Chapter 26 Nursing Care of Newborn and Family Flashcards
14 Questions on exam (and chapter 25)
What are the primary Newborn Needs after birth?
- Physiological Monitoring and Intervention
- Protection
- Warmth, body hygiene and nutrition
- Nurturing needs
What two Assessments are performed after birth?
Initial assessment using APGAR score and an initial physical assessment
What is body systems and physiology is part of the nurses Initial Physical Assessment?
- General appearance
- Central nervous system
- Cardiovascular system
- Respiratory system
- Skin
- Eyes, ears, nose, and throat
- Genitourinary system
- Gastrointestinal system
What is the APGAR assessment?
Rapid assessment of the newborn’s transition to extrauterine life; Based on 5 signs, each scored from 0-2
1) Appearance, colour
2) Pulse
3) Grimace, reflexes
4) Activity, muscle tone
5) Respirations
How often is the AGPAR assessment done?
At 1 and 5 minutes after birth
Reassessed at 10-20 minutes if their score was less than 7
What do the AGPAR scores indicate?
Score 0-3: severe distress
Score 4-6: moderate difficulty
Score 7-10: the newborn is having minimal or no difficulty adjusting to extrauterine life
Nursing Care involved in Airway Maintenance for newborns
- Side-lying position to help clear secretions then returned to supine
- Suction secretions in the nasal passage (obligatory nose breathers) and mouth if necessary
- Listen to respirations and auscultate lung sounds for crackles, rhonchi, stridor
How long should the nurse suction for?
No more than 5 seconds at a time to prevent vagal stimulation and hypoxia
Keep wall suction pressure to less than 80 mmHg
What are the four conditions essential for maintaining adequate O2 supply?
1) Clear Airway
2) Effective Respirations
3) Adequate Circulation, Perfusion and Cardiac function
4) Adequate Thermoregulation
Signs of Complications or Respiratory Distress in a newborn
- Abnormal respirations resulting in tachypnea or bradypnea (<30 or >60 breaths/min)
- Abnomal breath sounds (wheezing, rhonchi, stridor, grunting, diminished/absent air movement, crackles)
- Nasal flaring, retractions, apnea
- Cyanosis or mottling
- O2 sats <95%
Are crackles normally present upon auscultation after birth?
Yes. Crackles can be heard in the first few hours after birth.
How do Nurses maintain proper Body Temperature in a newborn?
- Adequate drying and wrapping after birth
- Early skin-skin contact with parents to stabilize temperature
- Keep the head well covered and the ambient temperature between 22-26 C
- ## Use of warmers when parent and child are separated
What are the benefits of early skin-to-skin contact?
- Strengthens parent-child relationship
- Increased oxytocin and prolactin in the mother
- Improved initiation of suckling activity in the newborn
- Temp stabilization
- Reduced crying
What is a thermistor probe used for?
Detects minor changes in temperature from the external environment or newborn factors (peripheral vasoconstriction, vasodilation, or increased metabolism)
How often should a newborn axillary (armpit) temperature be checked?
Every hour or more if needed until their temperature stabilizes
What is Ophthalmia neonatorum?
Inflammation of the eyes from gonorrheal or chlamydial infection.
The newborn can contract this during passage through the birth canal
What Eye Prophylaxis treatment is available to prevent Ophthalmia neonatorum after vaginal birth?
Erythromycin, an antibiotic.
Why is Vitamin K Prophylaxis administered after birth?
Prevents hemorrhagic disease of the newborn (HDNB). Vitamin K promotes the formation of clotting factors. Vitamin K is made by intestinal flora which is not present at birth but is introduced through the first feedings. Newborns can produce their own vitamin K by day 7.
What is the importance of assessment of gestational age?
It is important because perinatal morbidity and mortality rates are related to gestational age and birth weight
What is the New Ballard score?
Measures gestational ages of newborns between 20 weeks-36 weeks gestation.
Assesses 6 external physical and 6 neuromuscular signs, each with a numbered score that will cumulate to a maturity rating (gestational age)
What is classified as Large for gestational age (LGA)?
above
ninetieth percentile
What is classified as Small for gestational age (SGA)?
below tenth percentile
What is classified as Appropriate for gestational age
(AGA)?
Between the 10th and 90th percentile
Define preterm/premature
<37 weeks gestation
Define Very Pre-Term infant
<30 weeks gestation
Define Term infant
38-41 weeks gestation
Define post-term (postdate)
> 42 weeks gestation
What is the range for low, very low, and extremely low birth weight?
– Low birth weight (LBW): < 2500 g
– Very low birth weight (VLBW): <1500 g
– Extremely low birth weight (ELBW): <1000 g
What are newborns at risk for that can be detected during physical assessment?
At risk for impaired vision/hearing, chronic lung disorders, cognitive impairment
What are abnormal findings on a newborn physical assessment?
– Limp, weak muscles
– Weak cry
– Rapid, shallow respirations
– Pot belly abdomen, large genitalia
– Shiny skin
– Thin, permeable skin
– ++lanugo
Physical characteristics of a post-term (>42 weeks) newborn. What is the primary concern?
- Fetus receives poor oxygenation and nutrient transfer which depletes glucose reserves
- Physical characteristics:
– Long, lean, angular body
– Little subcutaneous fat
– Hair is coarse and thick
– Wrinkled, dry skin
How long do you access a newborns vitals for?
1 full minute
Name the normal newborn reflexes
- Grasp/Palmar
- Rooting
- Sucking
- Tonic neck
- Stepping
- Knee Jerk
- Ankle clonus
- Glabella
- Blink
- Babinski
Describe the normal newborn reflexes and how to elicit a response
- Grasp/Palmar: finger/touching inside of palm will cause it to close or grab finger
- Rooting: when touching side of face the head will move to the side being touched
- Sucking: when something touches the infants mouth it will suck on it
- Tonic neck: the arm and leg on the side that the infants head is facing will extend, the opposite side will flex
- Stepping
- Knee Jerk
- Ankle clonus
- Glabella
- Blink
- Babinski: when the foot is stroked from bottom to top the big toe will bend back and the other toes will spread out
When should the normal newborn reflexes go away?
- Grasp/Palmar: 4-6 months
- Rooting: 4 months
- Sucking: 4 months
- Tonic neck : 4 months
- Stepping
- Knee Jerk
- Ankle clonus
- Glabella
- Blink
- Babinski: 1 yr
Normal Skin Findings
- Pink with some acrocyanosis and mottling with bathing
- Lanugo
- Milia
- Vernix
- Erythema toxicum
- Mongolian spots
- Harlequin sign
- Birthmarks
– Port Wine Stains
– Stork’s bite marks
– Strawberry Marks
Abnormal Skin Findings
- Pallor
- Cyanosis
- Petechiae
- Fat necrosis
- Puncture wounds
- Forceps marks
- Hemangiomas
Normal Head Findings
- Skull consists of 6 bones
- 4 sutures separate the bones and are
felt as ridges - 2 fontanelles are soft areas at the
junction of each of the sutures - Molding of the head following vaginal
delivery
Abnormal Head Findings
- Tense or bulging fontanelles
- Depressed fontanelles
- Skull fracture
- Caput succedaneum
- Cephalhematoma
- Macrocephaly
- Microcephaly
Normal Eye Findings
- Eye colour is dark
- Sclera is bluish white
- Eyelids swollen or reddened
- Pseudostraismus
- Nystagmus
- Pupil reaction – PERRLA
Abnormal Eye Findings
- Asymmetry
- Discharge
- Fixed & dilated pupils
- Hemorrhages
- Jaundice
- Sun-setting sign
- Doll’s eye
- Drooping eyes
- Cataracts
- Corneal Opacities
Normal Nose Findings
- Symmetrical
- Nares patent
- Random sneezing present
Abnormal Nose Findings
- Deviations to the right or left
- Flaring of nostrils
- Closed nares
- Frequent sneezing
Normal Mouth Findings
- Mouth is pink
- Neck is short and mobile
- Mucous membranes moist
Abnormal Mouth Findings
- Cleft lip & palate
- Thrush
- Teeth
- Cysts
- Macroglossia
- Webbing of neck
- Goiter
- Excessive salivation and choking
Normal Ear Findings
- Symmetrical
- Cartlidge present
- Hearing
Abnormal Ear Findings
- Asymmetrical
- Absence of Moro Reflex with loud
sound - Low placement of ears
- Skin tags
- Small nodules
Normal Chest Findings
- At term, averages 30-37.2cm in size
- Circular and symmetrical
- Neonatal respirations are diaphragmatic and the
thoracic cage remains immobile while the abdomen
rises and falls - Breast tissue present, some milky secretion
- RR 30-60/min, regular, distinct and rhythmic
- HR 120-160/min, regular, distinct and rhythmic
- Preterm infant may have chest pulsating with heart
beat - Point of Maximal Intensity (PMI) at 4th intercostal
space
Abnormal Chest Findings
- Tachypnea
- Apnea
- Retractions, Grunting, Flaring nostrils
- Cyanosis
- Crackles, Wheezing, Stridor
- Heart sounds shifted to Rt side of chest
- Heart murmurs
- Weak pulses
- Difference in peripheral pulses
- Barrel shaped/Bulging
- Asymmetrical
Normal Abdominal Findings
- Liver palpation
- Abdomen symmetrical, cylindrical, protrude
slightly, moves with respirations - Umbilical stump bluish white with 3 vessels
present - Back symmetrical
- No distention or bulging
- Auscultate four quadrants for bowel sounds
– Present 1 hour after birth - Palpate clockwise for softness tenderness &
masses
Abnormal Abdominal Findings
- Enlarged liver
- Abdominal distention or masses
- Scaphoid abdomen
- Diastaisi recti
- Omphalocele
- Redness, discharge, odour on umbilical
stump - Abnormal curvature of spine, masses
or tuft of hair - Absent artery or vein in umbilical
stump
Normal Genital Findings
- Term female genitalia prominent
- Pseudomenses
- Term male testicles are usually in the
scrotum and urethral opening at top of
penis - Foreskin is not retractable until 6-8
mths - Anus is patent
Abnormal Genital Findings
- Hydrocele
- Epispadias
- Hypospadias
- Phimosois
- Cryptorchidism
- Ambiguous genitalia
- Closed Anus
Normal Extremity Findings
- Easily flexed
- Symmetrical
Abnormal Extremity Findings
- Polydactyly
- Syndactyly
- Limited movement
- Webbing, curving of digits
- Absence of extremities
- Abnormal spacing of digits
- Talipes or “Club feet”
- Simian creases in palms
- Extra skin folds of legs
- Amniotic bands
- Developmental Dysplasia of the Hip
Common newborn problems after birth
- Soft tissue injuries
- Lacerations
- Jaundice
- Hypoglycemia (blood glucose levels <2.6 mmol/L)
- Hypocalcemia (blood calcium levels <2 mmol/L)
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How often are newborn follow-ups?
– Follow-up needed within 2 to 3 days to check status of jaundice, feeding, and elimination.
– Follow-up at 2 to 4 weeks; then every 2 months until 6 to 7 months; then every 3 months until 18
months; then annually.
