IMMEDIATE ACTIONS UPON DELIVERY Flashcards
what are immediate assessments to perform on the mom upon delivery?
- assess bonding with baby such as face position, skin to skin, maintain eye contact with baby, responds to baby’s cry, smiles and talks to baby
- assess for lack of bonding, mood swings, conflict with role, and personal insecurity
what are immediate new born assessments to perform upon delivery?
- assess skin color, peeling, birthmarks, foot creases, meconium staining which can indicate fetal hypoxia
- chest= listen to heart and lungs for crackles/wheezing/bilateral breath sounds
- abdomen= rounded abdomen and umbilical cord with one vein and two arteries
- neuro= reflex reaction, palpation for presence of fontanels, assessment for bulging or full fontanels
what vitals should a newborn baby have?
- RR= 30-60 beats/min
- BP= 60-80/40-50
- temperature= 98.6
what do the scores of APGAR mean?
0-3: severe distress
4-6: moderate difficulty
7-10: minimal or no difficulty with adjusting to extrauterine life
what findings should the nurse look for when completing a head assessment on a newborn?
- head should be 2-3 cm and larger than chest circumference
- if head circumference is greater than 4 cm this can mean hydrocephallus and if head circumfeerence is less than 2 cm this can mean microcephaly
- anterior fontanel should be diamond shaped and about 5 cm
- posterior fontanel is smaller and triangle shaped
- fontanels can bulge when a baby cries, coughs, or vomits and they can flatten when baby is quiet
what is caput succedaneum?
localized swelling of the soft tissues of the scalp caused by pressure of the head during labor–> expected finding that resolves in 3-4 days and does not require treatment
what findings should the nurse look for when completing a neck assessment on a newborn?
neck should be short, thick, surrounded by skin folds and exhibit no webbing. neck should move freely from side to side and up and down.
