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Nursing 271 > Chapter 18: Caring for the Normal Newborn > Flashcards

Chapter 18: Caring for the Normal Newborn Flashcards

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1
Q

Immediate Neonatal Assessment

A
  • physical condition assessed
  • suction if indicated
  • infant handed to the nurse, placed in a sterile baby blanket, and placed on mother abdomen
  • nurse observes infants respiratory effort, color, muscle tone, and the activities under way are stimulating the neonate to breathe deeply and cry (lightly flicking the soles of feet might help make baby cry)
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2
Q

Placing infant under radiant heater

A

the nurse dries the infant before placing him unclothed on a clean, dry blanket under the radiant heater unit

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3
Q

Nursing Insight- Observing Standard precautions when handling the neonate

A

there is a possibility of transmission of viruses such as hepatitis B (HBV) and HIV from maternal blood and blood-stained amniotic fluid, the neonate is considered a potential contamination source
-nurses must wear gloves until blood and amniotic fluid are removed by bathing

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4
Q

What does respiratory difficulty look like in a newborn?

A
  • rib or sternal retractions
  • “grunting sounds”
  • nasal flaring
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5
Q

How does a nurse check the heart rate after delivery?

A

place the thumb and two fingers at the base of the umbilical cord and counts the pulsations

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6
Q

How to assess the temperature of the newborn

A
  • axillary

- thermoprobe and recording monitor to the skin

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7
Q

Number of Vessels in the Umbilical Cord upon assessment of newborn

A

3 Vessels (AVA)

  • 2 arteries
  • 1 vein
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8
Q

Apgar Score of the infant

A

-done at 1 and 5 minutes after birth
-score provides an objective means for assessing neonates immediate adaptation to extrauterine life
>5 categories:
1. Respiratory effort
2. Heart rate
3. Muscle tone
4. Reflex irritability
5. Skin color
>score for each categories ranges from 0-2

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9
Q

Normal Respirations for a Neonate at birth

A

30-60 breaths per minute

  • irregular
  • no retractions or grunting
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10
Q

Normal Apical Pulse for a Neonate at Birth

A

120-160 bpm

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11
Q

Normal Temperature for a Neonate at Birth

A

97.7-99.3 degrees F (36.5-37.4 D C)

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12
Q

Normal Skin Color for a Neonate at Birth

A

pink body, blue extremities (acrocyanosis)

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13
Q

Normal Gestational Age for a Neonate at Birth

A

full term; >37 completed weeks (should be 38-42 weeks to remain with parents for an extended time period)

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14
Q

Normal Weight for a Neonate at Birth

A

2,500-4,300 grams

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15
Q

Normal Length for a Neonate at Birth

A

45-54 cm (18 to 22 inches)

-measured in a recumbent length (crown-to-heel, in a supine position)

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16
Q

Indications that would necessitate the need for Infant stabilization

A
  • nasal flaring
  • grunting respirations
  • rib retractions
  • heart rate less than 120 bpm or greater than 160 bpm
  • pallor
  • serious congenital anomalies (ex: neural tube defect)
  • preterm infant (less than 38 weeks gestational age)
  • infant of diabetic mother
  • infant who appears small for gestational age
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17
Q

Signs and Symptoms of Neonatal Respiratory Distress

A
  • generalized cyanosis
  • tachycardia (> 160 bpm)
  • tachypnea (respirations >70 breaths/min)
  • rib retractions
  • expiratory grunting
  • flaring nostrils
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18
Q

Erythromycin

A

prophylactic ophthalmic agent

  • prophylaxis of ophthalmia neonatorum, eye inflammation from gonorrheal or chlamydial infection contracted during passage through mothers birth canal
  • bacteriostatic action
  • given to infant 1 hour after birth
  • Contraindicated: hypersensitivity
  • Side effects: irritation
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19
Q

Vitamin K (phytonadione)

A

given IM to newborn
-to prevent neonatal injury caused by hemorrhage
-newborn usually has low vitamin K at birth
-vitamin k acts as a catalyst to synthesize prothrombin, needed for blood clotting, in the liver
-prevention and treatment of hypoprothrombinemia
-prevention of bleeding
-administer within 2 hours after birth
>report symptoms of unusual bleeding or bruising (bleeding gums; nosebleed; black tarry stools; hematuria; or bleeding from the base of the umbilical cord or other wound)
>decrease in hemoglobin or hematocrit levels or any bleeding may indicate that the effects of the medicine have no been achieved and more vitamin k may be necessary

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20
Q

Newborn Hepatitis B Vaccination

A

helps prevent Hepatitis B

  • given in a series of 3 doses beginning at birth
  • given within 12 hours of birth
  • obtain written consent before administration
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21
Q

Assessment of Blood Glucose in the Newborn

A

helps prevent newborn injury r/t hypoglycemia
-monitoring takes places within 1st hour
-hypoglycemia for term infant= < 35 mg/dL, or plasma concentration of < 40 mg/dL
>S/S= jitteriness, apnea, seizures, or lethargy); require immediate attention to prevent brain cell damage

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22
Q

Body Positioning of the Newborn

A

-a position of flexion of the upper and lower extremities; enables them to touch their face, sucks their fingers, and explore their world
-symmetrical
>if asymmetrical, or cant move extremity= further investigation

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23
Q

Safe Positions to Prevent SIDS

A

-supine position for sleep (wholly on the back) for every sleep until 1 year of life
> side sleeping not safe

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24
Q

Assessment of Skin Color: Jaundice

A

(hyperbilirubinemia)

  • yellow coloration of the skin
  • develops gradually in a head-to-toe pattern
  • term infant < 24 hours who has visual jaundice = “pathological jaundice” and is because of blood incompatibility with mother
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25
Q

Physiological Jaundice

A

yellowing of the skin after first 24 hours of life and usually peaks on the 3rd to 5th day

  • has a nonhemolytic cause
  • results from failure to adequately process bilirubin because of inadequate intake or elimination, birth trauma, or minor blood incompatibilities
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26
Q

Breastfeeding associated jaundice

A

associated with insufficient feeding and infrequent stooling
-because colostrum has a natural laxative effect that stimulates the passage of meconium, frequent breastfeeding during early days of life is beneficial in reducing serum bilirubin levels

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27
Q

Breast-milk Jaundice

A

develops around the 4th day when the mothers mature breast milk comes in and peaks around day 10
-r/t factors in human milk that inhibit the conjugation or decrease the excretion of bilirubin
>advise discontinuation of breastfeeding for 12 to 24 hours to allow infants bilirubin levels to decrease

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28
Q

Nursing Actions to Decrease the Likelihood of High Bilirubin Levels

A
  • maintain infants temperature at or greater than 97.7 degrees F; because cold stress can cause acidosis which is linked to elevated serum bilirubin levels
  • monitoring of intake and output; with attention to stool characteristics (bilirubin is eliminated in feces)
  • encourage early feedings
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29
Q

Level of Reactivity

A

-is the neonate awake and quiet, or restless and crying?
-does the infant respond by looking and moving all extremities?
-is the infants sleep pattern best characterized by quiet slumber or agitated restlessness?
>infants reaction to the environment is indicator of neuromuscular development
>exhibit behavioral levels or states of awareness
>sleep states that include deep sleep and rapid eye movement sleep (REM)
>alert state= drowsy, quiet alert, active alert, and crying
>assess responses to voices and physical presence; if displays irritability and an overreaction to voices, touch, or movement needs to be comforted and special care must be taken to provide calming measures

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30
Q

Provide Calming Measures for a Newborn who displays irritability and an overreaction to voices, touch, or movement

A

-swaddling the neonate in blankets, cuddling, rocking, and gentle holding
>best to postpone the physical examination because the manipulation and handling will most likely cause further disruption and behavioral disorganization

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31
Q

Normal Blood Pressure in a Newborn at birth

A

-Systolic: 60 to 80 mm Hg
-Diastolic: 40 to 50 mm Hg
>10 days of age: Systolic 95 to 100, Diastolic: slight increase

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32
Q

Normal Head Circumference for a Newborn at Birth

A
  • taken 3 times; largest one = head circumference
  • taken with a tape measure; place above eyebrows and pinna of the ears and wrapped around to the occipital prominence on the back
  • measured in cm
  • 33 to 38 cm (13 to 15 inches)
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33
Q

Normal Chest Circumference for a Newborn at Birth

A
  • paper tape placed on the nipple line and then wrapped around entire thoracic area
  • 30.5 to 33 cm (12 to 13 inches)
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34
Q

Normal Abdominal Circumference for a Newborn at Birth

A

tape measure encircling the body directly above the umbilicus
-same size as chest

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35
Q

Large for Gestational age, Appropriate for Gestational Age, and Small for gestational age

A

nurse plots the weight, length, and head circumference against the gestational age to determine appropriate size category
LGA: weight above the 90th percentile at any week
AGA: weight falls between the 10th and 90th percentiles for infants age
SGA: weight falls below the 10th percentile for infants age

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36
Q

True Cyanosis Vs Acrocyanosis

A

-rub the sole of the neonates foot, if the sole turns pink = acrocyanosis
-if the sole remains blue = true cyanosis
>true cyanosis= produces a bluish coloration and pallor (paleness) of the lips and on the area around the mouth
>acrocyanosis= disappears when the baby cries

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37
Q

Abnormal Skin Indications

A
  • pallor
  • plethora (deep purplish color r/t an increased number of circulating RBCs)
  • petechiae (pinpoint hemorrhagic areas)
  • central cyanosis
  • jaundice
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38
Q

Periauricular Papillomas

A

“skin tags”

  • benign
  • common
  • often run in families
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39
Q

Nuchal Cord

A

umbilical cord around neck

-commonly exhibit bruises or petechiae on the head, neck, and face

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40
Q

Normal Term Infants Skin

A

should feel smooth and soft

  • lanugo (fine, downy hair) may be noted on back, shoulders, and head
  • vernix caseosa may be present in axillary and genital areas
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41
Q

Post-term infants skin

A

tough and leathery, with cracking and peeling

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42
Q

Milia

A

small white papules or sebaceous cysts on the infants face that resemble pimples

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43
Q

Acne

A

may also appear on neonate

  • r/t excessive amounts of maternal hormones
  • disappears spontaneously from infants cheeks and chest
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44
Q

Erythema Toxicum

A

transient rash that covers the face and chest with spread to the entire body; normal

  • also called “erythema neonatorum”, “newborn rash”, or “flea bite” dermatitis
  • consists of small, irregular, flat red patches on the cheeks that develop into singular, small yellow pimples appearing on the chest, abdomen, and extremities
  • no treatment; cause unknown
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45
Q

Mongolian Spots

A

areas that appear gray, dark blue, or purple
-appear on back and buttocks
-also found on shoulder, wrist, forearms, and ankles
-seen in Mediterranean area, Latin America, Asia, or Africa
>changes will fade and disappear as infant grows older
>may be mistaken for bruises for nurse must chart the Mongolian spots

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46
Q

Mottling

A

“cutis marmorata”

  • r/t prolonged apnea
  • r/t vasomotor response to lower environmental temperature
  • disappears once adjusted
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47
Q

Brown Nevi

A

“birthmark”

  • brown skin marks whose color can vary from brown to deep black
  • can represent early form of precancerous lesion, just be checked throughout life
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48
Q

Nevus Flammeus

A

birthmark; “port wine stain”

  • non-elevated
  • red to purple network of dense capillaries that vary in size, shape, and location
  • commonly on face
  • does not blanch on pressure, grow in size, or disappear
  • Sturge-Weber syndrome may be indicated if accompanied by convulsions or other neurological problems
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49
Q

Telangiectatic Nevus

A

red birthmark

  • seen at the nape of the neck; “Stork bite” or “angel kiss”
  • may also occur on the face between the eyebrow or on the eyelids, nose, or upper lip
  • fades when infant grows older, usually by 2nd birthday
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50
Q

Nevus Vasculosus

A

“strawberry mark”

  • red, raised capillary hemangioma
  • can occur anywhere on body
  • sharp borders and a rough surface
  • disappear over time
  • unless it interferes with a vital organ, or located on the face, surgical removal is not recommended
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51
Q

Polycythemia

A

condition characterized by excessive number of red blood cells
-occurs from the transfer of maternal blood into the infants circulation during the time when the umbilical cord was cut
>can be confirmed by a capillary hematocrit value of 65 or greater or a venous hematocrit of 60 or more
-Treatment: partial exchange perfusion

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52
Q

Examination of Infants Hair Pattern

A

texture, color, and distribution
-noting disruptions to the hair distribution or areas of asymmetry on the scalp
>hair that covers the forehead and creates a shortened distance between the hairline and the eyebrows may be indicative of a congenital syndrome

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53
Q

Examination of the eyes

A

-shape and size
-coordinated movement of the eyelids
-eye color and placement on the forehead are recorded
-sclera is normally white
-bluish sclera= osteogenesis imperfecta
-coloboma= disruption in the iris of the eye, appears as a keyhole in the circle of the iris and pupil and will affect vision in that eye
-congenital cataracts= noted when white or pale yellow tissue covers the pupil and iris and occludes the red reflex
(red reflex normally red or reddish orange in color)
-congenital glaucoma= requires instillation of eye drops to prevent blindness

54
Q

Examination of the lips

A

for movement

  • damage to the seventh cranial nerve (facial) can result in unilateral drooping of the tongue or mouth, unequal movement of the cheek muscles, or inappropriate eyelid movement
  • upper and lower lips approximately uniform in size
  • lip color consistent with tongue and buccal mucosa of the mouth
55
Q

Examination of the Ears

A

shape, size, and placement

  • low-set ears= evaluation and chromosomal abnormalities
  • one ear slightly lower than the other is common
  • to determine ear placement, an imaginary line is drawn from the inner to outer canthus of the eye and then to the ear
  • palpates to determine thickness of ear lobe and pinna
  • ear pits and ear tags common preauricular ear malformations; if infection is present (redness, edema, or draining fluid) ear pits should be surgically repaired
56
Q

Examination of the chin

A

readily apparent when viewed in a profile position
-micrognathia, or small jaw, may interfere with tooth development, sucking, swallowing, and tongue movement during speech

57
Q

Examination of the Head

A

-fontanelles, suture lines
-anterior fontanelle: diamond shaped; must remain opened during first year of life for brain growth
-posterior fontanelle: may be closed
-normal intracranial pressure characterized by fontanelle fullness without bulging, either on visual inspection or palpation
>Bulging, tense fontanelles with a large head circumference = increased intracranial pressure (associated with hydrocephalus)

58
Q

Caput Succedaneum

A

diffuse edema that crosses the cranial suture lines an disappears without treatment during the first few days of life

59
Q

Cephalhematoma

A

serious condition
-results from a subperiosteal hemorrhage that does not cross the suture lines on the skull
-appears as a localized swelling on one side of the infants head and persist for weeks while the tissue fluid is slowly broken down and absorbed
>may experience jaundice r/t the damaged red blood cells from the subperiosteal hemorrhage

60
Q

Recognizing an Ophthalmic Emergency in the Infant

A

using an ophthalmoscope to examine the infants eyes
-absence of the red reflex indicates an interference with the transmission of light to the retina; optic nerve suppression from obstructed light pathways may result in permanent blindness

61
Q

Epstein Pearls

A

whitish hardened nodules on the gums or roof of the mouth may be visualized or palpated
-pearl-like inclusion cysts are not unusual and disappear within a few weeks

62
Q

Examination of Uvula

A

midline

-a bivalve or double lobed uvula may indicate a cleft in the palate

63
Q

How to Evaluate a Newborns sucking

A

inserts gloved finger into infants mouth and notes and records the strength of suctioning motion
-hard and soft palates can be examined at this time

64
Q

Evaluating hard and Soft palates in the mouth

A

for size, shape, and cleft formations

  • if present, a cleft defect is felt as an open space or a notched ridge
  • a high arched palate may be associated with difficulty swallowing or with later speech development
65
Q

Examination of the throat

A

gag reflex is elicited

  • back of the throat, tongue, uvula is visualized
  • throat is externally palpated to check for enlargement of thyroid gland and to ensure trachea is midline
  • chin is lifted to assess neck area; neck is short with skin folds
  • check neck rotation by observing head movements and by turning the head from side to side
66
Q

Torticollis

A

deviation of the neck to one side caused by a spasmodic contraction of the neck muscles
-apparent when the head is positioned on one side while the chin points to the opposite side

67
Q

Newborn Hearing Screening

A

routine hearing screening before a newborn is discharged

  • use otoacoustic emissions (OAEs) test and/or the automated auditory brainstem response (AABR) test
  • used to identify congenital hearing loss and refer those affected for early intervention
68
Q

Choanal Atresia

A

malformation of the bucconasal membrane
-to assess nasal patency, the nurse carefully occludes one naris while the infants mouth is closed, a rise in the infants chest confirms that the nasal passageway is open and air has been inhaled, assessment is repeated on other naris; if infant demonstrates difficulty with this = choanal atresia
>an inability to pass a small catheter into the nares confirms the diagnosis

69
Q

Assessing Respiratory function

A

supine position

  • respirations counted, and pattern and use of accessory muscles are noted
  • slight sternal retractions may occur
  • prominence of the xiphoid process is normal and will diminish with growth and development
  • breathing patterns may be irregular accompanied by periods of apnea that last for up to 15 to 20 seconds
  • lung sounds auscultated anteriorly and posteriorly
70
Q

How to Recognize Breathing Difficulties

A
  • has above normal respirations
  • has prolonged (greater than 15 seconds) periods of breath holding
  • shows sucking-in and seesaw movements around rib cage
  • flares nostrils
  • makes grunting sounds
71
Q

Assessing Cardiovascular System

A
  • inspection of the skin, lips, gums, and buccal mucosa; shows evidence of cardiac perfusion
  • palpates the chest for thrills or heaves, auscultates the apex of the heart
  • normal heart rate between 120 and 160
  • greater than 160= tachycardia
  • common to hear murmurs in infants less than 24 hours old
  • murmurs characterized by a sound that grows louder during systole; if remains audible after 2nd day of life and intensifies to a “whoosh’ sound further investigation
72
Q

Ventricular Septal Defect (VSD)

A

condition in which a small hole exists in the ventricle wall between the right and left chambers of the heart
-produces a sound created by the leaking of blood through the small defect
>loud defects associated with smaller murmurs; small defects associated with loud murmurs (because of pressure build-up)

73
Q

Assessment of GI System

A

auscultate bowel sounds

  • abdomen round and bilaterally symmetrical
  • abdomen may appear distended because of stool that has not yet been emptied
  • Diastasis rectus (thinning of the abdominal wall) can be present; can also be identified as the presence of a long raised “lump” along the midline that becomes prominent when the infant is crying
74
Q

Conditions that may warrant further assessment with the GI system

A
  • abdominal distention
  • absence of bowel sounds
  • discharge from the umbilical cord or cord site
  • palpation of an abdominal mass
75
Q

Necrotizing Enteroclitis

A

life-threatening
-occurs when a lack of blood flow to the bowel results in the destruction of the intestinal mucosa; loss of bowel function results and toxins are released from the damaged, necrotic tissue
>surgical intervention

76
Q

Umbilical Cord Assessment

A
  • discharge = infection, unless a bacteriostatic dye has been used
  • pale yellow in appearance
  • extra clamp may be applied if blood is actively leaking
  • if meconium was passed in utero, cord may be stained gray-green
  • area around the base should be kept clean and dry
  • during diapering, avoid urine or stool to come in contact with cord or base
  • inspect for redness; may indicate omphalitis (treat with antibiotics)
77
Q

Symptoms that may indicate Acute Abdomen

A
  • rigid, board-like abdomen
  • inability to palpate abdominal organs
  • indicators of pain (continuous crying, facial changes, or gross motor movements)
78
Q

Examination of Testes

A

-both have been descended; if flat or depressed areas are indicated this may indicate not descended
>use the index finger and the thumb, the nurse palpates the left side of the scrotum for presence of testis and then uses the third finger and thumb to palpate the right side
-if testis not detected, stroke inguinal canal
-if 35 weeks gestation and older and testis not descended go to urological consultation

79
Q

Examination of female genitalia

A

the extent to which the labia cover the surrounding tissues corresponds with the developmental maturity

  • the borders of the labia majora touch and the clitoris is covered completely
  • a full term infant may have delayed genital development and the nurse can easily view the labia minora and exposed clitoris
  • vernix caseosa, whitish cheesy substance, may be covering the tissue between the labia
  • “pseudomenstruation”, small amounts of blood and whitish mucoid discharge may be noted in the vaginal area (normal)
80
Q

Bowel Sounds In Scrotum

A

to confirm that no bowel is trapped in the scrotum, the nurse carefully auscultates the scrotum for bowel sounds
-if bowel sounds are present, immediate assistance must be obtained

81
Q

Hypospadias

A

the urethral opening on the penis is present on the ventral (not central) surface

  • should not be circumfixed
  • repaired with foreskin
82
Q

Epispadias

A

the vertical urinary opening is located on the dorsal surface on the penis instead of on the glands
-repaired with the use of excess foreskin

83
Q

Micropenis

A

penis less than 2 cm in length

-associated with a pituitary tumor

84
Q

Ambiguous genitalia

A

condition in which the male has genital structures that mimic labia or the female has structures similar to a penis

85
Q

Imperforate anus

A

anal ring skin tags or an anal ring that has no opening

  • absence of an opening in the anal ring
  • medical emergency as the infant is unable to pass stool
86
Q

Assessment of Musculoskeletal System

A
  • starts with shoulders then down to lower extremities
  • muscle and joints assessed for symmetry
  • gentle passive range of motion
  • full rotation of neck (ability to turn their head toward the location of the noise, followed by their eyes)
  • Head lag; nurse pulls infant up and watched the head fall back
  • assess hip joint
  • observe spontaneous movements in the crib
87
Q

Developmental Dysplasia of the Hip (DDH)

A

congenital condition, if left untreated, can affect future ability to walk and maintain balance
-occurs when the acetabulum is flat, rather than round and cuplike in shape
-often results when the developing fetus assumed a dominant breech position with upwardly extended legs during the period of bone growth
>confirmed by ultrasound or computed tomography
>managed by use of a splint to keep the infants leg in position of abduction
>Pavlik harness, does not immobilize the hip but prevents hip extension or abduction; worn continuously for 3 to 6 months until new bone growth has formed around the head of the femur and a normal cup-shaped hip joint has been created

88
Q

Assessment of Developmental Dysplasia of the Hip (DDH)

A

begins with the inspection of the skin folds on the infants thighs in both prone and supine position

  • asymmetry of the skin folds
  • assess leg length and knee height for unevenness
  • slowly moves lower extremities in a kicking motion to observe for signs of distress or pain
  • check for “hip clunk”, feeling the head of the femur pop out of the hip socket
89
Q

Performing the Barlow Test to determine Developmental Dysplasia of the Hips (DDH)

A
  1. place infant supine
  2. place your thumbs on the infants inner thighs and your fingers on the outside of the greater trochanters of the hips
  3. flex the infants knees toward abdomen and move the legs inward until your fingers touch
    >while maintaining this position, the nurse exerts a downward pressure on the head of the femur in an attempt to dislodge the femur head from the acetabulum
90
Q

Performing the Ortolani Maneuver to determine Developmental Dysplasia of the Hips (DDH)

A
  • using gentle but firm pressure, rotate the hips outward so that the knees touch the flat surface while keeping the infants knees flexed
  • no clicking or crepitus should be detected
  • if detected= DDH
91
Q

Assessment of the feet

A

pronation, or inward turning, of both feet is common; nurse can show the parents that stroking of the infants insoles prompts a ready return to normal position

  • if severely pronated, spontaneous normal alignment may be unattainable
  • Club foot= suspected when there is a medial displacement of the heel from the posterior knee alignment and can be confirmed by x-ray and a cast is placed on the affected extremity
92
Q

Musculoskeletal System: Conditions that may warrant further assessment

A
  • before assessment make sure there are no broken bones; do not move or reposition if indicated
  • clavicle bone most commonly fractured; palpate to check for separation between the bone ends or for presence of crepitus (grating sound); usually heal over time without intervention; teach parents to position infant on the opposite side of the injury and how to hold and support the head and shoulders until healing complete
  • neonatal fractures at the ribs, humerus, and skull; casts applied to humerus fractures, rib fractures generally wrapped, and skull fractures often go to intensive care unit
  • polydactyly
  • syndactyly
93
Q

Signs and Symptoms of fractures

A
  • swelling at fracture site
  • bruising
  • discoloration of the affected area
  • expression of discomfort when moved
94
Q

Polydactyly

A

infants born with extra fingers (digits) and toes

  • must palpate for bone which then needs to be surgically removed
  • if no bone, can be tied with suture silk to occlude the capillary to cause necrosis and loss of the digit
  • familial characteristic
95
Q

Syndactyly

A

webbing of the skin between the digits and toes

  • does not interfere with balance or walking
  • often surgically corrected
96
Q

Inspection of the palms of the hands

A

-for presence of palmar creases
-usually contain 3 or 4 curved palmar creases
>simian crease= single, straight crease that appears in the middle of the palm on one or both hands; usually insignificant; if accompanied with other symptoms it may be associated with other syndromes such as Down syndrome

97
Q

Assessment of Neurological System

A

focuses on reflexes and other movements that provide
s an indication of the infants level of neurological function
-major reflexes (reflective of normal neurological function; gag, Babinski, Moro, and Galant reflexes)
-minor reflexes (finger grasp, toe grasp, rooting, sucking, head righting, stepping, and tonic neck)

98
Q

Minor Reflex: Palmar Grasp

A

the infant curls his fingers around an object

99
Q

Minor Reflex: Toe or Plantar Grasp

A

the infant curls his toes around an object that has been placed at the sole of the foot

100
Q

Minor Reflex: Rooting and Sucking Reflex

A

stroke the infants cheek and watch him turn toward the finger, open his mouth, and suck on an object placed in his mouth

101
Q

Minor Reflex: Extrusion Reflex

A

touch the tip of the infant’s tongue and the tongue will protrude outward

102
Q

Minor Reflex: Stepping

A

hold the infant in an upright position with the legs flexed. The soles of the feet are lightly brushed against a flat surface. In response to the stimulation, the infant lifts his feet and then places them back down in a stepwise pattern that imitates walking

103
Q

Minor Reflex: Tonic Neck or Fencing Reflex

A

in a supine position, extend his arm and leg on the side to which his head and jaw is turned while flexing his arm and leg on the opposite side

104
Q

Major Reflex: Babinski

A

lightly stroke the plantar surface of the foot from the heel toward the toes
-infant responds to the stimulation by first incurving the toes, then uncurling and stretching them out

105
Q

Major Reflex: Moro Reflex

A

observe the infants head as it is lifted while the nurse mimics a release and watches for extension of both arms along with flexion of the legs

106
Q

Major Reflex: Galant Reflex

A

observe the infant while supported in a prone position

  • stroke one side of the vertebral column
  • infant responds by moving his buttocks in a curving motion toward the side that is being stroked
107
Q

Neurological Injuries that may Warrant further Assessment

A

most frequent= involve the brachial plexus and r/t difficulties with shoulder rotation and delivery at the time of birth

  • shoulder dystocia
  • Erb’s palsy
  • cerebral palsy
  • spina bifida (meningocele, myelomeningocele)
  • anencephaly
108
Q

Shoulder Dystocia

A

a temporary decrease in the movement and muscle tone of a shoulder and upper arm
-improves after delivery

109
Q

Erb’s Palsy

A

brachial plexus injury
-one or both arms and hands are extended and do not move into a flexed position
-on palpation, decrease in muscle tone, decrease in grasp reflex, and an absence of arm recoil on the affected side
>”waiter position”; resembles a waiter who keeps one arm by the side while the other is held out for a tip

110
Q

How to Care for Newborns With Brachial Plexus Injuries (Erb’s palsy or shoulder dysotcia)

A

usually resolve in 2 weeks without treatment
-positioned with arm in a gently flexed position and when held, care should be taken to support the arm on the affected side
>teach how to use gentle exercise to facilitate healing process
>simple arm strengthening exercise that passively flex and extend the infants arm can be practiced during each parent-infant interaction

111
Q

Cerebral Palsy

A

results from oxygen deprivation

  • demonstrate motor difficulties, such as difficulty swallowing, breathing, or moving
  • length of anoxia correlates with the severity of brain damage
112
Q

Spina Bifida

A

in utero development of the brain ad spinal cord is a process initiated during the embryonic period; during the first 30 days of gestation, the primitive neural tube closes

  • a failure of the tube to close at the posterior end results in an open area that may be filled with fluid or with a section of the spinal cord = spina bifida
  • detected during routine maternal-fetal antenatal testing
  • Treatment is based on location and extent of lesion
113
Q

Variations of Spina Bifida

A

> Meningocele
-resembles skin-covered sac; may contain dura mater and spinal fluid
-located between 5th lumbar and 1st sacral vertebrae
-does not cause loss of motor function or paralysis below the waist
-sac is surgically closed to prevent infection
Spina Bifida Occulta:
-mild variation; small defect in the spinal vertebrae
-all motor activity remains intact
Myelomeningocele:
-serious lesion
-sac that contains dura mater, spinal fluid, ad a portion of the spinal cord
-have no bladder or bowel control
-loss of motor function below the waist
-sac surgically closed to prevent infection

114
Q

Anencephaly

A

an incomplete closure of the anterior portion of the neural tube causes this

  • causes portions of the brain, forehead, skull, and occiput to be missing
  • usually placed on respirators and monitored to assess viability
115
Q

Temperature Assessment

A
  • axillary
  • taken before a bath is given (not necessary at home)
  • can be assessed with a continuous skin probe or tympanic thermometer or portable sensor probe
  • keep between 97.7 to 99.3 Degrees F
116
Q

Bathing the Newborn

A
  • take place in a warm area free from drafts
  • can be given a sponge bath using only warm water or the first few days of life; face and hands can be wiped off daily; infants bottom cleansed several times throughout day
  • after cord stump has dried completely and fallen off (2 weeks) the infant can be immersed in a small tub filled with about 4 to 5 inches of water
  • do not require daily bathing; usually 3 times a week
  • mild, unscented soap for bath
  • unscented lotion can be used if dry skin is a problem
  • head to toe cleaning
  • clean clothes, hair, nails, and teeth is important in proper growth and development
117
Q

Nail Care

A
  • rarely trimmed in hospital or birthing center in initial days of life because there is a increased potential for injury surrounding tissue that may result in infection
  • filing the nails with a fine emery-textured board or covering the infants hands with a cuffed T-shirt or mittens are safer
  • however, covering the hands should be avoided if possible because this action prevents the infant from sucking on fingers for self-consolidation
  • can file nails often while sleeping
118
Q

Umbilical Cord Care

A

appears as a gelatinous white stump with two arteries and one vein (AVA)
-immediately after birth it is cut with sterile scissors and clamped
-initially be cleaned with sterile water or a neutral pH cleanser and thereafter with water
-cord begins to dry out in 1 to 2 hours
-cord clamp must remain in place for 24 hours until it can be removed by a special cord clamp remover
-by the 3rd day, appears to be discolored and shrunken
-by 10 to 14 days, the cord usually detaches completely and often find remnants on bedding or in diaper
>show parents how to fold and position the diaper below the cord stump; keep area free from urine and wetness during bathing and when to expect cord detachment

119
Q

Clothing for the Newborn

A

often wears a T-shirt, diaper, and booties in hospital
-two or three blankets and a hat are required to help the newborn maintain body temperature within a normal range
-at home, type and amount of clothing is dependent on the local climate and temperature
>infant can be dressed like other family members; appropriate for the temperature and season
>special care for outdoors; a cap or bonnet decreases body heat loss and protects newborn from dangerous sun rays and wind drafts to the ears
>during warm weather, covered in lightweight clothing and placed in shady spots
>sunscreens= check with healthcare provider, some not recommend until 6 months of age

120
Q

Diapering

A

infants sensitive skin may react adversely to the perfume in the diaper
-if diaper rash or dermatitis occur, try another brand of diaper but contact their healthcare professional if problem persists
>cloth diapers must be laundered separately from other clothing, using 1/4 cup detergent, presoaking often necessary to remove stains
>breastfed baby stools do not have an odor or cause diaper stains
-keep baby’s diaper area clean and dry
-change baby’s diaper often
-clean bottom between diaper changes, using a mild soap and plain warm water
-during a wet or soiled diaper change, allow the baby’s skin to dry completely before putting on another diaper
-allow the baby to go without a diaper whenever possible to let the air dry the skin

121
Q

Fostering Attachment

A

-create a non-threatening and nonjudgmental environment in which parents an openly express ideas and ask questions
-healthy bonding is essential for adequate physical, emotional, and spiritual growth
>nurse should watch for behaviors commonly observed:
-mothers and fathers usually begin with an exploration of their infants physical characteristics by examining each tiny finger tip, then extremities, then stroke full length of infants trunk
>parents assume an en face position= establish and maintain direct visual contact with their infant

122
Q

En face

A

parents establish and maintain direct visual contact with their infant

123
Q

Strategies to Promote Family Attachment

A
  • provide time in the first few hours after birth for privacy and time for the new family to get to know one another
  • delay any unnecessary procedures immediately after birth, such as measurements and other admission procedures. Instead, allow the family adequate time alone after birth to spend time getting to know one another
  • encourage early breastfeeding by providing proper education and support
  • teach behavioral cues for feeding (rooting, sucking on fingers or fist, increasing motor activity, or crying) and hot to respond to their infant
  • understand that crying is an infants way of communicating, and all newborns have distinguishable cries for hunger, pain, tiredness, fussiness, or getting attention
  • newborns have built-in capacity to console themselves and do so by sucking, motion, and distraction
  • help parents to recognize the joys and frustrations that go along with ongoing parenting. Assure them it takes time to feel comfortable in meeting their newborns unique needs
  • introduce the concept of anticipatory guidance to help prepare patients for important developmental milestones that will occur
  • encourage parents to invite siblings and other family members to visit for short periods of time to share the joy and provide support
  • provide consistent nurses during the hospital or birthing center stay
124
Q

Circumcision

A

surgical procedure that involves removal of the foreskin on the glans penis

  • appropriate analgesia provided
  • bleeding, dehiscence and trauma can be complications of procedure
  • performed using sterile technique
125
Q

The Circumcision Procedure

A

-sterile technique
-infant is restrained on a board or chair and warmed blankets may be placed on upper body to enhance comfort and prevent heat loss
-hospitalization is necessary if older than 1 month
-must be stable, and a physical examination by a physician or other healthcare provider, along with a signed permit, should have been completed before the circumcision
-device used is a Gomco (Yellen) clamp or a Mogen Clamp
-after procedure, a petrolatum gauze dressing or generous amount of petrolatum is applied for 1 to 2 days to prevent diaper from adhering to surgical site
>another method, Plastibell device, which is fitted over the glans penis. a suture is tied around the bells rim, the excess prepuce is cut away and the plastic rim remains in place until it falls of in 5 to 7 days; no petrolatum gauze is used after

126
Q

Nursing Care after circumcision

A

alleviation of pain and prevention of infection
-assessed q 30 minutes for at least 2 hours following procedure
-observe for the first voiding to evaluate for urinary obstruction r/t penile injury or edema
-patient/ care giver education
-parents should continue to apply a petroleum ointment as directed by physician
>report bleeding or signs and symptoms of infection (increased swelling, pus, or cessation of urination)
>diaper is neither too loos (causes rubbing with movement) not too tight (causes pain)
-therapeutic touch is a beneficial comfort measure for infants

127
Q

Questions the nurse can ask the mother to assess attachment

A
  • Can you tell me more? are you in pain? are you feeling sleepy? are you afraid?
  • does your baby have a name yet?
  • do you have any concerns about basic care for your baby such as holding, feeding, diapering, or bathing?
  • how will you respond when your baby fusses or cries?
128
Q

Care for the Uncircumcised Penis

A
  • during the separation process, sterile sloughed cells build up between the layers; it is harmless
  • cleans penis with water each time you change diaper and at bath time; take care not to force the foreskin back over the penis; over time (3 to 5 years), the foreskin will retract normally
  • around age 4 or 5, the foreskin fully retracts, boys should be taught how to wash underneath the foreskin everyday; clean by gently pulling it back away from the head of the penis and then rinsing the head of the penis and inside fold of the foreskin with soap and warm water; after washing, foreskin should be pulled back over the head of the penis
129
Q

Ensure Optimal Nutriton

A

-breastfeeding
-or bottle feeding
>diet must include essential nutrients such as protein to support rapid cellular growth; carbohydrates to provide energy; and fat to supply the needed calories, regulate fluid and electrolyte balance, and sustain development of the brain and neurological systems
-water intake, essential for tissue hydration, should amount to 140 to 160 mL/kg per day
-full-term infants who are breastfed do not need supplemental iron until 6 months of age; at that time they need iron-fortified formula in combination with breast milk
-bottle-fed infants should receive formula fortified with iron from the beginning
>105 to 108 kcal/kg per day

130
Q

Car Seat Safety

A
  • seat must meet certain federal guidelines. A label on the seat tag or packaging box states whether the product has met the guidelines
  • car seat instructions must be followed when installing car seat
  • several community resources are available to the family that will rent or loan a car seat for the infants discharge home. The hospital or birthing center may have a car seat program (other programs American Red Cross, the Local Health and Safety Council, and the State Department of Health)
  • infant must be dressed so that the clothing facilitates ease of positioning and strap placement. To ensure correct fit, the infant can wear a single layer of clothing, preferably pants, so that the strap can fit between the legs. Sack sleepers are not recommended, and bundling is discouraged because the strap may not fit snugly
  • head support recommended. Parents can use a commercially made product or place a rolled-up receiving blanket around the head and neck area. To protect infant from burns and overheating in warm weather, parents should check the temperature of the car seat by touching the surface
  • trained professionals may be available to perform safety checks to help parents with proper car seat installation and use
  • new cars are required to be equipped with tethers and low anchors to ensure child safety
131
Q

Child Care for New Families

A

nurse can encourage family to

  • communicate their needs and express their concerns about child care
  • interview the facility director along with other individuals who may be involved in the child’s care
  • evaluate the educational programs related to qualification of teachers and structure of the learning environment
  • investigate the provision of meals, nutrition, and related sanitation
  • visit the child care facility on a few occasions, announced and unannounced
  • identify practical aspects of child care such as location, hours of operation, fee requirements and payment schedule, child to worker ratio, environmental safety, indoor and outdoor space, sick day policies, and availability of care during a holiday or inclement weather
  • evaluate the infection control and injury prevention measures
  • gain info about breastfeeding, discipline, nurturing, diapering/toileting, stimulating growth and development, play, nap/rest time, and field trips
  • discover state regulations and read the care facilities policies and related public record
  • become familiar with early childhood programs that offer voluntary accreditation
132
Q

Newborn Metabolic Screening Tests

A

designed to identify newborns with genetic, metabolic, and/or infectious conditions

  • usually 24 hours following birth (sample taken before then may be unreliable)
  • a small sample of blood is taken from the infants heel and placed on special filter paper
  • the specimen should be obtained as close to the time of the infants hospital discharge as possible and not later than 7 days
  • if the patient is discharged before completing first 24 hours of life, a sample must be obtained, and the infants parents must be instructed to contact the physician within 2 weeks to arrange to have another specimen drawn

Nursing 271 (208 decks)

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