Module 7: Newborn Assessment

Question 1

APGAR Score

Answer 1

• routine standard assessment at 1 and 5 mins, lets us know how much intervention is needed
• point scale 0-10 ( no newborn receives 10)
• 8-10
• 5-7 needs interventions, (suction/ supportive O2, stimulate them by rubbing feet and body)
• 4 or less is even more interventions could be crucial (nicu or neonatal care)
• Activity - muscle tone ( moving arms and legs around)
• Pulse
• Grimace (reflexes and irritability)
• Appearance (skin colour) - uncommon for child to receive 2 as child can appear cyanotic on extremities (called acrocyanosis)
• Respirations

Question 2

Moulding

Answer 2

• caused when partial bones go over top of one another

- encourage alternating sides the child lays on whether it be in travel or when child is sleeping or laying

Question 3

caput

Answer 3

• suture swelling
• tissue swelling
• makes the newborns head look elongated

Question 4

Moro reflex (startle reflex)

Answer 4

• infants draw their legs up and then arms fan out and then come toward midline in an embrace position if the crib is jarred or the infant is startled
• if not present could indicate neurological delays

Question 5

cephalohematoma

Answer 5

• blood collection between scalp and cranium and does not cross a suture line
• vacuum assisted deliveries may cause this
• suctioning may cause this
• important teaching points:
  
  • will go away with time

Question 6

meconium

Answer 6

• first stool, thick dark green - black
• expelled in the first 8 - 24 hours
• amniotic fluid, lanugo and vernix make up meconium
• vaseline helps clean the stool because its sticky and thick

Question 7

acrocyanosis

Answer 7

• peripheral blueness in the hand and feet result from poor circulation is normal and will resolve
• when assessing signs of adequate oxygentation do not use limbs

Question 8

vernix caseosa

Answer 8

• cheese like substance that covers new borns skin, function is to protect babies skin from irritation
• ask parents if they want it fully removed or kept on the skin to hydrate the skin

Question 9

lanugo

Answer 9

• fine hair that covers the babies body

- disappear after week or so

Question 10

milia

Answer 10

• tiny pin point pimples
• obstruction of sebaceous glands, usually on face
• will go away on their own

Question 11

temperature

Answer 11

• 36.2 -37.7
• unstable heat regulating system
• cannot adapt to change in temperatures easily
• sweat glands do not function during neonatal period, infant is at risk for developing elevated temperature if overdressed or placed in overheated environment

Question 12

Heart Rate

Answer 12

• 110-160
• murmurs may be present as some fetal circulatory pathways may have not closed
• majority are not serious but need a follow up to rule out other serious complications

Question 13

Respirations

Answer 13

• 30-60 breaths per minute
• full lung expansion occurs after several days
• use of bulb suction to remove mucus from mouth and nostrils
• first breath helps to expand the lungs
• anything less than 30 is concerning

Question 14

Weight

Answer 14

• average 2722g - 4082 g

- in the first 3-4 days the infant loses 5-10% of the birth weight, birth weight is regained by 10 days

Question 15

Head circumference

Answer 15

• normal circumference 32-36 cm
• measure from the top of the eyebrow to the widest part of the occiput
• anterior and posterior fontanelles
  
  • measure the widest point of the width and widest point of the length add these values together and then divide by 2

Question 16

Colour

Answer 16

• Jaundice (Icterus neonatorum)
  
  • characterized by yellow tinge of the skin
  • caused by rapid destruction of excess RBC’s
  • plasma levels of bilirubin increase
  • observable within the second and third day of life lasting for about a week
  • Assess with: icterometer- plastic strip yellow colour, press against the infants nose until blanches and then compare the underlying colour with strip
  • transcutaneous bilirubin measurement

Question 17

Tone

Answer 17

bones are soft

Question 18

Movement

Answer 18

• random and uncoordinated

- cephalocauddal and proximodistal development and control (developing from core to distal)

Question 19

Behaviour

Answer 19

• hand to mouth, mouth and tongue movements, sucking motions and rooting movements , clenched fists, kicking of legs and crying are signs of newborn hunger

Question 20

Cry

Answer 20

• for 3 months no tears when crying, lacrimal ducts have not developed effectively yet to produce tears

Question 21

Cord

Answer 21

• is the cord dry (takes about 24 hours)
• signs of infection around the umbilicus
• don’t put umbilical cord under diaper
• daily clean with a tip around umbilicus
• don’t let it soak for long periods of time

Question 22

Feeding

Answer 22

• let down reflex, tingling sensation with milk dripping from nipple
• infant nurses for 15 mins per breast 8-10 times per day
• an audible swallow is heard
• infant appears relaxed after feeding
• infant has six to eight wet diapers per day
• infant passes several stools per day
• breast feels soft after feeding

Question 23

elimination

Answer 23

• one void within first 24 hours
• 6 wet diapers per day
• look for the presence of an anus and where the urethra is
• first stool is a combination of amniotic fluid, lanugo and secretions from intestinal glands, dark green to black and thick tarry passed within 8-24 hours
• transitional stools - gradually changes during the first week becoming loose and greenish-yellow with mucus
• breastfed infant: stools are right yellow, soft and pasty
• constipated stool: small , hard and thick may look like rabbit stool lol

Question 24

Describe the care of a macrosomic infant

Answer 24

complications before birth: insulin production, congenital abnormalities
Complications during delivery: birth injuries
Complications after birth: respiratory system, blood glucose level - low levels can result in permanent brain damage
Nursing care:
- assess BGL for first 2 days of life
- assess for signs of irritability, tremors, and RDS
- assess respirations