Chapter 20: Assessment of the Normal Newborn Flashcards
Acrocyanosis
Bluish color of the hands and feet
Brick dust stain
Pinkish color on a wet diaper
Choanal atresia
Abnormality of the nasal septum causing obstruction
Crepitus
Grating sensation during palpation
Chordee
Ventral curvature of the penis
Rugae
Scrotal skin creases
Scaphoid
Sunken appearance
Strabismus
“Crossed” eyes
The three immediate newborn assessments after birth are for:
a. Respiratory problems
b. Thermoregulation
c. Obvious abnormalities
Explain the possible significance of each neonatal assessment:
a. Two-vessel umbilical cord:
b. Simian crease or line:
c. Unequal gluteal creases:
d. Hair tuft on lower spine:
e. Ears below the level of the outer canthi of the eyes:
f. Drooping of one side of the mouth:
a. Two-vessel umbilical cord: Associated with other anomalies; assess the infant carefully
b. Simian crease or line: Single palmar crease that often occurs in infants who have chromosomal abnormalities such as Down syndrome but may be normal.
c. Unequal gluteal creases: Suggests that one leg is shorter than the other; often associated with developmental hip dysplasia.
d. Hair tuft on lower spine: May indicate spina bifida occulta, or failure of one or more vertebrae to close fully.
e. Ears below the level of the outer canthi of the eyes: Associated with chromosomal disorders.
f. Drooping of one side of the mouth: Indicates facial nerve injury during birth resulting in paralysis.
Why should the nurse avoid taking a rectal temperature on newborns?
Taking a rectal temperature on newborns may irritate the mucosa or perforate the rectum, which turns at a right angle 3cm from the anal sphincter.
List signs that suggest neonatal respiratory distress.
a. tachypnea (sustained)
b. retractions that continue after the first hour
c. cyanosis involving the lips, tongue, and trunk (central cyanosis)
d. nasal flaring after the first hour
e. grunting
f. seesaw respirtations
g. asymmetry of chest expansion
List signs that suggest neonatal hypoglycemia.
Jitteriness, poor muscle tone, seating, respiratory signs, low temperature, poor suck, high-pitched cry, lethargy, seizures, eventually coma; some show no signs of hypoglycemia
Describe normal assessments of full-term genitalia.
a. Female:
b. Male:
a. Female: Labia majora darker than surrounding skin and completely covering the clitoris and labia minora; white mucous discharge or pseudomentruation; hymenal or vaginal tags; urinary meatus and vagina present
b. Male: Pendulous scrotum that is darker than surrounding skin and covered with rugae; testes palpable in the scrotal sac; meatus centered at the tip of the glans penis; prepuce covering the glans and adherent to it.
State the possible significance of each skin variance. Note whether any special care is needed.
a. Ruddiness:
b. Green-tinged discoloration of skin and vernix:
c. Red blotchy areas with white or yellow papules in center:
d. Bluish-gray marks over the sacral area:
e. Flat pink to dark reddish-purple area that does not blanch with pressure:
f. Red, raised, rough lesion on the head:
g. Light brown spots:
a. Ruddiness: Suggests polycythemia; may cause higher bilirubin levels as the excessive erythrocytes break down, so observe for more severe jaundice and explain need for observation to parents.
b. Green-tinged discoloration of skin and vernix: Indicates meconium passage in utero; observe infant for associated respiratory difficulties resulting from aspirated meconium.
c. Red blotchy areas with white or yellow papules in center: Erythema toxicum; differentiate from infection; teach parents that rash is self-limiting
d. Bluish-gray marks over the sacral area: Mongolian spots, more common in dark-skinned infants; most disappear during early years; teach parents who are unfamiliar with these.
e. Flat pink to dark reddish-purple area that does not blanch with pressure: Nevus flammeus (port wine stain); permanent; large or obvious ones can later by removed by laser surgery.
f. Red, raised, rough lesion on the head: Nevus vasculosis (strawberry hemangioma); grows larger for 6 months, then gradually disappears.
g. Light brown spots: Cafe-au-lait spots; six or more spots or spots larger than 0.5cm are associated with neurofibromatosis and should be reported to the physician.
