Newborn Nursing Care

Question 1

What is the focus of care through the first two hours:

Answer 1

Assessing and stabilizing the newborn

Question 2

What is the first priority in the immediate care period?

Answer 2

establish effective respirations

Question 3

When is routine care only needed during the immediate care of the newborn?

Answer 3

• full term
• good muscle tone
• crying
• breathing

Question 4

List routine interventions in the immediate care period:

Answer 4

-drying -removing wet linens -warm blanket -cap on head -nasal and oral secretions wiped -bulb syringe if airway blocked

Question 5

What are the focuses of ongoing assessment during the first few hours?

Answer 5

-breathing -color -activity

Question 6

When might the new born be placed under a warmer?

Answer 6

-poor muscle tone -preterm -not crying

Question 7

What should the skin look like in the initial assessment?

Answer 7

trunk and lips pink extremities bluish (acrocyanosis)

Question 8

What is the appropriate intervention for a newborn who is apneic or has gasping respirations?

Answer 8

-put under warmer -positive pressure ventilation

Question 9

What intervention is made if central cyanosis persists?

Answer 9

pulse ox is applied

Question 10

How is supplemental oxygen guided?

Answer 10

O2 saturation + age in minutes

Question 11

During initial care the heart rate is quickly assessed by:

Answer 11

-grasping the base of the cord OR -auscultating the chest with a stethoscope. -The nurse counts for 6 seconds and multiplies by 10 to calculate the heart rate -should be greater than 100 beats/ min.

Question 12

How is the newborn’s identification documented right after birth?

Answer 12

-wrist band that matches mom/dad -electronic theft prevention tag -footprint or scanning device -colored photographs

Question 13

Describe the 5 parameters applied to the newborn’s apgar score:

Answer 13

(1) heart rate, based on auscultation with a stethoscope or palpation of the umbilical cord (2) respiratory effort, based on observed movement of the chest wall (3) muscle tone, based on degree of flexion and movement of the extremities (4) reflex irritability, based on presence of a grimace, crying, or active withdrawal (5) generalized skin color, described as pallid, cyanotic, or pink

Question 14

APGAR:

Answer 14

Heart Resp Muscle Reflex Skin

Question 15

Describe apgar scores related to level of difficulty adapting to environment:

Answer 15

0 to 3 =indicate severe distress 4 to 6 =indicate moderate difficulty 7 to 10 =indicate minimal to none

Question 16

Look on page 488. Draw the algorithm for newborn rescuscitation:

Answer 16

pg 488

Question 17

Describe newborn respirations:

Answer 17

Newborn respirations are shallow and irregular; this irregularity is called periodic breathing, and is a normal finding in the newborn. Because of the normal irregularity, respirations should be counted for a full minute.

Question 18

Describe norma vs. abnormal respiratory rates in newborns:

Answer 18

The normal range for newborn respirations is 30 to 60 breaths/ min; the respiratory rate can exceed 60 breaths/ min if the newborn is very active or crying. A consistent respiratory rate greater than 60 breaths/ min can be a sign of distress and should be evaluated.

Question 19

What is the normal weight of a newborn?

Answer 19

Birth weight of a term newborn is typically in the range of 2700 to 4000 g (6 to 9 lb)

Question 20

How is the newborn measured after birth?

Answer 20

-Weight (scale) -head circumfrence (occipitofrontal) -body length (extend leg, head against perpendicular)

Question 21

Safety Alert The thermistor probe should be checked periodically to make sure:

Answer 21

it is securely attached to the infant’s skin. If it becomes loose, the radiant heating device will increase heat output, potentially overheating the newborn. Using the manual control mode on the radiant warmer can have the same effect on the newborn; the radiant warmer will continue to increase heat output, potentially overheating the newborn. Therefore radiant warmers should only be used in the servo-controlled setting.

Question 22

The nurse assesses the axillary temperature of the newborn every:

Answer 22

-hour (or more often as needed) until the newborn’s temperature stabilizes.

Question 23

prophylactic agent in the eyes of all newborns to prevent:

Answer 23

ophthalmia neonatorum or neonatal conjunctivitis, which is an inflammation caused by sexually transmitted bacteria acquired during passage through the mother’s birth canal

Question 24

Nursing Considerations=Eye Prophylaxis: Erythromycin Ophthalmic Ointment, 0.5%:

Answer 24

Administer within 1-2 h of birth. Wear gloves. Use a sterile cotton ball to wipe each eyelid prior to administering the ointment. Open the eyes by putting a thumb and finger at the corner of each lid and gently pressing on the periorbital ridges. Squeeze the tube, and spread the ointment from the inner canthus of the eye to the outer canthus. Do not touch the tube to the eye. Gently massage the closed eyelids to disperse the ointment. After 1 min, excess ointment may be wiped away. Observe eyes for irritation. Explain the treatment to the parents.

Question 25

Vitamin K prophylaxis:

Answer 25

a single dose of phyto-nadi-one 0.5 to 1 mg to prevent vitamin K– dependent hemorrhagic disease of the newborn.

_{Administration of this injection should be delayed to allow for the infant to spend some skin-to-skin time with the parents and for the first breastfeeding.}

Question 26

Ecchymoses and petechiae can be signs of a more serious disorder, such as thrombocytopenic purpura. To differentiate hemorrhagic areas from a skin rash or discolorations, the nurse:

Answer 26

attempts to blanch the skin by pressing with two fingers, lifting the fingers off the skin, and waiting for the return of blood.

Petechiae and ecchymoses will not blanch because extravasated blood remains within the tissues, whereas skin rashes and discolorations will blanch.