Final AD - newborn

Question 1

APGAR scoring?

Answer 1

A = appearance (Pallid, Cyanotic, or Pink Color)
P = pulse (auscultated or felt via umbilical cord)
G = grimace (response to suctioning of nares or nasopharynx) When suctioning the baby, it makes a look or cries.
A = activity (degree of flexion and movement)
R = respiration (observed movement of chest wall)

OVERALL GOAL is 10! It takes more than a min, needs to get all blood circulating 1st. APGAR is usually an 8 in the 1st one min. Color: is different in the 1st min. APGAR: 5 min they will have a 9 - less than 7 (NICU to get APGAR score up). Less than 7 in 5 min need someone to help.

When? 1 minute after birth, 5 minutes after birth, and 10 minutes after birth it need be.

Why? Physiologic state of the neonate and rapid need assessment for resuscitation.

Question 2

How is APGAR scored?

Answer 2

Appearance (color):
0= blue, pale 1= body pink, extremities blue 2= all pink: hands. Feet, body, etc.

Pulse: HR
0=absent1=slow<1002=>100

Grimace (reflex irritability) stimulation
0 = no response from the baby 1= grimace, trying to cry, 2= cry

Activity (Muscle tone): stretching, start reflex.
0= flaccid, do not move 1= some flexion, barely move, or only move arms and not legs or legs and not arms. 2= well flexed; moving everything

Respiration (movement of chest wall)
0=absent 1= slow, weak cry 2= good cry, screaming head off and turning pink

Question 3

Hip dysplasia?

Answer 3

abnormal development=t of the hip and/or the hip joints. Can be related to genetics or environment in utero. 3 degrees 1. preluxation no dislocation – femoral head remains in the acetabulum – will resolve on its own 2. Subluxation – incomplete dislocation of the hip – head of femur is partially dislocated 3. dislocation – head of femur is not in the acetabulum. How to check Ortolani and Barlow test. The goal of the treatments to obtain and maintain a safe congruent position of the hip joints to promote normal hip joint development & ambulation. In the nursery you may see an infant with several THICK diapers on and have a Pavlik harness on. this keeps the hips stabilized. If this does not work, they may be in casts with traction or even surgery.

Question 4

NB VS?

Answer 4

HR: 110-160 BPM
RR: 30-60 Breaths/M
O2 on room air: 94-100%
Temperature: 36.5 to 37.4 (97.7-99.3) - bradycardia is a result of hypothermia
BP: 60-80/40-50 (usually not done on newborns unless there is a cardiac problem)

Question 5

NB glucose level?

Answer 5

Blood glucose stabilizes within the 1st several H @ 50-60 mg/dL (low blood glucose = FEED BABY). Impaired liver problems = blood glucose < 40 mg/dL.

Question 6

NB reflexes?

Answer 6

Sucking and rooting reflex
Palmar grasp
Plantar grasp
Mono reflex
Tonic neck reflex (fencer position)
Babinski reflex
Stepping

Question 7

AGA, SGA, & LGA?

Answer 7

AGA = weight is between the 10th and 90th percentile
SGA = weight is less than the 10th percentile
LGA = weight is greater than the 90th percentile

Question 8

Low Birth Weight (LBW)?

Answer 8

weight of 2500 g or less at birth

Question 9

Caput succedaneum?

Answer 9

Localized swelling of the soft tissues of the scalp caused by pressure on the head during labor. Is an expected finding that can be palpated as a soft edematous mass and can cross over the suture line. Caput succedaneum usually resolves in 3 to 4 days and does not require treatment.

Question 10

Cephalohematoma?

Answer 10

a collection of blood between the periosteum and the skull bone that it covers. It does not cross the suture line; it results from trauma during birth such as pressure of the fetal head against the maternal pelvis in a prolonged difficult labor or forceps delivery. It appears in the 1st 1 to 2 days after birth and resolves in 2 to 8 weeks.

Question 11

Describe the 3 stages of newborn transition (Activity)?

Answer 11

First period of reactivity - the NB is alert, exhibits exploring activity, makes sucking sounds, and has a rapid HR and RR. HR can bas a high as 160-180 BPM but will stabilize at a baseline of 100 to 120 BPM during a period that last 30 M after birth.

Period of relative inactivity - the NB will become quiet and begin to rest and sleep. The HR and RR will decrease, and this period will last from 60 to 100 M after birth.

Second period of reactivity - the NB awakens, becomes responsive again, and often gags and chokes on mucus that has accumulated in the mouth. This period usually occurs 2 to 8 H after birth and can last 10 M to several H.

Question 12

Client edu regarding a circumcision?

Answer 12

A signed inform consent is needed

The NB will not be able to be bottle fed for up to 2-3 H prior to the procedure to prevent vomiting and aspiration based. NBs can breastfeed up until the procedure.

The NB is restrained on a board during the procedure

Keep the area clean. Change the NB diaper at least every 4 H and clean the penis with warm water with each diaper change. With clamp procedures, apply petroleum jelly with each diaper change for at least 24H after the circumcision to keep the diaper from adhering to the penis.

Avoid wrapping the penis in tight gauze, which can impair circulation to the glans.

Do not give a tub bath until the circumcision is healed. Until then, trickle warm water gently over the penis.

Notify the DR if there is any redness, discharge, swelling, strong odor, tenderness, decrease in urination, or excessive crying from the NB.

A film of yellow mucus can form over the glans by day 2. Do not wash it off.

Avoid using pre-moistened towelettes to clean the penis because they contain alcohol.

The NB can be fussy or can sleep for several H after circumcision. Provide comfort measures for 24 H to 48 H to include acetaminophen as prescribed.

The circumcision should heal completely with a couple weeks

Report any frank bleeding, foul smelling drainage, or lack of voiding to DR.

Question 13

Nursing actions regarding a circumcision?

Answer 13

Remove the NB from the restraining board, and swaddle to provide comfort

Monitor for bleeding and voiding per facility protocol. Apply gauze lightly to penis if bleeding or oozing is observed.

Fan-fold diapers to prevent pressure on the area

Liquid acetaminophen 10 to 15 mg/kg can be admin orally after the procedure and repeated every 4-6 H as prescribed for maximum of 30-45 mg/kg/day.

Provide discharge instructions to the parents about CMs of infection, comfort measures, medications, and when to notify the provider.

Question 14

body surface to cooler ambient air (wrap newborn, keep nursery warm)

Answer 14

convection

Question 15

body surface to cooler solid surface not in direct contact but in relative proximity (keep cribs away from windows)

Answer 15

radiation

Question 16

loss of heat when liquid is converted to a vapor (dry infant directly after birth and bathing)

Answer 16

evaporation

Question 17

body surface to cooler surface in direct contact (warm crib when admitted to nursery, skin to skin contact with mother)

Answer 17

conduction

Question 18

what are the 4 mechanisms of heat loss?

Answer 18

convection
radiation
evaporation
conduction

Question 19

what is physiologic jaundice?

Answer 19

considered benign. The NB who has physiological jaundice exhibits an increase in un-conjugated bilirubin levels 72 H to 120 H after birth, with a rapid decline to 3 mg/dL 5 to 10 days after birth.

Question 20

what is pathological jaundice?

Answer 20

a result of an underlying disease. Appears before 24 H of age or is persistent after day 14. In the term NB, bilirubin levels increase more than 0.5 mg/dL, peaks at greater than 12.9 mg/dL, or it’s associated with anemia and hepatosplenomegaly. Pathologic Jaundice is usually caused by a blood group incompatibility or an infection but can be the result of RBC disorders.

Question 21

what is an indirect coombs test?

Answer 21

Coombs test is done on the mother’s first prenatal visit
* To determine if she has built up antibodies to the Rh antigens
* Again at 28 weeks
* Can cause hemolysis of the RBC in the infant
* Indirect Coombs test – negative = that sensitization has not occurred, and she is given Rhogam IM  positive = sensitization has occurred, she will still be given Rhogam and sensitization it will be redone q 4-6 weeks until it is lower or negative
* After delivery, it’s important to decrease stress, especially cold, check for sepsis & hypo glycemia. These will decrease the newborn’s risk for severe hemolytic disease and susceptibility to kernicterus.

Question 22

what is a direct coombs test?

Answer 22

Coombs test is done on fetal cord blood after delivery to determine if there are any maternal antibodies in the fetal blood.
* If titer is high an exchange transfusion may be necessary (Not many have to have this)
* On baby core blood, high, baby will get a total blood transfusion.

Question 23

Bulb suctioning, purpose and teachings?

Answer 23

Purpose - to clear secretions from oral and nasal passages

Teach parents - proper technique for use of the bulb syringe and ask for them to demonstrate. Proper care of the bulb syringe, wash in warm soapy water each day and after each use to allow to air dry. Store the bulb syringe at the infant’s bedside.

Question 24

steps to nasal suctioning?

Answer 24

Assess the infant for nasal congestion.

Position the infant’s head to the side or downward if they are vomiting or gagging. 3. Compress the bulb syringe.

Insert the bulb syringe into the tip of the infant’s nostril. Avoid obstructing the nasal passageway.

Gently release the compression of the bulb syringe to allow it to fill with mucus or nasal drainage.

Gently remove the bulb syringe; expel drainage into a tissue.

Repeat as needed.

Question 25

steps to oral suctioning?

Answer 25

Assess the infant for oral secretions.

Position the infant’s head to the side or downward if vomiting or gagging occurs.

Compress the bulb syringe.

Insert the bulb syringe approximately 1 inch into one side of the infant’s cheek. Avoid contact with the roof of the mouth and the back of the throat.

Gently release compression of the bulb syringe and allow it to fill with oral secretions.

Gently remove the bulb syringe; expel drainage into a tissue.

Repeat the process on the other side of the infant’s cheek.

Repeat as needed.

Question 26

NB fluid intake?

Answer 26

First 2 days = 60 – 80 mL/kg/day (24 H)
Day 3-7 = 100-150 mL/kg/day (24 H)
Day 8-30 = 120 -180 mL/kg/24H

Question 27

benefits of breastfeeding for mom?

Answer 27

Decrease risk of breast, ovarian and uterine cancer
Decrease risk of Type 2 diabetes mellitus
Enhanced postpartum weight loss
Enhanced involution (caused by uterine contractions, triggers by release of Oxytocin) and decreased risk of postpartum hemorrhage
Enhanced bonding with infant
Less expensive than formula

Question 28

benefits of breastfeeding for baby?

Answer 28

Enhanced immunity through the transfer of maternal antibodies; decreased incidence of infections including otitis media, respiratory infections, pneumonia, urinary tract infections, gastrointestinal infections and necrotizing enterocolitis, bacteremia and bacterial meningitis
Enhanced maturation of GI tract
Decreased risk of sudden infant death syndrome
Decreased risk of developing Type 1 diabetes
Decreased risk of asthma
Decreased risk of child obesity
Decreased pain during procedure such as an injection

Question 29

Discuss phototherapy and anticipatory guidance for parents?

Answer 29

Phototherapy - the NB bilirubin should start to decrease within 4-6 H after starting treatment.

Client Education:
- Remember and adhere to the NB’s plan of care
- Infants who have low to moderate risk of hyperbilirubinemia should receive follow-up care within 2 days. Infants at higher risk should be seen within 24 H.

Question 30

Umbilical cord?

Answer 30

At term - 2cm in diameter, 30-90 cm in length
Wharton’s jelly (connective tissue) - cushions vessels from compression
Vessels - (2 arteries, 1 vein) supply nutrients and O2 from mom. Arteries (carry deoxygenated blood from the embryo). Veins (carries oxygenated blood to the embryo)

Question 31

Cleaning and care of an umbilical cord?

Answer 31

Clean with H2O, do not use soap or alcohol preparation for cord care.

The plastic clamp should be removed before discharge or when its dry. The stump and base of cord should be assessed for infection, keep dry and above diaper. Assess for redness, smell, and purulent drainage. Cord separation occurs 10-14 days.

Discharge from umbilical cord or site indicates infection the cord should be pale yellow

An extra clamp can be applied if blood is actively leaking from cord

If meconium was passed the cord may be green/gray

Use 2 fingers to identify hernias at the umbilical cord, small hernias are common and often close with no interventions.

Question 32

may be caused by insufficient folic acid. Nonpregnant childbearing should take 0.4 mg daily and pregnant women 0.6 mg/daily. May be isolated, chromosomal or a syndrome or other defects. Some can be detected by U/s before delivery.

Answer 32

Neural Tube Defects (NTD)

Question 33

failure of the end of the neural tube to close. Herniation of the brain. And meninges of the skull usually the occiput area, TX surgery, shunting to relieve hydrocephalus.

Answer 33

encephalocele

Question 34

failure of the anterior end of the neural tube to close. Absence of both cerebral hemispheres & overlaying skull. Basically, the baby is not born with a brain and sometimes only has the brain stem visible. Many are born dead or only live a few days. Comfort measures and allowing parents to rock the baby to heaven.

Answer 34

anencephaly

Question 35

failure of the laminae to close leaving the spinal cord, meninges and nerve roots outside the neural tube. SB Occulta not herniated outside the defect. SB Manifesto is outside the defect but not outside the skin)

Answer 35

spina bifida

Question 36

is outside the skin or with a very thin skin covering

Answer 36

Myelomenigocele

Question 37

H2O on brain. excess Central spinal fluid in the ventricles of the brain (water head baby) – increasing intracranial pressure. Surgery to place a shunt will be performed.

Answer 37

hydrocephalus

Question 38

small head – usually 2 or more deviations below the mean for age and sex. Brain growth may be restricted, the parents will need support and education to care for a child with cognitive impairment and developmental delays

Answer 38

microcephaly

Question 39

posterior nares are blocked by a boney or soft-tissue obstruction. Can’t pass a suction catheter, SNS respiratory distress, cyanosis, or pallor relieved by crying. Until surgery can be performed, oral airway placed in posterior pharynx & infant placed in prone position, remember babies are normally nose breathers.

Answer 39

choanal atresia

Question 40

congenital anomaly where esophagus ends in a blind pouch = no passageway to the stomach. Usually see cardiac anomalies with this, or cleft lip/palate, and others. Surgery to open the area and close observation. These infants usually have GURD after surgery

Answer 40

esophageal atresia

Question 41

congenital anomaly where the midline fissure or opening in the palate or lip do not fuse together. These can be repaired by surgery when the infant is older. With cleft lip, encourage breastfeeding. The mouth will be able to form better around the breast than a manmade nipple. If infant has cleft palate expect some milk to come out the nose. It is considered an orofacial defect. Milk may come out of baby’s nose

Answer 41

cleft lip/pallet

Question 42

a covered defect of the umbilical ring into which varying amounts of abdominal organs can herniate out. The peroneal sac can rupture during birth, congenital heart defects are also associated with this.

Answer 42

omphalocele

Question 43

the herniation of bowel through a defect in the wall to the right of the umbilical cord. No membrane covering. Intestinal atresia can occur. Immediately after birth, sterile wet gauze and a plastic bowel bag is placed over the area, infant is placed in lateral position, viscera are inspected for live tissue, and supported with a blanket under the herniation to prevent vascular compromise. The infant will have surgery ASAP. Some hospitals cannot perform this surgery and the infant will be sent to a hospital soon after birth. Hard on the mom because she is left behind to recuperate. Emergency surgeries.

Answer 43

gastroschisis

Question 44

anal rectal malformation – no anal opening & usually a fistula between the rectum and perineum. Several surgeries will be done, 1st will be to make an annual opening again ASAP. Then others to repair the fistula in stages

Answer 44

imperforate anus

Question 45

penile anomaly where the urinary meatus is not located in the normal area. It can open below the glans penis or in any area down to and including the perineal area. HCP will not circumcise the infant until surgery with a urologist is performed. The urethra will be reconstructed, and the foreskin form the penis may be used during the surgery. This is usually done before the age of 2. (Before Impaired body image) after surgery the male will have full normal function. Long term follow-up is needed because of the chance of testicular cancer and cryptorchidism

Answer 45

hypospadias

Question 46

sometimes it is difficult at birth to determine the sex of a child. It will be recorded as ambiguous genitaled. A genital area may look like an enlarged clitoral hood or clitoris or a malformed penis. Do not determine if male or female until pediatric endocrinologist, physician, geneticist and others have been involved. - Poly, oligo & syn – we have talked about these last weeks.

Answer 46

ambiguous genitala

Question 47

positional or congenital anomaly. Positional is held in utero in a way that it could not move, congenital is more severe. – Talipes means foot – types of club foot talipes varus – inversion or bending forward, valgus – eversion or bending outward, equinus plantar flexion - toes are lower than the heels, calcaneous – dorsiflexion toes are higher than the heels. Infants will be placed in a cast usually before discharge. And will see the physician more often. New casts will be placed as the child grows. Sometimes this takes years.

Answer 47

clubfoot

Question 48

Effects of cold stress and nursing actions?

Answer 48

Oxygen consumption increases as oxygen and energy are diverted from maintaining normal function and growth to thermogenesis for survival

Respiratory rate increases because of demand for oxygen (increase O2 consumption)

Vasoconstriction to ensure blood flow to vital organs jeopardizes pulmonary perfusion – may reopen shunt across the ductus arteriosus

BMR increases and may result in anaerobic glycolysis – increased acid production

PO2 and pH decrease

Excess fatty acids displace the bilirubin from albumin-binding sites —> increased level of circulating unbound bilirubin that increases the risk of kernicterus.

Kernicterus is a rare kind of preventable brain damage that can happen in newborns with jaundice. The bilirubin gets too high and causes brain damage

Nursing actions:
- Monitor for CM of cold stress (skin pallor with mottling and cyanotic trunk, tachypnea)
- The NB should be warmed slowly over a period of 2-4H. Correct hypoxia by admin O2. Correct acidosis and hypoglycemia.

Question 49

Hypothermia nursing actions?

Answer 49

Monitor axillary temp and assess every H until stable

If temp is unstable place newborn in radiant warmer and maintain skin temp

All exams and assessments should be performed while NB is under a radiant warmer or during skin-to-skin with the parent.

Question 50

Nursing care & education for the infant born to a mother positive with HIV

Answer 50

Procedure such as amniocentesis and episiotomy should be avoided due to the risk of maternal blood exposure.

Use of internal fetal monitors, vacuum extraction, and forceps during labor should be avoided due to the risk of fetal bleeding.

NB admin of injects and blood test should not take place until after 1st bath is given.

Nursing care:
- Review plan for scheduled C-section birth at 38 weeks for maternal viral load of more than 1000 copies/mL.
- Vaginal birth can be an option for a client who has a viral load less than 1000 copies/mL at 36 weeks.
- Wear gloves when caring for the NB after delivery
- Infant should be bathed after birth before remaining with the mother.

Client education: DO NOT BREASTFEED!

Question 51

how to bathe a NB?

Answer 51

bathing can begin once the NB’s temp has stabilized to at least 36.5. A complete sponge bath should be postponed until thermoregulation stabilizes. Gloves should be worn until the newborn’s first bath to avoid exposure to body secretions

Question 52

Output of a NB?

Answer 52

Output: NB should void once within 24 H of birth, they should void 6-8 times per 24 H after day 4. Meconium should be passed within the 1st 24 H to 48 H after birth. The NB will then continue to pass stool 3 to 4 times a day depending on whether they are being breast or bottle fed.

1st – 2nd Day – 2-6 Voids/day
3rd – 4th Day – 5-25 Voids/day
> 4 days – 6-8 Voids/day