objective 6 Flashcards
what are the 3 transition periods?
period of reactivity
period of decreased responsiveness
second period of reactivity
30 mins to 1hr
best time to initiate BF and bonding
period of reactivity
1 to 3 hrs
infant either sleeps or becomes less active
period of decreased responsiveness
3 to 8 hrs
infant becomes responsive and alert again
second period of reactivity
how do we maintain cardiorespiratory function?
Once umbilical cord is clamped & cut, lungs take on function of breathing
Full expansion does not occur for several days
Face, nose, & mouth are gently wiped
Gentle bulb suctioning to clear airways
Infant may be cyanotic at birth
ACROCYANOSIS
Sternal retractions, grunting, flaring nostrils, or resp >60 → requires 02 via face mask and report immediately
how do we maintain thermoregulation?
Neonate has unstable heat-regulating system
Hypothermia can lead to cold stress
Hypoglycemia and resp distress
Sweat glands do not function during neonatal period
Risk of elevated temp if overdressed or placed in overheated env
Essential nursing care:
Dried after birth, and placed skin to skin or BF
First bath after 24hrs
Place in warmer, wrap in warm blankets
Place hot on infants head
____ of liquids from skin
skin wet from amniotic fluid
evaporation
_____ caused by direct contact with a cold surface
cold hands, stethoscopes, scales
conduction
_____ caused by heat drawn away from the body by drafts
AC, windows, O2 admin
convection
caused by being near a cold surface, although not in direct contact
cold env of walls, windows, placing ice on incubator
radiation
Standardized method of evaluating newborns condition immediately after birth
APGAR scoring
what are the 5 factors evaluated in APGAR scoring?
HR
Respiratory effort
Muscle tone
Reflex response to suction or gentle stimulation
Skin color
no action (continued observation & support)
8-10
gentle stimulation (rubbing back)
4-7
active resuscitation required
less than 3
May not urinate for as long as 24 hrs
Document if infant urinates in birthing room
May be cloudy in color after first void
Should see one wet diaper in first 24 hrs
Diaper count every shift (should be 6-8 wet diapers by day 5-6)
urination
This is the first newborn stool
Dark greenish, black thick & tarry
Mixture of amnotic fluid & secretions of intestinal glands
Should be passed before 24hrs post birth
Most pass it within 12 hrs
Meconium should be passed before discharge
meconium
usually taken by the axilla (hold arm against side), should be between 36.5-37.5, report any variations
temp
count before taking temp as infant may cry when disturbed, count for 1 full min
Newborns pule is irregular and rapid 110-160bpm
Resps are 30-60 breaths/min
Blood pressure is low; averaging 65 to 95 mm Hg systolic over 30-60 mm Hg diastolic
pulse
resps rate
BP
what is average length and weight?
Average length
45-55cm
Average weight
2500 to 4000g
what is the average head circumference?
33-35cm
how do we do cord assessment?
assess 3 vessels
AVA
what is normal for pre and post term for skin?
Preterm: thin, transparent
Post-term: peeling
what is normal for vernix, pre, term, and post term?
Preterm: covers most of skin;
Term: only in creases
Post-term: absent
what is normal for hair pre and post term?
Preterm: heavily covered
Post-term: hair in few places
what is normal for ears pre and term?
Preterm: spring back slowly
Term: quickly
what is normal for breast tissue pre and term?
Preterm: minimal or none
Term: palpable mass
what is normal for genitalia preterm?
Preterm: scrotum smooth and small, labia majora and minora nearly equal in size
what is normal for sole creases pre, term, and post?
Preterm: ⅓ foot
Term: ⅔ foot
Post-term: whole foot
what are the reflexes that the full-term infant is born with?
Blinking
Sneezing
Gagging
Sucking
Grasping
crying
swallowing
when startled, the infant draws their legs up and the arms fan out and then come toward midline in an embrace position
moro reflex
what is the abnormal moro reflex?
note the clenches fist of one hand that does not follow a symmetrical embracing motion. This infant requires follow-up care
Stroke the side of the foot; big toe dorsiflexes, and the toes flare out
babinski reflex
Place object in hand of the newborn and newborn will grasp it tightly
palmar grasp
Causes the infants head to turn in the direction of anything that touches the cheek, in anticipation of food
rooting
The infant turns the head to one side, and the arm and leg are extended on that side. The opposite arm and leg flex (fencing position)
tonic neck reflex
Prancing movements of the legs, seen when an infant is held upright on the examining table
dancing/stepping reflex
fetal head conforms to size and shape of birth canal
May have swelling of the soft tissues of the scalp, called caput succedaneum
May see a cephalohematoma: a collection of blood beneath the periosteum of the cranial bone
Does not cross the suture line
Fontanels (soft spots) protect the head during delivery & allow further brain growth
molding
Newborn is born with ability to control the head in some positions
normally occur when the newborn is raised for the bed in a supine position
If lasts past 6 months- follow up care required
head lag
Yellow tinge to skin
Caused by rapid destruction of excess RBCs
Becomes evident between 2nd and 3rd day of life and lasts 1 week
Treated with phototherapy
Normal process; not harmful to infant
Assessed: transcutaneous bilirubin measurement (TcB) followed by blood work
icterus/hyperbilirubinemia
what are the S&S of hypoglycemia?
Jitteriness
Poor muscle tone
Sweating
Respiratory difficulty
Low temp
Poor sucking
High pitched cry
Lethargy
Seizures
Test for PKU is mandatory
If infant has this disorder, special formula is started in 1st months of life preventing disability and severe intellectual and development delays
PKU test done on day of discharge
phenylketonuria (PKU)
what are the areas of teaching before discharge?
Basic infant care
Bath, diapers, cord care
Safety measures
Suction with bulb syringe, SIDS, safe sleep
Immunization
Follow up appointments
Proper, use of a car seat
S&S of health concerns, & who to contact
parents should contact someone if…?
Temp greater the 38 by axilla
Refusal to two feedings in a row
Two green watery stools
Frequency or forceful vomiting
Lack of voiding or stooling
A change in usual behaviour
