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exam 3 nur 365 > module 8 > Flashcards

module 8 Flashcards

1
Q

evaporation

A

heat loss due to evaporation of liquid from the body

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2
Q

conduction

A

transfer of heat by direct contact with a cooler object

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3
Q

convection

A

heat transfer from the newborn to the surround air

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4
Q

radiation

A

transfer of heat from or the newborn from or to nearby surface

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5
Q

risk for heat loss

A
  • high body surface to mass ratio
  • blood vessels are close to the surface of the skin
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6
Q

how do infants produce heat

A

brown fat

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7
Q

respiratory : chemical stimuli

A
  • cessation of placenta blood flow
  • decreased O2 - mild hypoxia
  • increase of carbon dioxide - decrease of pH (acidosis)
  • stimulation of respiratory center in medulla
  • stimulation of respirations
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8
Q

respiratory : mechanical stimuli

A
  • delivery of face = loss of variable amounts of amniotic fluid from lungs
  • delivery of chest = expansion of chest to pre-delivery proportions - negative pressure - passive inspirations of air - first breath
  • entry of air into alveoli replacing the expelled amniotic fluid
  • lung fluid is reabsorbed via lymphatic system
  • neonate crying - intrathoracic positive pressure
  • alveoli remain open
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9
Q

what stimulates breathing?

A
  • cord is clamped and placenta cannot provide gas exchange
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10
Q

mechanical mechanism to absorb fluid in lungs

A

squeezing through the birth canal create a negative pressure and recoil

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11
Q

what helps absorb fluid in lungs?

A

crying
- once air enters the lung and crying happens, it pushes the fluid out of alveoli

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12
Q

cyanosis : clinical considerations

A
  • acrocyanosis (blue color of the neonate’s hands and feet) = normal in the first 24 h postpartum
  • central cyanosis, which is indicated by bluing of the lips and chest, is abnormal
  • transient cyanosis when crying is not uncommon immediately after birth
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13
Q

apnea: clinical considerations

A
  • cessation for breathing for 20 s or more is concerning
  • shorter periods of apnea in the absence of other signs of distress are considered normal
  • apnea over 20 s may indicate sepsis, hypothermia, hypoglycemia, or another problem
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14
Q

tachypnea: clinical considerations

A
  • neonates typically take 30-60 breaths per minute
  • sustained tachypnea is abnormal and may indicate respiratory distress syndrome or fluid in the lungs
  • it may indicate infection or cardiac metabolic illness
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15
Q

intercostal or substernal retractions: clinical manifestations

A
  • retractions are pulling in of tissue with each breath and indicate reduced pressure inside the lungs, likely because of occlusion of the upper airways
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16
Q

grunting: clinical considerations

A
  • grunting with expiration occurs with a partially closed glottis
  • this partial occlusion increases the pressure within the lungs so more oxygen can diffuse into the bloodstream =
  • grunting may be auscultated with a stethoscope, or in more severe cases, heard without assistance
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17
Q

nasal flaring: clinical considerations

A
  • nasal flaring expands the airway and reduces airway resistance
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18
Q

seesaw breathing: clinical manifestations

A

the chest and abdomen rise simultaneously in the absence of respiratory distress
- seesaw breathing, like retractions, suggest partial blockage of the airways

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19
Q

stridor: clinical considerations

A
  • stridor, which is an abnormal, high-pitched breath sound, a sign of upper airway obstruction
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20
Q

gasping: clinical considerations

A

sign of upper obstruction

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21
Q

adapting to extrauterine life - cardiac

A
  • first breaths dilate pulmonary vasculature = pulmonary vascular resistance = increased blood return from lungs to left atrium (higher pressure than right atrium causes closing of foramen ovale)
  • ductus arteriousus closes within a few days after birth
  • clamping of the umbilical cord causes decreased blood flow to the ductus venous, which will then begin to atrophy
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22
Q

physiological changes : circulatory system

A
  • initiation of changes
  • ductus venosus : closes by day 3
  • foramen ovale: closes when pressure is the LA is higher than RA
  • ductus arteriosus: closed within 15 hrs/ RT decreased pulmonary resistance
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23
Q

vitamin K

A
  • infants git is sterile and does not have the bacteria needed to make vitamin K, which is used by the body to help blood clot
  • an injection of vitamin K is given to prevent a pathologic bleed
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24
Q

GI system: physiological changes

A
  • gastric emptying time 2-4 hrs; babies need to eat every 2-4 hours
  • 5-10 mL capacity initially (stomach can only hold this much)
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25
Q

meconium

A
  • 24-48 hrs
  • dark, black, tarry, sticky
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26
Q

transitional stool

A
  • 3-7 days
  • looser
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27
Q

breastfed stool

A
  • yellow
  • semi-formed
  • pasty
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28
Q

formula fed stool

A
  • drier
  • more formed
  • pale yellow or brown
  • odorous
  • more dirty diapers per day than breast fed baby
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29
Q

diarrhea

A
  • loose
  • green
  • watery
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30
Q

how much wt do neonates lose in the first 3-5 days? (%)
when is the weight regained?

A
  • 5-10%
  • within 2 weeks
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31
Q

low GFR risk for (limited ability to concentrate urine)

A
  • overhydration
  • dehydration (NEVER give babies water)
  • electrolyte imbalance
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32
Q

how many wet diapers a day?

A

6-8

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33
Q

uric acid crystals

A
  • red/rusty normal
  • if persists after first couple of days = not normal
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34
Q

straight catheter, when?

A

if baby has not voided in first 24 hrs

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35
Q

hyperbilirubinemia

A
  • increased levels of unconjugated bilirubin in the blood
  • newborns at risk because they have extra immature RBCs, when they breakdown they get bilirubin
  • bilirubin is conjugated for them through the mom, when they are born they have to conjugate it themselves so that they can excrete it
  • bilirubin is a product of RBC breakdown
  • bruising puts the baby at risk because its a breakdown of RBCs
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36
Q

physiologic jaundice

A
  • normal process we expect
  • yellowing of skin and sclera
  • increased RBC: resulting in increased bilirubin
  • immature liver: lag in time to start conjugating bilirubin
  • bilirubin cannot be excreted through feces because its not conjugated in the liver
  • bilirubin expected to rise for first 2-3 days; tapers off within a week
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37
Q

breastfeeding jaundice

A
  • less colostrum (moms only making a few drops at beginning) = less stools = less bilirubin leaving the body
  • baby is not eating a lot, not pooping a lot, not excreting bilirubin
  • bilirubin can be reabsorbed in their guts
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38
Q

at risk for hypoglycemia

A

glucose < 40

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39
Q

hypoglycemia patho for babies

A
  • production of new glucose occurs mainly in the liver
  • before birth, mom supplies the blood glucose, but baby makes their own insulin
  • after birth, the baby continues to produce insulin, but without mom’s supply of glucose
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40
Q

s&s of hypoglycemia late signs

A
  • hypotonia
  • apnea
  • temperature instability
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41
Q

s&s of hypoglycemia early sign

A
  • jitteriness (looks like tremors)
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42
Q

s&s of hypoglycemias other signs

A
  • irritability
  • lethargy
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43
Q

three things that go together? (hint: H,R, T)

A
  • hypoglycemia, respiratory depression, temperature instability
  • if baby is cold, have to metabolize brown fat to stay warm, have to increase their metabolic rate, which increases their risk for hypoglycemia
44
Q

hypoglycemia risks

A
  • babies born to diabetic mothers (mom has higher blood sugar that they have been supplying to the baby, baby may have been making more insulin to respond to that, baby continues to make that insulin but don’t have the blood glucose)
  • LGA - babies are bigger and need more insulin
  • post term (after 40-wks) = placenta may not perfuse as well and baby might not be getting what they need
  • preterm = greater needs because metabolic rate is higher
  • SGA
  • hypothermia
  • infection, body is stressed
  • respiratory distress
  • resuscitation
  • birth trauma
45
Q

nursing actions: hypoglycemia

A
  • monitor s& s
  • assess BG when risk factors present or when s&s present = 30-60 min after birth, every 3-6 hrs for first 24-48 hrs
  • assist w/ early breastfeeding (when then to eat something in the 1st hour)
  • supplement with formula per protocol per protocol = if glucose continues to drop
  • maintain neutral thermal environment to prevent
46
Q

active humoral immunity

A
  • B cells detect antigens and produce antibodies
  • acquired or natural immunity
47
Q

passive immunity

A
  • not permanent. acquired from placental transmission
  • 3 months
48
Q

lymphocytes

A
  • adequate number of lymphocytes but immature, delayed action
49
Q

immunogobulins

A
  • IgG, IgA, IgM, IgD, IgE
  • IgG = placenta to provide passive immunity
  • IgA = present in breastmilk, provides passive immunity
  • IgM = first to be produced by the infant as immune system matures
50
Q

risk for infection due to:

A

immature defense systems, lack of exposure to organisms, breakdown of skin and mucous membranes that provides a portal of entry

51
Q

after birth neonates begin to: (immunity)

A
  • develop normal microbial flora
  • skin, respiratory tract, GI tract
  • respond to bacterial colonization
  • first exposed to bacteria in maternal genital tract
52
Q

periods of reactivity = first phase

A
  • occurs 1-2 hours after birth
  • awake and alert
  • optimal time for initiating breastfeeding and bonding
  • minimize taking baby away from mom
53
Q

second phase of transition

A
  • may last several hours
  • let mom get rest, take baby for testing if needed (hearing screen)
54
Q

final phase of transition

A
  • occurs between 2-8 hours after birth
  • meconium often passed at this time
  • wake up, be alert again, and want to eat
55
Q

sleep wake states = deep sleep

A

possible startle reflex but no other movement; regular breathing; no eye movement or change in state due to external stimuli

56
Q

sleep wake states = light sleep

A
  • some body movement; irregular breathing; rapid eye movement; possible change in state due to external stimuli
57
Q

sleep wake states = drowsy

A
  • muscle movement; irregular breathing; eyes open and close; external stimuli typically results in change of state
58
Q

sleep wake states = quiet alert

A
  • regular respirations; eyes open, may focus on stimuli; optimal time to attempt breastfeeding.
59
Q

sleep wake states = active alert

A

body movements and possible fussiness; increased startle reflex and motor activity; eyes open; irregular respirations

60
Q

sleep wake states = crying

A
  • intense crying, difficult to calm, ample body movement. Breathing irregular
61
Q

APGAR = appearance

A

0 = cyanotic
1 = cyanotic limbs, pink core and head
2 = pink baby

62
Q

APGAR = pulse

A

0 = no pulse
1 = <100/min
2 = >100/min

63
Q

APGAR = grimace

A

0 = mo facial reaction
1= slight reaction
2 = strong reaction

64
Q

APGAR = activity

A

0 = no movement
1 = slight movement in arms
2= lots of movement

65
Q

APGAR = respiration

A

0 = no respirations
1 = weak, slow
2 = strong cry

66
Q

gestational age assessment

A

evaluation of an infant’s physical and neuromuscular maturity (typically done within 12 hours of birth) = how long was the baby actually in utero

67
Q

posture

A

arms and legs should be flexed

68
Q

pulse

A

at rest expect 120-160 beats per minute, maybe higher if crying, or lower if in deep sleep

69
Q

respirations

A

expect a rate of 30-60 breaths per minute and irregular; no nasal flaring/grunting/intercostal retractions

70
Q

temperature

A

36.5C to 37.2 C
- taken axillary or temporal

71
Q

chest general assessment

A
  • should be symmetrical, barrel-shaped nipples in line with each other
72
Q

integumentary assessment

A
  • inspect for color, bruising, birthmarks, lanugo (fine hairs), vernix, or rashes
  • expect skin to be centrally pink but may have bluish hands and feet (acrocyanosis)
73
Q

head assessment

A
  • molding and caput is common
  • fontanels should be soft; may be slightly depressed (should not be sunken or bulging)
  • caput = edema (from head pushing on cervix), crosses suture lines
  • cephalhematoma = collection of blood, does not cross suture lines
74
Q

neck assessment

A
  • should be short, thick, and mobile, with no webbing
  • check clavicles for crepitus for indication of broken bone
75
Q

abdomen assessment

A
  • umbilical stump should be white or gray. The clamp is removed after 24 hours
  • should not be oozing with draining
  • no obvious lumps or bumps
76
Q

rooting reflex

A
  • when mouth or cheek is touched, infant turns toward the stimulus and opens the mouth
  • lets us know the baby is hungry
77
Q

sucking reflex

A
  • when fed, the neonate coordinates sucking, swallowing, and breathing
  • gloved pinky in mouth to assess how strong their sucking is
78
Q

extrusion

A

when the tip of the tongue is touched, the infant sticks out the tongue

79
Q

palmar reflex

A

infant curls fingers around the object placed in the hand

80
Q

plantar reflex

A

the infant curls toes around the object placed at the base of the toes

81
Q

moro reflex

A

the infant abducts and extends arms when startles by a loud noise (loud clap) or if experiencing a dropping sensation or rattling of crib a little

82
Q

babinski reflex

A

when an infant’s foot is stroked along the lateral aspect and then across the ball of the foot, the toes fan outward

83
Q

nursing care for the neonate - first 4 hours

A
  • universal precautions
  • maintain body heat
  • support respirations
  • apgar score
  • vital signs
  • identifying bands
  • neonatal assessment
  • gestational age assessment
  • administer erythromycin ophthalmic to prevent infection that could occur in birth canal
  • administer vitamin K (phytonadione)
  • bath with neutral pH soap - delay at least an hour until temp and glucose are stable
  • promote parent-infant attachment
84
Q

nursing care for the neonate - 4 hours to discharge

A
  • vital signs (depending on hospital protocol)
  • temperature regulation
  • neonatal assessment
  • promote parent-infant attachment
  • promote sibling attachment
  • prevent infant abduction
  • instruct parents to place neonate on back when sleeping with no blankets or pillows to prevent suffocation
  • assist with feedings
  • provide information on newborn care
  • provide information on normal newborn characteristics
85
Q

laboratory + diagnostic tests

A

tests for many metabolic disorders that don’t have symptoms right away
- heel stick
- state and national requirements
- obtain blood sample
- newborn hearing screen (infant has to be asleep for) = otoacoustic emissions (OAEs), auditory brainstem response (ABR)

86
Q

immunizations : hepatitis B

A

need 3 doses
- prior to discharge, 1-2 months, 6-18 months

87
Q

risk of circumcision

A

bleeding, infection
- more than a quarter sized area of blood in diaper needs to be looked at

88
Q

benefits of circumcision

A

lower risk of penile cnacer, easier to keep clean

89
Q

circumcision care

A
  • with every diaper change, have parents drip water on penis to =keep it clean pat (not rub)
  • should not pull gauze off; wait for it to fall off
  • loosely fasten diapers due to infant’s pain
  • notify provider if no void in 24 hours
90
Q

when are prolactin levels highest

A
  • 10 days after birth
  • gradually decline but remain above baseline levels for duration of lactation
91
Q

when is prolactin produced

A
  • in response to infant suckling and emptying of breasts ‘- lactating breasts never completely empty
  • milk is constantly produced as infant feeds
  • supply meets demand system
  • suckling stimulation - hypothalamus - anterior pituitary to produce prolactin - milk production
92
Q

oxytocin

A
  • other hormone essential to lactation
  • as nipple is stimulated by suckling infant, posterior pituitary, prompted by hypothalamus, produce oxytocin
  • responsible for milk-ejection reflex or let-down reflex
  • nipple-erection reflex is integral to lactation
93
Q

lactogenesis stage I

A
  • beginning at 16-18 wks of pregnancy
  • colostrum = thick , clear, yellow fluid
  • more concentrated than mature milk
    extremely rich in immune globulins
  • higher concentration of protein and minerals
  • less fat than mature milk
94
Q

lactogenesis stage II

A
  • occurs by day 3-5 when copious amount of milk comes in to breast
  • breast milk changes based on body’s needs
95
Q

infant feeding readiness cues

A
  • early infant = rooting reflex, licking lips, sucking notions, smaking lips, moving as if looking for the breast (trying to suck blankets, hands, or searching movements)
  • late infant feeding cues = crying
96
Q

breast-feeding positioning

A
  • cradle, cross-cradle, football, side-lying
97
Q

latch on

A

baby’s nose and chin touch breast
- lips flanged outward
- most or all of areola in mouth; baby’a mouth open wise
- no dumpling of cheeks
- no audible suckling should just hear them swallowing the breast milk

98
Q

milk ejection or let-down

A
  • can feel like a cramp or numbing sensation
99
Q

frequency of feedings

A

deed on cue Q2-3 or 8-12x/day

100
Q

duration of feedings

A
  • should empty breast
  • let infant decide how long feeding will last (when baby lets go)
  • no switch feedings ok
101
Q

signs of effective milk transfer

A
  • 8-12 feeds in 24 hours
  • audible swallowing when milk lets down
  • the infant is alert with good muscle tone and activity
  • infant is content between feeds
  • rule of fives; by day 5, 6 or more wet diapers every 24 hours
  • 3-8 soiled diapers every 24 hours for the first 6 weeks
  • recovers birth weight by 2-3 weeks of age
  • mothers breast may feel full before feeding and softer after feeding
102
Q

engorgement

A
  • supportive bra
  • no pumping due to prolactin feedback loop - hand express
  • warm shower, hold breast in pan of warm water
  • cabbage leave
  • ice packs for comfort
103
Q

sore nipples

A
  • lanolin
  • vitamin E
  • soothie gel packs
  • assess for proper latch
  • switch positions
  • no-switch feeding
104
Q

plugged milk ducts

A
  • feel lump in breast, uncomfortable, warm to touch, no fever
  • warm shower, massage, frequent feeding on affected side
  • puts mom at risk for mastitis
105
Q

mastitis

A
  • fever, chills, flu-like symptoms, pain, rash on breast
  • antibiotics, good hydration, continue to breastfeed (frequent emptying of breast)
  • follow up after hospital discharge
106
Q

Important points for formula feeding

A

Check the expiration dates on the formula
○ Do not place mixed bottles in boiling or boiled water
○ Never use a microwave oven to prepare formula
○ After feeding, throw away any formula remaining in the bottle
○ Rinse bottles and nipples after use
○ Never leave mixed formula unrefrigerated for more than 2 hours; risk for bacterial
contamination
○ Do not freeze formula

exam 3 nur 365 (3 decks)

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