Newborn Physiological and Behavioral Responses Flashcards
Expected findings for term neonate:
Posture
(what should be happening w/ extremeties)
Extremities should be flexed.
What is the regular RR of a newborn
30 to 60 breaths per min
Expected findings for term neonate:
Weight
2500 to 4000 g
(5lb 8oz to 8 lb 13oz)
what is acrocyanosis
Hands and/or feet are blue
What are mongolian spots?
Flat, blush discolored area on the lower back and/or back
resolves on its own
What is lanugo?
Fine, downy hair that may be seen on neonates back, shoulders and forehead
assists on estimating gestational age, often a sign of prematurity
What is milia?
white papules on the face;
more frequently seen on the bridge of the nose and chin
Resolves on their own
What is vernix caseosa?
white, creamy, naturally occurring biofilm covering the skin of the fetus during the last trimester of pregnancy
assist on estimating gestational age
What is a caput succedaneum?
swelling (edema) of the scalp in a newborn.
Can cross suture lines.
Results from prolonged labor, forceps delivery, or use of vacuum
What is a cephalohematoma?
Blood swelling under the scalp of neonate
What characterstic is unique of caput succedaneum compared to cephalohematoma?
caput succedaneum can cross suture lines
cephalohematoma is unilateral
What are epstein’s pearls?
white, pearl-like cysts in a neonates gum margins and palate
What is the moro (startle) reflex?
How is it initated?
Hold the baby in a semi-sitting position and the let head slightly drop back
What is the tonic neck reflex?
How is it initated?
with the neonate in the supine position, turn the head to the side so that chin is over the shoulder
What is the rooting reflex?
How is it initated?
Neonate turns the head toward direction of stimulus and opens the mouth
Brush the side of a cheek or corner of the mouth
What is the sucking reflex?
How is it initated?
Sucking motion
gloved finger in neonate mouth
What is the palmer grasp?
How is it initated?
Neonate grasps fingers tightly
place a finger in the palm of neonates hands
What is the plantar grasp?
How is it initated
Toes flex tightly down in grasping motion
Place a thumb firmly agianst the ball of the infants foot
What is the neonate babinski reflex?
How is it initated
Hyperextension and fanning of toes
Stroke the lateral surface of the sole in an upward motion
What is the stepping reflex?
How is it initated
The neonate steps up and down in place
Hold the neonate upright w/ feet touching a flat surface
What is the purpose of ballard maturational assessment?
estimate babies gestational age
What are the two screening tests for neonates before discharge?
- Phenylketonuria (PKU)
- Hearing test
pku = heel stick blood test
What medication is given as a prophylaxis for gonoccocal and chalmydial eye infections upon birth?
Erythromycin
How many doses is Heb B given?
3
(before discharge, 1 to 2 months, & 6 to 8 months)
Nursing Interventions
Transition period of newborn
(4)
- Maintain respiratory function
- Mantain body heat
- Decrease risk of infection
- Assist parents in providing nutrition, hydration, and newborn care.
Why is a neutral thermal environment needed to support newborn transition?
Neutral thermal environment is needed to support and prevent cold stress to newborn
cold stress leads to hypothermia
Nursing Intervention
Hypoglycemia in newborn
(4)
- Maintain neutral thermal environment
- Regularly check blood glucose levels.
- Establish feeding
- Assess for s&s of hypoglycemia
What is the purpose of the Vitamin K injection for the neonate?
prophylaxis to decrease the risk of bleeding related to vitamin K deficiency
What is considered appropriate weight loss for an infant in the first week of life?
Newborns usually lose 5 to 10% of birth weight during the first week of life due to diuresis.
What newborn assessment is used to assess for congenital hip dislocation?
Barlow’s and Ortolani’s maneuvers
What is the newborn change in stools for the first 4 days?
Day 1 = one stool
Day 2 to 4 = three stools
What is the newborn change in urine output in the first 4 days
Day 1 = one wet diaper
Day 2 = two wet diapers
Day 3 = five to six wet diapers
Day 4 = six wet diapers
By what day does meconium stool usually change to transitional greenish black/brown?
Day 3
