care of the newborn Flashcards
physical examination of the newborn
- 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
acrocyanosis
bluish color of hands and feet due to immature peripheral circulation
first 24-48 hours after birth
lanugo
fine, downy hair
vernix caseosa
white protective coating on skin
hemangioa
newly formed capillaries in dermal and subdermal layers of skin
nevus flammeus
dilated skin capillaries
nevus simplex
stork bite, angel kiss
melanocytic nevi
mole; uncommon in newborn
erythema toxicum neonatorum
newborn rash; macules, papules, or vesicles on body
acne neonaorum
clogged hair follicles
milia
occluded sebaceous glands
dermal melanosis
mongolian spot; trapped melanocytes
head assessment
- note appearance, shape, circumference, suture lines
cephalohematoma
swelling on head, does not cross suture line
caput succedaneum
swelling of scalp
fontanel
soft spot; fibrous membrane that lies between bones of cranium
eye assessment
- examine eyes and eyelids for symmetry
- abnormal eye assessment findings
ear assessment
- note ear size, shape, and location
- abnormal ear assessment findings
nose
- should be midline w/ symmetrical nares
- clear nasal drainage is expected
- abnormal nose assessment findings
mouth assessment
- inspect lips, mouth, tongue, palate, and gums
chest assessment
- observe for shape and symmetry of movement
gynecomastia
breast enlargement from maternal hormones
respiratory system assessment
- breathing effort, chest movement, auscultation of lungs
- periodic breathing
- retractions
- apnea
retractions
skin pulling around ribs and sternum w/ difficult inhalation
apnea
cessation of breathing >20 seconds
cardiovascular system assessment
- heart sounds: APTM
- assess peripheral pulses for quality and equality
- capillary refill
abdomen and gi assessment
- observe shape, contour, and movement
- bowel sounds
- stool
genitourinary system assessment
- inspect female genitalia for placement of labia and urinary meatus
- pseudomenstruation
- inspect male penis: midline and straight, urethral opening midline
- urinary output
- ambiguous genitalia
neurologic system assessment
- immature at birth: jerking, twitching is normal
- reflexes
musculoskeletal system assessment
- resting posture
- hips: assess for dysplasia —> ortolani and barlow maneuvers
- spinal cord and back for curvatures and asymmetry
pain
neonatal infants pain scale
nursing care of the newborn: medications
- vitamin k
- erythromycin ointment
- hepatitis b vaccin
estimate gestational age
- 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
bath
- removes blood and body fluids
- sponge bathing, small tub bathing, large tub or immersion bathing, swaddling immersion bathing
newborn screening
- conducted for genetic, metabolic, endocrine disorders, infectious diseases, hearing loss, and congenital heart disease
- technique to obtain blood specimens
congenital heart defect screening
- critical congenital heart defect
- 24 hour or older infant
- uses pulse ox probes
hearing screen
- automated otoacoustic emission test
- automated auditory brainstem response
- brainstem auditory evoked response
