Exam 2 NB Assessment Flashcards
Normal RR of NB
30-60 Irregular
Normal NB HR
110-160 bpm
NB head to toe assessment is preformed how frequently
q4-8h
Abnormal Respiration Triad
Retractions, grunting, nasal flaring
S/s of infection
Rooting
Stroke NB’s cheek near the corner of mouth
–>find food
Disappears at 4 months
Palmar grasp
Place obj in NB palm
hand curls around finger in Palm
Tonic Neck (fencing)
Arm and leg on same side head is turned extend, arm and leg on opposite side flex
Breast milk contains:
Carbs protein cholesterol (needed for brain development) fat ANTIBODIES vitamins minerals
Moro Reflex
Startle
NB symmetrically extends: adducts both arms–> ( )
Circumcision is contraindicated for:
Preterm
Genitourinary defects
Bleeding prob
Unstable NB
Delee
Deep Suctioning
(mouth to stomach)
Continuous Suction by Occluding Hole
Apneic Periods
Normal
<15seconds
Normal Temp
97.7-99.5 (Axillary)
If low recheck, still low–>notify instructor
Heat Regulation is….
Critical
Heat loss in infants is d/t
large surface area
limited subcutaneous fat
superficial blood vessels
4 Types of Heat Loss
Convection
Radiation
Evaporation
Conduction
Convection
Body to Air Current
Body heat lost to a cooler surface w/out contact
radiation
Heat lost to air vapor
Evaporation
Heat lost to surface with contact
Conduction
Rapid Assessment of Cardiac, Pulmonary, and Neurosensory Status
Apgar
Apgar is preformed at…
1 and 5 minutes
Apgar Score for: absent respiratory effort
Absent=0
Apgar score for NB HR <100bpm
Apgar HR Score of 1
Apgar Score NB HR>100bpm
Apgar HR score of 2
Apgar score 0-3
Serious Danger
Apgar score 4-7
May need suction/ oxygen
Apgar Score 8-10
Stable
AVA
Umbilical Cord
3 Vessel Check - 2 arteries 1 vein
Omphalitis
Infected Umbilical Cord
The Umbilical Cord falls off in…
7-10 days
HR increase per degree of fever
10 beats
mo before Advil, Motrin, and Ibuprofen
6 months
Treat Fevers
When they show s/s
Infant Enema
120-240cc 1 inch
no plain water enema
2-4 years Enema
240-360cc 2 inch
no plain water enema
4-10 years Enema
360-480cc 3 inch
no plain water enema
11 years Enema
480-720cc 4 inch
no plain water enema
Weighing Diapers
1Gm =
1ml Output
BMI=
[Wt (lbs)/ Ht (in)]*703
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
Touches the sole of the NB’S foot @ base of the toes –> toes grasp
Disappears at 8-9 mos
Plantar grasp
Learns to finger feed
Starting at 12 mo
IV Checks
Need to check site Q1 hr
Administer via Buritrol
Rectal
Not desired route for pediatric clients
Unpredictable absorption
Upsetting to toddlers and preschoolers
5th finger (Pinkie for Rectal)
rectal for infants and children under 3 years old
avoid Ophthalmic Medication when
child is crying
Otic Medication <3yo
Pull pinna down and back
Hold in position for a few moments
Otic Administration
Drops @ Rm Temp
Affected Ear Up
Nasal Medication
head down
20 min prior to feedings
Keep head below shoulder level for 1 – 2 mins
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
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
PO Meds Infants 1-3 months
Best when Hungry
Control infant’s hands
Place syringe alongside tongue & give slowly to avoid choking
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
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
Spits deliberately
1 year – 2 ½ years old
Temper tantrums
Obtains and throws objects
1 year – 2 ½ years old
Shows pride in accomplishments
Does NOT know right from wrong
1 year – 2 ½ years old
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
Able to follow directions
Make decisions
Shows pride in accomplishments
May view illness as punishment
2 ½ years - 6 years old
Preferred IM Injection Sight for infants & toddlers
Vastus lateralis preferred
based on age and size
IM Dorsogluteal
after child has been walking 1 year
IM Ventrogluteal
3+ years`
IM Deltoid
4- to 5-year-olds
EMLA can be given
1 hr before injection
IM Injection Amt
never more than 1mL… if more–> 2 sites
IV meds
Maximum concentrations Assess IV site q1h Administer via Buritrol Smallest amount dilutent possible Must ALWAYS calculate safe dose range
Pain pathways and neurochemical processes are intact and functional in neonates! True or false
True
of weeks Gestation where pain may be felt
20 Weeks Gestation
Start to lie
2-3 yo
Acrocyanosis
blue discoloration of hands and feet
SGA
Sm For Gestational Age <10th%ile
LGA
Large for Gestational Age > 90th%ile
Normal Length Of Infant
19-21in
Head Circumference of Infant
Above Ears
Ave 13-14 in
Molding can alter measurements
Chest Circumference of Infant
Over the nipple line
12-13 in
3 Main NB Prophylaxis
Vitamin K-phytonadione
Erythromycin
Hepatitis B
Vitamin K-phytonadione
Pre-filled (IM) Do Not Aspirate
Prevent Hemorrhage
Admin-Lateral Aspect of Thigh (Vastus Lateralis)
1mg/ml
Erythromycin
Prophylactic-gonorrheal & chlamydial conjunctivitis in lower conjunctival sac
May cause slight edema and erythema;
Do Not Remove for 1h
Time Erythromycin Must Remain in lower conjunctival sac
Do not rinse or irrigate eye for at least 1h
Hepatitis B
Recombivax HB-Viral Vaccine
Given w/in 48h
IM-Aspirate
Vastus Lateralis
Head to Toe on the NB is preformed
q 4-8h
At start of shift, prior to NB assessments, wash hands for….
1 Full Min
Shape of Anterior Fontanelle
Diamond
Shape of Posterior Fontanelle
Triangle
Abnormal Fontanelles
firm, building, or depressed
want soft and flat
Scalp edema CROSSES Suture lines
d/t pressure on pelvis or cervix
Resolves on own
Fluid
Caput Succendum
Tx of Caput Succendum
Self Resolving
Cephalohematoma
unilateral swelling; does NOT cross suture line
Hematoma of scalp r/t forceps,vac, prolonged labor
Resolves
Protective white cheesy substance from sebaceous glands
Antimicrobial Properties
Do not need to get off w/ NB Bath
Vernix
The earlier the delivery, the cheesier the baby
Vernix
Desquamation
peeling of skin
post-term (>42wks)
Erythematous
beefy red coloring
norm (6-12h) after birth
Blotchy Skin on NB
Norm
No clear demark
Ecchymosis
Bruising
May be d/t forceps
Petechia
minute hemorrhages
worsens–>may be abnorm
White papules
Milia
self-resolving
Fine Hair
Heaviest on back, shoulders, forehead
Hispanics
Lanugo
The earlier, the hairier
Lanugo
white/ yellowish papules with redden skin
Erythema Toxicum
Benign/ Self-resolving
One side of the body pale while other side is deep red; Vertical split, well demarcated
Harlequin Color Change
Harmless d/t vasomotor instability
Circumoral Cyanosis
Blueing around mouth
Benign if transient
If Circumoral Cyanosis persist with crying & feeding –>
Cardiac Problems?
flat bluish area on lower back/buttock
Mongolian Spots
Dont mistake for bruising
Mongolian Spots are most common on
AA Asian Latin Native Americans Vietnamese
Telangietic Nevi-stork bites
Salmon colored hemangioma (strawberries)
fade @ ~18mo
Tear Production in NB
Absent for 1st 2 mo
Strabismus & nystagmus in NB
Normal
Yellowing of Sclera
Late sign of Jundice
Crackles in NB lungs
Normal right after birth
Cap Refill in NB
<3SEC
Abnorm Abd in NB
failure to meconium/ void w/in 24h
distention
NB bath
temp must be stable x2 (97.7)
J&J for 1st bath, then no soap/lotion/powder x 1 wk
Diarrhea in NB
Watery, green
Formula fed–> change formula
Colostrum
only need small amt (think frozen oj)
NB Caloric Need
110 cal/kg/day
S/S of formula Allergy
diarrhea, distention, skin rash, copious amts of gas, mucus/ blood in stool; Failure to thrive
Fast Flow Nipples
Pre-term
Formula preparation is
a clean procedure
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
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
HMD (PKU)
Screens for metabolic disorders, genetic diseases, and infections
Lateral heel stick after 24h, repeated @<28d
At Risk for PKU
French Canadians
Chinese
Greek Americans
Bilirubin
Do NOT massage foot–> break down blood cells
Pulse Ox of NB
Opposite arm and leg w/in 3% of ea. other (norm)
>95%
Circumcision is contraindicated for:
Preterm
Genitourinary defects
Bleeding prob
Unstable NB
Rn Actions of Circumcision
Do NOT feed prior
Witness consent/ preform timeout
Place restraint board
Bulb suction available
Post Circumcision
Petroleum jelly w/ diaper changes
Assess q15
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
Phases of separation anxiety
protest
despair
detachment
goal of a traumatic care
Prevent/ decrease separation from family
Promote a sense of control
Prevent/ minimize bodily injury and pain
Short peripheral catheters
therapy lasts <6 days
pH between 5-9
osmolarity most distal UE
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.
