Wk 10 Newborn Assessment Flashcards
1
Q
Define: acrocyanosis
A
Bluish discoloration of the hand and feet caused by reduced peripheral circulation
2
Q
Define: caput succedaneum
A
Area of edema over the presenting part of the fetus or newborn, resulting from pressure against the cervix
3
Q
Define: cephalohematoma
A
bleeding between the periosteum and skull from pressure during birth, does not cross suture lines
4
Q
Define: epispadias
A
Abnormal placement of the urinary meatus on the dorsal side of penis
5
Q
Define: erythema toxicum
A
Benign rash of unknown cause in newborns with blotchy red areas that may have white or yellow papules
6
Q
Define: hypospadias
A
Abnormal placement of the urinary meatus on the ventral side of the penis
7
Q
Define: jaundice
A
yellow discoloration of the skin and sclera caused by excessive bilirubin in the blood
8
Q
Define: lanugo
A
fine, soft hair covering fetus
9
Q
Define: milia
A
white cysts, 1 mm in size from distended sebaceous glands
10
Q
Define: molding
A
shaping of fetal heading during movement through the birth canal
11
Q
Define: mongolian spots
A
bruise like marks that occur mostly in newborns with dark skin tones
12
Q
Define: nevus flammeus
A
permanent purple birthmark; port wine stain
13
Q
Define: nevus vasculosus
A
rough, red collection of capillaries with a raised surface that disappears with time; strawberry hemangioma
14
Q
Define: polydactyle
A
more than 10 digits on hand or feet
15
Q
Define: pseudomenstruation
A
vaginal bleeding in the newborn, resulting from withdrawal of placental hormones
16
Q
Define: syndactyly
A
webbing between fingers or toes
17
Q
Define: tachypnea
A
respiratory rate greater than 60 bpm in newborn after the first hour
18
Q
Define: vernix caseosa
A
thick, white substance that protects the skin of the fetus
19
Q
Define: telangiectatic nevi
A
often referred to as “stork bites”
20
Q
Define: Epstein pearls
A
whitish-yellow cysts. These form on the gums and roof of the mouth in a newborn baby
21
Q
Define: precocious teeth
A
teeth that are already present at birth
22
Q
Define: circumoral cyanosis
A
blue discoloration around the mouth only. It’s usually seen in infants, especially above the upper lip
23
Q
Components of newborn assessment:
APGAR score
A
Appearance Pulse Grimace Activity Respiration's **point system, done within minutes of birth
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
Components of newborn assessment:
| Physical assessment
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
Components of newborn assessment:
| Medications
Vitamin K
Erythromycin ointment
Hepatitis B
27
Components of newborn assessment:
| Measurements
Weight: 5lbs 8oz - 8lbs 13oz
Length: 19-21"
Head: 32-38cm
Chest: 30-36cm
28
Gestational age of the newborn
New Ballard Score
Neuromuscular Maturity
```
Posture
Square window (wrist)
Arm recoil
Popliteal angle
Scarf sign
Heel to ear
```
29
Components of newborn assessment:
Gestational age
New Ballard Score
Physical Maturity
```
Skin
Lanugo
Plantar surface
Breast
Eye/Ear
Genitals
```
30
Components of newborn assessment:
| Nutritional needs
```
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
Components of newborn assessment:
| NORMAL skin variations
Milia: white dots, "baby acne"
Erythema toxicum: newborn rash
Skin tags
Mongolian spots: on bottom
32
Components of newborn assessment:
| ABNORMAL skin variations
```
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
```
Components of newborn assessment:
ABNORMAL skin (birthmarks)
```
Nevus Flammeous: port wine stain
Nevus Simplex: stork bite, between eyes
Nevus Vasculous: strawberry hemangioma
Cafe au lait spots: tan, irregular shape
34
Newborn head assessment
Sutures: Sagital and Coronal
Fontanels: anterior, diamond shape, closes 12-18 months. posterior, triangle shape, closes 2-3 months
35
Newborn abdomen
soft and rounded
bowel sounds within first hour
void within first 12-24 hours
three vessel cord: 1 vein, 2 arteries
36
Newborn extremities
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
Newborn BACK abnormalities
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
Newborn reflexes
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
Reactive phase of newborn
- first period
- period of sleep
- second period
```
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
Nursing care for Reactive phase
```
Protect "golden hour"
Monitor VS
Positioning
Observation
Maintain temp
Assist with breastfeeding
```
41
Types of circumcision
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
Significant newborn problems and associated nursing diagnosis
Hypothermia- ineffective thermoregulation
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
Significant newborn problems and associated nursing diagnosis
Respiratory distress- Ineffective airway clearance
Signs of distress
- tachypnea
- retractions
- nasal flaring
- cyanosis
- grunting
- seesaw or paradoxical resp
- asymmetry
Interventions
- positioning
- suctioning
- SpO2 monitoring
- supplemental O2 if necessary
44
Significant newborn problems and associated nursing diagnosis
Hypoglycemia- Risk for
```
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
Significant newborn problems and associated nursing diagnosis
Hypoglycemia- Risk for
Signs of hypoglycemia
```
Signs:
shaking/tremors
cyanosis
hypothermia
poor muscle tone
poor feedings
lethargy
seizures
```
46
Significant newborn problems and associated nursing diagnosis
Hypoglycemia- Risk for
Interventions
```
Interventions:
glucose monitoring
frequent feedings
supplementation
dextrose IV fluids
```
47
Significant newborn problems and associated nursing diagnosis
hyperbilirubinemia- Risk for hyperbilirubinemia (Jaundice)
Risk factors
```
Risk factors:
rapid RBC hemoysis
liver immaturity
blood incompatibilities
preterm infant
poor feedings
birth trauma
ethnicity/family history
```
48
Significant newborn problems and associated nursing diagnosis
hyperbilirubinemia- Risk for hyperbilirubinemia (Jaundice)
Assessment- observation vs measurement
Assessment- observation vs measurement:
plysical assessment
TcB (Transcutaneous bilirubin) and TSB (bilirubin level test)
49
Physiologic jaundice VS Non-physiologic (pathologic) jaundice
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
Hyperbilirubinemia interventions
Increased feedings
| Phototherapy
51
Developmental tasks of newborn
* Erikson's
* Piaget's
Erikson's: trust VS mistrust
Piaget's: sensorimotor stage, schemas of the newborn are shown through reflexes
52
Breastfed newborn
Assessment
Positioning
```
Assessment of breast/nipple:
Everted
Flat
Inverted
Positioning:
Cradle
Cross cradle
Football hold
side lying
```
53
Breastfed newborn
Latch
Amount and frequency
```
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
Formula fed newborn
Stomach size
Teaching
```
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
Newborn screening
Hearing
Blood draw
```
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
What is phenylketonuria (PKU)
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
What is galactosemia
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
What is hemoglobinopathies
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
Describe Seyle's model
Three stages
Alarm: fight or flight
Resistance: HR, BP and resp elevated
Exhaustion: can no longer compensate
