Chapter 24 Flashcards
What is the primary goal of care in the first moments after birth?
establishing effective respirations
When obtaining the heart rate either through the umbilical cord or apical pulse you count for how many seconds and multiply by what?
count for 6 seconds and multiply by 10
what 5 things does the apgar score test?
heart rate, respiratory effort, muscle tone, reflex irritability, skin color
when should the apgar test be done?
at 1 and 5 minutes
score of 0-3
indicates severe distress
score of 4-6
indicate moderate difficulty
score of 7-10
indicate infant is having minimal difficulty adjusting to extrauterine life
can you do a rectal temp?
no this can cause perforation
normal axillary temp is what
98.6 degrees
Respiratory rate should be what
between 30-60 breaths/minute
Birth weight ranges from what if normal?
2500-4000 g (5.5-8.8 lb)
head circumference ranges from what?
32-36.8 cm
length ranges from what?
45-55 cm
What is the New Ballard Score used for?
determining gestational age.
Preterm
born before 37 weeks
Late Preterm
34-37 weeks
Early Term
37-39 weeks
Full term
39-41 weeks
Late Term
41-42 weeks
Postterm
42 weeks and behond
Postmature
born after 42 weeks and showing the effects of progressive placental insufficiency.
What are some of the maneuvers used in assessing gestational age?
posture, square window, arm recoil, popliteal angle, scarf sign, heel to ear
characteristics of a postterm infant
little if any vernix caseosa, absence of lanugo, abundant scalp hair, long fingernails
what is the ideal method for maintaining neonatal body temp?
skin to skin contact
how often is the axillary temp of the newborn checked?
at least every hour
how quickly is eye prophylaxis usually given?
within an hour after birth; may be delayed up to two hours for breastfeeding
what are some adverse reactions to eye prophylaxis?
conjunctivitis for up to 48 hours and temporary blurred vision
how can the nurse differentiate hemorrhagic areas from a skin rash or discolorations?
the nurse attempts to blanch the skin by pressing with two fingers and lifting off to wait for the return of blood; petechiae and ecchymoses will not blanch whereas skin rashes and discolorations will blanch.
how often should every newborn be assessed for jaundice?
every 8-12 hours
what can adequate feeding prevent?
hyperbilirubinemia
what does colostrum do to help with hyperbilirubinemia?
colostrum acts as a laxative to promote stooling which helps rid the body of bilirubin
what is the purpose of phototherapy?
to reduce the level of circulating unconjugated bilirubin or keep it from increasing
phototherapy is delivered through
lamp, blanket, pad, cover body devices
what is important when using a phototherapy lamp?
to cover the infants eyes
why must you monitor urinary output during phototherapy?
as an indicator of hydration status
can you apply ointments, creams, or lotions during phototherapy?
no this can absorb heat and cause burns
What level indicates hypoglycemia that warrants treatment?
glucose levels less than 40 mg/dl
hypocalcemia symptoms in neonates can look like symptoms of what?
hypoglycemia
what is the most commonly diagnosed genetic disorder in newborns?
hearing loss
What can you do before a heelstick to help with getting a good sample?
warm the heel w/ application of heat for 5-10 minutes to dilate the vessels in the area
To prevent complications of a heelstick…
the puncture is made at the outer aspect of the heel and penetrates no deeper than 2.4 mm.
How can pain from a heelstick be reduced?
have mother hold the neonate, use oral sucrose, swaddling.
What kind of needle will be used for neonate venipuncture?
a 23-25 guage butterfly needle or hypodermic needle with a syringe.
why must you make every effort to keep the infant quiet and calm while doing venipuncture for blood gas studies?
because crying, fear, and agitation will affect the values
Urine Samples…
should be fresh and analyzed within 1 hour of collection
How do most falls occur?
when the mother falls asleep while holding the newborn in her bed or reclining chair.
IM injection
must be done with a 25 guage needle, 5/8 inch, no more than 0.5 ml, and the preferred injection site is the vastus lateralis
circumcision care
wash with water not wipes and apply petroleum to keep the penis from adhering to the diaper at each diaper change
