Maternity Nursing Chap 16 Flashcards
Normal (N) or potential (P) problems with adaption to extrauterine life: crackles on auscultation of the lungs.
P
Normal (N) or potential (P) problems with adaption to extrauterine life: respirations-36, irregular, shallow.
N
Normal (N) or potential (P) problems with adaption to extrauterine life: episodic apnea lasting 5 to 10 seconds.
N
Normal (N) or potential (P) problems with adaption to extrauterine life: nasal flaring and sternal retractions.
P
Normal (N) or potential (P) problems with adaption to extrauterine life: slight bluish discoloration of feet and hands.
N
Normal (N) or potential (P) problems with adaption to extrauterine life: blood pressure 76/43 mm Hg
N
Normal (N) or potential (P) problems with adaption to extrauterine life: apical rate 126, with murmurs
N
Normal (N) or potential (P) problems with adaption to extrauterine life: temperature 37.1* C axillary
N
Normal (N) or potential (P) problems with adaption to extrauterine life: head, 34 cm; chest, 36 cm
P
Normal (N) or potential (P) problems with adaption to extrauterine life: boggy edematous swelling over occiput
N
Normal (N) or potential (P) problems with adaption to extrauterine life: overlapping of parietal bones
N
Normal (N) or potential (P) problems with adaption to extrauterine life: white, pimple like spots on nose and chin
N
Normal (N) or potential (P) problems with adaption to extrauterine life: yellowish coloration on face and chest
P
Normal (N) or potential (P) problems with adaption to extrauterine life: regurgitation of small amount of milk after feedings
N
Normal (N) or potential (P) problems with adaption to extrauterine life: liver palpated 3 cm below right costal margin
P
Normal (N) or potential (P) problems with adaption to extrauterine life: spine straight with dimple at base
P
Normal (N) or potential (P) problems with adaption to extrauterine life: tight prepuce, unable to fully retract
N
Normal (N) or potential (P) problems with adaption to extrauterine life: edema of scrotum and labia
P
Normal (N) or potential (P) problems with adaption to extrauterine life: toes hyperextended and flared when sole is stroked upward
N
Normal (N) or potential (P) problems with adaption to extrauterine life: hematocrit 36%; hemoglobin 12 g/dL
P
Normal (N) or potential (P) problems with adaption to extrauterine life: white blood cell count 23,000/mm^3
N
Normal (N) or potential (P) problems with adaption to extrauterine life: blood glucose 40 mg/dL
P
Factors initiating breathing after birth:
-reflex triggered by such factors as pressure changes, chilling, noise, light, and other sensations associated with exposure to extrauterine life and chemoreceptor activation by lowered oxygen level, higher carbon dioxide level, and lower pH
Conditions essential for maintaining an adequate oxygen supply:
-removal of lung fluid, synchronous expansion of chest and abdomen, patent airway, and sufficient surfactant
Expected newborn respiratory pattern:
-shallow and irregular rate of 30 to 60 breaths/min, short periods of apnea less than 20 seconds, and loud and clear breath sounds
Signs of respiratory distress:
- nasal flaring, retractions, and increased use of intercostal muscles
- grunting with respirations
- seesaw respirations
- rate of less than 30 or more than 60 breaths/min at rest
- apnea longer than 20 seconds
- adventitious breath sounds
Foramen ovale: purpose/location–closure mechansim:
- formation of a valve opening that allows blood to flow directly to left atrium (shunting of blood from right to left atrium)
- functionally closed at birth, constant apposition gradually leading to fusion and permanent closure within a few months or years in majority of persons
- increased pressure in left atrium and decreased pressure in right atrium causing closure of valve over foramen
Ductus arteriosus: purpose/location–closure mechanism:
- patent, shunting of blooding from pulmonary artery to descending aorta
- functionally closed almost immediately after birth, anatomic obliteration of lumen by fibrous proliferation requiring 1-3 mo, becoming ligmentum arteriosum
- increased oxygen content of blood in ductus arteriosus creating vasospasm of its muscular wall
- high systemic resistance increasing aortic pressue; low pulmonary resistance reducing pulmonary arterial pressure
Ductus venosus: purpose/location–closure mechanism:
- closed, becoming ligamentum venosum after obliteration
- loss of blood flow from umbilical vein
Dangers of stress cold for a newborn:
- metabolic and physiologic demands on the newborn increase, leading to increased oxygen need and consumption
- oxygen and energy are diverted from brain cells, cardiac function, and growth
- decreased oxygen leads to vasoconstriction, respiratory distress, and reopening of the ductus arteriosus
- acidosis, increased level of bilirubin, hypoglycemia
Newborn behaviors associated with cold stress:
- increased respiratory rate
- cyanosis
- decrease in oxygen level, pH, and glucose level
- signs of acidosis
Measures to stabilize newborn temperature:
- implement measures that reflect application of heat loss mechanisms of convection, radiation, evaporation, and conduction
- dry infant and cover with warmed blankets or wrap with mother on her abdomen
- cover head
- use radiant heat shield or warmer to stabilize temperature initially
- assess newborn and perform procedures
- adjust environment
Convection–definition of heat loss/how to prevent:
- the flow of heat from the body surface to cooler ambient air
- ambient temperature is the nursery is kept at approximately 24* C, and newbornsin open bassinets are wrapped to protect them from the cold
Radiation–definition of heat loss/how to prevent:
- the loss of heat from the body surface to a cooler solid surface not in direct contact but in relative proximity
- to prevent this type of loss, nursery cribs and examining tables are placed away from outside windows, and care is taken to avoid direct air drafts
Evaporation–definition of heat loss/how to prevent:
- the loss of heat that occurs when a liquid is converted to a vapor
- dry infant completely after bath
Conduction–definition of heat loss/how to prevent:
- loss of heat from the body surface to cooler surfaces in direct contact
- place newborn in warm crib, scales used for weighing the newborn should have a protective cover
Characteristics of physiologic jaundice:
- manifestation of the pigment bilirubin in the tissues of the body
- appearance of jaundice after the first 24 hours of life
- should last less than 7 to 10 days
- appears when bilirubin level reaches 5 mg/dL
Variations in the state of consciousness of newborn infants are called the _________ states. The sleep states are ________ sleep and __________ sleep. The wake states are ________, ______, ________, and _________. The optimum state of arousal is the ______ state in which infants _______, ___________, __________, ___________, and _________.
- sleep/wake
- deep
- light
- drowsy
- quiet alert
- active alert
- crying
- quiet alert
- smile
- vocalize
- move in synchrony with speech
- watch parents’ faces
- respond to voices
________ is the ability of the infant to respond to and then inhibit responding to discrete stimuli (e.g., light, rattle, bell, pinprick) while asleep. It is a protective mechanism that allows the infant to be accustomed to ___________. It is a psychologic/physiologic phenomenon whereby the response to a ________ or ___________ stimulus is _________.
- habituation
- environmental stimuli
- constant
- repetitive
- decreased
_______, the individual variations in the primary reaction patterns of newborns, guides an infant’s style of behavior to stimuli.
-temperament
_________ refers to the ability of newborns to comfort themselves or be comforted by others. In the crying state most newborns initiate one of several ways to reduce their distress, including using ________ movements and alerting to _______, _________, or _______ stimuli.
- consolability
- hand to mouth
- voices
- noises
- visual
______ refers to the ability of newborns to mold into the contours of the person holding them.
-cuddliness
First period of transitioning to extrauterine life:
- lasts up to 30 mins after birth
- newborn’s heart rate increases rapidly to 160 to 180 beats/min but gradually falls after 30 mins or so to a baseline rate of between 100 and 120 beats/min
- respirations are irregular, with a rate between 60 and 80 breaths/min
- infant is alert
- bowel sounds are audible
- meconium may be passed
Second period of transitioning to extrauterine life:
- occurs roughly between 4 and 8 hours after birth and lasts from 10 mins to several hours
- brief periods of tachycardia and tachypnea occur, associated with muscle tone, skin color, and mucous production
- meconium is commonly passed
- most experience this transition regardless of gestational age or type of birth
Period of diminished response:
- this period either newborn sleeps or has a marked decrease in motor activity
- lasts from 60 to 100 mins
- followed by second period of reactivity
True or False: During the first 1 to 2 days of life, the newborn should void two to six times.
True
True or False: Crackles, grunting, nasal flaring and chest retractions are often noted during the second period of reactivity.
False – normally during first period of reactivity
True or False: Vitamin B12 is often given by injection to newborns immediately after birth to enhance clotting and prevent hemorrhage.
False – vitamin K
True or False: Blood tinged mucus on the diaper of the female should be documented by the nurse as pseudomenstruation and recognized as an expected assessment finding related to the withdrawal of maternal hormones.
True
True or False: Physiologic jaundice in the full term newborn disappears by 7 to 10 days of life.
True
True or False: A decrease of 20 mm Hg in the systolic blood pressure is an expected finding during the first hour after birth.
False – 15 mm Hg drop during the first hour
True or False: Meconium stool often has a strong odor as a result of bacteria present in the fetal intestine during intrauterine life.
False – The first meconium passed is generally sterile. but within hours all meconium passed contains bacteria and its amniotic fluid and its constituents, intestinal secretions, and cells shed from the mucosa.
True or False: Breast tissue in full term male and female newborns can be swollen and secrete a thin milky type discharge.
True
True or False: A newborn can be expected to lose up to 15% of his or her birth weight in the first 3 to 5 days after birth.
False – 10% in the first 3 to 5 days is acceptable
True or False: A newborn achieves active immunity from the mother by transplacental transfer of antibodies.
False – it is some what protected
Applying pressure to feet with fingers when infant’s lower limbs are semiflexed and legs are extended:
-magnet
Placing infant on flat surface and striking surface–infant shows symmetric abduction and extension of arms, fingers fan out, thumb and forefinger form a “C,” slight tremor can occur:
-moro
Placing finger in palm of hand or at base of toes–infant’s fingers curl around examiner’s finger, and toes curl:
-grasp
Placing infant prone on flat surface and running finger down side of back 4 to 5 cm lateral to spine–infant’s body flexes and pelvis swings toward stimulated side:
-trunk incurvation
Tapping over forehead, bridge of nose, or maxilla when eyes are open–infant blinks for first four to five taps:
-glabellar
Using finger to stroke sole of foot beginning at heel, moving upward along lateral aspect of sole, then crossing ball of foot–all of infant’s toes hyperextend, with dorsiflexion of big toe:
-babinski
Clapping hands sharply–infant’s arms abduct, with flexion of elbows, and hands remain clenched:
-startle downward
Testes retract when infant is chilled:
-cremasteric
Touching infant’s lip, cheek, or corner of mouth with nipple–infant turns head toward stimulus, opens mouth, takes hold, and sucks:
-rooting
Placing infant in a supine position and turning head quickly to one side as infant is falling asleep or is asleep–infant’s arm and leg extend on side to which head is turned while opposite arm and leg flex:
-tonic neck
Holding infant vertically and allowing one foot to touch surface–infant alternates flexion and extension of feet on table:
-stepping (walking)
touching or depressing tip of tongue–infant’s tongue is forced outward:
-extrusion
A newborn at 5 hours old wakes from a sound sleep and becomes very active. He exhibits the following signs when assessed. Which one would require further assessment?
a. increased mucus production
b. passage of meconium
c. heart rate of 160 beats/min
d. 2 apneic episodes of 16 and 20 seconds in duration
d.
- the newborn at 5 hours old is in the second period of reactivity during which tachycardia, tachypnea, increased muscle tone, skin color changes, mucus production, and passage of meconium occur
When assessing a newborn boy at 12 hours of age, the nurse notes a rash on his abdomen and thighs. The rash appears as irregular reddish blotches with pale centers. The nurse would:
a. document the finding as erythema toxicum
b. isolate the newborn and his mother until infection is ruled out
c. apply an antiseptic ointment to each lesion
d. request nonallergenic linen from the laundry
a.
-the rash described is erythemia toxicum; it is an inflammatory response that has no clinical significance and requires no treatment because it will disappear spontaneously
As part of a thorough assessment of a newborn, the nurse practitioner should check for hip dislocation and dysplasia. The technique the nurse would most likely use would be:
a. measurement of each leg from hip to heel
b. stepping or walking reflex
c. magnet reflex
d. ortolani maneuver
d.
- B and C are common newborn reflexes used to assess integrity of neuromuscular system; measurement of legs is not a method for determination of hip dysplasia
When assessing a newborn after birth, the nurse notes flat, irregular pinkish marks on the bridge of the nose, the nape of the neck, and over the eyelids. The areas blanch when pressed with a finger. The nurse would document this finding as:
a. milia
b. nevus vasculosus
c. telangiectatic nevi
d. nevus flammeus
c.
- telangiectatic nevi are also known as stork bit marks and can also appear on the eyelids
- milia are plugged sebaceous glands and appear like white pimples
- nevus vasculosus or a strawberry mark is a raised, sharply demarcated bright or dark red swelling
