Exam 3: General Flashcards
Caput succedaneum
edema of the presenting part of the newborn’s head due to pressure during labor. The edema extends across the suture lines of the skull.
cephalhematoma
swelling, indicating bleeding under the subcutaneous tissues of the newborn’s scalp. The collection of blood is beneath the periosteum of the cranial bone and therefore does not cross the suture line.
Molding
temporary misshaping of the fetal head due to overlapping cranial bones at the suture lines to accommodate the passage of the fetal head through the birth canal.
Pilonidal dimple
can be observed when assessing the vertebral column and can be associated with spina bifida
rooting reflex
elicited when the client strokes the newborn’s lips, cheek, or corner of the mouth with her nipple. The newborn will turn his head while making sucking motions with his mouth and latch onto the nipple
Babinski reflex
elicited by stroking upward along the lateral edge of the sole of the newborn’s foot.
Moro reflex
elicited by striking the surface next to the newborn to startle him.
Symptoms of mastitis
Localized breast tenderness along with fever and malaise
S/S Endometritis
Chills, fever, tachycardia, anorexia, fatigue, and pelvic pain, foul-smelling, profuse lochia
Methylergonovine
oxytocic medication that is administered to promote uterine contractions. This medication is indicated for treatment of postpartum hemorrhage caused by uterine atony or subinvolution; the desired effect is an increase in uterine tone.
A rise in blood pressure is an adverse effect of the medication.
A full bladder can do what in the immediate postpartum period?
Raise the level of uterine fundus and possibly deviate it to the side
At 1 hr postpartum, lochia rubra should be
Intermittent and associated with uterine contractions; volume of lochia resembles that of a heavy menstrual period; Small clots are common
Expected findings of a postmature newborn
- Physical findings that indicate postmaturity in a newborn (gestational age of greater than 42 weeks) include cracked, peeling skin.
- Reflexes that are present in a postmature newborn are the same as those that are present in a mature newborn. These reflexes include a positive Moro reflex.
- Long and hard fingernails
Manifestations of hydrocephalus in newborns include
Dilated scalp veins, separated sutures, and, in late infancy, frontal enlargement
Hydrocephalus increases pressure within the central nervous system, not within the cardiovascular system. Signs of increased pressure in the CNS include irritability, lethargy, and vomiting.
Newborns who have hydrocephalus will have widened suture lines and full or bulging fontanels due to pressure from the increased amount of cerebrospinal fluid.
Immediately after birth, the nurse ensures a patent airway. Following this, what is the priority nursing action?
The newborn should be thoroughly dried, covered with a warm blanket, placed on the mother’s abdomen, and a cap applied to the newborn’s head to prevent cold stress. The newborn responds to the cooler environment by increasing his respiratory rate, which can lead to respiratory distress. Based on Maslow’s hierarchy of needs, this is the most important nursing action after securing the airway.
Mongolian spots
bluish-black areas of pigmentation more commonly noted on the back and buttocks.
Most reliable indicator of fluid loss for infants and young children
Body weight
Prevention of jaundice can be facilitated best by
Early and frequent feeding, which stimulates intestinal activity and passage of meconium. Jaundice occurs due to elevated serum bilirubin, which is excreted primarily in the newborn’s stool. Physiologic jaundice manifests after 24 hr and is considered benign. However, bilirubin may accumulate to hazardous levels and lead to a pathologic condition.
A bulb syringe is used to…
Remove excess or tenacious mucus from the newborn’s nose and mouth and to maintain a patent airway.
Phototherapy is a treatment for …
hyperbilirubinemia
What is the priority assessment for a newborn immediately following a cesarean delivery?
The priority is to assess the newborn for respiratory distress
Shortly before labor, there is a decreased production of fetal lung fluid and a catecholamine surge that promotes fluid clearance from the lungs. Newborns born by cesarean, in which labor did not occur, can experience lung fluid retention, which leads to respiratory distress.
Acrocyanosis is…
A bluish discoloration of the hands and feet and is an expected finding in the first 24 hours following delivery
An infant who is dehydrated will exhibit
Irritability, tachycardia, increased temperature
Tetany (intermittent muscular spasms) is a manifestation of
hypoglycemia [also commonly caused by hypocalcemia]
Vitamin K (phytonadione)
Route - IM
Site - Vastus lateralis muscle (in the thigh)
Use - Prevents and treats hemorrhagic disease of the newborn, as newborns are born with vitamin K deficiency.
Time - Within 1 hour of birth
Usual time frame for the onset of breast milk production
3 to 5 days - By day 3 to 5, most clients who are breastfeeding begin to produce copious amounts of breast milk.
Why would a provider order an indirect Coombs test for a 6 hrs postpartum client who is Rh - with an Rh + baby?
To detect Rh-positive antibodies in the mother’s blood. An indirect Coombs test determines the presence of Rh antibodies. If the client has Rh-negative blood, she does not produce Rh factor. Exposure to Rh positive blood, such as from an Rh factor positive fetus, could trigger the client to begin producing antibodies against Rh factor. These antibodies can cross the placenta and harm an Rh-positive fetus.
What does a direct Coombs test measure?
The presence of maternal antibodies in the newborn’s blood.
Which anatomical landmark should be used when measuring the circumference of the newborn’s chest?
The nipple line
The nurse should measure the newborn’s chest circumference at the nipple line.
What is a reliable indicator that a breastfed infant is receiving enough breastmilk?
Newborns should wet 6 to 8 diapers per day. This is an indication that the newborn is getting enough fluids.
Why is monitoring of blood glucose levels a priority intervention in a newborn who is small for gestational age (SGA)?
Decreased stores of glycogen and a lower rate of gluconeogenesis place newborns who are SGA at higher risk for hypoglycemia. This makes monitoring of blood glucose levels is a priority intervention.
The expected reference range for a newborn’s resting respiratory rate is…
30 to 60/min.
Interventions to promote development in a preterm newborn
Continued development - By clustering activities and organizing care, the nurse prevents excessive interruptions and allows the newborn extended periods of rest and energy conservation that promote development.
Muscle flexion - Preterm newborns lack motor development that allows for muscle flexion. A prone position or the use of a sling promotes flexion.
Calming - The use of both hands is the most effective calming technique, especially when repositioning the newborn’s extremities close to his body.
Sleep - To promote sleep-wake cycles, newborns should be protected from light at night by dimming nursery illumination, placing a cover over the incubator, or positioning a mask over the eyes.
Umbilical cord stump care
Bathing - Sponge baths only - Immersing the umbilical cord stump in water can delay the process of drying, separation, and healing. Sponge baths are appropriate until the stump falls off. The client should be instructed to wash the skin around the base of the cord, not the cord stump, with mild soap and water.
Diaper - The parent should fold the edge of the diaper downward to avoid exposing the cord stump to urine and feces in the diaper.
Comfort measures for breast engorgement
Breast engorgement is characterized by painful overfilling of the breasts. The client should be instructed to feed every 2 hr to soften one breast and pump the other.
Cold compresses can be used to reduce the swelling of the breast tissue surrounding the milk glands and milk ducts. Cold compresses should be applied after feeding or pumping.
Raw cabbage leaves placed over the breast between feedings can help reduce swelling. The client should wash the cabbage leaves and place them in the refrigerator to cool. The leaves are crushed and placed over the breasts for 15 to 20 min and can be repeated for two to three sessions.
Crib safety
Loose bedding such as sheets and blankets need to be removed to prevent suffocation
Infants should be placed in the fully supine position
Infants should sleep on a firm crib mattress
The cribs should be a safe distance from any heat source
Is blood pressure a reliable measure of impending shock from hemorrhage?
Blood pressure is not a reliable indicator of impending shock from hemorrhage because compensatory mechanisms prevent a significant drop in blood pressure until the client has lost 30 to 40% of her blood volume.
What intervention is priority in the initial management of excessive uterine bleeding?
Firm massage of the uterine fundus. This action stimulates contraction of the uterine muscles, which constrict the maternal uterine blood vessels.
If manual massage of the uterine fundus does not increase contractility and slow bleeding, it would then be appropriate to empty the bladder and administer a continuous IV infusion of oxytocin.
When assessing the postpartum client, if the nurse finds the uterus to be boggy and displaced, what is the priority intervention?
To assist the client to the restroom to void.
A full bladder causes the uterus to be displaced above the umbilicus and off to one side. This prevents the uterus from contracting normally and increases the risk of hemorrhage.
VBAC considerations
The most common type of incision during a cesarean birth is transverse, which is made across the lower, thinner part of the uterus. It is the primary criteria that permits a vaginal birth after a cesarean (VBAC). Other types of incisions increase the risk of uterine rupture. Additional criteria for VBAC include an adequate maternal pelvis, no uterine scars or history of rupture, the availability of a provider to monitor labor, and personnel to perform a cesarean birth if needed.
Flushed face, high fever with chills, and myalgia are all findings associated with:
Influenza
Sneezing, coughing, nasal congestion, intermittent fever, and in severe cases, apneic spells, most common in infants between 2 and 12 months of age, are all findings associated with:
Bronchiolitis
Stridor (not wheezing) and a barky cough, often seen in children who are between 6 months to 3 years of age, are all findings associated with:
Croup
The most common cause of postpartum infections is…
Endometritis
A uterus that is over distended, such as from a macrosomic fetus, has an increased risk of
Uterine atony
The expected reference range for an apical pulse in a newborn who is awake is
120 to 160/min
Myelomeningocele
Congenital disorder that causes the spine and spinal canal to not close prior to birth, which results in the spinal cord, meninges, and nerve roots protruding out of the child’s back in a fluid-filled sac.
Priority in care of the infant born with myelomeningocele
Maintain the integrity of the sac
Before surgery, the infant must be handled carefully to reduce damage to the exposed spinal cord and to maintain the integrity of the sac.
An adverse effect of methylergonovine is
hypertension
Methylergonovine is administered
Intramuscularly
Methylergonovine is an
oxytocic medication. It causes uterine contractions, which control postpartum bleeding.
Methylergonovine is given to control
postpartum hemorrhage
What is the purpose of putting a toddler with laryngotracheobronchitis in a cool mist tent?
Laryngotracheobronchitis, or croup, is a condition caused by an infection of the upper airway (larynx, trachea, and bronchus) and is characterized by a barking cough. Edema and obstruction in the upper airways cause the characteristic cough and stridor (noisy breathing). The direct purpose of a cool mist tent is to humidify the inspired air, which decreases respiratory effort.
What is the purpose of placing a newborn under a radiant heat warmer?
To prevent cold stress.
When an infant is stressed by cold exposure, oxygen consumption increases and pulmonary and peripheral vasoconstriction occurs. Metabolic demands for glucose increase. If the cold stress continues, hypoglycemia and metabolic acidosis can result.
Iron supplements should be administered…
- Between meals
- With citrus fruit or juice to aid absorption
- At least 1 hr prior to bedtime
Maternal/newborn blood group incompatibility is the most common form of
pathologic jaundice and the jaundice appears within the first 24 hr of life
The absence of vitamin K results in
increased bleeding and hemorrhagic disease of the newborn
Physiologic jaundice in the term newborn appears after
24
The newborn exposed to maternal cocaine abuse is often
small for gestational age, exhibits tremors, irritability, hyperactivity to stimuli, and poor feeding
