newborn congenitatal d/o wk7

Question 1

hydrocephalus manifestations

Answer 1

 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)

Question 2

increased ICP in infant

Answer 2

will cause a shrill cry, vomiting

Question 3

tretralogy of fallot manifestations

Answer 3

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

Question 4

transposition of the great arteries

Answer 4

• Aorta and pulmonary artery switch
• Fatal if not treated

Question 5

ventricular septal defect

Answer 5

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

Question 6

cleft lip and cleft palate manifestations

Answer 6

Opening in the lip or palate

Question 7

down syndrome manifestations (trisomy 21)

Answer 7

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

Question 8

Cleft palate post op nursing interventions

Answer 8

• 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

Question 9

Identification steps to safeguarding baby

Answer 9

• 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

Question 10

Client education circumcision

Answer 10

• 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

Question 11

Circumcision health benefits

Answer 11

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

Question 12

APGAR meaning

Answer 12

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

Question 13

APGAR interventions

Answer 13

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

Question 14

Cesarean postop care of newborn

Answer 14

Airway is priority

Question 15

Vitamin K administration location

Answer 15

• 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.

Question 16

Client education for breastfeeding

Answer 16

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

Question 17

Jaundice nursing considerations

Answer 17

• 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

Question 18

Myelomeningocele nursing priorities

Answer 18

Maintain the integrity

Question 19

Newborn expected findings r/t vital signs

Answer 19

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

Question 20

Transient strabismus nursing consideration

Answer 20

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

Question 21

Newborn born to a GDM mom nursing considerations

Answer 21

• 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

Question 22

Post dates manifestations

Answer 22

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.

Question 23

Phototherapy nursing considerations

Answer 23

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

Question 24

Nursing actions for bubbling mucus

Answer 24

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

Question 25

Discharge education for new parents

Answer 25

• 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

Question 26

Types of heat loss in newborn

Answer 26

• 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

Question 27

Newborn reflex manifestations.

Answer 27

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

Question 28

tretralogy nursing interventions

Answer 28

• 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

Question 29

Acrocyanosis (redish or blueish skin)

Answer 29

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

Question 30

Nursing assessment of normal newborn

Answer 30

• 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.

Question 31

APGAR TOOL

Answer 31

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

Question 32

transposition of the great arteries

Answer 32

• Aorta and pulmonary artery switch
• Fatal if not treated

Question 33

ventricular septal defect

Answer 33

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