newborn congenitatal d/o wk7 Flashcards by Melissa Viniegra

hydrocephalus manifestations

 Rapid head growth with widening cranial sutures
 Dilated scalp veins
 Bulging fontanels
 Sun-setting sign
 Neck muscles fail to develop sufficiently, newborn has
difficulty raising or turning head
 Increasingly helpless, increased intracranial pressure
MONITOR FOR INCREASED ICP (SHRILL CRY, VOMITING)

How well did you know this?

Not at all

Perfectly

increased ICP in infant

will cause a shrill cry, vomiting

How well did you know this?

Not at all

Perfectly

tretralogy of fallot manifestations

• Cyanotic! Inadequate oxygenation
• Poor feeding or poor weight gain
• Clubbing fingers
• Dyspnea
• Polycythemia: hydration!

How well did you know this?

Not at all

Perfectly

transposition of the great arteries

• Aorta and pulmonary artery switch
• Fatal if not treated

How well did you know this?

Not at all

Perfectly

ventricular septal defect

you may hear a loud harsh, murmur, bounding pulse and fatigue

How well did you know this?

Not at all

Perfectly

cleft lip and cleft palate manifestations

Opening in the lip or palate

How well did you know this?

Not at all

Perfectly

down syndrome manifestations (trisomy 21)

Brachycephaly; short stature; upward slanted eyes short,
flattened bridge of nose; thick, hypotonic muscles, protruding
tongue; dry, cracked, fissured skin that may be mottled; small
hands with short broad fingers and curved fifth finger; single
deep crease on palm of hand; wide space between first and
second toes; lax muscle tone; heart and eye anomalies; greater
susceptibility to leukemia

How well did you know this?

Not at all

Perfectly

Cleft palate post op nursing interventions

• Monitor weight and for dehydration
• NPO 2 hr post-op, then liquid 3-4 days.
• Encourage parental attachment
• Suction and Position to facilitate drainage, gentle w/bulb syringe
as needed
• Assist with feeding techniques

How well did you know this?

Not at all

Perfectly

Identification steps to safeguarding baby

• VERIFY ID BANDS ON BOTH MOM AND BABY
• VERIFY GENDER
• VERIFY DOB
• VERIFY MOM’S MEDICAL RECORD NUMBER
• VERIFY ANY HEALTHCARE WORKER THAT ENTERS HAS AN ID BADGE

How well did you know this?

Not at all

Perfectly

Client education circumcision

• MONITOR FOR S/S INFECTION: DRAINAGE OR REDNESS AT BASE
• AS HEALING OCCURS A YELLOW CRUSTY MATERIAL WILL FORM
• APPLY PETROLEUM JELLY W/ DIAPER CHANGES
• NO BATHS UNTIL HEALED

How well did you know this?

Not at all

Perfectly

Circumcision health benefits

• EASIER HYGIENE
• DECREASED RISK OF STIs; PENILE CA AND CERVICAL CA IN
PARTNERS

How well did you know this?

Not at all

Perfectly

APGAR meaning

simple method of quickly assessing the Health and vital signs of a newborn baby after delivery. The five criteria assessed in the Apgar score are
• A- appearance (skin color)
• P- pulse (heart rate)
• G- grimace (reflex irritability/response)
• A- activity (muscle tone)
• R- respiration (breathing ability)
Apgar scores
0-3 are critically low
4-6 are below normal
7+ are considered normal

How well did you know this?

Not at all

Perfectly

APGAR interventions

Interventions
• SCORE 7-10: NO INTERVENTIONS, BABY DOING GOOD JUST NEEDS
ROUTINE POST- CARE
• SCORE 4-6: SOME RESUSCITATION ASSISTANCE REQUIRED. OXYGEN,
SUCTION, STIMULATE THE BABY, RUB BABY’S BACK (recheck score in 5 minutes)
• SCORE 0-3: NEED FULL RESUSCITATION

How well did you know this?

Not at all

Perfectly

Cesarean postop care of newborn

Airway is priority

How well did you know this?

Not at all

Perfectly

Vitamin K administration location

• NOT ALL THE NECESSARY BLOOD COAGULATION
FACTORS ARE MANUFACTURED DIRECTLY AFTER BIRTH,
AND THE GUT IS STERILE, SO VITAMIN K IS GIVEN
INTRAMUSCULARLY –VASTUS LATERALIS TO STIMULATE
APPROPRIATE CLOTTING.

How well did you know this?

Not at all

Perfectly

Client education for breastfeeding

Encourage early feeding/helps prevent hemorrhage/will
help with infant stools 2-3 day
Engage a lactation consultant for proper latching
o Each feeding around 30 minutes
Assess nipples
o Apply milk prior to feeding to breasts
o Change infant position
o Rotate breasts at beginning
o If nursing will expect 2-3 stools/day

Jaundice nursing considerations

• IF JAUNDICE IS NOT PRESENT BEFORE THE NEWBORN IS
24 HOURS OLD.
• IF NEWBORN UNDERGOING PHOTOTHERAPY, THE NURSE
SHOULD ASSESS FOR DEHYDRATION AND ENCOURAGE
BREASTFEEDING 1-2 HOURS.
• MONITOR BILIRUBIN LEVEL

Myelomeningocele nursing priorities

Maintain the integrity

Newborn expected findings r/t vital signs

RESPIRATORY FUNCTION IS THE NURSE’S PRIORITY: NORMAL RATE IS 30-
60 BREATHS/MIN WITH SHORT APNEA LESS THAN 15 SECONDS

Transient strabismus nursing consideration

supportive; monitor vital signs and
oxygen saturation levels; IV fluids; supplemental
oxygen; assist family to understand; education
about situation

Newborn born to a GDM mom nursing considerations

• NEWBORN HYPOGLYCEMIA IS A BLOOD GLUCOSE LEVEL
LESS THAN 50 MG/DL.
• NEWBORNS CAN BE ASYMPTOMATIC OR MAY
DEMONSTRATE MULTIPLE SIGNS.
• THE MOST COMMON SIGN IS JITTERINESS.
• NEWBORNS BORN TO MOMS WITH GDM ARE AT A
HIGHER RISK

Post dates manifestations

The baby will be larger, more chunky and not so flexible. The skin literally appears burned
(dried, cracked & peeling). There are also deep creases on the hands/feet.

Phototherapy nursing considerations

THE NURSE
SHOULD ASSESS FOR DEHYDRATION AND ENCOURAGE
BREASTFEEDING 1-2 HOURS.

Nursing actions for bubbling mucus

Mouth is first then nose with a bulb syringe that will prevent aspiration

Discharge education for new parents

• STOOL COLOR WILL CHANGE IN 4-5 DAYS • IF FUSSY CHECK: DIAPER, FEEDING, BURPING • BABIES SLEEP 16-19 HOURS A DAY • PLACE INFANT IN SUPINE POSITION WHEN SLEEPING • SPONGE BATHS UNTIL CORD FALLS OFF • FLAME-RETARDANT FABRIC • NEVER LEAVE UNATTENDED WITH PETS OR OTHER SMALL CHILDREN • CAR SAFETY CHECK

Types of heat loss in newborn

• KEEPING THE NEWBORN WARM AND PREVENTING COLD STRESS IS THE PRIORITY AFTER RESPIRATORY FUNCTION • DRYING THE NEWBORN IS THE PRIMARY ACTION TO PREVENT COLD STRESS, FOLLOWED BY KANGAROO CARE

Newborn reflex manifestations.

IF SUCTIONING THE NURSE SHOULD SUCTION MOUTH FIRST FOLLOWED BY THE NARES-ASSESS FOR MUCUS AND SUCTIONING NEED THE MAIN REFLEXES TESTED TO DETERMINE NEUROLOGIC STATUS ARE ROOTING, SUCKING, SWALLOWING, GRASPING, MORO, BABINSKI, AND TONIC NECK. • MORO: SHARP HAND CLAP NEAR NEWBORN • GRASPING: PLACE FINGER IN PALM • TONIC NECK: TURN HEAD QUICKLY TO ONE SIDE • SUCKING: STROKE CHEEK • BABINSKI: STOKE OUTER EDGE OF SOLE OF FOOT

tretralogy nursing interventions

• Hydration for risk of clots • High risk for CHF after surgery • During spells: young baby knee to chest; older squat provide pacifier when crying; small frequent feedings • If hgb is over 22 call the provider

Acrocyanosis (redish or blueish skin)

may be present on a normal newborn and will go away in 24-48hrs

Nursing assessment of normal newborn

• THE EXPECTED WEIGHT RANGE IS 5 LB 8 OZ TO 8 LB 13 OZ (2,500 TO 4,000 G). • LENGTH IS 19 TO 21 IN (48 TO 53 CM). • HEAD CIRCUMFERENCE IS 13 TO 14 IN (33 TO 33.5 CM), AND CHEST CIRCUMFERENCE IS 12 TO 13 IN (30.5 TO 33 CM). • THE NEWBORN EXAMINATION IS AN IMPORTANT WAY TO DETERMINE HOW WELL THE NEWBORN IS ADAPTING TO LIFE OUTSIDE THE WOMB. • THE LEAST DISTURBING ASPECTS OF THE EXAMINATION ARE COMPLETED FIRST. • RESPIRATORY RATE AND HEART RATE ARE TAKEN FIRST, WHILE THE NEWBORN IS QUIET. • THEN EXAMINATION PROCEEDS IN A HEAD-TO-TOE MANNER AND INCLUDES PHYSICAL MEASUREMENTS AND INSPECTION OF EACH BODY PART. • CLEAN GLOVES SHOULD BE USED IF BATH HAS NOT BEEN GIVEN- STANDARD PRECAUTIONS • EYE MOVEMENTS ARE USUALLY UNCOORDINATED, AND SOME STRABISMUS/NYSTAGMUS (CROSSED EYES) IS EXPECTED.

APGAR TOOL

APPEARANCE/COLOR • PALE OR BLUE=0 • BODY NORMAL SKIN TONE BUT EXTREMITIES BLUE=1 • NORMAL SKIN TONE=2 PULSE • Absent=0 • 100Less than 100 bpm=1 • 100 bpm or more=2 GRIMACE • NO RESPONSE TO STIMULATION=0 • GRIMACE BUT NO CRY TO STIMULATION=1 • CRY AND ACTIVE MOVEMENT=2 ACTIVITY • NONE, FLACCID=0 • SOME FLEXION OF ARMS AND LEGS=1 • ARMS AND LEGS FLEXED AND IN MOTION=2 RESPIRATORY • ABSENT=0 • WEAK, IRREGULAR CRY=1 • STRONG, VIGOROUS CRY=2

transposition of the great arteries

• Aorta and pulmonary artery switch • Fatal if not treated

ventricular septal defect

you will hear a harsh murmmur, a bounding pulse and fatigue