Chapter 24

Question 1

What is the primary goal of care in the first moments after birth?

Answer 1

establishing effective respirations

Question 2

When obtaining the heart rate either through the umbilical cord or apical pulse you count for how many seconds and multiply by what?

Answer 2

count for 6 seconds and multiply by 10

Question 3

what 5 things does the apgar score test?

Answer 3

heart rate, respiratory effort, muscle tone, reflex irritability, skin color

Question 4

when should the apgar test be done?

Answer 4

at 1 and 5 minutes

Question 5

score of 0-3

Answer 5

indicates severe distress

Question 6

score of 4-6

Answer 6

indicate moderate difficulty

Question 7

score of 7-10

Answer 7

indicate infant is having minimal difficulty adjusting to extrauterine life

Question 8

can you do a rectal temp?

Answer 8

no this can cause perforation

Question 9

normal axillary temp is what

Answer 9

98.6 degrees

Question 10

Respiratory rate should be what

Answer 10

between 30-60 breaths/minute

Question 11

Birth weight ranges from what if normal?

Answer 11

2500-4000 g (5.5-8.8 lb)

Question 12

head circumference ranges from what?

Answer 12

32-36.8 cm

Question 13

length ranges from what?

Answer 13

45-55 cm

Question 14

What is the New Ballard Score used for?

Answer 14

determining gestational age.

Question 15

Preterm

Answer 15

born before 37 weeks

Question 16

Late Preterm

Answer 16

34-37 weeks

Question 17

Early Term

Answer 17

37-39 weeks

Question 18

Full term

Answer 18

39-41 weeks

Question 19

Late Term

Answer 19

41-42 weeks

Question 20

Postterm

Answer 20

42 weeks and behond

Question 21

Postmature

Answer 21

born after 42 weeks and showing the effects of progressive placental insufficiency.

Question 22

What are some of the maneuvers used in assessing gestational age?

Answer 22

posture, square window, arm recoil, popliteal angle, scarf sign, heel to ear

Question 23

characteristics of a postterm infant

Answer 23

little if any vernix caseosa, absence of lanugo, abundant scalp hair, long fingernails

Question 24

what is the ideal method for maintaining neonatal body temp?

Answer 24

skin to skin contact

Question 25

how often is the axillary temp of the newborn checked?

Answer 25

at least every hour

Question 26

how quickly is eye prophylaxis usually given?

Answer 26

within an hour after birth; may be delayed up to two hours for breastfeeding

Question 27

what are some adverse reactions to eye prophylaxis?

Answer 27

conjunctivitis for up to 48 hours and temporary blurred vision

Question 28

how can the nurse differentiate hemorrhagic areas from a skin rash or discolorations?

Answer 28

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.

Question 29

how often should every newborn be assessed for jaundice?

Answer 29

every 8-12 hours

Question 30

what can adequate feeding prevent?

Answer 30

hyperbilirubinemia

Question 31

what does colostrum do to help with hyperbilirubinemia?

Answer 31

colostrum acts as a laxative to promote stooling which helps rid the body of bilirubin

Question 32

what is the purpose of phototherapy?

Answer 32

to reduce the level of circulating unconjugated bilirubin or keep it from increasing

Question 33

phototherapy is delivered through

Answer 33

lamp, blanket, pad, cover body devices

Question 34

what is important when using a phototherapy lamp?

Answer 34

to cover the infants eyes

Question 35

why must you monitor urinary output during phototherapy?

Answer 35

as an indicator of hydration status

Question 36

can you apply ointments, creams, or lotions during phototherapy?

Answer 36

no this can absorb heat and cause burns

Question 37

What level indicates hypoglycemia that warrants treatment?

Answer 37

glucose levels less than 40 mg/dl

Question 38

hypocalcemia symptoms in neonates can look like symptoms of what?

Answer 38

hypoglycemia

Question 39

what is the most commonly diagnosed genetic disorder in newborns?

Answer 39

hearing loss

Question 40

What can you do before a heelstick to help with getting a good sample?

Answer 40

warm the heel w/ application of heat for 5-10 minutes to dilate the vessels in the area

Question 41

To prevent complications of a heelstick…

Answer 41

the puncture is made at the outer aspect of the heel and penetrates no deeper than 2.4 mm.

Question 42

How can pain from a heelstick be reduced?

Answer 42

have mother hold the neonate, use oral sucrose, swaddling.

Question 43

What kind of needle will be used for neonate venipuncture?

Answer 43

a 23-25 guage butterfly needle or hypodermic needle with a syringe.

Question 44

why must you make every effort to keep the infant quiet and calm while doing venipuncture for blood gas studies?

Answer 44

because crying, fear, and agitation will affect the values

Question 45

Urine Samples…

Answer 45

should be fresh and analyzed within 1 hour of collection

Question 46

How do most falls occur?

Answer 46

when the mother falls asleep while holding the newborn in her bed or reclining chair.

Question 47

IM injection

Answer 47

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

Question 48

circumcision care

Answer 48

wash with water not wipes and apply petroleum to keep the penis from adhering to the diaper at each diaper change