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NUR 126 > Wk 10 Newborn Assessment > Flashcards

Wk 10 Newborn Assessment Flashcards

1
Q

Define: acrocyanosis

A

Bluish discoloration of the hand and feet caused by reduced peripheral circulation

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2
Q

Define: caput succedaneum

A

Area of edema over the presenting part of the fetus or newborn, resulting from pressure against the cervix

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3
Q

Define: cephalohematoma

A

bleeding between the periosteum and skull from pressure during birth, does not cross suture lines

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4
Q

Define: epispadias

A

Abnormal placement of the urinary meatus on the dorsal side of penis

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5
Q

Define: erythema toxicum

A

Benign rash of unknown cause in newborns with blotchy red areas that may have white or yellow papules

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6
Q

Define: hypospadias

A

Abnormal placement of the urinary meatus on the ventral side of the penis

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7
Q

Define: jaundice

A

yellow discoloration of the skin and sclera caused by excessive bilirubin in the blood

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8
Q

Define: lanugo

A

fine, soft hair covering fetus

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9
Q

Define: milia

A

white cysts, 1 mm in size from distended sebaceous glands

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10
Q

Define: molding

A

shaping of fetal heading during movement through the birth canal

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11
Q

Define: mongolian spots

A

bruise like marks that occur mostly in newborns with dark skin tones

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12
Q

Define: nevus flammeus

A

permanent purple birthmark; port wine stain

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13
Q

Define: nevus vasculosus

A

rough, red collection of capillaries with a raised surface that disappears with time; strawberry hemangioma

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14
Q

Define: polydactyle

A

more than 10 digits on hand or feet

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15
Q

Define: pseudomenstruation

A

vaginal bleeding in the newborn, resulting from withdrawal of placental hormones

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16
Q

Define: syndactyly

A

webbing between fingers or toes

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17
Q

Define: tachypnea

A

respiratory rate greater than 60 bpm in newborn after the first hour

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18
Q

Define: vernix caseosa

A

thick, white substance that protects the skin of the fetus

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19
Q

Define: telangiectatic nevi

A

often referred to as “stork bites”

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20
Q

Define: Epstein pearls

A

whitish-yellow cysts. These form on the gums and roof of the mouth in a newborn baby

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21
Q

Define: precocious teeth

A

teeth that are already present at birth

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22
Q

Define: circumoral cyanosis

A

blue discoloration around the mouth only. It’s usually seen in infants, especially above the upper lip

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23
Q

Components of newborn assessment:

APGAR score

A 
Appearance
Pulse
Grimace
Activity
Respiration's
**point system, done within minutes of birth
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24
Q

Components of newborn assessment:

vital signs

A 
Normal limits
Temp 97.9-99.5 (36.5-37.5) AXILLARY
Pulse 120-160
Respirations 30-60 (count for full min)
BP 65-95(s)/30-60(d)
25
Q

Components of newborn assessment:

Physical assessment

A

Color: pink or tan with acrocyanosis
Vernix: present in creases
Lanugo: on shoulders, sides of face, forehead, upper back
Turgor: quick recoil
Some cracking or peeling of skin: normal especially on post term

26
Q

Components of newborn assessment:

Medications

A

Vitamin K
Erythromycin ointment
Hepatitis B

27
Q

Components of newborn assessment:

Measurements

A

Weight: 5lbs 8oz - 8lbs 13oz
Length: 19-21”
Head: 32-38cm
Chest: 30-36cm

28
Q

Gestational age of the newborn
New Ballard Score
Neuromuscular Maturity

A 
Posture
Square window (wrist)
Arm recoil
Popliteal angle
Scarf sign
Heel to ear
29
Q

Components of newborn assessment:
Gestational age
New Ballard Score
Physical Maturity

A 
Skin
Lanugo
Plantar surface
Breast
Eye/Ear
Genitals
30
Q

Components of newborn assessment:

Nutritional needs

A 
Calories
Breast fed: 85-100 kcal/kg/day
Formula: 100-110 kcal/kg/day
Breast and formula: 20 kcal/oz
Nutrients
Carbs, Proteins, Fat
31
Q

Components of newborn assessment:

NORMAL skin variations

A

Milia: white dots, “baby acne”
Erythema toxicum: newborn rash
Skin tags
Mongolian spots: on bottom

32
Q

Components of newborn assessment:

ABNORMAL skin variations

A 
Petechiae: pin point bruising
Facial bruising: quick delivery
Forceps markings
Harlequin color: half red color
Mottling: cold stress
Jaundice: yellowing of skin
Meconium stained cord/skin: infant passes stool
33
Q 
Components of newborn assessment: 
ABNORMAL skin (birthmarks)
A

Nevus Flammeous: port wine stain
Nevus Simplex: stork bite, between eyes
Nevus Vasculous: strawberry hemangioma
Cafe au lait spots: tan, irregular shape

34
Q

Newborn head assessment

A

Sutures: Sagital and Coronal
Fontanels: anterior, diamond shape, closes 12-18 months. posterior, triangle shape, closes 2-3 months

35
Q

Newborn abdomen

A

soft and rounded
bowel sounds within first hour
void within first 12-24 hours
three vessel cord: 1 vein, 2 arteries

36
Q

Newborn extremities

A

Upper: two transverse palm creases
Lower: gluteal and thigh creases, no hop ‘clunk’, normal position of feet

**equal and bilateral movement, correct number/formation of fingers/toes,good muscle tone.

37
Q

Newborn BACK abnormalities

A

Spina Bifida: failure of one or more vertebrae to close
Meningocele: protrusion of spinal fluid and meninges
Myelomeningocele: protrusion of spinal fluid, meninges and spinal cord
Pilonidal dimple

38
Q

Newborn reflexes

A

Moro (startle)
Palmer grasp (fingers curl)
Plantar grasps (toes curl)
Babinski (toes flare with dorsiflexion of the big toe)
Rooting (turns head to side)
Sucking
Tonic neck (turns head to one side while infant is supine)
Stepping (hold infant so feet touch solid surface)

39
Q

Reactive phase of newborn

  • first period
  • period of sleep
  • second period
A 
First period:
begins at birth
Infant is wide awake, alert
Lots of movement
Rooting
Decreased temp, increase HR and Resp
Period of sleep:
Deep sleep or decreased activity
Pulse and resp within normal range
Second period:
Interested in feeding
Pass first meconium
Pulse and resp increase
Increased mucus secretions
40
Q

Nursing care for Reactive phase

A 
Protect "golden hour"
Monitor VS
Positioning
Observation
Maintain temp
Assist with breastfeeding
41
Q

Types of circumcision

A

Gomco: pulls prepuce over cone shaped device. Needs dressing with petroleum jelly each diaper change for 4-7 days.
PlastiBell: plastic ring over glans, draws prepuce over, ties suture. Falls off 10-14 days
**need consent

42
Q

Significant newborn problems and associated nursing diagnosis

Hypothermia- ineffective thermoregulation

A

Prevent heat loss

  • convection (drafts/air current)
  • conduction (contact with cold objects/surface)
  • radiation (placed near cold surfaced, window/exterior wall)
  • evaporation (bathing, wet linens, insensible water loss from lungs)

Interventions

  • skin to skin
  • hat
  • warm blanket
  • radiant warmer
43
Q

Significant newborn problems and associated nursing diagnosis

Respiratory distress- Ineffective airway clearance

A

Signs of distress

  • tachypnea
  • retractions
  • nasal flaring
  • cyanosis
  • grunting
  • seesaw or paradoxical resp
  • asymmetry

Interventions

  • positioning
  • suctioning
  • SpO2 monitoring
  • supplemental O2 if necessary
44
Q

Significant newborn problems and associated nursing diagnosis

Hypoglycemia- Risk for

A 
At risk infants:
diabetic mother
infection
birth defects
congenital metabolic disorders
incompatible blood types
distress during labor/delivery
poor feeding
maternal terbutaline administration (stop contractions)
45
Q

Significant newborn problems and associated nursing diagnosis

Hypoglycemia- Risk for
Signs of hypoglycemia

A 
Signs:
shaking/tremors
cyanosis
hypothermia
poor muscle tone
poor feedings
lethargy
seizures
46
Q

Significant newborn problems and associated nursing diagnosis

Hypoglycemia- Risk for
Interventions

A 
Interventions:
glucose monitoring
frequent feedings
supplementation
dextrose IV fluids
47
Q

Significant newborn problems and associated nursing diagnosis

hyperbilirubinemia- Risk for hyperbilirubinemia (Jaundice)
Risk factors

A 
Risk factors:
rapid RBC hemoysis
liver immaturity
blood incompatibilities
preterm infant
poor feedings
birth trauma
ethnicity/family history
48
Q

Significant newborn problems and associated nursing diagnosis

hyperbilirubinemia- Risk for hyperbilirubinemia (Jaundice)
Assessment- observation vs measurement

A

Assessment- observation vs measurement:
plysical assessment
TcB (Transcutaneous bilirubin) and TSB (bilirubin level test)

49
Q

Physiologic jaundice VS Non-physiologic (pathologic) jaundice

A

Physiologic jaundice: occurs on the 2nd or 3rd day of life, normal variant

Non-physiologic jaundice: occurs within the first 24 hours, cause for concern

50
Q

Hyperbilirubinemia interventions

A

Increased feedings

Phototherapy

51
Q

Developmental tasks of newborn

  • Erikson’s
  • Piaget’s
A

Erikson’s: trust VS mistrust

Piaget’s: sensorimotor stage, schemas of the newborn are shown through reflexes

52
Q

Breastfed newborn
Assessment
Positioning

A 
Assessment of breast/nipple:
Everted
Flat
Inverted
Positioning:
Cradle
Cross cradle
Football hold
side lying
53
Q

Breastfed newborn
Latch
Amount and frequency

A 
Latch:
-lips and tongue
-breaking the latch
Amount/frequency:
-offer breast on demand and at least every 2-3 hours
-feed on each side until satisfied
-audible swallowing should be heard
54
Q

Formula fed newborn

Stomach size
Teaching

A 
Stomach size:
-1/2-1 oz per feeding for the first 1-2 days
-2-3 oz per feeding after 2-3 days
-gradual increases as the child ages
Teaching:
-hand washing
-preparation
-heating (no microwave)
-positioning
-burping (every 1/2-1 oz)
-frequency/amount
55
Q

Newborn screening

Hearing
Blood draw

A 
Hearing:
-hearing impairments
-done before discharge
-otoacoustic emissions/acoustic brainstem response is measured
Blood draw:
-inborn errors of metabolism
-genetic conditions
-phenylketonuria (PKU)
-hypothyroidism
-galactosemia
-hemoglobinopathies (sickle cell/thalassemia)
56
Q

What is phenylketonuria (PKU)

A

inborn error of metabolism that results in decreased metabolism of the amino acid phenylalanine. Untreated, PKU can lead to intellectual disability, seizures, behavioral problems, and mental disorders. It may also result in a musty smell and lighter skin.

57
Q

What is galactosemia

A

which means “galactose in the blood,” refers to a group of inherited disorders that impair the body’s ability to process and produce energy from a sugar called galactose. When people with galactosemia injest foods or liquids containing galactose, undigested sugars build up in the blood

58
Q

What is hemoglobinopathies

A

medical term for a group of blood disorders and diseases that affect red blood cells. These disorders include both sickle cell disease (SCD) and thalassemia.

59
Q

Describe Seyle’s model

A

Three stages
Alarm: fight or flight
Resistance: HR, BP and resp elevated
Exhaustion: can no longer compensate

NUR 126 (23 decks)

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