Nursing Management of Newborn Flashcards
1
Q
Signs that Indicate a Problem
A
- Nasal flaring, chest retraction
- Grunting, labored breathing
- Generalized cyanosis, flaccid body posture
- Abnormal breathing/respiratory rates
- Abnormal HR/newborn size
2
Q
Initial Newborn Assessment
A
- APGAR score
- Length/weight, vital signs
- Gestational age assessment
- Physical maturity
- Neuromuscular maturity
3
Q
Apgar Score
A
used to evaluate a newborn’s physical condition at 1 and 5 minutes after birth
4
Q
When may an additional Apgar score be done?
A
At 10 minutes if the 5 minute score is less than 7 points
5
Q
What are the 5 parameters of the Apgar score?
A
A-appearance P-pulse G-grimace A-activity R-respiratory
6
Q
A
A
appearance; color
7
Q
P
A
pulse; heart rates
8
Q
G
A
grimace; reflex irritability
9
Q
A
A
activity; muscle tone
10
Q
R
A
respiratory; respiratory effort
11
Q
How is the newborn HR obtained?
A
taking an apical pulse for 1 minute
12
Q
When are newborn respirations counted?
A
when they are quiet and sleeping
13
Q
What tool is typically used to establish gestational age?
A
Ballard Scale
14
Q
What physical maturity areas are assessed for the Ballard Scale?
A
Skin texture Lanugo Plantar creases Breast tissue Eyes and ears Genitals
15
Q
What are the 6 maneuvers the newborn must perform to establish neuromuscular maturity with the Ballard Scale?
A
Posture Square window Arm recoil Popliteal angle Scarf sign Heel to ear
16
Q
Preterm/premature
A
born prior to 37 weeks gestation
17
Q
Term
A
born between 38 and 42 weeks
18
Q
Postterm/postdates
A
born after 42 weeks
19
Q
Postmature
A
born after 42 weeks and demonstrating signs of placental aging
20
Q
SGA
A
small for gestational age
21
Q
LGA
A
large for gestational age
22
Q
AGA
A
appropriate for gestational age
23
Q
Immediate Newborn Period Nursing Interventions
A
Maintaining airway patency
Ensuring proper identification
Administering prescribed meds
Maintaining thermoregulation
24
Q
What is the order of suctioning for newborns?
A
mouth then nose
25
During the immediate newborn period what 2 drugs are commonly ordered?
Vitamin K and erythromycin
26
What will Vitamin K do for the newborns?
promote blood clotting
27
What can happen if their is a vitamin K deficiency?
hemorrhage
28
Why is eye prophylaxis medication mandatory for all newborns in the US?
to prevent ophthalmia neonatorum
29
What is caused by Ophthalmia Neonatorum?
neonatal blindness
30
How often should the newborns temp be taken for the first 2 hours?
q 30 minutes
31
Nursing interventions to promote Thermoregulation
- dry newborn immediately after birth
- wrap in warmed blankets
- skin to skin w/ mom ASAP
- use warmed cover on scale
- warm stethoscope and hands before exam
- delay initial bath until temp is stable
32
When should a physical exam not be started on the newborn?
when the newborn is crying or appears to be upset
33
When is the initial newborn physical exam performed?
within 24 hours after brith
34
Anthropometric Measurements
length, weight, head circumference, chest circumference
35
What is the average length of most newborns?
50 cm = 20 inches
36
What is the baby's weight affected by?
```
racial origin
genetics
maternal age
size of the parents
maternal nutrition
placental perfusion
```
37
What is the average newborn head circumference?
32-38 cm/13-15 inches
38
Average newborn chest circumference
30-36 cm/12-14 inches
39
Skin Assessment
color, texture, turgor, integrity
40
Acrocyanosis
persistent cyanosis of fingers, hands, toes, and feet w/ mottled blue or red discoloration and coldness
41
What are some common skin variations?
```
vernix caeosa
stork bites
milia
Mongolian spots
erythema toxicum
harlequin sign
nevus flammeus
nevus vasculosus
```
42
Vernix Caeosa
thick white substance that protects the skin of the fetus
43
Stork Bites
superficial vascular areas found on the nape of the neck, eyelids, between the eyes and and upper lip
44
Milia
multiple pearly-white or pale yellow unopened sebaceous glands frequently found on newborns nose
45
What is milia called when it is found in the newborn's mouth and gums?
Epstein pearls
46
Mongolian Spots
benign blue or purple splotches that appear on the lower back and buttocks
-may occur as multiples on legs/shoulders
47
Erythema Toxicum
"newborn rash"
| benign, idiopathic, generalized, transient rash; small papules/pustules
48
Harlequin Sign
dilation of blood vessels on only one side of the body giving the newborn the appearance of wearing a clown suit
49
Nevus Flammeus
port-wine stain
50
Nevus Vasculosus
strawberry mark/hemangioma
51
Head Assessment
size
fontanels
variations in size/appearance
abnormalities
52
What are considered common variations of the newborn head size/appearance?
Caput succedaneum
Molding
Cephalhematoma
53
Molding
elongated shaping of fetal head to accommodate passage through birth canal
54
What are Abnormalities to watch for in the newborn head?
Microcephaly
Macrocephaly
Large fontanels
Small or Closed fontanels
55
Face Assessment
nose, mouth, eyes, and ears
56
Neurologic Status Assessment
Alertness
Posture
Muscle tone
Reflexes
57
What will general newborn care involve?
```
Bathing/hygiene
Diaper care
Cord Care
Circumcision care
environmental safety measures
prevention of infection
```
58
What are the traditional reasons for why nurses bathe the newborn?
- physical assessment
- reduce effect of hypothermia
- allow mom to rest
59
How should the newborn sleep?
on their back
60
What are the typical newborn screens?
PKU
Congenital hypothyroidism
Galactosemia
Sickle cell anemia
61
PKU
autosomal recessive inherited deficiency in one of the enzymes necessary for metabolism of phenylanine to tyrasine
62
Congenital Hypothyroidism Screen
deficiency of thyroid hormone necessary for normal brain growth, calorie metabolism, and development
63
Galactosemia Screen
absence of the enzyme needed for conversion of the milk sugar galactose to glucose
64
Sickle Cell Anemia Screen
recessively inherited abnormality in hemoglobin structure
65
What is the most common birth disorder in the US?
hearing loss
66
What are the common concerns during newborn transition?
Transient tachypnea
Jaundice
Hypoglycemia
67
When does transient tachypnea occur in newborns?
the fetal liquid in the lungs is removed slowly or incompletely
68
What is used to relieve transient tachypnea?
low dose oxygen therapy
69
Nursing Interventions for Transient Tachypnea
Provide oxygen
Ensuring warmth
Observing respiratory status frequently
Allowing time for pulmonary capillaries and the lymphatics to remove remaining fluid
70
What will be seen with physiologic jaundice?
yellow skin, mucous membranes, and sclera w/in the first 3 days of life
71
Hypoglycemia
BG level < 30 mg/dL or a plasma concentration of < 40 mg/dL in the first 72 hours of life
72
S/S of hypoglycemia
```
Mostly asymptomatic
jitteriness
lethargy
cyanosis
apnea
seizures
high-pitched/weak cry
hypothermia
poor feeding
```
73
Treatment of Hypoglycemia
Administration of rapid acting source of glucose such as sugar/water mix or early formula feeding
74
What does the newborn's caloric needs range from?
110-120 cal/kg of body weight
75
Fluid requirements for newborns
100-150 mL/kg daily
76
What should be done before feeding the newborn?
- determine ability to suck/swallow
- clear any mucous
- auscultate bowel sounds/check for abdominal distention
- inspect anus for patency
77
How often are mothers encouraged to feed their newborns at home?
q 2-4 hours
78
LATCH Method
```
L- how well infant latches
A- amount of audible swallowing
T- nipple type
C- level of comfort
H- amount of help mom needs
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