newborn assessment part 1. Part 2 is newborn care

nevi

also known as a birth mark

when holding baby

always support the neck.

stork bite

these are developmental vascular abnormalities. found usually at nape of neck, on the eyelid, between the eyes, or on the upper lip. they deepen in color

mottling

this is a sign that the baby is cold. warm the baby and reassess in 15 minutes.

vital signs orders with newborns

1. observe respiratory rate while parents hold baby. 2. warm the stethoscope and check the heart rate and RR after with hand 3. unwrap baby and check temperature.

weight newborn

2500 - 4000 grams (5 lbs. 8oz.-8 lbs. 13oz.) AGA: average for gestational age LGA: large for gestional age. babies in the greater 90th percentile are common from diabetic mothers SGA: small for gestational age: due to prematurity, intrauterine growth restriction, malnutrition babies lose 5-10% of birth weight normally because of urine, stool. metabolism for lungs, or limited fluid intake. the neonate will regain birth weight in 10 days get weight in kilos as well as pounds. parents want pounds babies feed about 15 mL each time. if weight is dropping too much look at feeding log.

newborn respirations

30 - 60 bpm Irregular, but unlabored (no nasal flaring or grunting sounds) Perform while newborn is quiet or asleep Count for a full minute Observe color, especially lips Tachypnea: sepsis, hypothermia, hypoglycemia, resp distress syndrome resp less than 30 could be analgesics from mom Apnea: can have periods of apnea, also assess color and worked resp labor. abnormal is greater than 15 seconds

newborn temperature

97.7°- 99° Fahrenheit (axillary) 36.5°- 37.2° Celsius (axillary) Hypothermia: cold stress= excessive heat loss and baby has to use metabolism to heat themselves up. axillary temp below 36.5 (97.7) Hyperthermia: fever, might indicate a sick mom or a sick baby. Interventions: wrap a blanket and dry infant immediately. hat is placed due to heat loss by radiation and convection. nurses do rectal temps, not students

newborn measurement

A. Head Circumference: 33 - 35.5 cm (13 - 14 in.) B. Chest Circumference: 30.5 - 33 cm (12 - 13 in.) C. Length: 45 - 53 cm (19 - 21 in.) D. Abdominal Girth: could also be bloated

newborn reflexes

A. Palmer Grasp B. Moro/Startle C. Tonic Neck D. Babinski E. Stepping or Dancing Reflex

epispadias newborn

the urethra opening is on the dorsal side of the penis this is a significant surgery by GU doctor, baby has to be older. have to check bladder as well.

newborn pulse and where to place stethoscope

Apical 120 -160 beats per minute (bpm) Place stethoscope over 3rd or 4th intercostal space, left midclavicular line Count for full minute Should be regular in rhythm Tachycardia > 160. when a baby cries can get up to 170, give back to mom and let baby calm down redo HR if still over 160 get instructions. may indicate sepsis, resp distress, congital heart abnormality Bradycardia < 120. if a baby is sleeping may be 100 or 110, look at color, respirations, perfusion to make sure adequate blood exchange. may indicate sepsis, increase ICP, hypoxemia Murmurs: may be heard, most are not pathological and disappear by 6 months

newborn eyes

Assess for symmetry, color of sclera, pupil size & reaction Iris blue-grey Sclera bluish white: could indicate possible osteogenesis imperfecta Follows object w/in 12 in. No tears until 2 mos. Transient strabismus related to immature muscular control babies can be born cross eyed but gets normal later.

hypospadias newborn

the urethra opening is on the ventral surface of penis. can be fixable, need to report

newborn posture

Extremities flexed Hands clenched Symmetrical movements: both arms moving, not in synchrony but can move Slight tremors on crying this shows great tone. be concerned with a limp baby. should always be in this toned position even when sleeping extension of extremities can indicate prematurity or effect of medicine or magnesium sulfate on baby. hypoglycemia

apgar score

Initial assessment of the newborn's cardiopulmonary adjustment after birth Performed by RN @ 1 minute and 5 minutes Final apgar score of 7, no intervention required Apgar score < 7, requires intervention need stimulation to wake them up, usually just towel drying can wake them up

newborn back and pilonidal dimple

Inspect & palpate the spine No openings observed or palpated in vertebral column: make sure no openings or tunneling if tunneling is seen this is a neurological condition and needs to be reported! No dimpling or tufts of hair noted Pilonidal dimple: Pilonidal dimple is a condition that can occur anywhere along the crease between the buttocks, which runs from the bone at the bottom of the spine (sacrum) to the anus. Pilonidal dimple may appear as: A pilonidal abscess, in which the hair follicle becomes infected and pus collects in the fat tissue.

newborn rectum or stool

Inspect anus for patency Sphincter tightly closed First stool - meconium within 24 hours, very tough to clean its like tar. can put vasoline to help soften and clean Transitional stool: greenish black/brown/yellow 1 to 3 stools/day Breast fed - yellow, sour smelling, pasty/soft stool not stinky Formula fed - pale yellow/brown, more formed stool, unpleasant odor

newborn extremities

Inspect extremities, gluteal folds Flexed, good muscle tone Equal in strength & symmetrical in length Correct number of digits Nail to end of each digit Palms - 2 transverse creases Gluteal & thigh folds equal Knee height equal

ears

Inspect for position, shape, drainage Top of the pinna is located @ level of outer canthus of the eye Skin tags common look for position. if ears are lower than eyes, some correlation with lower IQ. positive startle reflex to loud sounds

newborn mouth

Inspect lips, gums, tongue, palate, mucus membranes Tongue pink, moves freely Lips and palates intact Sucking pads present Epstein's pearls: cysts on gums and palate. benign and usually disappear within a few weeks. may need to be removed so baby doesn't choke Positive rooting, sucking, swallowing, & gag reflexes

newborn male genitals

Inspect penis, position of meatus Foreskin/prepuce non-retractable Meatus at tip of penis Advanced Practitioner will: Inspect & palpate scrotum Scrotum large, pendulous Rugae present on scrotum Testes within the scrotal sac

newborn abdomen

Inspect shape and size. palpate for tone, hernias, and diastasis recti. auscultate for bowel sounds Round and soft, feels like bread dough Positive bowel sounds: may be hypoactive for first few days. passage of meconium stool within 48 hours of birth. Umbilical cord - note 3 vessels, whitish-blue color, no drainage. dries very quickly, within 2 hours the vessels cant even be seen anymore. cord dries within 24 hours and detaches within 2 weeks.

newborn chest

Inspect shape, symmetry, chest excursion Cylindrical/barrel-shaped, symmetrical Nipples and breast buds present Breast engorgement/drainage: breast enlargement due to hormones from mom, leaking from nipples from mom, resolves in a few weeks. Auscultate breath sounds Lung sounds clear, equal; crackles within few hours of birth, due to retained amniotic fluid in lungs, it will be absorbed in lymphatics later. Heart sounds S1, S2 murmurs: report if heard

newborn head

Inspect the shape of the head, palpate fontanels Sutures slightly separated: can see significant changes in 1-2 days Anterior fontanel diamond-shaped; 2.5-4 cm., soft & flat Posterior fontanel triangular-shaped; 0.5-1 cm., soft & flat Hair - silky, soft, curly, straight measure head above ears and eyebrows circumference: 33-35.5 cm normal

newborn skin

Inspect the skin for color, intactness, birth marks, rashes, bruises, warmth, texture Color - pink/tan with acrocyanosis on hands and feet usually Vernix in creases at term Small amounts of lanugo on shoulders, sides of face, forehead, upper back. hair has to with gestational age. older babies have less hair peeling is often noted on baby before 40 weeks. if cracked skin make sure there is no breakage in skin. lotion will not work or help. Turgor - quick recoil Small amount of desquamation

newborn neck/ clavicle

Lift the chin to assess neck area Short neck with skin folds (cleanliness) Turns head easily from side to side Raises head when prone Clavicles intact Check for crepitus: this is cracking sounds Positive tonic neck reflex. negative neck tone indicates nerve damage. babies have almost no neck, babies can damage their clavicles

newborn urine

Monitor output First void within 24 hours Voids 1-2 x first 24 hours Urate crystals on diaper Document voiding by counting wet diapers Goal: 6-8 wet diapers/day a little yellow dot on a diaper can be considered a void.

caput succedaneum

a localized soft tissue edema of scalp. it feels spongy and can cross suture lines. this results from prolonged pressure of the head against the cervix during labor. resolves within the first week.

newborn blood pressure

Not routinely taken on well babies Varies with gestational age & activity 50- 75 systolic 30 - 45 diastolic Taken in arm or leg

newborn face

Note symmetry in appearance and movement Parts proportional and appropriately placed

infant nose

Observe shape of nose Inspect nares for opening Test patency by closing mouth & pressing against one nostril @ a time Nasal flaring is a sign of respiratory distress neonates breath through nose. a flat nasal bridge is seen with down syndrome

peripheral pulses on newborns

Palpate for presence, quality and equality Brachial Femoral Pedal (check for equal warmth in each foot)

care after circumcision

Petroleum ointment/Vaseline applied to dressing and wrapped around incision for first 24 hours for Gomco and Mogen No ointment for use of PlastiBell instrument Monitor for voiding, bleeding, and signs of infection Demonstrate gauze dressing for circumcision takes about a week to heal

when is newborn assessment done?

Physical assessment of newborn done within first two hours of birth to evaluate overall newborn well being and transition to extrauterine life ; use inspection, auscultation and palpation Newborn is not bathed yet, wear gloves

umbilical cord care

Purpose: Keep area clean and dry to minimize infection Report: Any bleeding from cord site Foul smelling drainage Redness in surrounding areas care: roll down diaper so it doesn't get wet or infected, let it air dry until it falls off no tub bathes until cord falls off, do spongebath until cord is off. this reduces infection. clamp is placed on cord for first 24 hours, cord falls off within 7-10 days

newborn hearing screen

Purpose: To assess for hearing impairment 2-3/1000 born with hearing impairment in US Done in hospital prior to discharge Does not provide of type or degree of impairment After 24 hours of birth (why?) Conducted in quiet room Residual vernix, blood, and amniotic fluid in the ear may interfere with accurate screening Baby does not "fail"; The baby "does not pass" rescreened (often again prior to discharge) according to hospital policy and may vary from book suggestions. want to make sure baby is happy and fed first. if baby doesn't pass recheck in 2 week and if still fails refer to a specialist.

newborn cry

Strong, Lusty Infant Cry Abusive Head Trauma/ Shaken Baby Syndrome: do not shake baby. blood vessels in head pops What strategies can a nurse suggest for parents? try to give baby alone time

care of the neonate objectives on other quizlet notes

Student will be able to: Maintain normal body temperature while caring for a newborn State correct administration of Vitamin K and erythromycin ointment to the newborn Demonstrate use of bulb syringe in the newborn Discuss correct positions of the newborn for feeding and sleeping Discuss variety of formulas, bottles, and nipples used for newborn feedings Discuss how to help the mother breastfeed Demonstrate baby bath and diapering Describe care of the newborn after circumcision

gestational age: preterm, term, postterm age

Term → newborn delivered between 37 and 42 weeks gestation Preterm < 37 weeks (Concerns for organ immaturity) Postterm > 42 weeks (Concerns for placental insufficiency; placenta may age out, vascularity and blood flow can wear out after 40 weeks) as pregnancy goes on more frequent testing occurs

ortolani's maneuver

an advanced skill. The Ortolani test or Ortolani maneuver is part of the physical examination for developmental dysplasia of the hip, along with the Barlow maneuver. It relocates the dislocation of the hip joint that has just been elicited by the Barlow maneuver

palmer grasp

at birth and disappears at 3-4 months baby grasps finger tightly, with two hands grasping neonate can be put into sitting position

hydrocele

can put a light on and see its translucent, it is filled with fluid.

plantar grasp

disappears at 3-4 months toes flex tightly

polydactyly

extra digit. treatment depends on how severe, may only need a string

newborn female genitals

first baby bath always wear gloves. always wear gloves as HC worker when changing diaper. Inspect genitalia by placing thumbs on either side of labia & separate tissue very quickly Labia majora dark: cover clitoris & labia minora Clear/white vaginal discharge present Urinary meatus and vagina present & midline Normal variations: pseudomenstruation this is from moms hormone Teaching: How to diaper, cleaning front to back, wash after urination, wear gloves ? nurses must wear gloves not parents

vernix

found heavily in creases. wash off. if baby is preterm they may have thin and translucent skin with a lot of vernix

acrocyanosis

found usually on hands and feet. this happens more often when baby is cold

lanugo

hair decreases with advanced age

cephalhematoma

hematoma formation btw the periosteum and skull with unilateral swelling. it appears within a few hours of birth and can increase over days. does not cross suture lines. cause is related trauma due to prolonged labor, forceps delivery, use of vacuum extractor. can contribute to jaundice due to large amounts of RBC being hemolyzed. resolves within 3 months

café au lait spot

lighter in color, correlation of more than 6- brain cancer

milia

looks like baby acne, do not pop. not interventions will disappear within a few days present on nose and chin

hemangiomas

more common of females. blood vessels accumulation. developmental vascular abnormalities

erythema toxicum

more visible on white babies, little rash with white dots. it seems to migrate and can come and go. babies have to get used to their new environment

moro/ startle

moro- 6 months disappear startle- 4 months disappear moro- let head drop back slightly and symmetical abduction and extension of arms and legs startle- make a loud noise and same response

babinski

present at birth disappears at 1 year stroking the lateral surface of sole upwards and the hyperentension and fanning of toes if absent may have neurological disorder

rooting reflex

present at birth disappears btw 3-6 months brush the side of babies cheek, turns head towards side of stimulation. anything that touches babies cheek it will try to nurse instruct mothers who are lactating to touch corner of babies mouth with nipple and baby will turn to feed baby wont turn if they have just been fed. prematurity or neurological defects may cause weak or absent response

scalp eclectrode

scan used on scalp, the ectrode. can use some Add to dictionary to keep it clean and dry.

Mongolian spot

seen in darker babies, are permenant its a birth mark.

newborn hand crease

simian crease is linked to downs syndrome

molding

some newborns should wear a hat for the first day. Newborn head molding is an abnormal head shape that results from pressure on the baby's head during childbirth. C section baby has less molding a vaginal baby will have more molding. should be soft not bulging. resolves in a week.

circumcision

the plastibell is a string, do not use vasoline. will loose circulation and skin will fall off. use for 7-10 days gomco and mogen clamp cuts off skin, tip can be raw and irritated, you can use vasoline to help. should not bleed after circumcision. a drop of blood can be significant.

syndactyly

webbing of the finger