Exam 2 NB Assessment Flashcards
1
Q
Normal RR of NB
A
30-60 Irregular
2
Q
Normal NB HR
A
110-160 bpm
2
Q
NB head to toe assessment is preformed how frequently
A
q4-8h
3
Q
Abnormal Respiration Triad
A
Retractions, grunting, nasal flaring
S/s of infection
4
Q
Rooting
A
Stroke NB’s cheek near the corner of mouth
–>find food
Disappears at 4 months
5
Q
Palmar grasp
A
Place obj in NB palm
hand curls around finger in Palm
6
Q
Tonic Neck (fencing)
A
Arm and leg on same side head is turned extend, arm and leg on opposite side flex
7
Q
Breast milk contains:
A
Carbs protein cholesterol (needed for brain development) fat ANTIBODIES vitamins minerals
8
Q
Moro Reflex
A
Startle
NB symmetrically extends: adducts both arms–> ( )
10
Q
Circumcision is contraindicated for:
A
Preterm
Genitourinary defects
Bleeding prob
Unstable NB
11
Q
Delee
A
Deep Suctioning
(mouth to stomach)
Continuous Suction by Occluding Hole
12
Q
Apneic Periods
A
Normal
<15seconds
13
Q
Normal Temp
A
97.7-99.5 (Axillary)
If low recheck, still low–>notify instructor
14
Q
Heat Regulation is….
A
Critical
15
Q
Heat loss in infants is d/t
A
large surface area
limited subcutaneous fat
superficial blood vessels
16
Q
4 Types of Heat Loss
A
Convection
Radiation
Evaporation
Conduction
17
Q
Convection
A
Body to Air Current
18
Q
Body heat lost to a cooler surface w/out contact
A
radiation
19
Q
Heat lost to air vapor
A
Evaporation
20
Q
Heat lost to surface with contact
A
Conduction
21
Q
Rapid Assessment of Cardiac, Pulmonary, and Neurosensory Status
A
Apgar
22
Q
Apgar is preformed at…
A
1 and 5 minutes
23
Q
Apgar Score for: absent respiratory effort
A
Absent=0
24
Q
Apgar score for NB HR <100bpm
A
Apgar HR Score of 1
25
Apgar Score NB HR>100bpm
Apgar HR score of 2
26
Apgar score 0-3
Serious Danger
27
Apgar score 4-7
May need suction/ oxygen
28
Apgar Score 8-10
Stable
29
AVA
Umbilical Cord
| 3 Vessel Check - 2 arteries 1 vein
30
Omphalitis
Infected Umbilical Cord
31
The Umbilical Cord falls off in...
7-10 days
32
HR increase per degree of fever
10 beats
33
mo before Advil, Motrin, and Ibuprofen
6 months
34
Treat Fevers
When they show s/s
35
Infant Enema
120-240cc 1 inch
| no plain water enema
36
2-4 years Enema
240-360cc 2 inch
| no plain water enema
37
4-10 years Enema
360-480cc 3 inch
| no plain water enema
38
11 years Enema
480-720cc 4 inch
| no plain water enema
39
Weighing Diapers
| 1Gm =
1ml Output
40
BMI=
[Wt (lbs)/ Ht (in)]*703
41
Stimulate the lips
NB makes sucking motion; sucks & takes food
Begins to diminish ~ 6 mo.
Disappears immediately if it is never stimulated. May observe during sleep.
Sucking
42
Touches the sole of the NB'S foot @ base of the toes --> toes grasp
Disappears at 8-9 mos
Plantar grasp
43
Learns to finger feed
Starting at 12 mo
44
IV Checks
Need to check site Q1 hr
| Administer via Buritrol
45
Rectal
Not desired route for pediatric clients
Unpredictable absorption
Upsetting to toddlers and preschoolers
46
5th finger (Pinkie for Rectal)
rectal for infants and children under 3 years old
47
avoid Ophthalmic Medication when
child is crying
48
Otic Medication <3yo
Pull pinna down and back
| Hold in position for a few moments
49
Otic Administration
Drops @ Rm Temp
| Affected Ear Up
50
Nasal Medication
head down
20 min prior to feedings
Keep head below shoulder level for 1 – 2 mins
51
Pediatric Drug Doses Based on
Unit of drug per kilogram of body weight
Unit of drug per body surface area
dose should not exceed min. adult dose
52
```
Reaches randomly toward mouth
Head drops or bobs
Sucks reflexively in response to tactile stimulation
Tongue may project food out of mouth
Stops taking fluids when full
```
Infants 1-3 months
53
PO Meds Infants 1-3 months
Best when Hungry
Control infant’s hands
Place syringe alongside tongue & give slowly to avoid choking
54
True/ False May use empty nipple to give PO Meds to Infants 1-3 mo
True
| Regardless of method used, frequently need to retrieve medication from chin and re-feed
55
True/ False May cup feed PO meds to infant 1-3 mo
True
| Regardless of method used, frequently need to retrieve medication from chin and re-feed
56
Spits deliberately
1 year – 2 ½ years old
57
Temper tantrums
| Obtains and throws objects
1 year – 2 ½ years old
58
Shows pride in accomplishments
| Does NOT know right from wrong
1 year – 2 ½ years old
59
PO Med 1 year – 2 ½ years old
**Approach is important!
Option to take medication is NOT given
Do NOT hold nose, force meds, or give if crying--> danger of aspiration
60
Able to follow directions
Make decisions
Shows pride in accomplishments
May view illness as punishment
2 ½ years - 6 years old
61
Preferred IM Injection Sight for infants & toddlers
Vastus lateralis preferred
| based on age and size
62
IM Dorsogluteal
after child has been walking 1 year
63
IM Ventrogluteal
3+ years`
64
IM Deltoid
4- to 5-year-olds
65
EMLA can be given
1 hr before injection
66
IM Injection Amt
never more than 1mL… if more--> 2 sites
67
IV meds
```
Maximum concentrations
Assess IV site q1h
Administer via Buritrol
Smallest amount dilutent possible
Must ALWAYS calculate safe dose range
```
68
Pain pathways and neurochemical processes are intact and functional in neonates! True or false
True
69
of weeks Gestation where pain may be felt
20 Weeks Gestation
70
Start to lie
2-3 yo
71
Acrocyanosis
blue discoloration of hands and feet
72
SGA
Sm For Gestational Age <10th%ile
73
LGA
Large for Gestational Age > 90th%ile
74
Normal Length Of Infant
19-21in
75
Head Circumference of Infant
Above Ears
Ave 13-14 in
Molding can alter measurements
76
Chest Circumference of Infant
Over the nipple line
| 12-13 in
77
3 Main NB Prophylaxis
Vitamin K-phytonadione
Erythromycin
Hepatitis B
78
Vitamin K-phytonadione
Pre-filled (IM) Do Not Aspirate
Prevent Hemorrhage
Admin-Lateral Aspect of Thigh (Vastus Lateralis)
1mg/ml
79
Erythromycin
Prophylactic-gonorrheal & chlamydial conjunctivitis in lower conjunctival sac
May cause slight edema and erythema;
Do Not Remove for 1h
80
Time Erythromycin Must Remain in lower conjunctival sac
Do not rinse or irrigate eye for at least 1h
81
Hepatitis B
Recombivax HB-Viral Vaccine
Given w/in 48h
IM-Aspirate
Vastus Lateralis
82
Head to Toe on the NB is preformed
q 4-8h
83
At start of shift, prior to NB assessments, wash hands for….
1 Full Min
84
Shape of Anterior Fontanelle
Diamond
85
Shape of Posterior Fontanelle
Triangle
86
Abnormal Fontanelles
firm, building, or depressed
| want soft and flat
87
Scalp edema CROSSES Suture lines
d/t pressure on pelvis or cervix
Resolves on own
Fluid
Caput Succendum
88
Tx of Caput Succendum
Self Resolving
89
Cephalohematoma
unilateral swelling; does NOT cross suture line
Hematoma of scalp r/t forceps,vac, prolonged labor
Resolves
90
Protective white cheesy substance from sebaceous glands
Antimicrobial Properties
Do not need to get off w/ NB Bath
Vernix
91
The earlier the delivery, the cheesier the baby
Vernix
92
Desquamation
peeling of skin
| post-term (>42wks)
93
Erythematous
beefy red coloring
| norm (6-12h) after birth
94
Blotchy Skin on NB
Norm
| No clear demark
95
Ecchymosis
Bruising
| May be d/t forceps
96
Petechia
minute hemorrhages
| worsens-->may be abnorm
97
White papules
Milia
| self-resolving
98
Fine Hair
Heaviest on back, shoulders, forehead
Hispanics
Lanugo
99
The earlier, the hairier
Lanugo
100
white/ yellowish papules with redden skin
Erythema Toxicum
| Benign/ Self-resolving
101
One side of the body pale while other side is deep red; Vertical split, well demarcated
Harlequin Color Change
| Harmless d/t vasomotor instability
102
Circumoral Cyanosis
Blueing around mouth
| Benign if transient
103
If Circumoral Cyanosis persist with crying & feeding -->
Cardiac Problems?
104
flat bluish area on lower back/buttock
Mongolian Spots
| Dont mistake for bruising
105
Mongolian Spots are most common on
```
AA
Asian
Latin
Native Americans
Vietnamese
```
106
Telangietic Nevi-stork bites
Salmon colored hemangioma (strawberries)
| fade @ ~18mo
107
Tear Production in NB
Absent for 1st 2 mo
108
Strabismus & nystagmus in NB
Normal
109
Yellowing of Sclera
Late sign of Jundice
110
Crackles in NB lungs
Normal right after birth
111
Cap Refill in NB
<3SEC
112
Abnorm Abd in NB
failure to meconium/ void w/in 24h
| distention
113
NB bath
temp must be stable x2 (97.7)
| J&J for 1st bath, then no soap/lotion/powder x 1 wk
114
Diarrhea in NB
Watery, green
| Formula fed--> change formula
115
Colostrum
only need small amt (think frozen oj)
116
NB Caloric Need
110 cal/kg/day
117
S/S of formula Allergy
diarrhea, distention, skin rash, copious amts of gas, mucus/ blood in stool; Failure to thrive
118
Fast Flow Nipples
Pre-term
119
Formula preparation is
a clean procedure
120
Feeding a NB
NEVER prop a bottle/ warm in microwave
DONT over feed (.5-1oz)
Burp frequently (1/2 way & end)--Spitting up, burp more
121
ABR-auditory brain response
@6h of age
May take up to 30 min (Warn parents)
Electrodes on head, neck, shoulder pick up electrical current-- may have interference
122
HMD (PKU)
Screens for metabolic disorders, genetic diseases, and infections
Lateral heel stick after 24h, repeated @<28d
123
At Risk for PKU
French Canadians
Chinese
Greek Americans
124
Bilirubin
Do NOT massage foot--> break down blood cells
125
Pulse Ox of NB
Opposite arm and leg w/in 3% of ea. other (norm)
| >95%
126
Circumcision is contraindicated for:
Preterm
Genitourinary defects
Bleeding prob
Unstable NB
127
Rn Actions of Circumcision
Do NOT feed prior
Witness consent/ preform timeout
Place restraint board
Bulb suction available
128
Post Circumcision
Petroleum jelly w/ diaper changes
| Assess q15
129
Parent Teaching Post Circumcision
```
AVOID soap & removing clots
Petroleum jelly for 3-5d
gentle retraction after 3-5d
No ointments or creams
Plastibell remains in place until healed
```
130
Phases of separation anxiety
protest
despair
detachment
131
goal of a traumatic care
Prevent/ decrease separation from family
Promote a sense of control
Prevent/ minimize bodily injury and pain
132
Short peripheral catheters
therapy lasts <6 days
pH between 5-9
osmolarity most distal UE
133
Do NOT use hand veins for
- vesicant medications
- older adults who've lost sub-Q tissue surrounding vein
- pts who'll be getting in & out of bed frequently or using their hands for other activities.
