nursing care of the newborn Flashcards
opening of the lungs
- squeeze from contraction takes fluid out of lungs
- lungs recoil and first breath also due to it being cold
- hypoxic during pushing
abc approach when baby born
- bukb syringe mouth @ side of cheek in back
- bulb nose
- after airways clear, do skin the skin
- dry and stimulate baby
- make sure baby dry completely
- apgar score
why do babys normally loose points
for color, completely normal in first 24 hr
APGAR
appearance pulse grimace activity respirations
less than 7
needs resciation
how to count pulse right after
count at umbillicord for 6 sec x 10
Nursing Interventions: Immediate Newborn Period
- Maintaining airway patency
- Bulb syringe proper technique?
- Ensuring proper identification
- Administering prescribed medications
- Maintaining thermoregulation
medications
Vitamin K
Eye prophylaxis
Hepatitis B Vaccine
first hour
skin to skin
breast feeding
after hr
head, chest abdominal cirumfrence, weight and legth
immediate care
dry and stimulate
vitamin k action
- Provides the newborn with vitamin K (necessary for production of adequate clotting factors II, VII, IX, and X by the liver) during the first week of birth until newborn can manufacture it
- Prevents vitamin K deficiency bleeding (VKDB) of the newborn
vitamin k nursing implication
- Administer within 1–2 hr after birth.
Give as an IM injection at a 90-degree angle into the outer middle third of the vastus lateralis muscle.
Use a 25-gauge, 5/8-in needle for injection. - Hold the leg firmly and inject medication slowly.
- Adhere to standard precautions.
- Assess for bleeding at injection site after administration.
erythromycin action
Provides bactericidal and bacteriostatic actions to preventNeisseria gonorrheaandChlamydia trachomatisconjunctivitis
Prevents ophthalmia neonatorum
erythromycin nursing implications
- Be alert for chemical conjunctivitis for 1–2 days.
- Wear gloves, and open eyes by placing thumb and finger above and below the eye.
- Gently squeeze the tube or ampoule to apply medication into the conjunctival sac from the inner canthus to the outer canthus of each eye.
- Do not touch the tip to the eye.
- Close the eye to make sure the medication permeates.
- Wipe off excess ointment after 1 min.
heb b vaccine action
The first dose is highly effective in preventing mother-to-baby infection.
The vaccine is well tolerated in infants.
heb b nursing implication
Administer within 24 hours after birth and complete the series of 3 injections giving #2 at 1-2 mths & #3 at 6-18 mths. of life.
Follow other steps from the Vitamin K injection above
indications for injections
.5ml
vastas lateralis
righty hepiti lefty Vk
respirations
30-60
heart rate
100-160
temp
97.7-99.5
rectal temps
should not routinely be performed on a newborn because of the risk for perforation and vagal stimulation.
Initiation of respirations:
adjusting from a fluid-filled intrauterine environment to gaseous extrauterine environment
role of surfactant
surface tension reducing lipoprotein that prevents alveolar collapse
Surfactant production begins at 24 wks. Gestation & is in sufficient amounts by 35 wks.
respirations
30 to 60 breaths per minute; irregular, shallow, unlabored; short periods of apnea (<15 seconds); symmetrical chest movements
issue w c/s
does not have the same benefit of the birth canal squeeze as does the newborn born by vaginal delivery. Closely observe the respirations of the newborn after cesarean delivery.
S/S of Newborn Respiratory Distress
- Nasal flaring, chest retractions
- Grunting on exhalation, labored breathing
- Generalized cyanosis, flaccid body posture
- Abnormal breath sounds, abnormal respiratory rates
- Abnormal heart rates, abnormal newborn size
- grunting
early s/s of resp distress
nasal flarring, chest retractions
late s/s of respiraotry distress
generalized cyanosis, flaccid body posture
mechanisms for neonatal heat loss
conduction
convection
evaporation
radiation
conduction
Transfer of heat from object to object when the two objects are in direct contact with each other
convection
Loss of heat from warm body surface to cooler air current
evaporation
Loss of heat when water is converted into vapor
“Insensible water loss”
radiation
Loss of body heat to cooler, solid surfaces in close proximity but not in direct contact
cold stress
the newborn can lead to the following problems if not reversed: depletedbrown fatstores, increased oxygen needs, respiratory distress, increased glucose consumption leading to hypoglycemia, metabolic acidosis, jaundice, hypoxia, and decreased surfactant production
do infants shiver
DO NOT shiver. If an infant appears to be shivering it is either withdrawing from maternal substance use or hypoglycemic.
Neonate will pull limbs in to conserve heat
urine
Urine is less concentrated and has lower specific gravity.
Does not excrete salt, water loads, or medications quickly
of wet diapers after birth
Day 1 = 1 wet diaper / Day 2 = 2 wet diapers / Day 3 = 3 wet diapers / Day 5 = 5 wet diapers / Day 6 and on = 6 wet diapers (min)
brick dust
“Brick dust” urine in diaper- could mean baby is dry or dehydrated- fairly normal in first few days
amount of intake needed
To gain weight the newborn requires an intake of 108 kcal/kg/day from birth to 6 months of age
umbilical cord
Umbilical cord should be clamped, will dry within 24 hours and fall out 7-10 days after birth
abd and anus
Abd rounded, non-distended, + BS in all 4 quadrants
Anus should be patent
stool
1st stool in 24 hrs (meconium), after milk comes in: 3-4 stools a day is normal (may have variation)
modleing baby
spidery looking skin
normal
baby as risk for jaundice
too many red blood cells baby is yed then yellow
stork bite
patch of deep pink skin on head or face
normal
new born baby rash (erythema toxicum)
normal on baby skin goes away dont pick at it
mongolian spots
normal fade during 1st few years of life
hemangioma
strawberry mark
normal should fade
port wine stain nervus flammerus
non reverible red on half of the face
vernix
super sticky natural lotion in young baby, most seen in preme
dry baby
dry cracked leathery baby: post due, overcooked
caput succedenum
normal from baby being birthed vaginnaly
cross suture lines
cranial molding
normal from baby fitting through pelvis
cephalhematoma
swelling that doesn’t cross the suture line not normal
neurological status
alertness, posture, muscle tone, reflexes
moro
started lift shoulders, drop and they get startled
rooting
tickle side of cheeck turn head and open mouth
Gestational age assessment is important because
allows the nurse to plot growth parameters and to anticipate problems related to prematurity, postmaturity, and growth abnormalities.
preterm
prior to 37 weeks
term
38-42
posterm
after 42 weeks
postmature
after week 42 placental aging
sga
small for gestational age
aga
appropirate for gestational age
lga
large of gestational age
wrong age can lead to
hypoglycemia and other things to do
new ballard scale: physical maturity
Skin texture Lanugo Plantar creases Breast tissue Eyes and ears Genitals
24hr screening
- PKU/Metabolic condition screening
- Hearing tests
- CCHD- critical congenital heart defect screening
- Bilirubin check
- Weight
- Bath (depending on facility policy/parent’s wishes)
cotton swabs
no swabs in nares, or inside ear cana;
Preoperativecircumcisionpreparation should include confirmation of the following
- Infant is at least 12 hours old or older
- Infant has received standard vitamin K prophylaxis
- Infant has voided normally at least once since birth
- Infant has not eaten for at least an hour prior to the procedure
- Written parental consent has been obtained
- Correct identification of the infant brought to procedure room
plastibell
If the Plastibell was used; clean with water, no petroleum jelly, it will fall off by itself in about 1 week.
- the ring will fall off by itself within 1 week, call md if see any bleeding, make sure diaper is loose in the front (don’t need petroleum jelly and shouldn’t clean with soap/water)
