Newborn Assessment and Care Flashcards
1
Q
8 Priority Needs of the Newborn
A
- respirations
- extrauterine circulation
- body temperature
- nutrition
- elimination
- infection
- parents relationships
- developmental care
2
Q
Production of fetal lung fluid ________ __ to __ days before labour
A
decreases 2-4 days
3
Q
___ to ___ml fetal lung fluid remains in the air passage of a _______ newborn
A
80-100
full term
4
Q
What occurs during birth to the fetal chest?
A
Compressed and squeezes fluid to rid body as much fluid as possible
5
Q
What 2 things trigger the first breath in a newborn?
A
- The exit/recoil from the vaginal squeeze/chest compression
- partial pressure changes (increased PCO2 and decrease in pH and PO2)
6
Q
What type of newborn would you anticipate having a greater amount of fluid in the lungs?
A
Short labour or c-section
7
Q
What respiratory nursing diagnosis would occur for a c-section baby?
A
diagnosis would occur for a c-section baby?
Inadequate airway resulting in inadequate gas exchange
8
Q
APGAR HR Score 0, 1, 2
A
0- absent
1- < 100
2- < 100
9
Q
APGAR Respiration Score 0, 1, 2
A
0- absent
1- slow/irregular
2- crying
10
Q
APGAR Activity Scoring 0, 1, 2
A
0- flaccid
1- some flexion
2- active movement
11
Q
Apgar Grimace Scoring 0, 1, 2
A
0 - none
1 - grimace
2- vigorous cry
12
Q
Apgar Appearance Scoring
A
0- pale, blue
1- acrocyanotic
2- pink
13
Q
Why ask about expected gestational age before delivery?
A
Maturity of lungs (risk factor for respiratory issues in prematurity)
14
Q
Why ask about colour of amniotic fluid before delivery?
A
Presence of meconium makes it harder for fetus to breath
15
Q
How many arteries v veins are in the umbilical cord and what type of blood do they carry?
A
2 arteries (UNOXYGENATED) 1 vein (OXYGENATED)
opposite than adult circulation
16
Q
What does venous blood tell us when collecting cord blood gases and why
A
Oxygenated, returning from placenta
THEREFORE
tells us about placental function
17
Q
What does arterial blood tell us when collecting cord blood gases and why
A
Deoxygenated, goes back to maternal circulation
THEREFORE
tells us about fetal tolerance of birth
18
Q
What is Warton’s jelly?
A
Covers umbilical vessels to prevent cord compression in utero
19
Q
3 values that demonstrate metabolic acidosis in newborn assessment
A
pH < 7
base excess > 12
APGAR < 3 for 5 min
20
Q
What does metabolic acidosis increase the risk for in newborn?
A
Anoxia brain damage
21
Q
Normal venous pH, pO2, pCO2, and base deficit in cord blood gases
A
pH: 7.3-7.35
pO2: 28-32
pCO2: 38-42
Base: 5
22
Q
Normal arterial pH, pO2, pCO2, and base deficit in cord blood gases
A
pH: 7.24-7.29
pO2: 12-20
pCO2: 45-50
Base: 10
23
Q
Newborn priorities immediately after birth/golden hour
A
- skin to skin and stimulation
- APGAR
- cord blood gases
- bonding/feeding
> only removed during 1st hour if baby requires resuscitation
24
Q
One hour neonate assessments
A
- medications
- weight, length, head
- head to toe/vitals
25
Interventions for 4 hours post birth neonate
VS q1h x4
26
Newborn temperature
36.5-37.5
27
Newborn heart rate
110-160
28
Newborn respirations
30-60
29
Newborn BP
50-75/30-45
30
Early neonatal signs of respiratory distress
1. tachypnea
2. circumoral cyanosis
3. nasal flaring and accessory muscle use
4. grunting/cooing
31
How long is acrocyanosis normal for?
24-48hr
32
What APGAR indicates need for resuscitation
< 7
33
Why is the newborn at risk for hypothermia?
1. large SA related to body mass
2. no ability to shiver
3. lower adipose tissue
34
What is the primary source of thermoregulation in newborns?
Non-shivering thermogenesis/Brown adipose tissue
35
How does brown fat contribute to thermoregulation in new borns
Brown fat contains a high number of mitochondria, the cell's energy factories, and it can burn stored fat and glucose to produce heat directly.
36
Define evaporation as source of heat loss and why is it a concern in newborn
loss of heat when liquid is converted to vapor
Wet with amniotic fluid
37
Define convection as a source of heat loss and why is it a concern in newborn
flow of heat from body to cool surround ing air
heat from body into cooler air circulating over if not maintaining NTE
38
Define radiation as source of heat loss and why is a concern in newborn
loss of body heat to cooler solid surfaces that are in proximity but not direct contact
placing cold objects near incubator/window
39
Define conduction as source of heat loss and why is it a concern in newborn
the transfer of heat when there is direct contact
cold stethoscopes
40
When is newborn at risk for altered thermogenesis
first 8-12hr of life
41
5 risk factors for altered thermogenesis
1. premature
2. SGA
3. CNS problems
4. prolonged resuscitation efforts
5. sepsis
42
Signs of cold stress
1. vasoconstriction - acrocyanosis/pallor
2. tachypnea and tachycardia
3. fussiness, hyperactivity, irritable
- won't shiver
43
True or false: if a baby is acrocyanotic, tachypneic, tachycardiac, and fussy, these things only indicate hypothermia
False
All of these are common indicators of anything being wrong (ex. Hypoglycemia); assess further
44
Common temperature of delivery room
23-25 degrees; not optimal for infant
45
How can you prevent cold stress
1. dry baby quickly
2. hat r/t large area for heat loss
3. skin to skin with prewarmed blanket
46
Why is neonatal hypoglycemia a large concern?
no glucose = neurological compromise
47
When are babies most susceptible to hypoglycemia and why?
In 1st hour r/t no umbilical flow for glucose delivery AND insulin is still being made at steady rate expecting steady flow from umbilicus
48
BGM of hypoglycemic neonate
repeated readings of <2.6 or single reading of < 1.8
49
Normal newborn glucose
2.2 - 6
50
Infants at risk for hypoglycemia and why
SGA: decreased glycogen stores
LGA: hyperinsulinism
IDM: hyperinsulinism
Premature: decreased glycogen store
Sick/stressed/cold: increased metabolism
51
S+S of hypoglycemia in newborn (10)
· Jitteriness or tremor
· Apathy
· Cyanosis
· Convulsions
· Apneic spells or tachypnea
· Weak or high-pitched cry
· Limpness or lethargy
· Difficulty in feeding -poor suck, refusal to feed
· Eye rolling
· Sweating, sudden pallor hypothermia and cardiac arrest (less common)
52
What does vitamin K admin @ 1 hr prevent
to prevent... hemorrhagic disease of the newborn (HDN) or vitamin K deficiency bleeding (VKDB). HDN can occur in the first few days to weeks of life and is characterized by uncontrolled bleeding, which can be life-threatening.
53
Reason vitamin K admin is necessary
Newborns are typically born with low vit K levels because
a) it doesn't cross placenta
b) they have a sterile gut so they do not produce it
54
Vitamin K dose order:
1mg IM within 6 hours OD
vastus lateralis
55
Besides a sterile gut, what other reasons are newborns at increased risk for bleed?
Prothrombin levels are low
56
What does erythromycin prevent?
Gonorrhea transmission
57
Describe administration of erythromycin at birth
both eyes inner to outer canthus in lower conjunctival sac with single application tube
58
1st Period of Reactivity; newborn behaviour patterns
30min-2hr
- awake/active
- hungry
- natural opportunity to start BF
- encourage en-face
- elevated vitals
59
Period of Decreased Responsiveness; newborn behaviour patterns
After 2 hours, next 2-3 hours (so hours 3-6)
- sleep
- HR RR decrease
- difficult to awake
- no interest in feed
60
2nd Period of Reactivity; newborn behaviour patterns
3rd period lasting 2-8 hours (hours 5-14)
- HR RR increase
- be aware of apneic period
- passess meconium, voids, sucks, roots, swallows
61
Vital signs of newborn until d/c
q1h x 4, q4h x 24 - 48 hours , then BID.
62
how often is a head to toe done on newborn before d/c
twice, once at 1hr then once before leaving
63
how often are weights done on newborn before d/c
- birth weight
- OD
- prior to d/c
- weight loss = daily
64
Expected weight changes of newborn
By day 3-4, a drop of < 10% is normal, if over 10% weight occurences will increase
65
When should a baby begin to regain weight?
By 2 weeks
66
What interventions regarding cord care for the newborn must occur?
air dry, will fall off 5-15 days
intervention: keep dry to avoid infection
67
When is a TCB done?
24 hours - if abnormal blood draw because other blood work is also being done at this time
68
Usual head circumference
33-37 cm
69
Usual chest circumference
30-33cm
70
Usual weight
2500-4000g
71
Usual length
45-55cm
72
What is a stork bite (salmon patch)?
a cluster of pink to reddish-purple blood vessels (capillaries) that appear on a newborn's skin on the back of their head or neck
harmless and fade over time
73
Why is it important to assess palm creases?
should be 3
1 indicates trisomy 21
74
Describe posteriorfontanelle
<1cm, triangle, ossifies in 8 weeks
75
Cephalohematoma location, cause, description, when it appears
collection of blood between bone and periosteal membrane
hemorrhage causes by forceps/vaccum that seperated membrane
does not cross sutures
appears later, takes 2-3 weeks to disappear
76
caput succedaneum location, cause, description, when it appears
collection of fluid/edema on scalp - not bone
caused by pressure or trauma
crosses suture lines
present at birth and resolves in a few days
77
Dermal melanocytosis/slate grey nevus
(Mongolian spots): blue discolorations of skin in patches on buttocks and lower back in non-white babies
NORMAL
78
Is acrocyanosis normal finding?
Yes in 24-48hr
79
Epstein's Pearls
small, harmless cysts that form in a newborn's mouth during the early weeks and months of development. They contain keratin and usually go away within a few weeks
80
Telangiectatic nevi
Stork bites, salmon patch, angel kiss
small dilated blood vessels near the surface of the skin or mucous membranes that commonly develop on the face around the nose, cheeks and chin
NORMAL
81
Molding
Shaping of the fetal head during movement through the birth canal.
NORMAL
82
vernix caseosa
cheesy substance covering the skin of the fetus
should decrease as baby gets closer to gestational age
83
Lanugo
fine, soft hair, especially that which covers the body and limbs of a human fetus or newborn.
84
Milia
Benign, keratin-filled cysts that can appear just under the epidermis and have no visible opening
NORMAL
85
Erythema toxicum
newborn rash
86
What are you assessing for eyes of newborn?
- placement relative to ears
- subconjunctival hemorrages
- tearless for 2 months
- follow stimuli for short periods
- immature muscular control x 3mos
87
What you assessing for mouth of newborn?
- palate
- tongue ties
- epstein's pearls
- selective response to taste
88
What are you assessing for ears of newborns?
- recoil of cartilate
- pre-auricular skin tags
- response to stimuli
89
What are you assessing the nose for in newborns?
- preferential nose breathing
- patency
90
Blinking reflex disappearance
persists into adulthood
91
Moro reflex disappearance
4 months
92
grasp reflex disappearance
3-4 months
93
stepping reflex disappearance
1-2 months
94
tonic neck reflex description and disappearance
fencing reflex; When a baby's head is turned to one side, the arm on that side stretches out and the opposite arm bends up at the elbow.
3-4 months
95
sneeze reflex disappearance
persists into adulthood
96
rooting reflex disappearance
4-6 months
97
gag and cough reflex disappearance
persist into adulthood
98
babinski sign disappearance
12 months
99
Define cold stress
The excessive heat loss that requires a newborn to use compensatory mechanisms (non-shivering thermogenesis)
100
Describe posterior fontanelle
<1cm, triangle, ossifies in 8 weeks
101
what reflexes are present at birth
stepping and rooting
102
important teaching points about newborn baths
- no interruptions/drafts
- low water level
- soap not initially recommended
- organization
- 37 degree for water
- clean to dirty
-dry cord area and creases well r/t infc
- vaseline to butt
- q2-3 days
103
Describe normal progression of stool
1. meconium within 48 hours
2. transitional: thin brown- green
3. varies based on breast or bottle fed
104
Describe breastfed infant stool
yellow-gold, soft, seedy, turns mushy after 2-3 days, more 1x a day
105
Describe bottlefed infant stool
pale yellow, formed and pasty, may not go everyday
106
_____ void by _____ hour after birth
93, 24
107
Initial bladder volume of infant
6-44ml
108
If no void within 48 hours:
assess adequacy of intake, bladder distention, restlessness, symptoms of pain
109
Is brick colored urine a concern?
No - Urate crystals, normal in first week of life; immature kidney function
110
Normal colour of urine and appropriate number of voids
6 per day after day 6, pale - clear
111
What is pseudomenses
* Female - pseudomenses - r/t maternal transfer of hormones.. blood in urine continue after week contact physician
112
Average amount of times mom should be feeding
8 feeds in 24 hours (every 1-3 hours
113
Care on uncirumcised infant
- keep clean/no special care
- do not pull back/force
- fully retractable by age 3-5
114
Sleeping in the same bed as your baby can lead to
SIDS, or Sudden Infant Death Syndrome, is a term for the unexplained death of an otherwise healthy baby under one year of age, typically occurring during sleep. It is a devastating and mysterious condition with no clear cause. To reduce the risk of SIDS, it's recommended that babies sleep on their backs, in a separate crib or bassinet with no loose bedding, pillows, or stuffed animals, and in a smoke-free environment.
115
Physiological Outcome Criteria for Newborn
1. vitals WNL
2. feeding 8x/24 hours
3. no jaundice in 24 hours
4. meconium in first 24
5. regular pale, colourless urination
6. TCB done
7. no more than 10% weight loss
116
description of skin, lanugo, plantar surface, breast, eye/ear, genitals of LARGE GESTATIONAL AGE INFANT
leathery, cracked, wrinkled
bald lanugo
creases over plantar surface
full areola
thick stiff ear cartilage
pendulous testes with deep rugae/majora covers clitoris and minora
117
description of skin, lanugo, plantar surface, breast, eye/ear, genitals of SMALL GESTATIONAL AGE INFANT
sticky, friable, transparent
no lanugo
40-50mm no crease
imperceptible breast tissue
lids fused, pinna flat/folded
scrotum flat/smooth
clitoris prominent/labia flat
