Chapter 21: Care Of The Normal Newborn Flashcards
APGAR Score
Method for rapid evaluation of the infant’s cardiorepsiratory adaptation after birth
What does APGAR stand for?
A - Appearance (color) P - Pulse (HR) G - Grimace (reflex response) A - Activity (muscle tone) R - Respirations (respiratory effort)
What is a normal APGAR score?
8-10
An APGAR score of < 7 indicates
Need to watch out for neurological damage.
Watch baby closely.
How is an APGAR score obtained?
- Nurse scores an infant at 1 minute and 5 minutes in each of the five areas.
- Assessments are arranged from most important to least
- Infants are assigned a score of 0-2 in each of the five areas and the scores are totaled.
Resuscitation should NOT be delayed until
The 1 minute score is obtained.
General guidelines for infant’s care is based on 3 ranges of 1 minute scores:
- 0-2
- 3-6
- 7-10
Vitamin K (Phytonadione): Indication
Given to neonates because they receive only small amounts of the vitamin from the mother and cannot synthesize vitamin K in the intestines without bacteria.
What is the action of vitamin K?
Promotes the formation of clotting factors by the liver (II, VII, IX, X)
What is the usual dose of vitamin K?
0.5 to 1 mg
IM, usually within 1 hour after birth.
What are adverse effects of Vitamin K?
- Erythema, pain and edema at injection site.
- Anaphylaxis, hemolysis and hyperbilirubinemia
Nursing Considerations for Vitamin K:
- Protect the drug from light until just before administration
- Observe all infants for signs of Vitamin K deficiency (ecchymoses or bleeding from any site)
- Check that the infant had Vitamin K before a circumcision is performed.
Erythromycin Opthalmic Ointment: Indications
Prophylaxis against organisms Neisseria gonorrhoeae and clamydia trachomatis.
Erythromycin Ophthalmic Ointment helps prevent:
- ophthalmia neonatorum in infants of mothers infected with gonorrhea
- conjunctivitis in infants of mothers infected with chlamydia
Prophylaxis against gonorrhea
Is required by law for all infants, even if the mother is not known to be infected.
Normal Dosage and Route of Erythromycin Ophthalmic Ointment
- A ribbon of ointment (~1 cm long)
- Applied to lower conjuctival sac of each eye within 1 hour after birth.
What are adverse reaction of Erythromycin Ophthalmic Ointment?
- Burning, itching
- Irritation may result in chemical conjunctivitis lasting 24-48 hours
- May cause temporary blurred vision.
Nursing Considerations for application of Erythromycin Ophthalmic Ointment
- Cleanse infant’s eyes as need before application.
- Hold tube horizontal rather than vertical to prevent injury to eye from sudden movement
- Administer from inner to outer canthus
- Do not touch tip of tube to any part of the eye (may spread infectious material from one eye to another)
- Do not rinse. Ointment may be wiped from outer eye after 1 minute.
If any discharge from the eyes, especially purulent, is noted, this should alert the nurse to
A possibility of infection. (Culture may be ordered and drainage should be removed with sterile saline and cotton ball)
Erythromycin Ophthalmic Ointment can be delay until
The end of the first hour after birth without adverse effects.
Hepatitis B Vaccine: Indications
- Prevents hep B in exposed and unexposed infants
- Provides immunization against hep B infection
Hep B Vaccine: Dosage and Route
-5mcg (recombivax HB)
-10 mcg (energix-B):
1st dose: before discharge
2nd dose: age 1-2 months
3rd dose: 6-18 months
What are contraindications to Hep B vaccinations?
Hypersensitivity to yeast
What are adverse reactions to Hep B?
Pain or redness at site
Fever
Fatigue
Headache
Nursing Considerations for administration of Hep B Vaccine
- If used vial, shake well before preparing.
- Give vaccine within 12 hours of birth to infants of infected moms
- Parenteral administration NOT IV or intradermally (need to obtain parental consent)
Administration of Injections in Newborn: Preparation
- Wash infants thigh if the bath has not been given yet.
- Use a 1 mL syringe and a 5/8 inch, 25 gauge needle.
- Use filter if drawing medication from glass ampule.
Administration of Medication in Newborns: Injection
- Cleanse area with alcohol wipe.
- Stabilize leg firmly while grasping thigh between the thumb and fingers.
- Insert needle at 90 degree angle
- Withdraw the needle and apply gentle pressure to the site with an alcohol wipe.
Where is the best site for injection in newborns?
- Vastus lateralis muscle.
- Divide area between the greater trochanter of the femur and the knee into thirds.
- Give the injection in the middle third of the muscle, lateral to the midline of the anterior thigh.
Monitoring Safe Glucose Levels
Assess all newborns for risk factors associated with decrease blood glucose levels.
A newborns temperature should be assessed PRIOR to **
Accucheck
Blood glucose levels should be noted it they are at what levels?
< 40-45 mg/dL
Interventions for Hypoglycemia
- Feed the newborn if glucose screening shows a level of <40-45 mg/dl to prevent further depletion of glucose.
- Infants with severe hypoglycemia may need IV feedings to provide glucose rapidly. (For most infants, breastfeeding or giving formula is sufficient)
For hypoglycemia, agency protocols usually allow the nurse to
Intervene for hypoglycemia and then notify the physician of the infant’s response.
Planning for hypoglycemia revolves around the nurses role including:
- ) assess for signs of hypoglycemia
- ) Notify physician about signs of hypoglycemia or follow hospital protocol for infant’s with signs of hypoglycemia and then notify physician
- ) Intervening to minimize hypoglycemia.
Why is glucose-water alone not recommended for newborns?
Increases glucose level = increases insulin production = decrease glucose level.
What can provide a longer-lasting supply of glucose?
Milk
If infants do not have enough glucose, what can happen?
They may experience a drop in temperature -> respiratory distress as oxygen is needed for NST
Hearing Screening
- Is done on every baby.
- Auditory screening is performed within the first month.
- Most common congenital abnormality.