Module 6 (Exam1) ****4****

Question 1

Characteristics of a normal apical heart rate in the neonate

Answer 1

1. 120-160beats/minute
2. Some variablity
3. May have murmurs
4. Most murmurs are benign and have to do with a patent ductus arteriosus

Question 2

When are apgar scores taken?

Answer 2

Minute 1 and 5 of life

Question 3

What do 0 points indicate for each the 5 components of Apgar?

Answer 3

1. Absent heart rate
2. No spontanious respirations
3. Limp muscle tone
4. No reflex response to suction or gentle slaps on soles
5. Color is pallor or cyanotic

Question 4

What does a total apgar score of 3-6 indicate?

Answer 4

Nursing Interventions:

1. Gently stimulate by rubbing infant’s back while administering oxygen
2. Determine whether mother received narcotics, which may have depressed infant’s respirations
3. Have narcan available for administration

Question 5

What are the components of apgar?

Answer 5

1. Heart Rate
2. Respiratory effort
3. Muscle Tone
4. Reflex Response
5. Color

Question 6

What does 1 point indicate for each the 5 components of Apgar?

Answer 6

1. Heart rate is below 100 beats/minute
2. Slow respirations or weak cry
3. Minimal flexion of extremities; sluggish movement
4. Minimal response (grimace) to suction or gentle slap on soles
5. Bluish colored hands and feet only

Question 7

What does 2 points indicate for each the 5 components of Apgar?

Answer 7

1. Heart rate of 100 beats per minute or higher
2. Respirations are spontaneous with strong, lusty cry
3. Flexed body posture, spontaneous and vigorous movement
4. Responds promptly to suction or gentle slap to sole with cry or active movement
5. Pink (light skinned) or absence of cyanosis (dark skinned); pink mucous membranes

Question 8

What does a total apgar score of 0-2 indicate?

Answer 8

Nursing Interventions:

INFANT NEEDS RESUSCITATION!!!!

Question 9

What does a total apgar score of 7-10 indicate?

Answer 9

Nursing Interventions:

Provide no action other than support of infant’s spontaneous effort and continued observation.

Question 10

What is the significance of a two-vessel umbilical cord?

Answer 10

May indicate congenital malformation (renal or chromosomal)

Question 11

What is a nursing intevention for jitteriness in the neonate?

Answer 11

Immediate blood glucose check

Question 12

Where should a heel stick take place on the neonate?

Answer 12

Lateral aspects of heel

Question 13

Why do neonates lose weight?

Answer 13

1. Mother’s true milk does not come in until day 3,4 so breastfeeding infants have greater weight loss than formula feeding infants
2. Excretion on meconium
3. Normal loss of extraceelular fluid
4. Inadequate calorie intake

Question 14

Subconjuctival Hemmorrhages

Answer 14

1. Reddened areas of the sclera of eye
2. Results from pressure on the head during birth which causes capillary rupture in the sclera
3. Edema diminishes in a few days and the hemorrhages should resolve in 7-10 days

Question 15

Chemical Conjuctivitis

Answer 15

1. Results from reaction to medications

Question 16

Palatal Closure

Answer 16

1. Cleft lip results if the lip or palate fails to close
2. May involve the hard or soft palate or both and may appear alone or with a cleft lip
3. Palate is inspected when the infant cries
4. A gloved finger is inserted into the mouth to palpate the hard and soft palate

Question 17

Thrush

Answer 17

1. Usually not apparent in the mouth immediately after birth
2. May appear 1-2 days after birth
3. Lesions resemble milk curds on the tongue and cheeks that bleed if attempts are made to wipe them away
4. May have become infected during passage through the birth canal if the mother has a candidal vaginal infection
5. Treated with antifungal medication such as nystatin suspension

Question 18

Why does brick dust staining occur?

Answer 18

1. Urine is highly concentrated at first because of the small amount of colostrum the baby is able to digest in the first stages of life
2. Caused by temporary dehydration where the kidneys are not making normal liquid urine
3. Instead, uric acid crystals appear causing a reddish or pink stain on the diaper
4. Does not continue beyond the first few days as the kidneys mature

Question 20

Erythromycin ophthalmic ointment

Answer 20

1. Antibiotic, bacteriostatic
2. Prophylaxis against Neisseria gonorrhoeae
3. Prevents ophthalmia neonatorum in infants of mothers infected with gonorrhea
4. Required by law for all infants, even if the mother is not known to be infected
5. Ribbon of 1cm ointment applied to the lower conjunctival sac of each eye within 1 hour after birth
6. Burning, itching, irritation may result in chemical conjuctivitis lasting 24-48 hours, ointment may cause tmeporary blurred vision
7. Do not rinse, ointment may be wiped from the outer eye after 1 minute, observe for irritation

Question 21

Vitamin K-Phytonadine (Aquamephyton)

Answer 21

1. Fat soluable vitamin, antihemorrhagic
2. Prevention or treatment of vitamin K-deficiency bleeding (hemorrhagic disease of the newborn)
3. Provides vitamin K for clotting
4. 0.5-1mg given IM within 1 hour of birth for prophylaxis. May be delayed for breastfeeding in delivery room.

Question 22

Hepatitis B Vaccine (Engerix-B, Recombivax HB)

Answer 22

1. Vaccine, Immunization against Hepatitis B infection
2. Prevention of hepatitis B in exposed and unexposed infants
3. 5mcg for Recombivax HB and 10mcg for Engerix-B
4. First dose of Hepatitis B vaccine is given to newborns before hospital dischagre. The second dose of vaccine is given at age 1-2 months. The third dose is given and 6-18 months
5. For mothers who are positive: vaccine is given within 12 hours of birth along with hep b immune globulin which is given at a different site. infant is then tested after completing three doses of vaccine
6. Unknown status: The vaccine is given within 12 hours of birth and the mother is tested. If the mother tests positive than the infant should receive the immune globulin as soon as possible and no later than 1 week of age.
7. Absorbed slowly
8. Contraindicated in hypersensitivity to yeast
9. Pain, redness at site, dever, headache are adverse reactions
10. Do not inject IV or intradermally. Obtain consent before administering. Give vaccine within 12 hours of birth to infants with Hep B positive mother.

Question 23

Ineffective Thermoregulation