Chapter 24 Flashcards by Fatima Avila

BIRTH THORUGH FIRST 2 HOURS
-What is happening during this time?

Immediate care + initial physical assessment

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BIRTH THORUGH FIRST 2 HOURS
-When is APGAR scoring done?
-What does it check?

-1 minute & 5 minutes
-How well the baby is adapting to extrauterine life

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BIRTH THORUGH FIRST 2 HOURS
-What are the 5 components of APGAR?

Appearance (skin color)
Pulse (HR)
Grimace (reflex irritability)
Activity (muscle tone)
Respiration (RR)

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BIRTH THORUGH FIRST 2 HOURS
-What does the physical assessment consist of? (2)

General appearance
Vital signs

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BIRTH THORUGH FIRST 2 HOURS
-Why are baseline measurements of physical growth plotted?
-What are they?

-To see how they are growing as they age
-Weight, head circumference, & body length

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BIRTH THORUGH FIRST 2 HOURS
-What is tested for neurologic assessment? (3)

Newborn reflexes
Gestational age assessment
New Ballard Scale

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BIRTH THORUGH FIRST 2 HOURS
-What are the classifications of newborns based on?
-What are they?

-gestational age & birth weight
1. Appropriate for gestational age (AGA)
2. Large for gestational age (LGA)
3. Small for gestational age (SGA)

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NB ASSESSMENT
-How should NB posturing be?

Flexed extremities (frog position –> arms & legs are flexed)

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NB ASSESSMENT
-Lack of flexion is due to what?

Prematurity or depressed NB

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NB ASSESSMENT
-What is acrocyanosis?
-Why does this occur?

-Hands & feet are blue
-Oxygen gets to core first –> head, face, & belly pink up first (vital organs!!)

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NB ASSESSMENT
-What is gestational age based on?

Maternal hx
LMP, EDC
US
NB maturational evaluation

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NB ASSESSMENT
-What does the ballard scale measure?

Posture, weight, height, head circumference, & other measurements

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NB ASSESSMENT
-What is the normal head circumference?

33-35 cm (13-14 in)

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NB ASSESSMENT
-What is the normal chest circumference?

30.5-33 cm (12-13 in)

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NB ASSESSMENT
-What is the normal length?

45-53 cm (19-21 in)

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NB ASSESSMENT
-What is the normal weight?

2,500-4,000 grams (5 lbs 8 oz-8 lbs 13 oz)

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NB ASSESSMENT
-What is the normal axillary temperature?

36.5-37.2C (97.7-99)

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GESTATIONAL AGE ASSESSMENT
-What is preterm/premature?

Born before 37 weeks, REGARDLESS of birth weight

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GESTATIONAL AGE ASSESSMENT
-What is late preterm
-Describe these infants

-34 0/7-36 6/7
-They usually do pretty well, but they may have respiratory issues because lungs aren’t fully developed

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GESTATIONAL AGE ASSESSMENT
-What is early term

37 0/7-38 6/7

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GESTATIONAL AGE ASSESSMENT
-What is full term?

39 0/7-40 6/7

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GESTATIONAL AGE ASSESSMENT
-What is late term?

41 0/7-41 6/7

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GESTATIONAL AGE ASSESSMENT
-What is postterm?

42 0/7 & beyond

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GESTATIONAL AGE ASSESSMENT
-What is postmature?
-What do they show the effects of?

-Born AFTER completion of 42 weeks
-Progressive placental insufficiency

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**IMMEDIATE INTERVENTIONS** -What are the steps? (6)

**1. Maintain Airway!!!** --> suction!! 2. Maintain adequate oxygen supply --> breathing 3. Maintain body temperature --> dry & warm them, skin-skin 4. Eye prophylaxis 5. Vitamin K prophylaxis 6. Promote parent-infant interaction

**IMMEDIATE INTERVENTIONS** -What is eye prophylaxis? -What is it used for?

-Erythromycin -To prevent opthalmia neonatorum or neonatal conjunctivitis

**IMMEDIATE INTERVENTIONS** -What must moms be tested for late in pregnancy? -Why?

-Chlamydia -Because it can cause blindness

**NEWBORN REFLEXES** -What are the newborn reflexes? (7)

1. Moro 2. Tonic neck 3. Rooting 4. Sucking 5. Palmer & plantar grasp 6. Babkinski 7. Stepping/dancing

**NEWBORN REFLEXES** -What is the *moro reflex* -When does it disappear?

-Arms extend & then restract when startled and cry -3-6 months

**NEWBORN REFLEXES** -What is the tonic neck reflex? -When does it disappear?

-Head turns and arm/leg on same side extends -4-6 months

**NEWBORN REFLEXES** -What is the rooting reflex? -When does it disappear?

-turns head when cheek is stroked (trying to find nipple) -3-6 months

**NEWBORN REFLEXES** -What is the sucking reflex? -When does it disappear?

-Sucks when lips/mouth are touched -10-12 months

**NEWBORN REFLEXES** -What are the palmar & plantar grasps? -When do they disappear? -What does a weak/absent plantar possibly mean?

-Grasps object when palm is touched; Toes curl when sole is touched -3-4 months -Spinal cord injury

**NEWBORN REFLEXES** -What is the Babinski reflex? -When does it disappear? -What does absent/weak possibly mean?

-Toes **FAN** out when sole is stroked -1 year -Neuro defect

**NEWBORN REFLEXES** -What is the stepping/dancing reflex? -When does it disappear?

-infants makes walking motion when held upright on solid surface -3-4 weeks

**NEWBORN ASSESSMENT** -What is the normal RR? -What kind of breathing do they exhibit? -How long do you count for?

-30-60 breaths per minute -diaphragmatic & abdominal breathing --> slightly irregular -a full minute

**NEWBORN ASSESSMENT** -What is the normal apical pulse (HR)? -How long do you count for?

-120-160 bpm -a full minute

**NEWBORN ASSESSMENT** -What is the normal BP? -Where is this usually done?

-50-75/30-45 mmg Hg -NICU

**NEWBORN ASSESSMENT** -What is the normal skin color?

Pink with acrocyanosis; may be peeled/cracked

**NEWBORN ASSESSMENT** -What is milia?

Little white bumps on bridge of nose/chin

**NEWBORN ASSESSMENT** -What is lanugo? -Does it fall off? -What is it used for?

-Downy hair on back, shoulders, & forehead -Yes -Temperature regulation

**NEWBORN ASSESSMENT** -What are mongolian spots?

Dark patches, usually on darker skin tones

**NEWBORN ASSESSMENT** -What are stork bites? -Where are they usually found?

-Red marks -Around the neck area

**NEWBORN ASSESSMENT**: *Head* -What do you want to look at?

Shape/size, palpate fontanels/suture lines

**NEWBORN ASSESSMENT**: *Head* -How are the fontanels? -What do they do when the newborn cries?

-Open, soft, flat, & slightly depressed -They may bulge

**NEWBORN ASSESSMENT**: *Head* -Describe the anterior fontanel -When does it close by?

-it is diamond shaped -18 months of age

**NEWBORN ASSESSMENT**: *Head* -Describe the posterior fontanel -When does it close by?

-it is triangular shaped -2-4 months

**NEWBORN ASSESSMENT**: *Head* -The suture lines should be _____ -They may sometimes ______ just after delivery. Should they be separated? -Why does molding occur?

-approximated -override; no -so that the head fits through the vaginal canal

**NEWBORN ASSESSMENT**: *Head* -What is Cephalohematoma?

Collection of blood beneath the periosteum that **DOES NOT** cross the suture lines --> may reabsorb

**NEWBORN ASSESSMENT**: *Head* -What is caput succedaneum?

Soft tissue swelling --> collection of fluid that **CAN** cross suture lines

**NEWBORN ASSESSMENT**: *Eyes & Ears* -What should you note? -What should you check the eyes for?

-position & discharges of eyes/ears -Sclera, pupil size, & blink reflex

**NEWBORN ASSESSMENT**: *Eyes & Ears* -What will the pediatrician check for?

positive red reflex

**NEWBORN ASSESSMENT**: *Eyes & Ears* -What should you check the ears for? -What is state mandated?

-Vernix & drainage -A hearing screen

**NEWBORN ASSESSMENT**: *Eyes & Ears* -Describe the outcomes of the hearing screen -If the newborn fails to pass the screen in one or both ears, what happens? -Why does the NB usually fail?

-they can either pass or be deferred -they are referred to an audiologist -due to AF in ears

**NEWBORN ASSESSMENT**: *Nose* -What are you observing the nose for?

Shape & nares for patency

**NEWBORN ASSESSMENT**: *Neck* -How should the neck be?

Short with skin folds

**NEWBORN ASSESSMENT**: *Mouth* -Inspect what? -Test what reflexes? -Make sure the palate is _____

-lips, gums, palate, & tongue -rooting, sucking, swallowing, & gag -closed

**NEWBORN ASSESSMENT**: *Chest/Lungs* -How is the chest shaped?

Barrel shaped & symmetrical

**NEWBORN ASSESSMENT**: *Chest/Lungs* -Where do you auscultate breath sounds? -What may be heard? Why? -What will you obtain?

-In all lung fields --> anterior/posterior/lateral -Crackles due to AF in lungs -RR

**NEWBORN ASSESSMENT**: *Chest/Lungs* -Observe the chest for what?

Retractions (sub, intercostal, supra)

**NEWBORN ASSESSMENT**: *Cardiac* -Where will you listen? -What will you assess? -What will you obtain?

-All cardiac landmarks (APETM) -S1S2 -HR

**NEWBORN ASSESSMENT**: *Cardiac* -Where is the PMI?

3-4th ICS

**NEWBORN ASSESSMENT**: *Cardiac* -Murmurs in ___% of NB disappear within ___ days -Is it normal to hear them initially?

-30 -2 -yes

**NEWBORN ASSESSMENT**: *Cardiac* -Check _____ pulses bilaterally. -What are they?

-peripheral -apical, brachial, femoral

**CARDIAC LANDMARKS** -The NBs heart is tipped (lower/higher) in the chest than in the adult -As a result, where is the mitral area?

-higher -3-4th ICS

**NEWBORN ASSESSMENT**: *Abdomen* -What are you going to check? -What will you palpate for? -What do you listen to?

-Size/shape -tone, hernias, & diastasis recti -BS in all 4 quadrants

**NEWBORN ASSESSMENT**: *Abdomen* -In terms of the umbilical cord, what will you check? -Make sure of what?

-Intactness of cord clamp -NB alam is activated & intact if located on cord stump

**NEWBORN ASSESSMENT**: *Abdomen* -Where else may the alarm be located?

on the leg

**NEWBORN ASSESSMENT**: *Abdomen* -When will the umbilical cord usually fall off? -How should the area be kept?

-within 2 weeks -Dry & warm --> no powders or creams

**NEWBORN ASSESSMENT**: *Rectum* -You should inspect the anus **prior** to what? -What is needed for this?

-inserting a rectal thermometer -An order

**NEWBORN ASSESSMENT**: *Rectum* -What is the usual mode for assessing the inital temperature of the NB?

Rectal

**NEWBORN ASSESSMENT**: *Rectum* -Observe for meconium. NB should have first stool within ...?

24 hours

**NEWBORN ASSESSMENT**: *Female Genitalia* -What will you inspect? -How may the labia be? -What will you check the perineum for?

-labia majora & minor -edematous -urethra, clitoris, & vaginal opening (Introitus)

**NEWBORN ASSESSMENT**: *Female Genitalia* -Pseudo-menstruation may present as what? -What is this directly related to? -Is it normal?

-slight vaginal bleeding -the excretion of maternal hormones -Yes!

**NEWBORN ASSESSMENT**: *Male Genitalia* -Inspect the ______ & note the position of what?

-Penis -Urethral opening

**NEWBORN ASSESSMENT**: *Male Genitalia* -What is hypospadias?

An abnormal finding --> opening of the urethra is on the **underside** of the penis instead of tip

**NEWBORN ASSESSMENT**: *Male Genitalia* -What is epispadias?

Opening of the urethra is on the upper aspect of the penis instead of tip

**NEWBORN ASSESSMENT**: *Male Genitalia* -Inspect the scrotum for what? -Palpate the scrotum for what? -Inspect the testes for _____

-rugae/septum -presence of testes -Hydrocele (excess fluid)

**NEWBORN ASSESSMENT**: *Male Genitalia* -NB should urinate within ____ hours

**NEWBORN ASSESSMENT**: *Neurological* -Assess NB for ____, ____ -What reflexes are you assessing? (10)

-posture, tone 1. Moro 2. Startle 3. Tonic Neck 4. Rooting 5. Sucking 6. Palmar grasp 7. Plantar grasp 8. Gag 9. Babinski 10. Dance (step)

**NEWBORN ASSESSMENT**: *Skeletal* -How should the extremities be? -What two additional things will you inspect?

-MAE --> moving all extremities -spine & gluteal folds

**NEWBORN ASSESSMENT**: *Skeletal* -Why do you perform the Barlow-Ortolani Maneuver? -What are you looking for?

-To check fro hip dysplasia -Hip click

**NEWBORN ASSESSMENT**: *Skeletal* -Unequal gluteal folds and/or positive Barlow-Ortolani can mean what?

Hip dysplasia

**NEWBORN ASSESSMENT**: *Skeletal* -Polydactyly?

Extra digits

**NEWBORN ASSESSMENT**: *Skeletal* -Syndactyly?

Webbed digits

**NEWBORN ASSESSMENT**: *Skeletal* -What is decrease ROM indicative of?

Possible trauma, prematurity, or neuro disorder

**NEWBORN ASSESSMENT**: *Pain Scale* -What pain scale is used? -What are the components?

FLACC --> face, legs, activity, cry, consolability

**NEWBORN ASSESSMENT**: *Behavior* -What are the 3 periods?

1. Initial period of reactivity 2. Sleep state 3. 2nd period of reactivity

**NEWBORN ASSESSMENT**: *Behavior --> Initial Period of Reactivity* -When does this begin? -How is the NB? -The NB vigorously responds to what? -HR may be as high as ______ bpm & respirations can be what? -Brief periods of ____ can occur

-15-30 after birth -alert, active, crying, or in quiet alert state (just looking around) -environmental stimuli (cold, heat, touch, sounds, light) -180; irregular & rapid --> up to 90 -cyanosis

**NEWBORN ASSESSMENT**: *Behavior --> Sleep State* -When does this begin? -How is the NB? -Describe respirations. -Describe HR.

-30 minutes after birth -unresponsive to external stimuli -they decrease, sometimes **BELOW** normal range -decrease WNL

**NEWBORN ASSESSMENT**: *Behavior --> 2nd Period of Reactivity* -This follows the _____ state & lasts how long? -NB varies between what? -What happens here? -The NB may ______

-sleep; 2-8 -alert & quiet alert state -Increased bowel activity & may have first meconium stool -void

**NEWBORN MEDICATIONS** -Eythryomycin opthalmic ointment (0.5%) is prophylaxis for what? -Administration is ___ mandated

-GC --> gonorrhea &/or chlamydial eye infections -state

**NEWBORN MEDICATIONS** -Where is vitamin K injected? -What is it for?

-IM into left vastus lateralis -clotting factors

**NEWBORN MEDICATIONS** -In regards to the Hep B vaccine, what is Hepatitis?

A disease spread through contact of the blood of an infected person OR by sexual contact with an infected person

**NEWBORN MEDICATIONS** -When is the first dose (of 3) of Hep B given? -What must be signed **BEFORE** administration? -Can students obtain or witness hospital consents?

-in the hospital -consent -No, but they must check before administration

**NEWBORN MEDICATIONS** -When is the HBIg (Hepatitis Immune Globulin) given?

-Within 12 hours of birth

**NEWBORN MEDICATIONS** -When is the 2nd dose of Hep B given? -When is the 3rd dose given? -What area is this administered?

-1-2 months -6-18 months -RIGHT vastus lateralis

**NB CIRCUMCISION** -What is this? -The decision is made by who? -What does this require?

-Elective surgery to remove the foreskin of the penis -The parents -Consent

**NB CIRCUMCISION** -What are contraindications? (5)

1. Uro-genital defect 2. Premature 3. NBs with bleeding problems 4. RDS 5. other unstable conditions

**NB CIRCUMCISION**: *Pre-op* -What must you ensure? -The NB must be ______ _-_ hours prior to procedure

-NB vital signs & NB must have voided -NPO; 2-3

**NB CIRCUMCISION**: *Pre-op* -What does pain management consist of?

1. elma cream --> lidocaine & prilocain both 2.5% applied to penis 2. OR injected into surgical site by MD 3. Acetaminophen PO one hour prior 4. Non-nutritive glucose sucking

**NB CIRCUMCISION**: *Post-op* -How often should you check the penis for bleeding? -Administer _____ every ___-___ hours -What is the penis covered by? -Monitor what? -What should be done for comfort?

-q15 minutes -acetaminophen; 4-6 -petroleum gauze -VS & voiding -swaddling infant & feeding prn

**ABNORMAL FINDINGS** -Hypoglycemia

less than 40 mg/dl

**ABNORMAL FINDINGS** -Extension of extremities may be due to what? (4)

prematurity, drugs during labor, birth injury, hypoglycemia

**ABNORMAL FINDINGS** -Microcephaly -What is it related to? (3)

-HC **below*** 10th percentile -maternal infection, substance use, congenital malformation

**ABNORMAL FINDINGS** -Macrocephaly -What is it due to?

-HC **above** 90th -hydrocephalus

**ABNORMAL FINDINGS** -Abnormally large weight? -What is this due to?

-above 90th percentile -diabetic mothers

**ABNORMAL FINDINGS** -Abnormally small weight? -What is this due to?

-less than 10th percentile -IUGR

**ABNORMAL FINDINGS** -Tachycardia -What does this possibly indicate? (3)

-160+bpm -sepsis, congenital heart, RDS

**ABNORMAL FINDINGS** -Bradycardia -What does it possibly indicate? (3)

-less than 100 bpm -sepsis, hypoxemia, increased ICP

**ABNORMAL FINDINGS** -What is ecchymosis or petechiae due to? (3)

thrombocytopenia, sepsis, congenital infection

**ABNORMAL FINDINGS** -What do low set ears indicate

Down syndrome

**ABNORMAL FINDINGS** -What is absent startle reflex possibly due to

hearing loss

**ABNORMAL FINDINGS** -One umbilical artery indicates what?

heart or kidney malformation

**ABNORMAL FINDINGS** -Failure to pass meconium indicates what?

imperforated anus or ileus

**ABNORMAL FINDINGS** -Murmurs are due to what?

persistent fetal circulation or heart defects

**ABNORMAL FINDINGS** -What is dextrocardia

heart displaced on right side

**NURSING CARE POST-BIRTH** -What is the priority nursing intervention immediately after birth?

Maintain airway, breathing, & temperature

**NURSING CARE POST-BIRTH** -How can you decrease cold stress?

Drying, warming, skin-to-skin, blankets

**NURSING CARE POST-BIRTH** -What do you use to clear the airway in a newborn?

Bulb syringe

**NURSING CARE POST-BIRTH** -What is the Ballard scale used for?

to assess gestational age

**NURSING CARE POST-BIRTH** -What does PKU screening test for? -Why is PKU dangerous?

-Ability to metabolize phenylalanine -It causes brain damage if untreated

**NURSING CARE POST-BIRTH** -Who needs glucose testing after birth?

1. Infants of diabetic mothers 2. LGA (>9 lbs) 3. Premature infants 4. S/S of hypoglycemia

**NURSING CARE POST-BIRTH** -Which newborns need a car seat test before discharge? -What does this monitor for?

-Preterm neonates (<37 weeks) -Respiratory immaturity & risk of adverse cardiopulmonary events when upright

**NURSING CARE POST-BIRTH** -Read through all

Chapter 24 Flashcards

Nursing Care of the Newborn and Family (125 cards)