Newborn care - day 2
Milia
-white papules found on the forehead, face, chin, and cheeks of infant
When is the fetus capable of producing IgM?
8th week of gestation
What do neonates with subdural hematoma usually present with?
Apnea Unequal pupils Tense fontanel Seizures Coma
When is mature breast milk established?
Approx. 10 days after birth
What can occur without prompt eye prophylaxis in newborns?
Blindness
What is considered hypoglycemia that warrants treatment in infants?
Blood glucose levels less than 40mg/dL
When is the normal finding when assessing breast tissue in newborns?
Breast nodule: approx. 6mm in term infants
When does the cord begin to dry, shrivel, & blacken
By the 2nd or 3rd day of life
What pain assessment tool is used by nurses in the NICU?
CRIES
What types of pumps are designed for working mothers?
Electric self-cycling double pumps
What is considered bradycardia in infants?
HR < 100 bpm HR can be in 80s or 90s in term infant when sleeping (should increase when awake)
Indication for HepB vaccine
HepB vaccine is for immunizing against infection caused by all known subtypes of hepatitis B virus (HBV).
Newborn smell
Highly developed Can recognize mothers smell by 5th day of life Can smell breast milk & can differentiate their mothers from other lactating women
What immunoglobulin in breast milk acts locally in the intestines to neutralize bacterial & viral pathogens?
IgA
What could cause Subconjunctival (scleral) & retinal hemorrhages in infants?
Increased ICP during birth
What is mastitis?
Inflammation/infection of the breast
What is the pulmonary artery pressure like after birth?
It decreases
Should parents put cereal in the infants boodle?
NO
Car seat when less than 2
Rear-facing In back seat
What does fecal discharge from the vagina indicate in an infant?
Rectovaginal fistula
How does swaddling an infant help manage pain?
Swaddling limits the neonate's boundaries, aids in self-regulation, & reduces physiologic & behavioral stress resulting from acute pain
What is the average neonatal BP?
Systolic = 60-80mmHg Diastolic = 40-50mmHg MAP = approximate week of gestation
Indications for HBIG
The HBIG vaccine provides prophylaxis against infection in infants born of HBsAg-positive mothers
What is the optimal state of arousal in an infant?
The quiet alert state
What position might women with perineal pain & swelling prefer to breastfeed in?
The side-lying position
What can trigger the milk ejection reflex?
Thoughts, sighs, sounds, or odors that the mother associated with her baby (or other babies) such as hearing the May occur during sexual activity because oxytocin is released during orgasm
How does oxygenation of the fetus occur during intrauterine life?
Through transplacental gas exchange
What should be noted about the infants first stool?
Time Color Character
When does milk stool appear?
Usually by the 4th day
What might occur when breastfeeding after birth?
Uterine contractions for first 3-5 days because the oxytocin that causes milk let down also can stimulate UCs They are often painful Typically resolve within 1 week after birth
What to include in the assessment of the newborns back
anatomy inspect & palpate Spine shoulders scapulae iliac cress Base of spin
After day 4 of life, what indicates adequate fluid intake in infants?
approximately 6 to 8 voidings per day of pale straw-colored urine
When do levels of coagulation factors reach adult levels?
by 9 months
What is the "rebooting zone"?
fussy/crying state
What factors may contribute to diaper rashes?
infrequent diaper changes diarrhea use of plastic pants to cover the diaper a change in the infant's diet such as when solid foods are added, or when breastfeeding mothers eat certain foods.
Describe convection (form of heat loss)
the flow of heat from the body surface to cooler ambient air.
Signs of effective breastfeeding in the infant?
• Latches without difficulty • Has bursts of 15 to 20 sucks/swallows at a time • Audible swallowing is present • Easily releases breast at end of feeding • Infant appears content after feeding • Has at least three substantive bowel movements and six to eight wet diapers every 24 hours after day 4
Interventions to promote warmth:
!Skin-to-skin contact !Drying infant !Wrapping newborn in warmed blanket immediately after birth Keeping head well covered Keeping the ambient temp in rom at 72-28F !Radiant warmer Warm incubater
Erythema toxicum/neonatorum
"Newborn rash"
What is the "ready zone"?
Allert state
How long after circumcision is it assessed? What is assessed?
Assess for bleeding q15-30mins for first hour Hourly for next 4-6 hours Monitor urinary output, noting the time & amount of first voiding after circumcision
Signs of developmental dysplasia of the hips (DDH)
Asymmetric gluteal & thigh skinfolds Uneven knee levels Positive Ortolani test Positive Barlow test
When is screening for critical congenital heart defects performed?
At 24 to 48 hours of age
How to clean/care for nipples when breastfeeding
Avoid soap -- has drying effect on nipples Breast creams should not be used routinely because they can block the natural oil secreted by the Montgomery glands on the areola
____ is the most common type of paralysis associated with a difficult birth
Brachial plexus injury
When is temperature in a newborn usually stabilized?
By 8-10 hours of age
Why might there be swelling of the breast tissue in term infants?
Caused by the hyperestrogenism of pregnancy
What might the pupils appear like when the infant is in pain?
Dilated
________ is usually related to increased bilirubin production
Early-onset jaundice
What are complications of hyperbilirubinemia?
Encephalopathy Kernicterus
How often should formula-fed infants be fed?
Every 3-4 hours
What is polydactyly?
Extra digits
Eye placement
Eyes & space between eyes each 1/3 the distance from inner to outer canthus
Risk factos for severe hyperbilirubinemia
Gestation age less than 38 weeks Exclusive breastfeeding Significant jaundice in a sibling Isoimmune or other hemolytic disease Cephalhematoma Significant bruising East Indian race
____ is a protective mechanism that allows the infant to become accustomed to environmental stimuli
Habituation
What is microcephaly?
Head </= 32cm
Route/dose of vitamin K administration
IM injection of 0.5-1mg NEVER IV
What is human milk feeding?
If the infant is fed expressed breast milk from the mother or a donor milk bank
What are the major immunogloumbnins in human milk?
IgA! IgG! IgM! IgD IgE
What type of immunity is important to blood-borne infections?
IgM
Where is brown fat located?
In superficial deposits in the inter scapular region of the axillae In deep deposits at the thoracic inlet Along the vertebral column Around the kidneys
What might the ICP appear like when the infant is in pain?
Increased
How might the infant react to exposure to cold?
Increased RR Becoming cyanotic!
What to inspect for when assessing the abdomen
Inspect & palpate umbilical cord Inspect size of abdomen & palpate contour Ausculate bowl sounds Note number, amount, character of stools
How does the nurse obtain a healstick in the infant? What is helpful?
It's helpful to warm the heel before the sample is taken; application of heat for 5-10 mins helps dilate the vessels in the area Wear gloves when collecting any spicmen
icterus = ____
Jaundice
What body movements & posture may be noted when the infant is in pain?
Limb withdrawal Thrashing Rigidity Flaccidity Fist clenching
What type of injury can be found on the skull of the infant?
Linear fracture Depressed fracture Occipital osteodiastasis
What might be given after circumcision to an infant for pain?
Liquid acetaminophen 10-15mg/kg q4-6hrs
How should a diaper be applied after circumcisions?
Loosely over the penis to prevent pressure on the circumcised area
Neonatal risk factors for birth injury:
Macrosomia Preterm or post term birth Congenital anomalies
What is the aim of treatment of hypoglycemia with IV dextrose in infants?
Maintaining the blood glucose levels greater than 45mg/dL
What aids in the digestion of fat in newborns?
Mammary lipase in human milk (neonates don't make their own lipase)
What are galactogogues?
Medications or other substances that are believed to increase milk supply
What are the most commonly prescribed galactogogues?
Metoclopramide Domperidone They are both dopamine antagonists typically used to treat gastroesophageal reflux.
If breastfeeding is interrupted, what is essential to maintaining milk supply?
Milk expression
What occurs when an infant has absent or decreased surfactant?
More pressure must be generated for inspiration, which can tire the preterm or sick infants
What infants are at risk for hypoglycemia?
Mothers with DM Macrosomic infants Small for gestation age Prolonged birth Hypoxia Preterm birth
How is skin exposure maximized during phototherapy?
Multiple devices may be used simultaneously (e.g., may be under phototherapy lamp while lying on a fiberoptic pad or LED mattress) Infant wears diaper only
What is the concern associated with prolonged hypoglycemia in infants?
Neurologic injury
What can hyperthermia cause?
Neurologic injury Increased risk of seizures Heat stroke Death
Which statement is incorrect regarding bathing of a new baby? Newborns should be bathed every day, for the bonding as well as the cleaning. Tub baths may be given before the infant's umbilical cord falls off and the umbilicus is healed. Only plain warm water should be used to preserve the skin's acid mantle. Powders are not recommended because the infant can inhale powder.
Newborns should be bathed every day, for the bonding as well as the cleaning.
Can thawed milk be refrozen?
No
Does pumping during engorgement cause a problematic increase in milk supply?
No
Is it abnormal for a formula fed infant to have a BM every other day?
No
When should circumcision be performed after a ring block or DPNB?
Not for at least 5 minutes after injections
What is the most common treatment of hyperbilirubinemia?
Phototherapy
Crawling reflex
Place newborn on abdomen ---- they make crawling movements with arms & legs Disappears by about 6 weeks
When assessing the eyes, what is noted?
Placement on face Symmetry in shape, size Discharge Eyeballs present, shape, size Pupils Eyeball movement Eyebrows; Amt of hair, pattern
A nurse is performing an assessment on a newborn and notes 6 digits on each foot. This finding is an example of: Congenital hip dysplasia. Hypospadias. Polydactyly. Clubfoot.
Polydactyly.
What does appearance of jaundice during the first 24 hours of life or presence after normal physiologic jaundice indicate?
Potential pathologic process that requires investigation
Mixing concentrate formula
Pour desired amount of formula into clean bottle and add equal amount of cooled boiled water. Add nipple and ring and shake well.
Newborn taste
Preference for sweet solutions
What is normal eyeball movement like in a newborn>
Random, jerky, uneven, focus possible briefly, following to midline
What symptoms may the baby have in the first week of life if mom was taking SSRIs?
Related to drug toxicity or withdrawal Irritability Agitation Tremors Hypoglycemia Tachypnea Vomiting Diarrhea
What could prolonged cyanosis other than the hands or feet in a newborn indicate?
Respiratory and/or cardiac problems
What might flaring of nares indicate?
Respiratory distress
What types of anesthesia & analgesia are used for newborn circumcision?
Ring block Dorsal penile nerve block (DPNB) Topical anesthetic such as eutectic mixture of local anesthetic (EMLA) (prilocaine-lidocane) LMX4 (4% lidocaine) Oral sucrose
What should be noted when assessing the newborns ears?
Size Placement on head Amount of cartilage Open auditory canal
What is kangaroo care?
Skin-to-skin contact
What should the vertebrae appear like in the newborn?
Straight & flat
____, a common type of ICH, occurs in term infants as a result of trauma and in preterm infants as a result of hypoxia.
Subarachnoid hemorrhage
What are 2 of the most commonly occurring birth injuries?
Subconjunctival (scleral) & retinal hemorrhages
What type of breast implants are less likely to cause problems with breast feeding?
Submuscular implants
A newborn male, estimated to be 39 weeks of gestation, exhibits: Testes descended into the scrotum. Extended posture when at rest. Abundant lanugo over his entire body. Ability to move his elbow past his sternum.
Testes descended into the scrotum.
For at least the first 12 hours after birth, how often should LGA infants & infants of mothers with diabetes have glucose screenings? When is further testing required?
Testing before feedings for first 12 hours Further testing is done if glucose levels are less than 45mg/dL
Where are coagulation factors synthesized?
The liver
What could be the cause of unsatisfactory weight gain if urine output & BMs are adequate?
The mother may be switching to the second breast too soon
What is tandem nursing?
The practice of breastfeeding a newborn & an older child
Why do newborns assume a position of flexion? What does this help them with?
This position helps them to conserve heat --- it helps guard against heat loss because it diminishes the amount of body surface exposed to the environments
What could ecchymoses & petechiate be signs of at birth?
Thrombocytopenic purpura
What is the goal of cord care?
To prevent or decrease the risk for hemorrhage & infaction
Assessment of newborn ears
Top of pinna should match an imaginary line extending form the corner of the eye
What is a non-invasive method of assessing hyperbilirubinemia?
Transcutaneous bilirubinometry [TcB]
What facts influence cord separation time?
Type of cord care Type of birth Other perinatal events
What indicates a fractured clavicle?
Unequal movement of the upper extremities Crepitus over the clavicular area
When should healthcare workers use gloves when handling infants?
Until blood & amniotic fluid have been removed from skin When drawing blood (heelstick) When caring for a fresh wound (circumcision) During diaper changes
What is epispadias?
Urethra is located on the dorsal surface of the penis
What is hypospadias?
Urethra located on the ventral surface of the penis
What are common interventions for engorgement?
Use of cold after breastfeeding Chilled cabbage leaves Warm compresses/showers before breastfeeding Antiinflammatory medications Breast massage Pumping
What is the normal finding when assessing the labia majaor of the newborn?
Usually edematous, covering labia minora in term newborns
Treatment for infants with hypocalcemia
Usually self-limiting & resolves within 1-3 days Early feeding of appropriate source of calcium such as fortified human milk or preterm infant formula
When do Subconjunctival (scleral) & retinal hemorrhages resolve after birth?
Usually within 5 days `
Define "sleep-wake states" in infants
Variations in the state of consciousness of infants
What are the coagulation factors activated by?
Vitamin K
Why to neonates need a vitamin K injection?
Vitamin K is synthesized by intestinal flora, which are not present at birth. It's used for preventing & treating hemorrhagic disease in the newborn
What should the infant have received prior to circumcision?
Vitamin K shot If they have not had it, they can not get circumsized
What is the normal finding when assessing the urinary pattern of the newborn?
Void within 24h Voiding 2-6 times per 24h for first 1-2 days Voiding 6-8 times per 24h by day 4 or 5
What should the cord be cleaned with during the initial bath?
Water (using cleanser sparingly if needed to remove debris) Evidence does not support the routine use of antiseptic or antimicrobial preparations for cord care
When weighing a newborn, the nurse should: Leave its diaper on for comfort. Place a sterile scale paper on the scale for infection control. Keep a hand on the newborn's abdomen for safety. Weigh the newborn at the same time each day for accuracy.
Weigh the newborn at the same time each day for accuracy.
Weight measurements of infant
Weighed shortly after birth Weight nude in center of scale Cover with disposable pad to prevent heat loss via conduction & to prevent cross-infection Will have 5-10% weight loss in first few days (water weight) -- will go back to normal after 2 weeks
When do comfort measures work best in regards to procedures?
When initiated a few minutes before the procedure to allow the newborn time to relax & reorganize
How do must newborn falls occur? (yes this is actually in the book)
When mother falls asleep while holding newborn in bed or in reclining chair At birth when the infant is transported
When is the initial bath done?
When the newborns skin temp is stable & can adjust to heat loss from a bath
When does nonshivering thermogenesis begin? How does it start?
When the thermal receptors in the skin detect skin temps of 95-96.8 F The thermal receptors stimulation is then transmitted to the hypothalamus thermal center In response to hypothalamus stimulation, norepinephrine is released in brown fat----- this initiates its metabolism!
What are early signs of hunger during the first few weeks of the baby's life?
Wiggling Making sucking movements Bringing hand to mouth
How often does the formula fed infant poop in the first 2 weeks?
With each feeding Can decrease to 1-2 stools per day
In infants, within how long after obtaining a urine sample should be passed before it it analyzed?
Within 1 hour of collection
When should newborns be first breastfed?
Within 1-2 hours after birth
When should the HepB vaccine be given in infants born to HepB+ mothers?
Within 12 hours after birth
When should the infant be foot printed?
Within 2 hours of birth
When engorgement occurs when is it usually resolved?
Within 24hours
How long after initiating phototherapy does it take for bilirubin levels to begin to decrease?
Within 4-6 hours
Can you combine great milk from pumping sessions in the same day?
Yes Cool freshly expressed milk before adding it to the refrigerated container. Do not add warm milk to a container of refrigerated milk
When is the cord clamp removed?
after 24 hours when it is dry
How much of a term neonates weight is water?
approx. 75%
When should vomiting be reported to the HCP?
more than one episode of forceful vomiting or frequent vomiting (over a 6-hour period)
What is hydrop fetalis?
most severe form of Rh incompatibility The fetus has marked anemia, cardiac decompensation, cardiomegaly, & hepatosplenomegaly Hypoxia results from serve anemia Fluid leaks out of intravasuclar space because of decreased intravascular oncotic pressure --- results in generalized edema --- placenta is often edematous, which can cause uterine rupture
How does the mother facilitate latch?
mother supports her breast in one hand with the thumb on top & four fingers underneath at the back edge of the areola. The breast is compressed slightly with the fingers parallel to the infant's lips, as one might compress a large sandwich in preparing to take a bite, so an adequate amount of breast tissue is taken into the mouth with latch.
Sucking reflex
offer gloved finger Infant will suck 10-12 months
____ jaundice is usually self-limiting and requires no treatment
physiologic
Parents of children with brachial palsy are taught to avoid ____
picking up the child under the axillae or by pulling on the arms
When should fever be reported to the HCP?
temperature greater than 38° C (100.4° F) axillary; also a continual rise in temperature (Note: Tympanic [ear] thermometers are not recommended for infants younger than 3 months.)
what is the frequency of voiding after birth in infants like?
varies from 2 to 6 times per day during the first & second days of life increases during the subsequent 24 hours.
What might stools appear like if an infant is allergic or unable to digest a formula?
very soft with a high water content that is signaled by a distinct water ring around the stool on the diaper
What is jaundice primarily caused by?
Accumulation in the skin of unconjugated bilirubin
What are potential complications of circumcision?
Acute pain Hemorrhage Infection Penile injury Long-term implications (adverse effects on sexual function & pleasure)
If the infant is </= 2000g, and the mothers HepB status is unknown, what actions are taken?
Administer HepB vaccine & HBIG within 12 hours after birth
An Rh-negative woman has a miscarriage during the 8th week of pregnancy and a D&C is required. Which priority intervention would be required in the recovery period following the surgical procedure? Type and screen for two units of blood. Maintain hydration level by increasing fluids by mouth. Administer RhoGAM. Perform fundal massage.
Administer RhoGAM
What helps to prevent bleeding problems in newborns?
Administration of IM vitamin K shortly after birth
How long after eye prophylaxis administration before the ointment can the excess be wiped off?
After 1 minute
When does the period of decreased responsiveness occur?
After first period of reactivity; lasts 60-100 minutes
Why might head circumference need to be remeasured on the 2nd or 3rd day?
After resolution of molding & caput succedaneum
What do Transcutaneous bilirubinometry [TcB] devices do?
Allow for repetitive estimations of bilirubin Can be used to screen for clinically significant jaundice & decrease the need for serum bilirubin measurements
What is in meconium?
Amniotic fluid & its constitutes Intestinal secretions (including bilirubin) Cells (shed from the mucosa) Possibly blood (ingested maternal blood or minor bleeding of alimentary tract vessels)
What is a thermistor probe?
An automatic sensor that can be placed on the upper quadrant of the abdomen immediately below the right or left costal margin (never over a bone) Reflector adhesive patch used over probe to provide adequate warming Detects minor temp changes resulting from external environmental factors or neonatal factors before dramatic change in core body temp develops
If the mom is Rh- and the baby could be Rh+, what is done at the first prenatal visit?
An indirect Coombs' test to determine if mom has antibodies to the Rh antigen
An Apgar score of 10 at 1 minute after birth indicates: An infant having no difficulty adjusting to extrauterine life and needing no further testing. An infant in severe distress that needs resuscitation. A prediction of a future free of neurologic problems. An infant having no difficulty adjusting to extrauterine life but who should be assessed again at 5 minutes after birth.
An infant having no difficulty adjusting to extrauterine life but who should be assessed again at 5 minutes after birth.
Why is side-lying position not recommended for infant sleeping?
Anatomically, the infant's shape—a barrel chest and flat, curveless spine—facilitates the infant to roll from the side to the prone position
Where are venous blood samples drawn from in infants?
Antecubital veins Saphenous veins Superficial wrist veins Rarely, scalp veins
What is AGA?
Appropriate for Gestational Age (between 10th & 90th percentiles)
A 3.8-kg infant was delivered vaginally at 39 weeks after a 30-minute second stage. There was a nuchal cord. After birth the infant is noted to have petechiae over the face and upper back. Information given to the infant's parents should be based on the knowledge that petechiae: Are benign if they disappear within 48 hours of birth. Result from increased blood volume. Should always be further investigated. Usually occur with forceps delivery.
Are benign if they disappear within 48 hours of birth
In Erb-Duchenne paralysis or palsy, what does the child look like?
Arm hangs limply alongside the body Shoulder & arm are adducted & internally rotated Elbow is extended Forearm is pronated Wrist & fingers flexed
When does the sucking reflex begin in utero?
As early as 15-16 weeks gestation
When can infants coordinate sucking, swallowing, & breathing while breatfeeding?
As early as 28 weeks gestation
How often should newborns be breastfed?
At least 8-12 times/24h
Why is it important to breastfeed for a long enough amount of time?
Because of the changing composition of human milk during each feeding
What is the Infant Car Seat Challenge?
Before discharge from the birth institution, infants born at less than 37 weeks of gestation should be observed in a car seat (preferably their own) for at least 90 to 120 minutes or a period of time equal to the length of the car ride home. The infant is monitored for apnea, bradycardia, and a decrease in oxygen saturation. If the infant exhibits any of these clinical signs, travel home should be in a Federal Motor Vehicle Safety Standard 213 (FMVSS 213)
When should the infant receive hearing screening?
Before hospital discharge or no later than 1 month of age
What is plotted onto a standardized graph to identify normal values for gestational age?
Birth weight Length Head circumference
What is subgaleal hemorrhage?
Bleeding into the subgaleal compartment
What is a subgaleal hemorrhage??
Bleeding into the subgaleal compartment the result of traction or application of shearing forces to the scalp, commonly associated with difficult operative vaginal birth, especially vacuum extraction
What could be early signs of a subgaleal hemorrhage?
Boggy scalp! Pallor Tachycardia Increasing head circumference Forward & lateral positioning of infant's ears because the hematoma extends posteriorly
What can be early signs of a subgaleal hemorrhage?
Boggy scalp! tachycardia increasing head circumference Lateral positioning of newborns ears
What is considered to be "preterm"?
Born before completion of 37 weeks of gestation, regardless of birth weight
How does the mother prevent nipple trauma as the baby is taken off the breast? (breaking the latch)
Break the suction by inserting a finger in the side of the baby's mouth between the gums Leave it there until the nipple is completely out of the mouth
What are complications of mastitis?
Breast abscess Chronic mastitis Fungal infections of breast
With regard to the long-term consequences of infant feeding practices, the nurse should instruct the obese client that the best strategy to decrease the risk for childhood obesity for her infant is: An on-demand feeding schedule. Breastfeeding. Lower-calorie infant formula. Smaller, more frequent feedings.
Breastfeeding
_____ is defined as the transfer of human milk from the mother to the infant; the infant receives milk directly from the mothers breast
Breastfeeding
The concept of tandem feeding is based on: Adequate nutritional stores for the mother and infant. Using both breasts to nurse the baby. Breastfeeding an infant and an older sibling during the same period. Supplementing breastfeeding with bottle feeding to maintain adequate weight gain.
Breastfeeding an infant and an older sibling during the same period.
What injury may be noted as a result of face presentation?
Bruises over the face
What injury may be noted as a result of breech presentation?
Bruising & swelling over the buttocks or genitalia
Rooting reflex. What is it & when does it go away?
Brush infants cheek --- the infant will turn head & open mouth Disappears after 3-4 months
What are some infant behavioral signs of stress?
"Spacing out" (going form an alert state to a drowsy state "switching off" (gaze aversion, or looking away from parent) "Shutting down" (going from drowsy to a sleep state)
When the infant is awake, _____ can be provided under parental supervision so the infant can begin to develop appropriate muscle tone for eventual crawling
"tummy time"
what are the purposes of bathing the infant?
(1) cleansing the skin (2) observing the infant's condition (3) promoting comfort (4) parent-child-family interaction.
What veins & arteries are associated with the umbilical cord?
(AVA) 2 umbilical arteries 1 umbilical veins
What serving sizes should breast milk be stored in?
2-4 ounces to prevent waste
The nurse is planning care for a newborn of a mother with diabetes mellitus. What is the priority nursing consideration for this newborn? 1.Developmental delays because of excessive size 2.Maintaining safety because of low blood glucose levels 3.Choking because of impaired suck and swallow reflexes 4.Elevated body temperature because of excess fat and glycogen
2.Maintaining safety because of low blood glucose levels
The nurse in a newborn nursery is performing an assessment of an infant. What procedure should the nurse use to measure the infant's head circumference? 1.Wrap the tape measure around the infant's head, and measure just below the eyebrows. 2.Place the tape measure under the infant's head, wrap around the occiput, and measure just above the eyebrows. 3.Place the tape measure under the infant's head at the base of the skull, and wrap around to the front just below the eyes. 4.Place the tape measure at the back of the infant's head, wrap around across the ears, and measure across the infant's mouth.
2.Place the tape measure under the infant's head, wrap around the occiput, and measure just above the eyebrows.
The nurse is monitoring a client who is receiving oxytocin (Pitocin) to induce labor. Which assessment finding would cause the nurse to immediately discontinue the oxytocin infusion? 1.Fatigue 2.Drowsiness 3.Uterine hyperstimulation 4.Early decelerations of the fetal heart rate
3.Uterine hyperstimulation
The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care? Select all that apply. 1.Avoid stimulation. 2.Decrease fluid intake. 3.Expose all of the newborn's skin. 4.Monitor skin temperature closely. 5.Reposition the newborn every 2 hours. 6.Cover the newborn's eyes with eye shields or patches.
4.Monitor skin temperature closely. 5.Reposition the newborn every 2 hours. 6.Cover the newborn's eyes with eye shields or patches.
What angle are IM injections in infants given at?
90
What is considered bradypnea in newborn?
<30 respiration's/min
What glucose level is considered abnormal in infants?
<40mg/dL
Which reflexes should be present in the newborn at birth?
ALL OF THEM
Adverse reactions to neonatal eye prophylaxis
Can cause chemical conjunctivitis that lasts 24-48 hours; vision can be blurred temporarily
Newborn hearing
Can hear & differentiate among various sounds Will turn toward sound & attempt to locate source Prefers high-pitched intonation Responds to rhythmic sounds (used to mothers heartbeat)
What could pallor skin in a newborn indicate?
Cardiovascular problem CNS damage Blood dyscrasia Blood loss Twin-to-twin transfusion Infection
What is vernix caseosa?
Cheese-like, whitish substance that covers parts of the newborn at birth
When might an infant be hypocalcemic?
Common in critically ill neonates Can occur in infants of mothers with diabetes In infants who had perinatal asphyxia or trauma In low-birth-weight & preterm infants Infants born to mothers treated with anticonvulsants during pregnancy
What containers are preferred for long-term storage of breast milk?
Contains with hard sides such as hard plastic or glass with an airtight seal Flexible polyethylene bags are not recommended for long-term milk storage (>72h) because of greater chance for leakage, puncture, & loss of immune cells
What might a cold infant look/act like??
Cry or appear restless Skin feels cool to touch (due to vasoconstriction) Acrocyanosis
What is the normal finding when assessing the prepuce of the newborn?
DO NOT FORCIBLY RETRACT SKIN IF UNCIRCUMSIZED Prepuce covering glans penis & not retractible
What is Klumpke paralysis?
Damage to the lower plexus (less common)
What oxygenation signs may indicate pain in the neonate?
Decreased transcutaneous oxygen saturation Decreased arterial oxygen saturation
what are neonates with Phrenic nerve injury at risk for?
Developing pneumonia
What does injury to the phrenic nurse result in?
Diaphragmatic paralysis
____ is a common response of the breasts to the sudden change in hormones and the onset of significantly increased milk volume
Engorgement
Vitamin K is given to the newborn to: Reduce bilirubin levels. Increase the production of red blood cells. Enhance the ability of blood to clot. Stimulate the formation of surfactant.
Enhance the ability of blood to clot.
What type of injury can cause intracranial injuries of the infant?
Epidural hematoma Subdural hematoma Subarachnoid hemorrhage Cerebral contision Cerebellar contusion Intracerebellar hematoma
What should pupils in the newborn be like?
Equal in size Reactive to light Present
_____ is damage to the upper plexus and is less serious than brachial palsy
Erb palsy
What type of injury can cause plexus injuries of the infant?
Erb-Duchenne palsy Klumpke paralysis Total (mixed) brachial plexus injury Horner syndrome Diaphragmatic paralysis Lumbosacral plexus injury
What do you do if the at-risk infant (for hypoglycemia) is asymptomatic with glucose levels less than 25mg/dL in the first 4 hours or less OR less than 35mg/dL from 4-24 hours of age?
FEED THEM Glucose testing should be repeated 1 hour after feeding If levels remain low despite feeding, IV dextrose is warranted
What is the most variable component of human milk?
Fat changes concentration over a feeding, over a 24-hour period, & across time
What can inhibit the let down reflex?
Fear Stress Alcohol consumption
How is bilirubin excreted?
Feces
Who does developmental dysplasia of the hips (DDH) most often occur in?
Female infants, in breech presentations Infants with family history of DDH
What breast is offered when feeding the baby?
First breast is offered until baby falls asleep, then wake baby and offer second breast Alternate what breast starts first with each feeding
When newborns are adapting to extrauterine life, what are the 3 stages of transition?
First period of reactivity Period of decreased responsiveness Second period of reactivity
What area should be washed last when bathing the baby?
Genital
What is an increased number of creases in hands associated with?
Greater maturity rating
What facial expressions may be noted when the infant is in pain?
Grimaces Brow furrowed Chin quivering Eyes tightly closed Mouth open & squarish
______ is the most commonly diagnosed genetic disorder of all the core conditions in the universal screening program
Hearing loss
Describe the pathogenesis of Rh incompatibility
Hematopoieis (formation, production, & maintenance of blood cells) in the fetus is established by 9th week gestation When the fetal RBCs that have the Rh antigen pass through the placenta into the maternal circulation of an Rh neg mom, the maternal immune system produces antibodies against the forigen fetal antigens (maternal sensitization)
What are RBC's broken down into?
Heme = bilirubin+iron
What are the main core disorders that the USDHHS recommends for screening in newborns?
Hemoglobinopathies (e.g., sickle cell) Inborn errors of metabolism (e.g., PKY, galactosemia) Severe combined immunodeficiency Critical congenital heart disease
Action of HepB injection
Hepatitis B (HepB) vaccine induces protective antihepatitis B antibodies in 95% to 99% of healthy infants who receive the recommended three doses.
Action of HepB Immune Globulin
Hepatitis B immune globulin (HBIG) provides a high titer of antibody to hepatitis B surface antigen (HBsAg).
Stepping or "walking" reflex
Hold infant vertically under arms or on trunk, allowing one foot to touch table surface------Infant will simulate walking, alternating flexion & extension of feet; term infants walk on soles of their feet, & preterm infants walk on their toes. Response is normally present for 3-4 weeks
How do you feed the formula fed baby?
Hold the infant close in a semi-reclining position. Talk to him or her during the feeding. This time is ideal for social interaction and cuddling
What is nonshivering thermogenesis?
How infants produce heat instead of shivering Accomplished primarily through metabolism of brown fat & by increased metabolic activity in the brain, heart, & liver
What is the most severe form of Rh incompatibility?
Hydrops fetalis
____ from excessive heat loss is a common and dangerous problem
Hypothermia
What could cyanosis in a newborn indicate?
Hypothermia Infection Hypoglycemia Cardiopulmonary diseases! Neurologic or respiratory malformations
What could be the first sign that a critical congenital heart defect is present?
Hypoxemia
What is the ABC mnemonic used to promote safe sleeping practices?
I sleep safest ALONE, on my BACK, in my CRIB
How do you reduce swelling of the breast tissue surrounding the milk ducts?
Ice packs in 15-20 minutes on, 45-minutes off rotations between feedings Ice packs should cover both breasts
When should the New Ballard Score be determined?
If gestational age is < 26 weeks --- within 12h In term = within first 48 hours
When might an infant need to be placed in a radiant warmer?
If infant doesn't remain skin-to-skin with mother during the first 1-2 hours after birth
When should sucking habits (thumb, etc.) be restrained?
If it continues past 4 years or past the time when permanent teeth erupt
When might early pumping be indicted?
If the baby is too sleepy to feed effectively If there are issues with latching or milk transfer
With regard to injuries to the infant's plexus during labor and birth, nurses should be aware that: If the nerves are stretched with no avulsion, they should recover completely in 3 to 6 months. Erb palsy is damage to the lower plexus. Parents of children with brachial palsy are taught to pick up the child from under the axillae. Breastfeeding is not recommended for infants with facial nerve paralysis until the condition resolves.
If the nerves are stretched with no avulsion, they should recover completely in 3 to 6 months.
When should glucose levels be measured in neonates at 34 weeks gestation or more?
If they have risk factors If they have clinical manifestations of hypoglycemia
What immunoglobulin in breast milk can lessen the risk of allergy & food intolerance through modulation of exposure to foreign milk protein antigens?
IgA
What are most of the circulating antibodies in the newborn at birth?
IgG that were transported across the palcenta from the maternal circulation
What is the major immunoglobulin synthesized in the first month of the fetus?
IgM
What are the effects of smoking by breastfeeding mothers?
Impaired milk production Secondhand smoke to infant Nicotine is transfered
When does alcohol levels peak in breast milk?
In 30-60 minutes on an empty stomach In 60-90 minutes when consumed with food
Why does hyperbilirubinemia occur in hemolytic disease?
In hemolytic disorders, maternal antibodies are present naturally or form in response to an antigen from the 883fetal blood crossing the placenta and entering the maternal circulation. The maternal antibodies of the immunoglobulin G (IgG) class in turn cross the placenta, causing hemolysis of the fetal RBCs, resulting in hyperbilirubinemia and jaundice.
When do normal periods of apnea usually occur in infants?
In the active (REM) sleep cycle They decrease in frequency & duration with age Count for 1 full minute
Where in the refrigerator or freezer should breastmilk be stored?
In the middle or back of the freezer, not on the door
When the clavicle is broken during birth, where does the brake typically occur?
In the middle third of the bone
Warning signs of ineffective breastfeeding
Inadequate weight gain Minimal output Feeding constantly
What might the muscle tone appear like when the infant is in pain?
Increased
What vital signs may indicate pain in neonates?
Increased HR Increased BP Rapid, shallow respirations
What is the hypertonic infant like?
Increased resistance to passive movement
How is the temperature of a radiant warmer controlled?
Infant's skin temp is used as the point of control in a warmer with a servo-controlled mechanism Usually is maintained between 96.8 & 98.6 F
What tests are used to assess newborn hearing?
Initial screening is done with the evoked otoacoustic emissions (EOAE) test. The auditory brainstem response (ABR) test is used as follow-up if the initial screening is abnormal
What interventions help to stabilize infants blood glucose levels?
Initiation of feedings (early feedings)
What to look for when assessing the mouth of a newborn?
Inspect & palpate Assess buccal mucosa Assess lips for color, configuration, movement Check gums Assess tongue for color, mobility, movement, size Assess palate (soft, hard): arch, uvula Assess chin Evaluate saliva for amount,character Check reflexes: rooting, sucking extrusion Check for teeth
What setting is an exchange transfusion done in?
Intensive care setting
Why is abrupt weaning likely to be stressful?
It can be distressful for mother & baby Can be physically uncomfortable for the mother because it can cause engorgement & mastitis
Can you get pregnant while breastfeeding?
It confers a period of infertility, but it's not considered an effective method of contraception unless the mother is strictly following guidelines for the lactational amenorrhea method of contraception
Significance of the hindmilk?
It contains the denser calories from fat necessary for ensuring optimal growth & contentment between feedings
A nurse examining a newborn infant notes that the infant is jaundiced. Which observation would lead the nurse to continue to monitor but not to intervene and contact the physician? Jaundice appeared within the first 24 hours of life. Jaundice appeared on the third day of life. Preterm infant who is 12 hours old. Infant is being bottle fed and within the first 24 hours of life.
Jaundice appeared on the third day of life.
Why might a coagulation deficiency occur in a newborn? When might this occur?
Lack of intestinal bacteria needed to synthesize vitamin K result in transient blood coagulation deficiency--- between 2nd & 5th day
What type of flora is colostrum important in establishing?
Lactobacillus bifidus flora in the infant's digestive tract
What is LGA?
Large for gestational age (more than 90th percentile) Presumed to have grown at an accelerated rate during fetal life
What is the normal finding when assessing the scrotum of the newborn?
Large, edematous, pendulous Covered with rugae
When does the first period of reactivity occur?
Lasts up to 30 minutes after birth
What term infant is sometimes referred to as "the great impostors?" Why?
Late preterm infants Because they are often the size & weight of term infants & are often treated as healthy newborns
Which action of a breastfeeding mother indicates the need for further instruction? Holds breast with four fingers along bottom and thumb at top. Leans forward to bring breast toward the baby. Stimulates the rooting reflex and then inserts nipple and areola into newborn's open mouth. Puts her finger into newborn's mouth before removing breast.
Leans forward to bring breast toward the baby
What factors affect total serum bilirubin levels in newborns?
Length of gestation Age Weight Race Nutritional satus Mode of feeding
Temperature of bath water
Less than 120F
When should decreased urination be reported to the HCP in infants?
Less than 6-8 wet diapers per day after 3-4 days of age
What is considered hypocalcemia in infants?
Levels less than 7.8-8 mg/dL in term infants Slightly lower in preterm infants (7mg/dL)
What could identify clavicle bone fracture?
Limited movement in arm Crepitus over bone Absence of Moro reflex on affected side
___ fractures are most common in the parietal bones, require no treatment, and are usually of no clinical significance
Linear
why might an infant lose 5%-10% of their birthweight in the first 3-5 days of life?
Loss of fluid through urine, feces, lungs, increased metabolic rate, & limited fluid intake Should regain birth weight within 10-14 days, depending on feeding method
What could cause microcephaly?
Maternal rubella Toxoplasmosis Cytomegalovirus Fused cranial sutures (craniosynostosis)
What is hemolytic disease of newborns caused by? What does it cause?
Maternal/newborn blood group incompatibility Most common cause of hyperbilirubinemia
Measurement of infants head circumference
Measured at widest part (usually the occipitofrontal diameter); just above infants eyebrows Term circumference = 30-36.8cm
What is the normal finding when assessing the urinary meatus of the male newborn?
Meatus at tip of penis
What is usually required for the first few days after birth in neonates with Phrenic nerve injury?
Mechanical ventilatory support
____ is greenish black and viscous and contains occult blood
Meconium
Which findings would lead to increased bilirubin levels in the newborn? (Select all that apply.) Cord clamped immediately following delivery of newborn Meconium passed after 24 hours Initiation of newborn feedings delayed following birth Hyperglycemia Twin-to-twin transfusion syndrome
Meconium passed after 24 hours Initiation of newborn feedings delayed following birth Twin-to-twin transfusion syndrome
Normal findings when assessing the nose of an infant
Midline Some mucus, no drainage Preferential nose breather Sneezing to clear nose
Results of ABO incompatibility
Mild anemia Jaundice
What all does oxytocin stimulate?
Milk let down Uterine contractions during labor
What is oligodactyly?
Missing digits
Why is measurement of length difficult in a newborn?
Molding Incomplete extension of knees
What are the nursing interventions for the following nursing diagnosis in the newborn: Risk for Injury related to sole dependence on caregiver
Monitor environment for hazards such as sharp objects (long fingernails, jewelry) Handle neonate gently & support head, ensure use of car seat by parents, teach parents to avoid placing neonate on high surfaces unsupervised, & to supervise pet & sibling interactions with neonate Assess neonate frequently for evidence of jaundice, & teach parents to monitor for jaundice
If the mom is drinking alcohol, can she pump & discard the milk to accelerate removal of alcohol from milk?
NO
Should you apply heat to the engorged breast? Why?
NO -- because heat increases blood flow However, a warm shower could help start the milk leaking, or the mother may be able to manually express enough milk to soften the areola sufficiently to allow the baby to latch & breastfeed
Is narcan used in infants born to narcotic addicts?>
NO because it can cause serve signs & symptoms of narcotic abstinence syndrome & seizures
Is the amount of time spent breastfeeding an indicator of the amount of milk the infant consumes?
NO because some of the time the breast is spent in nonnutritive sucking
How do infants produce heat?
NOT able to shiver Metabolism of brown fat Acrocyanosis/vasoconstriction Increase in cellular metabolic activity ---Increase in oxygen consumption ---Increase in glucose consumption Position of flexion
Signs of respiratory distress in a newborn:
Nasal flaring Retractions Stridor Gasping Chin tug
What is a frequently used method of determining gestational age?
New Ballard Score
Should parents have strict feeding schedules for infants?
No -- this can result in failure to meet the nutritional needs They should be fed whenever they exhibit feeding cues
Mixing ready-to-feed formula
No mixing is needed; do not add water. Pour desired amount of formula into clean bottle; add nipple and ring.
What is the normal finding when assessing the vagina of the newborn?
Open orifice Mucoid discharge Hymenal/vaginal tag
What is considered "passing" in screening for critical congenital heart disease?
Oxygen saturation greater than 95% in either extremity (right hand & one foot) with less than 3% absolute difference between the upper & lower extremity reedings
What skin changed may be noted when the neonate is in pain?
Pallor or flushing Diaphoresis Palmar sweating
Why is assessment of gestational age important?
Perinatal morbidity & mortality rates are related to gestational age & birth weight
_____ is usually effective in treating hyperbilirubinemia that has not reached levels associated with acute bilirubin encephalopathy or kernicterus.
Phototherapy
What are the 2 ways to help reduce the newborn's serum levels of unconjugated bilirubin?
Phototherapy Exchange blood transfusion
_____ almost always occurs as a component of brachial plexus injury rather than as an isolated problem.
Phrenic nerve injury
Adverse reactions to phytonadione
Phytonadione = vitamin K Edema erythema pain at injection site In preterm infants --hemolysis --jaundice --hyperbilirubinemia
How do you thaw frozen breast milk?
Place the container in the refrigerator for gradual thawing or under warm, running water for quicker thawing NEVER boil or microwave
What to include when assessing the anus of the newborn
Placement Patency Sphincter response Abdominal distention Passage of meconium from anal opening Fecal drainage
What is used to clean the diaper area in infants?
Plain water with mild soap, if needed Baby wipes with NO alcohol Allow skin to dry completely before applying another diaper
What adverse effect can occur with delayed cord clamping?
Polycythemia that occurs with delayed clamping is usually not harmful, although there can be an increased risk of jaundice that requires phototherapy
How are infants prepared for circumcision?
Positioned on a plastic restraint form Penis is cleansed with soap & water or antiseptic solution like povidone-iodine Draped to provide warmth & a sterile field Sterile equipment is readied for use
What might an odorous vernix indicate?
Possible intrauterine infection
What might green color vernix indicate?
Possible utero release of meconium or presence of bilirubin
When might an infant be born without brown fat?
Pre-term infants may be born before the stores of brown fat have accumulated Intrauterine growth restriction
What has maternal use of SSRIs during the second trimester been associated with?
Preterm birth & low birth weight
How is vitamin K given to a preterm infant? Why?
Preterm infant doesn't have muscle mass (typically vitamin K is an IM injection) --- instead, it's diluted & given over 10-15 minutes while closely monitoring with a cardiorespiratory monitor Rapid IV administration of vitamin K can cause cardiac arrest
What could dark red skin in a newborn indicate?
Preterm infant! Polycythemia
What are the health benefits to newborn male circumcision?
Prevention of UTI in males younger than 1 Reduced risk for penile cancer Reduced risk for heterosexual acquisition of STIs, particularly HIV
Pull-to-sit (traction response); posture tone reflex
Pull infant up by wrists from supine position with head in midline. Head lags until infant is in upright position; then head is held in same plane with chest and shoulder momentarily before falling forward; infant attempts to right head. Response depends on general muscle tone and maturity & condition of infant.
Why should the newborn be gradually warmed, not rapidly?
Rapid warming can cause apneic spells & acidosis Monitor to progress slowly over 2 to 4 hours
What does absence of babinski reflex indicate?
Requires neurologic evaluation
What are late preterm infants at risk for?
Respiratory distress Temperature instability Hypoglycemia Apnea Feeding difficulties Hyperbilirubinemia
What should be assess regarding respiratory patterns in the initial assessment?
Respiratory rate (1 full min) Observe for symmetry of chest movement
Why might there be eye edema confined to the eyelid?
Result of eye prophylaxis
What is isoimmunization?
Rh incompativility
How should mom be positioned for the initial feeding?
Semi-reclining position with newborn lying prone, skin-to-skin on mother's bare chest Her body supports the baby Mother is more relaxed, muscle pain is reduced or eliminated, & she has more freedom of movement to use her hands Approach is based on concept of "biological nurturing"
Why is there fetal jaundice in severe Rh incompatibility
Severe Rh incompatibility results in marked fetal hemolytic anemia because the fetal RBCs are destroyed by maternal Rh+ antibodies In extreme cases, fetal bilirubin levels increase because the placenta can't clear all the bilirubin resulting from the RBC breakdown
What to inspect for when assessing the newborns chest
Shape Respiratory movements Clavicles Ribs Assess nipples for size, placement, number Breast tissue Ausculate: heart & respiratory sounds
What to look for when assessing the newborns wittle nose?
Shape, placement, patency, configuration
What is significant about the location of the meatus in male infants?
Should be at the top Hypospadias/epispadis = located in abnormal position
What are the clinical manifestations of subarachnoid hemorrhage in infants?
Signs may be absent Early onset of alternating depression & irritability, with refractory seizures or apnea
What injury may be noted as a result of a tight nuchal cord?
Skin over the entire head may be ecchymotic & covered with petechiae
What is the ideal method for promoting warmth & maintaining neonatal body temperate?
Skin-to-skin contact (SSC) with mother
___ fractures are common in infants with a cephalhematoma
Skull
What is the resting zone?
Sleep states --Still/deep sleep --Active/light sleep
What is Hydrocephaly?
Sutures widely separated head circumference >/= 4 cm more than chest circumference
What can be helpful in easing withdrawal in neonates?
Swaddling Holding Reducing stimula
Nonpharmacologic management of pain in neonates:
Swaddling or snugly wrapping Facilitated tucking Hand-swadding Nonnutritive sucking (NNS) Skin-to-skin contact (kangaroo care) Breastfeeding or breast milk Distraction Sensorial saturation Touch Massage Rocking Holding Environmental modification
What is one of the most common measure of nonpharmacologic pain management in neonates?
Swaddling or snugly wrapping the infant with a blanket
besides the immunogloubins, what else does human milk contain?
T & B lymphocytes Epidermal growth factor Cytokines Interleukins Bifidus factor Compartment (C3 & C4) Lactoferrin
What is sensorial saturation
Technique that uses multiple senses to diminish minor pain involves speaking softly to the infant, massaging the face, and providing oral sucrose solution on the tongue
When should hypothermia be reported to the HCP?
Temp less than 97.7F axillary
What thermal factors are involved in the initiation of respirations in newborns?
Temperature in extrauterine environment is lower -- the profound change in environmental temperates stimulates receptors in the skin, resulting in stimulation of the respiratory center in the medulla
What are signs of infection in newborns?
Temperature instability or hypothermia (most babies do not react with fever) --->100.4/<97.7 Lethargy Irritability Poor feeding Vomiting Diarrhea Decreased reflexes Pale or mottled skin Respiratory distress Unusual discharge (circumcision, cord) Cyanosis Output
Significance of universal newborn screening
The USDHHS recommends screening for 31 core disorders & 21 secondary disorders the majority of disorders included in the screening are not symptomatic at birth
How is the Ortholani maneuver done?
The hip is then checked to determine if the femoral head can be returned into the acetabulum As the hip is abducted and upward leverage is applied, a dislocated hip returns to the acetabulum with a clunk that is felt by the examiner
What is developmental dysplasia of the hips (DDH)?
The hip joint has not formed normally. The ball is loose in the socket and may be easy to dislocate. May not be dislocated at birth
What happens during an exchange transfusion?
The infants blood is replaced with a combination of blood products such as RBCs mixed with 5% albumin or FFP
How does the nurse differentiate hemorrhagic areas from a skin rash or discolorations in newborns?
The nurse attempts to blanch the skin by pressing 2 fingers, lifting fingers off skin, & waiting for return of blood Petechiae & ecchymoses will NOT blanch because extraverted blood remains within the tissues, whereas skin rashes & discolorations will blanch
What is maternal sensitization?
The process of antibody formation in a mom that is Rh negative with an Rh+ baby
When should the infant who is at risk for hypoglycemia first be fed? When should glucose testing be administered?
They should be fed within the first hour, with glucose testing done 30 minutes after feeding
Why are plastic-lined breast pads not recommended when breast feting?
They trap moisture & can contribute to sore nipples
What is hand expression?
This simple technique can actually be more effective than an electric breast pump for expressing colostrum, which tends to be thicker than mature milk Hand expression during the first 3 days after birth can have a positive effect on milk production during the early weeks
Why is a prophylactic agent in the eyes of all neonates recommended?
To prevent ophthalmia neeonatorum or neonatal conjunctivitis, which is an inflammation caused by sexually transmitted bacteria acquired during passage through mother's birth canal
Extrusion reflex
Touch or depress tip of tongue --- newborn forces tongue outward Disappears in month 4-5
Which TORCH infection could be contracted by the infant because the mother owned a cat? Toxoplasmosis Varicella-zoster Parvovirus B19 Rubella
Toxoplasmosis
What is Phrenic nerve injury usually the result of?
Traction on the neck & arm during birth
What could pallor in the immediate post birth period be associated with?
Underlying problems such as anemia or marked peripheral vasoconstriction as a result of intrapartum asphyxia or sepsis
Which statement regarding infant weaning is correct? Weaning should proceed from breast to bottle to cup. The feeding of most interest should be eliminated first. Abrupt weaning is easier than gradual weaning. Weaning can be mother or infant initiated.
Weaning can be mother or infant initiated.
How is the infant placed/situated during phototherapy?
Wearing diaper only 45-50cm from light source Eyes must be protected by opaque mask to prevent retinal damage
What could increase the risk of brachial plexus injuries in birth?
Weight > 4000g Vaginal breech birth Forceps- or vacuum-assisted birth Maternal diabetes Prolonged second stage of labor
Can neonates feel pain?
YES
What is swaddled bathing?
a type of immersion bathing in which the newborn is swaddled in a blanket or towel and immersed in a tub of warm water. One body part at a time is unwrapped and washed
After what age is swaddling not recommended?
after approximately 2 months of age when the infant is capable of rolling over
During each feeding the concentration of fat gradually increases from the lower fat____ to the richer___
foremilk hindmilk
What is thermogenesis?
generation of body heat
What happens to an infants glucose levels once the umbilical cord is cut?
he newborn is cut off from its maternal glucose supply and as a result experiences an initial decrease in serum glucose levels
How does the nurse differentiate hemorrhagic areas from skin rashes & discolorations?
he nurse blanches the skin with two fingers. Because extravasated blood remains within the tissues, petechiae and ecchymoses do not blanch.
The head at term is approximately _____ of the total body length.
one fourth
In the newborn the legs are about ____ of the total body length
one third
Cold stress increases the need for ______ and can deplete ______ stores.
oxygen glucose
What are psychobehavioral concerns related to use of phototherapy?
parent-infant separation potential social isolation decreased sensorineural stimulation altered biologic rhythms altered feeding patterns activity changes
Moro reflex
startle the infant --- extension of arms & legs, fanning of fingers disappears by 1-4 months
Babinski (plantar) reflex
stroke finger up lateral edge & across ball of foot Toes will hyperextend, with dorsiflexion of big toe (positive sign) Last for 1 year
What position should the infant be placed to sleep in?
supine
What is neonatal abstinence syndrome (NAS) characteriezed by?
symptoms of CNS irritability, respiratory distress, GI dysfunction, & autonomic dysfunction
Galbeller (Myerson) reflex
tap over forehead, bridge of nose, or maxilla of newborn whose eyes are open--- new brown blinks for first 4-5 taps Continued blinking with repeated taps is consistent with extrapyramidal signs
Describe evaporation (form of heat loss)
the loss of heat that occurs when a liquid is converted to a vapor In the newborn, heat loss by evaporation occurs as a result of moisture vaporization from the skin
How is the Coombs test done?
the maternal blood serum is mixed with Rh-positive RBCs. If the Rh-positive RBCs agglutinate or clump, this indicates that maternal antibodies are present or that the mother has been sensitized.
What is circumcision?
the removal of all or part of the foreskin (prepuce) of the penis.
In Apgar scoring, how many points are given if there is a slow or weak cry?
1 for respiratory effort
What might purulent discharge from the eyes indicate?
infection
Palmar grasp
offer finger from ulnar side --- infant's fingers curl around the examiner's finger Response lessens by 3-4 months
What is the normal finding when assessing the back of the newborn?
Spine straight & easily flexed Infant able to raise & support head momentarily when prone
What are the 4 major blood groups in the ABO system?
A B AB O
What substances can cause lung irritation in infants?
Baby powder or corn starch
What are signs of Phrenic nerve injury?
Cyanosis Irregular thoracic respirations No abdominal movement on inspiration
What is the pulmonary artery pressure like before birth?
High pressure
What is the normal finding when inspecting the size of the abdomen of the newborn?
Rounded, prominent, dome shaped because abdominal musculature is not fully developed Liver possibly palpable 1-2cm below right costal margin No other masses palpable No distention Few visible veins on abdominal surface
What TO DO when the baby is crying?
• T: Talk quietly to baby in sing-song voice. • O: Observe to see if baby takes self-calming actions: brings his or her hand to his or her mouth, making sucking movements, or moves into the fencing reflex position. • DO: Bring baby's hands to his or her chest; encourage sucking; make gentle "shooshing" sounds; swaddle baby; and/or bring baby skin-to-skin.
What factors contribute to the initiation of respirations in a newborn?
Chemical Mechanical Thermal Sensory
What does the high protein level of colostrum facilitate?
Binding of bilirubin
For at least the first 24 hours after birth, how often should late preterm & SGA neonates feed? When should their glucose levels be measured
Every 2 to 3 hours Measure glucose before each feeding
What laboratory evidence may be noted when the infant is in pain?
Evidence of metabolic or endocrine changes --hyperglycemia --lowered pH --elevated corticosteroids
How can a cold infant progress into hyperbilirubinemia?
Excessive fatty acids are produce due to increased basal metabolic rate These excessive fatty acids can displace the bilirubin form the albumin-binding sites & exacerbate hyperbilirubinemia
When is neonatal BP highest? When does it fall?
Highest immediately after birth Falls to a minimum by 3 hours after birth
What can bruising increase the risk for in infants?
Hyperbilirubinemia
What can result as a cephalhematoma resolves?
Hyperbilirubinemia
____ is a condition in which the total serum bilirubin level in the blood is increased
Hyperbilirubinemia
What types of contraceptives are least likely to affect breastfeeding?
Nonhormonal methods such as the lactational amenorrhea method, natural family planning, barrier methods, & IUDs
what non-pharmacologic methods can be used to enhance pain management during circumcision of newborns?
Nonnutritive sucking! Swaddling
Diet while breastfeeding
Normal diet Continue taking prenatal vitamins
What does it mean if an infant falls asleep while eating?
Normal once they are full & sleepy
If the breastfeeding mother choses to have 1 or 2 drinks, when should she breastfeed?
Not for at least 2 hours
When do infants begin to sweat?
Not for the first 24h By day 3, it begins on the face, then progresses to palms
What should be noted when assessing the newborns thyroid gland?
Not palpable
When does an infant obtain the process of accommodation?
Not present at birth Improves over first 3 months of life
When is the mucosal barrier in the intestines fully mature?
Not until 4-6 months of age
When can the penis be washed with soap after circumcision?
Not until it is healed (5-6 days)
what should be assessed in the infant hasn't voided in the first 24 hours of life?
Notify HCP adequacy of fluid intake, bladder distention, restlessness, & symptoms of pain
How does the infant breath for the first 3 months of age?
Obligate nose breather
An infant weighing 4.1 kg was born 2 hours ago at 37 weeks of gestation. The infant appears chubby with a flushed complexion and is very tremulous. The tremors are most likely the result of: Birth injury. Hypocalcemia. Hypoglycemia. Seizures.
Hypoglycemia
What are infant factors that are possible indications for supplementary feeding?
Hypoglycemia Dehydration Weight loss more than 7% associated with delayed lactogenesis Delayed passage of BM or meconium stool continued to day 3 Poor milk transfer Hyperbilirubinemia
What are early term infants associated with a higher risk for?
Hypoglycemia respiratory problems (respiratory distress syndrome, TTNB) Greater likelihood of NICU admission Increased risk for long-term problems such as learning difficulties (ADHD) Higher neonatal, postnatal, & infant mortality rates
What is facial paralysis (palsy) generally caused by?
Pressure on the facial nerve during birth
What type of hold works well for early feedings?
The modified cradle or across-the-lap hold
What is pain response in infants influenced by?
The painful stimulus Gestational age Biologic factors Behavioral state
In Apgar scoring, how many points are given if the baby is completely pink?
2
In Apgar scoring, how many points are given if there is a cry to reflex irritability?
2
Skin turgor assessment in newborn:
Pinch skin between thumb & forefinger over abdomen & inner thigh
What should the newborns gums look like?
Pink
In Apgar scoring, how many points are given if the baby is blue or pale?
0
In Apgar scoring, how many points are given if there is an absent heart rate?
0
In Apgar scoring, how many points are given if there is an absent respiratory effort?
0
In Apgar scoring, how many points are given if there is flaccid muscle tone?
0
What is the normal finding when assessing the testes of the newborn?
Palpable on each side
What 4 conditions are essential for maintaining an adequate oxygen supply?
1 - Clear airway 2 - Effective establishment of respirations 3 - Adequate circulation, adequate perfusion, & effective cardiac function 4 - adequate thermoregulation
What physiologic adjustment tasks occur during the neonatal period?
1 - Establishing & maintaining respirations 2 - Adjusting to circulatory changes 3 - Regulating temperature 4 - Ingesting, retaining, & digesting nutrients 5 - Eliminating waste 6 - Regulating weight
What are the goals of the management of neonatal pain?
1 - minimize the instability, duration, & physiologic cost of the pain 2 - maximize the neonate's ability to cope with & recover from the pain
Why are formula-fed infants fed less often than breastfed infants?
Because formula takes longer to break down Also, bottle fed babies ear more so they don't need to be fed as often
What may be given to the infant for chlamydial conjunctivitis?
14-day course of oral erythromycin or an oral sulfonamide
During the first few days term infants generally excrete _____ ml/kg/day
15 to 60
How much formula does the infant consume in the first day or so?
15-30mL with each feeding
The postpartum nurse teaches a mother how to give a bath to the newborn infant and observes the mother performing the procedure. Which observation indicates a lack of understanding of the instructions? 1. The mother bathes the newborn infant after a feeding. 2. The mother states that she would gather all supplies before the bath is started. 3. The mother states that she would never leave the newborn infant in the tub of water alone. 4. The mother fills a clean basin or sink with 2 to 3 inches of water and then checks the temperature with her wrist.
1. The mother bathes the newborn infant after a feeding. It is not advisable to bathe a newborn infant after a feeding because handling may cause regurgitation.
Butorphanol tartrate (Stadol) is prescribed for a woman in labor, and the woman asks the nurse about the purpose of the medication. The nurse should make which most appropriate response? 1."The medication provides pain relief during labor." 2."The medication will help prevent any nausea and vomiting." 3."The medication will assist in increasing the contractions." 4."The medication prevents respiratory depression in the newborn infant."
1."The medication provides pain relief during labor."
Why could the fetus die as a result of severe Rh incompatibility?
Because of hydrous fetalis
At what ages do mothers notice increased appetite in formula fed infants? How much should formula increase?
10 days 3 weeks 6 weeks 3 months 6 months Increased formula per feeding by approx. 30mL
What is the average cord separation time?
10-14 days Can take up to 3 weeks
In Apgar scoring, how many points are given if the HR is >100/min
2
Why is circumcision not performed immediately after birth?
Because of the danger of cold stress & decreased clotting factors
Why might a woman report feeling thirsty or very relaxed during breastfeeding?
Because of the hormones prolactin & oxytocin
Why are newborns more prone to regurgitation, vomiting, & GER?
Because of the immaturity of the GI system
What are the 6 states that form the continuum for sleep-wake in infants
2 Sleep states ---Deep sleep ---Light sleep 4 Wake states ---Drowsy ---Quiet alert ---Active alert ---Crying
In Apgar scoring, how many points are given if there is a good cry?
2 for respiratory effort
If the breastfeeding mother smokes, how long should she wait before breastfeeding?
2 hours
How long should you allow cold water to run before collecting it for formula?
2 minutes
When does IgM reach adult levels?
2 years
Measurement at nipple line:
2-3 cm less than head circumference Average = 30-33 cm
When does the second period of reactivity occur? How long does it last?
2-8 hours after birth Lasts from 10mins to several hours
Why are hormonal contraceptives containing estrogen not recommend for breastfeeding mothers?
Because of the potential for reducing milk supply
The nurse in the delivery room is performing an assessment on a newborn to determine the Apgar score. The nurse notes an Apgar score of 6. On the basis of this score, what should the nurse determine? 1.The newborn requires vigorous resuscitation. 2.The newborn is adjusting well to extrauterine life. 3.The newborn requires some resuscitative interventions. 4. The newborn is having some difficulty adjusting to extrauterine life
3.The newborn requires some resuscitative interventions.
A newborn infant of a mother who has human immunodeficiency virus (HIV) infection is tested for the presence of HIV antibodies. An enzyme-linked immunosorbent assay (ELISA) is performed, and the results are positive. Which is the correct interpretation of these results? 1. Positive for HIV 2. Indicates the presence of maternal infection 3. Indicates that the newborn will develop AIDS later in life 4. Positive for acquired immunodeficiency syndrome (AIDS)
2. Indicates the presence of maternal infection
A newborn is delivered via spontaneous vaginal delivery. On reception of the crying newborn, the nurse's priority is to perform which action? 1.Determine Apgar score. 2.Auscultate the heart rate. 3.Thoroughly dry the newborn. 4.Take the newborn's rectal temperature.
3.Thoroughly dry the newborn.
Why is circumcision contraindicated in the presence of hypospadias or epispadias?
Because the foreskin is used to repair these anomalies
How much weight loss is considered safe when breastfeeding?
2.2-4.4 Ibs per month
The nurse is preparing to assist in administering neonatal resuscitation with a ventilation bag and mask because the newborn is apneic, gasping, and has a heart rate below 100 beats/min. The nurse should understand that how many ventilations per minute should be delivered to this neonate? 1.20 to 40 breaths/min 2.40 to 60 breaths/min 3.70 to 80 breaths/min 4.80 to 100 breaths/min
2.40 to 60 breaths/min
The nurse is preparing to check the respirations of a newborn who was just delivered. The nurse performs the procedure and should determine that the respiratory rate is normal if which respiratory rate is noted? 1.A respiratory rate of 20 breaths/min 2.A respiratory rate of 40 breaths/min 3.A respiratory rate of 70 breaths/min 4.A respiratory rate of 80 breaths/min
2.A respiratory rate of 40 breaths/min
Apneic periods longer than ______ indicate a pathologic process and should be evaluated.
20 seconds
How full should the container be filled with breast milk when planing to store it?
3/4 full, allowing space at the top of the container for expansion
What type of needle is used for venipuncture in infants?
23- or 25-gauge butterfly needle or hypodermic needle with a syringe
What is the average time for early feedings?
30-40 minutes or approximately 15-20 minutes per breast As they grow, the length of feedings decreases
When should an infant have their first void?
24 hours
When is the central nervous system well developed?
24 weeks gestation
What size needle is used for infant IM injections?
25-gauge, 5/8-inch needle
What considered normal respiratory rates/patterns for newborns?
30-60 breaths/min May be irregular & shallow 10-15 seconds of apnea are common (<20sec)
Why is it important to place the nipple well inside the baby's mouth when feeding?
Because the infant is unable to move food from the lips to the pharynx
In most healthy newborns, blood glucose levels stabilize at _________ mg/dL during the first hours after birth: 80 to 100 Less than 40 50 to 60 60 to 70
50 to 60
Anterior fontanel characteristics:
3 by 2 cm Diamond Closes by 18 months after birth
How many stools should the breastfead infant have for the first few weeks?
3 stools every 24h
By age _____ in the majority of boys, the foreskin can be retracted easily without causing pain or trauma.
3 years
When does breast milk usually come in?
3-4 days after birth
When should breast-fed infants be seen by a HCP to assess weight gain & offer encouragement & support to the mother?
3-5 days 2-3 weeks
What/when does "milk coming in" occur?
3-5 days after birth Noticeable increase in milk production
Why does the normal newborn have a limited ability to digest fats?
Because they do not have lipase which is necessary for the digestion of fat
The nurse is caring for a post-term, small-for-gestational age (SGA) newborn infant immediately after admission to the nursery. What should the nurse monitor as the priority? 1. Urinary output 2. Total bilirubin levels 3. Blood glucose levels 4. Hemoglobin and hematocrit levels
3. Blood glucose levels
What is the glucose level in most healthy term newborns?
50-60mg/dL during first several hours after birth Within first week they should be approx 60-80mg/dL
What is the pressure like in the left atrium, ventricle, & aorta before & after birth?
Before birth = low After birth = ligh
The nurse is developing a plan of care for a preterm newborn infant. The nurse develops measures to provide skin care, knowing that the preterm newborn infant's skin appears in what way? 1.Thin and gelatinous, with increased subcutaneous fat 2.Thin and gelatinous, with increased amounts of brown fat 3. Reddened, translucent, and gelatinous, with decreased amounts of subcutaneous fat 4. With fine downy hair on thin epidermal and dermal layers, with increased amount of brown fat
3. Reddened, translucent, and gelatinous, with decreased amounts of subcutaneous fat
The nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is most appropriate? 1.Apply gentle pressure. 2.Reinforce the dressing. 3.Document the findings. 4.Contact the health care provider (HCP).
3.Document the findings.
The nurse assisted with the delivery of a newborn. Which nursing action is most effective in preventing heat loss by evaporation? 1.Warming the crib pad 2.Closing the doors to the room 3.Drying the infant with a warm blanket 4.Turning on the overhead radiant warmer
3.Drying the infant with a warm blanket
Normal axillary temperature of infant
36.5-37.5 C 97.7-99.5 F
What is considered "early term"?
37 0/7 through 38 6/7
What is considered "full term"?
39 0/7 through 40 6/7
What temperature is refrigerator milk kept at? How long is it safe to be stored at this temperature?
39F or lower 72 hours = optimal 5-8 days is acceptable
When should HepB vaccine be given in infants of mothers with negative HepB status?
Before discharge from birthing facility
What if the parent notice a fragile baby "spaces out" or "shuts down" when trying to eat?
Bring this baby skin-to-skin and decrease stimulation before resuming feeding.
What apgar score indicates moderate difficulty?
4-6
When is production of adult concentrations of IgG reached?
4-6 years of age
The nurse is providing instructions to a new mother regarding cord care for a newborn infant. Which statement, if made by the mother, indicates a need for further instructions? 1. "The cord will fall off in 1 to 2 weeks." 2. "Alcohol may be used to clean the cord." 3. "I should cleanse the cord two or three times a day." 4. "I need to fold the diaper above the cord to prevent infection."
4. "I need to fold the diaper above the cord to prevent infection."
A nurse employed in a neonatal intensive care nursery receives a telephone call from the delivery room and is told that a newborn with spina bifida (myelomeningocele type) will be transported to the nursery. The maternity nurse prepares for the arrival of the newborn and places which priority item at the newborn's bedside? 1. A rectal thermometer 2. A blood pressure cuff 3. A specific gravity urinometer 4. A bottle of sterile normal saline
4. A bottle of sterile normal saline
The nurse is admitting a newborn infant to the nursery and notes that the health care provider has documented that the newborn has an omphalocele. While performing an assessment, where should the nurse document the location of the viscera in this condition? 1.Inside the abdominal cavity and under the skin 2.Inside the abdominal cavity and under the dermis 3.Outside the abdominal cavity and not covered with a sac 4. Outside the abdominal cavity but inside a translucent sac covered with peritoneum and amniotic membrane
4. Outside the abdominal cavity but inside a translucent sac covered with peritoneum and amniotic membrane
The mother of a 1-month-old infant is bottle-feeding her infant and asks the nurse about the stomach capacity of an infant. What should the nurse tell the client is the stomach capacity of a 1-month-old infant? 1.10 to 20 mL 2.30 to 90 mL 3.75 to 100 mL 4.90 to 150 mL
4.90 to 150 mL
The home care nurse is visiting a mother 1 week after she gave birth to an infant who is at risk for developing neonatal congenital syphilis. After teaching the mother about the signs and symptoms of this disorder, the nurse instructs the mother to monitor the infant for which finding? 1.Loose stools 2.High-pitched cry 3.Vigorous feeding habits 4.A copper-colored skin rash
4.A copper-colored skin rash
The nurse in the labor room measures the Apgar score in a newborn infant and notes that the score is 4. Which action by the nurse has highest priority? 1.Initiate an intravenous (IV) line on the newborn infant. 2.Place the newborn infant on a cardiorespiratory monitor. 3.Place the newborn infant in the radiant warmer incubator. 4.Administer oxygen via resuscitation bag to the newborn infant.
4.Administer oxygen via resuscitation bag to the newborn infant.
Adverse reactions to the HepB vaccine
Common adverse reactions are rash, fever, erythema, swelling, and pain at the injection site.
The nurse is assessing a newborn infant with a diagnosis of hiatal hernia. Which findings would the nurse most specifically expect to note in the infant? 1.Excessive oral secretions 2.Bowel sounds heard over the chest 3.Hiccups and spitting up after a meal 4.Coughing, wheezing, and short periods of apnea
4.Coughing, wheezing, and short periods of apnea
What is considered "postterm"?
42 0/7 and beyond
How long after preparing a formula bottle can it be stored before using?
48 hours
When does breast milk jaundice usually occur?
5-10 days of age
Fruit juices are not recommended before what age?
6 monthis
infants should be exclusively breastfed for ________, receive safe and nutritionally adequate complementary foods beginning at ______, and continue breastfeeding until age _______
6 months 6 months 2 or beyond.
How many formula feedings do most newborns need in 24 hours?
6-8
What apgar score indicates a stable baby?
7-10
What does fetal exposure to SSRIs in the 3rd trimester predispose the neonate to?
A behavioral syndrome resembling NAS
What might suggest testicular torsion in a male infant?
A bluish discoloration of the scrotum
What CRIES score is considered significant?
A score greater than 4
What is a simian line?
A single palmar crease Often seen in Asian infants & infants with Down Syndrome
When does physiologic jaundice begin?
After 24h
What should the nurse teach the patient who is tandem nursing?
Always feed the infant first to ensure that he or she is receiving adequate nutrition
What are the nursing interventions for the following nursing diagnosis in the newborn: Ineffective airway clearance r/t excess mucus production or improper positioning
Assess respiration & osculate lungs -- observe for signs of respiratory distress -- teach parents that gagging, coughing, & sneezing are NORMAL neonatal responses Teach parents feeding techniques that prevent overfeeding & distention of the abdomen & to burp neonate frequently Position neonate on back when sleeping Suction mout & naospharynx with bulb syringe PRN -- clean nares of crusted secretions
Route of temperature measurement in infant
Axillary
What occurs during the first period of reactivity?
Bonding; establish breast feeding HR increases rapidly to 160-180 bpm, but gradually falls after 30min or so to a baseline rate of 100-120bpm Respirations = irregular RR = 60-80 Fine crackles may be present Audible grunting, nasal flaring, & chest retractions may occur --- should cease within 1st hr of birth Infant is alert & may have spontaneous startles, tremors, crying, & head movement side-to-side Bowel sounds are audible
What is considered "postmature"?
Born after completion of week 42 gestation & showing the effects of progressive placental insufficiency
Which of the following would be considered to be an intrapartum risk factor for neonatal sepsis? Mechanical ventilation Chorioamnionitis Galactosemia Meconium aspiration
Chorioamnionitis
What might the vagal nerve tone appear like when the infant is in pain?
Decreased
What interventions are taken to prevent heat loss in infants?
Drying infant Skin-to-skin with mother Swaddling Radiant warmer!
When can maternal sensitization occur?
During pregnancy Birth Miscarriage Induced abortion Amniocentesis External cephalic version Trauma
What does the laxative action of colostrum facilitate?
Early passage of meconium
Preterm infants are more likely to become septic because: IgG and IgA levels are adequate at birth. Immune function is suppressed because of increased IgG levels. IgG level is directly proportional to gestational age. Serum complement levels are adequate.
IgG level is directly proportional to gestational age.
What type of breast pumps most closely duplicate the sucking action & pressure of the breastfeeding infant?
Full-service electric pumps, or hospital-grade pumps
what to look for when assessing the female infants genitalia
General appearance Clitoris Labia majora Labia minora Discharge Vagina Urinary meatus Check urination
What to include in the assessment of the male genitalia:
General appearance Penis Urinary meatus appearance Prepuce Scrotum (Rugae) Testes Check urination Check reflexes Cremasteric
Treatment for Nevi?
None --no clinical significant
What must the nurse do prior to administering the HepB vaccine in infants?
Obtain parental consent Note mothers HepB status
What position should the infant lay in when swaddled?
On back
How often should the infants hair be shampooed?
Once or twice a week
How is banked milk dispensed?
Only by prescription Per-ounce fee is charged by the bank to pay for processing costs Donors are not paid
What is CRIES an acronym for?
The physiologic & behavioral indicators of pain Crying Requiring increased oxygenation Increased vital signs Expression Sleeplessness
If a breastfed infant develops jaundice, what should the be evaluated carefully for?
Weight loss > 7% Decreased milk intake Infrequent stooling (<3/day) Decreased urine output (<4-6/day)
When does weight loss after birth need to be investigated?
Weight loss of more than 7% in a breastfeeding infant during the first 3 days of life
When is weaning initiated?
When babies are introduced to foods other than breast milk It concludes with the last breastfeeding
What is the normal finding when assessing the labia minora of the newborn?
possible protrusion over labia majora
How can a parent prepare the baby to sleep?
swaddling may help; feed in quiet, dark room at night and active, light environment during day.
When do term infants pass meconium?
within first 12-24 hours of life almost all do by 48 hours
Which would be considered a normal finding in a newborn less than 12 hours old? 1.Grunting respirations 2.Heart rate of 190 beats/min 3.Bluish discoloration of the hands and feet 4.A yellow discoloration of the sclera and body
3. Bluish discoloration of the hands and feet
What should be established during the first period of reactivity, before the period of decreased responsiveness occurs?
Breastfeeding
What could persistent bradycarda in an infant be associated with?
Congenital heart block hypoxemia
What are the RBC, hemoglobin, & hematocrit levels like at birth?
Higher than adults because more was needed in utero for transport of oxygen These levels fall slowly over the first month
List some signs of cardiovascular distress in newborns
cyanosis <95% tachycardia bradycardia
What are the benefits of delayed cord clamping(>2min after birth)?
expands the blood volume from the so-called placental transfusion of blood to the newborn improving hematocrit and iron status and decreasing anemia; such benefits can last up to 6 months risk of intraventricular hemorrhage is significantly reduced in preterm infants when cord clamping is delayed Transitional circulation is improved, red blood cell volume is better established, and there is a reduced need for blood transfusion
Next to establishing respirations and adequate circulation, ______ is most critical to the newborn's survival.
heat regulation
In Apgar scoring, how many points are given if the HR is less than 100/min?
1
What is the McRobert's maneuver?
hyperflexing mother's legs tightly to the abdomen
In Apgar scoring, how many points are given if the baby is pink with blue extremities?
1
In Apgar scoring, how many points are given if there is grimace?
1
In Apgar scoring, how many points are given if there is some flexion of extremities?
1
_____ is most often related to delayed elimination of bilirubin, with or without increased production
late-onset jaundice
What temperature is freezer milk kept at? How long is it safe to be stored at this temperature?
less than 24F 6 months optimal 12 months acceptable
When should decreased BMs be reported to the HCP?
in a breastfed infant, fewer than three stools per day; in a formula-fed infant, less than one stool every other day
Where does jaundice first appear in the infant
in the face
If the infant is weaned before 1 year of age, what should they receive?
iron-fortified formula instead of cow's milk
What is physiologic jaundice?
it is a normal hyperbilirubinemia in neonates Occurs on the 3rd or 4th day due to increased RBCs Does not exceed 12mg/dL Does not appear in first 24h
What are the risk factors for intracranial hemorrhage in infants?
vacuum- or forceps-assisted birth precipitous or prolonged second stage of labor increased fetal size
What is lanugo?
Fine hairs May be noted over face, shoulders, & back
What is syndactyly?
Fingers or toes being fused
Crib safety
Firm mattress Prone No crib bumpers Don't cover with blankets Slats should be no more than 2¼ inches apart. The space between the mattress and sides should be less than 2 fingerwidths. The bedposts should have no decorative knobs.
What are parents encouraged to dress their infant in at all times?
Flame-retardant clothing
Measurement of infants length
Flat surface with extended legs normal = 45-55cm
What is the posture of a newborn like?
Flexion of the arms at the elbows Flexion of the legs at the knees Hips abducted & partially flexed Intermittent fisting of hands is common
What are the 4 traditional positions for breastfeeding?
Football or clutch hold (under the arm) Modified cradle Cross-cradle or across the lap Cradle Side-lying
What to observe for after any venipuncture
For an hour, observe frequently for evidence of bleeding or hematoma formation at puncture site
What could cause a subgaleal hemorrhage?
Forces that compress & then drag the head through the pelvic outlet (mid forceps birth & vacuum extraction)
What are the male infants external genitalia like?
Foreskin or prepuce completely covers the glans Urethra should be at tip of penis Rugae cover scrotal sac by 40 weeks gestation Feel for descended testicles
What can occur during the birth of a macrosomic infant?
Fractured clavicle
What are formula-fed infants milk stools' like?
Stools pale yellow to light brown, firmer consistency, with a more offensive odor
What are breastfed infants milk stools' like?
Stools yellow to golden, pasty in consistency; resemble a mixture of mustard and cottage cheese, with an odor similar to sour milk
Once the infant is latched on and sucking, what are signs that indicate the feeding is going well?
(1) the mother reports a firm tugging sensation on her nipple but feels no pinching or pain; (2) the baby sucks with cheeks rounded, not dimpled; (3) the baby's jaw glides smoothly with sucking; (4) swallowing is usually audible
In Apgar scoring, how many points are given if there is no responses to reflex irritability?
0
What Apgar score indicates severe distress?
0-3
How could a mother relieve the discomfort of breast engorgement?
Can take mild analgesics such as ibuprofen Wear supportive bra Apply ice packs or cabbage leaves to breasts Pump small amounts if needed (avoid pumping if possible because the breasts should remain full enough to promote a decrease in milk supply)
What behavioral tasks occur during the neonatal period?
1 - Establishing a regulated behavioral tempo independent of mother-- involves self-regulating arousal, self-monitoring changes in state, & patterning sleep 2 - Processing, storing, & organizing multiple stimuli 3 - Establishing a relationship with caregivers & the environment
Neonatal dosage of eye prophylaxis
1- to 2-cm ribbon of ointment to the lower conjunctival sac of each eye; can also be used in drop form
The mother of a newborn calls the clinic and reports that when cleaning the umbilical cord, she noticed that the cord was moist and that discharge was present. What is the most appropriate nursing instruction for this mother? 1.Bring the infant to the clinic. 2.This is a normal occurrence. 3.Increase the number of times that the cord is cleaned per day. 4.Monitor the cord for another 24 to 48 hours and call the clinic if the discharge continues.
1.Bring the infant to the clinic.
In Apgar scoring, how many points are given if there are well flexed extremities?
2
How longer are feedings withheld before circumcision? Why?
2-3 hours before to prevent vomiting & aspiration
When does breastfeeding-associated jaundice usually begin?
2-5 days of age
A nurse is teaching the mother of a newborn infant measures to maintain the infant's health. The nurse identifies which as an example of primary prevention activities for the infant? 1.Selective placement of the infant 2.Periodic well-baby examinations 3.Phenylketonuria (PKU) testing at birth 4.Administration of an antibiotic for an umbilical cord staphylococcal infection
2. Periodic well-baby examinations
A client who is positive for human immunodeficiency virus (HIV) delivers a newborn infant. The nurse provides instructions to help the client regarding care of her infant. Which client statement indicates the need for further instruction? 1."I will be sure to wash my hands before and after bathroom use." 2."I need to breast-feed, especially for the first 6 weeks postpartum." 3."Support groups are available to assist me with understanding my diagnosis of HIV." 4."My newborn infant should be on antiviral medications for the first 6 weeks after delivery."
2."I need to breast-feed, especially for the first 6 weeks postpartum."
The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with this syndrome? 1.Length of 19 inches 2.Abnormal palmar creases 3.Birth weight of 6 lb, 14 oz 4.Head circumference appropriate for gestational age
2.Abnormal palmar creases
How long can thawed milk be stored in the refrigerator?
24 horus
What injury could develop in the infant as a result of pressure on the fetal head pushing through the dilated cervix?
Caput succdaneum & cephalhematoma
What type of injury can be found on the scalp of the infant?
Caput succedaneum Subgaleal hemorrhage Cephalhematoma
When does engorgement usually occur?
3-5 days after birth when the milk "comes in"
How long should pressure be maintained over arterial or femoral vein punctures in infants?
3-5 minutes
The nurse has provided instructions about measures to clean the penis to a mother of a male newborn who is not circumcised. Which statement, if made by the mother, indicates an understanding of how to clean the newborn's penis? 1. "I should retract the foreskin and clean the penis every time I change the diaper." 2. "I need to retract the foreskin and clean the penis every time I give my infant a bath." 3. "I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions." 4. "I should gently retract the foreskin as far as it will go on the penis and then pull the skin back over the penis after cleaning."
3. "I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions." In male newborn infants, the prepuce is continuous with the epidermis of the glans and is not retractable. If retraction is forced, this may cause adhesions to develop. The mother should be told to allow separation to occur naturally, which usually occurs between 3 years and puberty. Most foreskins are retractable by 3 years of age and should be pushed back gently at this time for cleaning.
The nurse in the newborn nursery is preparing to complete an initial assessment on a newborn infant who was just admitted to the nursery. The nurse should place a warm blanket on the examining table to prevent heat loss in the infant caused by which method? 1.Radiation 2.Convection 3.Conduction 4.Evaporation
3.Conduction
Which medication should the nurse plan to administer to a newborn by the intramuscular (IM) route? 1.Erythromycin 2.Tetracycline 1% 3.Phytonadione (Vitamin K) 4. Measles-mumps-rubella vaccination
3.Phytonadione (Vitamin K)
What is considered "late preterm"?
30 0/7 through 36 6/7
What manifestations are associated with esophageal & trachoesophageal anomalies in infants?
Change in color, gagging & projectile vomiting
The nurse prepares to administer a vitamin K injection to a newborn, and the mother asks the nurse why her infant needs the injection. What best response should the nurse provide? 1. "Your newborn needs vitamin K to develop immunity." 2. "The vitamin K will protect your newborn from being jaundiced." 3. "Newborns have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel." 4. "Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding."
4. "Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding."
What changes in state may be noted when the infant is in pain?
Changes in sleep-wake cycles Changes in feeding behavior Changes in activity level Fussiness, irritability Listlessness
What is considered "late term"?
41 0/7 through 41 6/7
What is caput succedaneum?
A generalized, easily identifiable edematous area of the scalp, most commonly found on the occiput Extends across suture lines of the skull Usually disappears spontaneously with 3-4 days Caused by pressure on presenting part (like with vacuum extraction)
Late-onset jaundice or breast milk jaundice affects a small number of breastfed infants and develops between _____ of age
5 and 10 days
What temperature is room temperature milk kept at? How long is it safe to be stored at this temperature?
60-85F 3-4hours optimal 6-8 hours acceptable
What is the temperature that a nursery should be kept at?
75.2 F
What should the temp be at in the infants bedroom to prevent heat loss?
79-81
In utero the glucose concentration in the umbilical vein is approximately ___% of the maternal level
80%
When do Jewish individuals commonly perform circumcision?
8th day after birth at home in ceremony called bris
What is considered tachypnea in newborn?
>60 respiration's/min
Concerning congenital abnormalities involving the central nervous system, nurses should be aware that: Although the death rate from most congenital anomalies has decreased over the past several decades, that from neural tube defects (NTDs) has gone up in the last few years. Spina bifida cystica usually is asymptomatic and may not be diagnosed unless associated problems are present. A major preoperative nursing intervention for a neonate with myelomeningocele is to protect the protruding sac from injury. Microcephaly can be corrected with timely surgery.
A major preoperative nursing intervention for a neonate with myelomeningocele is to protect the protruding sac from injury.
What is a cephalhematoma?
A collection of blood between a skull bone & its periosteum Does not cross a cranial suture line Firmer & more well defined than a caput Usually resolves in 2-8 weeks
The maternity nurse must be cognizant that cultural practices have significant influence on infant feeding methods. Many regional and ethnic cultures can be found within the United States. One cannot assume that generalized observations about any cultural group will hold for all members of the group. Which statement related to cultural practices influencing infant feeding practice is correct? A common practice among Mexican women is known as las dos cosas. Muslim cultures do not encourage breastfeeding because of modesty concerns. Latino women born in the United States are more likely to breastfeed. East Indian and Arab women believe that cold foods are best for a new mother.
A common practice among Mexican women is known as las dos cosas.
What happens if the infant does not pass the hearing screening test after repeated follow-ups?
A comprehensive audiologic evaluation should be done by 3 months of age
When does desquamation of the skin of a term infant occur?
A few days after birth
What is the flange (breast pump)?
A funnel-shaped device that fits over the nipple or area It should fit the nipple to prevent nipple pain, trauma, & possible reduction in milk supply
Which statement is accurate regarding the ABO blood typing system in the body? If you have type O blood, then you have antigens. If you have type AB blood, then you have antibodies. A person with type O blood has no antibodies. A person with type O blood has antibodies to type A and type B.
A person with type O blood has antibodies to type A and type B.
What is nervous flames?
A port-wine stain usually visible at birth and is due to an asymmetric postcapillary venule malformation.
What is a coombs test?
A screening tool for Rh incompatibility
What is done after circumcision is completed?
A small petrolatum gauze dressing is applied to the penis for the first 24h After, parents are instructed to apply petrolatum to keep the penis from adhering to the diaper
What is a nevus vascularis?
A strawberry hemangiona It consists of dilated newly formed capillaries occupying the entire dermal and subdermal layers with associated connective tissue hypertrophy Common in female infants Usually fade or shrink over time
What is "reverse pressure softening"?
A technique that manually displaces the areolar interstitial fluid 624inward, softening the areola and making it easier for the infant's mouth to grasp the nipple and areola with latch
What do many women report feeling in the breasts as milk ejection occurs?
A tingling "pins & needles" sensation
What is the most common behavioral sign of pain?
A vocalization or crying, ranging from a whimper to a distinctive high-pitched, shrill cry
Is it okay to drink alcohol when breastfeeding?
AAP Section on breastfeeding recommends that alcohol intake is minimal Should be limited to occasional consumption of less that 0.5g/kg of body weight (e.g., 8 oz wine or 2 beers)
What are the most common hemolytic diseases of the newborn?
ABO incompatibility Rh factor incompatibility
What is a Nevi?
AKA salmon patches, telagiectatic nevia, or "stork bites" or "angel kisses" Are the result of a superficial capillary defect Small, flat, pink, & easily blanched
What measures are taken to control infection in newborn nurseries?
Adequate floor space to permit the positioning of bassinets at least 3 feet apart in all directions Hand hygiene facilities Areas for cleaning & storing equipment & supplies Only specified personnel directly involved in the care of mothers and infants are allowed in these areas, thereby reducing the opportunities for the transmission of pathogenic organisms.
What is a sign of good anal sphincter tone?
An active rectal "wink" reflex (contraction of the anal sphincter muscle in response to touch)
_______ is essential in preventing hyperbilirubinemia
Adequate feeding
What could result from a subgaleal hemorrhage?
Anemia Hypovolemic shock Death
When does the fetus become covered in vernix?
After 35 weeks gestation
When is it recommended to initiate pumping?
After the milk supply is well established & the infant is latching & breastfeeding well
What factors can predispose infants to birth injuries?
Age <16 Age >35 Primigravida uterine dysfunction that leads to prolonged or precipitous labor Cephalopelvic disproportion Oligohydramnios Multifetal gestation Abnormal/difficult presentation Internal fetal monitoring of FHR Obstetric birth techniques Forceps- or vacuum-assisted birth Cesarean birth
In caring for a mother who has abused (or is abusing) alcohol and for her infant, nurses should be aware that: The pattern of growth restriction of the fetus begun in prenatal life is halted after birth, and normal growth takes over. Two thirds of newborns with fetal alcohol syndrome (FAS) are boys. Alcohol-related neurodevelopmental disorders (ARNDs) not sufficient to meet FAS criteria (learning disabilities, speech and language problems) are often not detected until the child goes to school. Both the distinctive facial features of the FAS infant and the diminished mental capacities tend toward normal over time.
Alcohol-related neurodevelopmental disorders (ARNDs) not sufficient to meet FAS criteria (learning disabilities, speech and language problems) are often not detected until the child goes to school.
What are the nursing interventions for the following nursing diagnosis in the newborn: Readiness for Enhanced Family Coping related to anticipatory guidance regarding responses to neonate's crying
Alert parents to crying as neonate's form of communication & that cries can be differentiated to indicate hunger, wetness, pain, & loneliness Teach parents normal patterns of infant crying & alert them to the danger of shaking a baby Differentiate self-consoling behaviors from fussing or crying Discuss methods of consoling the crying neonate, such as changing diapers, talking softly, holding neonates arms close to body, swaddling, picking up neonate, rocking, using pacifier, feeding , or burping
An examiner who discovers unequal movement or uneven gluteal skinfolds during the Ortolani maneuver: Tells the parents that one leg may be longer than the other, but they will equal out by the time the infant is walking. Alerts the physician that the infant has a dislocated hip. Informs the parents and physician that molding has not taken place. Suggests that if the condition does not change, surgery to correct vision problems might be needed.
Alerts the physician that the infant has a dislocated hip.
Who should have current infant CPR certifications?
All personnel working with infants Parents should receive instruction in relieving airway obstruction & CPR Babysitters should learn CPR
What is the treatment for mastitis?
Antibiotics such as cephalexin or dicloxacillin for 10-14 days & analgesic & antipyretic mediations such as ibuprofen
What is used as the initial assessment of the neonate & when is it performed?
Apgar score 1 minute after birth 5 minutes after birth Repeat at 10 minutes if score is <7
Which factors predispose an infant to birth injuries? (Select all that apply.) Multip between the ages of 25 and 30 Vertex presentation Application of an internal fetal scalp electrode Vacuum-assisted birth
Application of an internal fetal scalp electrode Vacuum-assisted birth
What do you do if bleeding occurs at the circumcision site?
Apply gentle pressure with a folded sterile gauze pad Hemostatic agent such as Gelfoam powder or sponge can be applied to help control bleeding Blood vessel may need to be ligated if bleeding is not easily controlled --- notify HCP & prepare necessary equipment while another nurse maintains intermittent pressure until HCP arrives
How do you differentiate cutaneous jaundice from normal skin color?
Apply pressure with finger over bony area for several seconds to empty all the capillaries in the spot, then release pressure by lifting finger If jaundice is present, the blanched area will appear yellowish before the capillaries refill Conjunctival sacs & buccal mucosa are assessed
When/how is identification of the baby acquired after birth?
As soon as possible after birth Identically numbered bands placed on infants wrist & ankle, on mother, & on father or significant other
How long before circumcision can EMLA cream be applied?
At lease 1 hour before
With demand feeding, how many times should the infant feed in 24h?
At least 8
How many times should a newborn breastfeed in a 24-hour period?
At least 8-12 times
How often should parents wake the baby to feed?
At least q3h during day At least q4h at night
When should pacificer use be used?
At nap time or sleep time after breastfeeding is well established at about 3-4 weeks of age
How is hip integrity of the newborn assessed?
Barlow test! Ortolani maneuver
Why is newborn screening not commonly discussed with parents before birth?
Because in the majority of states informed consent is not required for newborn screening
Where is the urethral opening located in a female infant?
Behind the clitoris
What is the normal finding when assessing the urinary meatus of the newborn female?
Beneath clitoris, difficult to see
When do glucose levels reach a low point after birth?
Between 30 & 90 minutes after birth
What is the neonatal period? (time frame)
Birth through day 28
What are Mongolian spots?
Bluish black areas of pigmentation (hyper pigmentation) May look like bruises Commonly located on back & buttocks occur more frequently in Latin Americans, Asians, American Indians, Africans They fade gradually over months or years
What can increased the amount of milk obtained during pumping?
Breast massage before & during pumping
What could the woman wear to help promote comfort if her nipples are sore?
Breast shells worn inside her bra these devices allow air to circulate while keeping clothing off sore nipples
Which statement is not accurate regarding the effect of breastfeeding on the family or society at large? Breastfeeding requires fewer supplies and less cumbersome equipment. Breastfeeding saves families money. Breastfeeding costs employers in terms of time lost from work. Breastfeeding benefits the environment.
Breastfeeding costs employers in terms of time lost from work.
What are the two forms of breastfeeding-related jaundice?
Breastfeeding-associated jaundice Breastmilk jaundice
What is cluster-feeding?
Breasting feeding every hour or so for 3-5 feedings & then sleeping for 3-4 hours between clusters
What occurs during the second period of reactivity?
Brief periods of tachycardia & tachypnea Increased muscle tone Changes in skin color Mucus production Meconium is passed
What are breath sounds often like in newborns?
Bronchial Loud, clear May have crackles after birth! Shallow & irregular ~40/min
What is often seen along with presence of a caput succedaneum?
Bruising of the scalp
What teaching should be included for suctioning with a bulb in an infant?
Bulb syringe should always be kept in the infant's crib MOUTH IS SUCTIONED FIRST to prevent the infant from inhaling pharyngeal secretions by gasping as the nares are touched The bulb is compressed & the tip is inserted into one side of mouth. Center of infant's mouth is avoided because of gag reflux Nasal passages are suctioned one nostril at a time When the infant's cry doesn't sound as though it is through mucus or a bubble, suctioning can be stopped
How should the mother prepare for latch?
By manually placing a few drops of colostrum or milk & spreading it over nipple This action lubricates the nipple & entices the baby to open the mouth as the milk is tasted
How do you warm refrigerated formula?
By placing the bottle in a pan of hot water Test by letting a few drops on inside of wrist
A nurse must administer erythromycin ophthalmic ointment to a newborn after birth. The nurse should: Instill within 15 minutes of birth for maximum effectiveness. Cleanse eyes from inner to outer canthus before administration if necessary. Apply directly over the cornea. Flush eyes 10 minutes after instillation to reduce irritation.
Cleanse eyes from inner to outer canthus before administration if necessary.
Which finding supports the diagnosis of pathologic jaundice? Serum bilirubin concentrations greater than 2 mg/dL in cord blood Serum bilirubin levels increasing more than 1 mg/dL in 24 hours Serum bilirubin levels greater than 10 mg/dL in a full-term newborn Clinical jaundice evident within 24 hours of birth
Clinical jaundice evident within 24 hours of birth
What could generalized petechiae in a newborn indicate?
Clotting factor deficiency Infection
How could a cold infant lead to metabolic acidosis? (sequence of events)
Cold Increased oxygen consumption Increased RR (leads to peripheral vasoconstriction too) Decreased O2 uptake by lungs Decreased O2 in tissues Increased anaerobic glycolysis Decreased in PO2 & pH Metabolic acidosis
What causes depletion of brown fat?
Cold stress
______ acts as a laxative to promote stooling, which helps rid the body of bilirubin
Colostrum
What type of milk does the baby receive for the first 2-3 days after birth? What is significant about it?
Colostrum It is rich in antibodies & higher in protein but lower in fat than mature milk
What is breast milk expression?
Common practice, typically performed to obtain breast milk for someone other than the mother to feed to the baby Associated with maternal employment Sometimes necessary or desirable when engorgement occurs, when nipples or sore or damaged, when mother & baby are separated (preterm infant after mom is discharged)
What is erythroblastosis fetalis?
Condition where the fetus compensations for anemia caused by Rh compatibility by producing large numbers of immature RBCs to replace those hemolyzed
A nurse is performing a pulse oximetry reading on a newborn to test for: PKU. Congenital heart disease. Sickle cell disease. Thalassemia.
Congenital heart disease.
What are the 4 modes of heat loss in infants?
Convection Radiation Evaporation Conduction
What is the key to preventing sore nipples when breastfeeding?
Correct technique
How many stools may formula-fed infants have after the first week of life?
Could be as few as 1 every other day
What might be suggested if the urethral opening is not located behind the clitoris?
Could be suggested that the clitoris is a small penis, which can occur in conditions such as adrenal hyperplasia
Manifestations of the hypoglycemic infant:
Could have complete absence of symptoms Jitteriness Lethargy Apnea Feeding problems Seizures Hypotonic Hypothermia Respiratory distress
How is feeding frequency measured?
Counting from the beginning of one feeding to the beginning of the next
What can affect the results of arterial punctures for blood gas studies?
Crying Fear Agitation
What vocalizations may be noted when the neonate is in pain?
Crying Whimpering Groaning
With regard to the respiratory development of the newborn, nurses should be aware that: Crying increases the distribution of air in the lungs. Newborns must expel the fluid at uterine life from the respiratory system within a few minutes of birth. Newborns are instinctive mouth breathers. Seesaw respirations are no cause for concern in the first hour after birth.
Crying increases the distribution of air in the lungs.
The healthcare provider is reviewing the laboratory results of a woman in her second trimester of pregnancy. Which of the following are expected results for this patient? Select all that apply. Increased red blood cell count Decreased hemoglobin Decreased mean corpuscular hemoglobin Increased fibrinogen Decreased hematocrit Increased white blood cell count
Decreased hemoglobin Increased fibrinogen Decreased hematocrit Increased white blood cell count
What can the pain response system in neonates cause?
Decreased tidal volume Increased demands on cardiovascular system Increase metabolism Neuroendocrine imbalances
What are possible positive benefits of leaving vernix intact after birth?
Decreasing skin pH Decreasing skin erythema Improving skin hydration
What to include in the assessment of the newborns extremities
Degree of flexion ROM Symmetry of motion Muscle tone Color Intactness Appropriate placement Number of digits Evaluate joints (shoulder, elbow, wrist, fingers) Palpate clavicles Assess femoral pulses
If the baby is breastfeeding, when can pacifier use begin?
Delay it for 3-4 weeks to ensure that breastfeeding is well established
What are mother factors that are possible indications for supplementary feeding?
Delayed lactogenesis Intolerable pain during feedings Previous breast surgery (augmentation or reduction)
What often results in a clavicular fracture in the infant?
Difficult delivery of the shoulders with a vaginal birth Extension of the arms in a breech position Vacuum-assisted birth Birth weight > 4000g
When should breathing difficulties be reported to the HCP?
labored breathing with flared nostrils or absence of breathing for more than 15 seconds (Note: A newborn's breathing is normally irregular and between 30 to 40 breaths/min. Count the breaths for a full minute.)
How does the nurse know where to perform a heelstick on an infant?
Draw an imaginary line from between the 4th & 5th toes & parallel to the lateral aspect of the foot to the heel, where the puncture is made
Which factor increases the risk of complications for infants of diabetic mothers? Glycemic control Hemoglobin A1c level of 7 Duration of maternal disease Hemoglobin A1c level of 7 prior to pregnancy
Duration of maternal disease
What if the mom who is Rh- has already had an Rh+ child & is pregnant with a second Rh+ child?
During the first pregnancy, the mom becomes sensitized but doesn't produce enough antibodies to cause lysis (destruction) of fetal blood cells During subsequent pregnancies, antibodies form in response to repeated contact with the antigen from the fetal blood, & lysis of fetal RBCs results
When should you discuss the option of circumcision with a mother?
During the prenatal period
What could indicate thrombocytopenic purport in an infant?
Ecchymoses & petechiae that doesn't disappear spontaneously in 2 days
What should the cord stump & base of the cord be assessed for with each diaper change?
Edema Redness Purulent drainage
What might be noted about the skin in an infant that was delivered with a face presentation, forceps assisted birth, or vacuum extraction?
Edema of face Ecchymosis or petechiae
The healthcare provider is caring for a woman during the birth of her baby. As the fetal head is delivered, the healthcare provider notes that the head retracts against the mother's perineum ("turtle sign"). What actions will the healthcare provider implement? Select all that apply. Attempt delivery with forceps Empty the woman's bladder Ask the woman to begin pushing Flex the woman's thighs against her abdomen Apply fundal pressure Call for assistance
Empty the woman's bladder Flex the woman's thighs against her abdomen Call for assistance
The birth weight of a breastfed newborn was 8 lb, 4 oz. On the third day the newborn's weight is 7 lb, 12 oz. On the basis of this finding, the nurse should: Encourage the mother to continue breastfeeding because it is effective in meeting the newborn's nutrient and fluid needs. Suggest that the mother switch to bottle feeding because breastfeeding is ineffective in meeting newborn needs for fluid and nutrients. Notify the physician because the newborn is being poorly nourished. Refer the mother to a lactation consultant to improve her breastfeeding technique.
Encourage the mother to continue breastfeeding because it is effective in meeting the newborn's nutrient and fluid needs. --- 10% of less weight loss is acceptable in first 3-5 days --- assess breastfeeding success if it is more than 10% to 15% (would be r/t growth failure or dehydration)
_____ is the result of injury to the upper plexus involving nerves C5 and C6 caused by stretching or pulling the head away from the shoulder during a difficult birth.
Erb-Duchenne paralysis or palsy
What are considered effective preventive medications for eye prophylaxis in newborns?
Erythromycin 0.5% ophthalmic ointment Tetarcycline 1% ointment Silver nitrate 1% solution
Following a vaginal delivery, the patient tells the nurse that she intends to breastfeed her infant but she is very concerned about returning to her prepregnancy weight. On the basis of this interaction, the nurse would advise the patient that: (Select all that apply.) She should join Weight Watchers as soon as possible to ensure adequate weight loss. Even though more calories are needed for lactation, typically women who breastfeed lose weight more rapidly than women who bottle feed in the postpartum period. Weight loss diets are not recommended for women who breastfeed. If breastfeeding, she should regulate her fluid consumption in response to her thirst level. If she decreases her calorie intake by 100-200 calories a day she will lose weight more quickly.
Even though more calories are needed for lactation, typically women who breastfeed lose weight more rapidly than women who bottle feed in the postpartum period. Weight loss diets are not recommended for women who breastfeed. If breastfeeding, she should regulate her fluid consumption in response to her thirst level.
____ means that the infant receives no other liquid or solid food
Exclusive breastfeeding
Why is the newborn at risk for hyperbilirubinemia?
Higher RBC mass at birth & shorter life span of neonatal RBCs mean that there is a need for greater bilirubin synthesis e ability of the liver to conjugate bilirubin is reduced during the first few days after birth; it can metabolize and excrete only about two thirds of the circulating bilirubin
Vision at birth
Eye is structurally incomplete, & muscles are immature Pupils react to light, blink reflex is stimulated easily, & corneal reflex is activated by light touch Can see as far as 50 cm away Clearest visual distance is 8-12 inches Prefer black & white colors
Where are Nevi most commonly located?
Eyelids Nose Upper lip Nape of neck
Swallowing reflex
Feed infant -- swallowing usually follows sucking & obtaining fluids
What is important in reducing serum bilirubin levels? Why?
Feeding because it stimulates peristalsis and produces more rapid passage of meconium, thus diminishing the amount of reabsorption of unconjugated bilirubin.
What peripheral pulses should be assessed in the newborn?
Femoral! Brachial Popliteal! Posterior tibial
What are some herbal galactagogues?
Fenugreek Blessed thistle goat's rue Shatavari
Intrauterine growth restriction (IUGR) definition
Fetus is below the 10th% for weight given at a certain gestational age.
Signs of illness in an infant that parents should know/notify HCP
Fever Hypothermia Foor feeding or little interest in food Vomiting Diarrhea Decreased BM Decreased urination Bathing difficulties Cyanosis Lethargy Inconsolable crying or continuous high-pitched cry Bleeding or purulent drainage form umbilical cord or circumcision; foul oder or redness at site Drainage from eyes
What could repeated trauma to the walking surface of the heel cause (related to heelsticks)?
Fibrosis & scarring that can lead to problems with walking later in life
Treatment for clavicle fracture in infant
Gentle handeling Immobilization (slings, splints, swaddling)
How should the penis appear after circumcision?
Glans penis is dark red after, then becomes covered with yellow exudate in 24h, which is normal & will persist for 2-3 days -- DO NOT attempt to remove it
What tools are used to perform circumcision in the hospital setting?
Gomco (Yellen) Mogen clamp PlastiBell device
What is considered tachycardia in infants?
HR > 160 bpm HR can be elevated if infant is crying (should decrease when infant stops crying)
A nurse is working in the nursery and observes a nursing student repeatedly performing an Ortolani test. What priority action should the nurse take? Help the nursing student with performing the test to make sure that it is being done accurately. Document the findings of the test as performed by the nursing student after the test has been repeated three times. Have the nursing student explain what the test is used for in terms of clinical assessment. Have the student stop performing the test immediately.
Have the student stop performing the test immediately.
How are blood samples for most laboratory tests obtained in infants?
Heal puncture, also know as a heelstick
With regard to the classification of neonatal bacterial infection, nurses should be aware that: Congenital infection progresses slower than health care-associated infection. Health care-associated infection can be prevented by effective handwashing; early-onset infection cannot. Infections occur with about the same frequency in boy and girl infants, although female mortality is higher. The clinical sign of a rapid, high fever makes infection easier to diagnose.
Health care-associated infection can be prevented by effective handwashing; early-onset infection cannot.
What are the 5 components to the Apgar score?
Heart rate Respiratory effort! Muscle tone! Reflex irritability Color!
____ of the newborn occur most often when the blood groups of the mother and baby are different..
Hemolytic diseases
What generalized ecchymoses in a newborn indicate?
Hemorrhagic diseease
What are some common IM injections that newborns receive?
Hep B vaccine before discharge Possible HepBIG (if mom is HepB+) Vitamin K shortly after birth
What reasons might a parent have for wanting to circumsize their infant?
Hygiene Religious conviction Tradition Culture Social norms
What could gray skin in a newborn indicate?
Hypotension Poor perfusion
How is oxygen saturated measured in infants?
In the right hand and one foot
What could cause the infant's temperature to fall below normal?
Inadequate drying & wrapping immediately after birth Cold birthing room Birth in a car on the way to the hospital
What are plugged milk ducts most often the result of?
Inadequate removal of milk from the breast, which can be caused by clothing that is too tight, a poorly fitting or underwire bra, or always using the same position for feeding.
What could cause hyperthermia in an infant?
Inappropriate use of external heat sources (radiant warmers, phototherapy, sunlight, increased environmental temperature, excessive clothing/blankets)
What could jaundice within the first 24h indicate?
Increased hemolysis Rh isoimmunization ABO incompatibility
How can a cold infant lead to hypoglycemia?
Increased metabolic rate causes anaerobic glycosis which depletes existing stores
While caring for the newborn, the nurse must be alert for any signs of cold stress. This would include which symptom? Decreased activity level Increased respiratory rate Hyperglycemia Shivering
Increased respiratory rate
What can swaddling an infant tightly with legs extending be associated with?
Increased risk for hip dislocation (developmental dysplasia of the hip [DDH])
Who are exchange transfusions indicated for?
Infants whose levels of serum bilirubin are rising rapidly despise the use of intensive phototherapy
What could cause hydrocephaly?
Infection
What is omphalitis?
Infection of the umbilical stump
What are signs of hypoglycemia in infants?
Jitterness Lethargy Poor feeding abnormal cry hypotonia temperature instability (hypothermia) Respiratory distress Apnea Seizures Complete absence of symptoms
Where is the tricuspid valve located in the newborn?
Junction of xiphoid process & sternum
How to collect water for formula?
Mix formula with tap water deemed safe by the local health department. Allow cold water to run for 2 minutes before collecting it. Then bring it to a rolling boil and continue boiling for 1 to 2 minutes. If using bottled water, make sure that it is labeled as "sterile"; unsterile bottled water must be boiled. After boiling allow water to cool before mixing the formula but not for longer than 30 minutes.
What to check for when assessing the newborns neck:
Inspect & palpate for movement, flexibility, masses, bruising Check sternocleidomastoid muscles, movement & position of head assess trachea for position & thyroid gland
What to inspect for when assessing eyes
Inspect for redness, swelling Symmetry Drainage
What is involved in the treatment of brachial plexus injuries in infants?
Intermittent immobilization across upper abdomen Proper positioning & ROM exercises (delayed 1 week to prevent additional injury to brachial plexus)
How long is acrocyanosis normal for?
Intermittently over first 7-10 days, especially with exposure to cold
What could help to avert hydrops fetalis?
Intrauterine transfusions
When are healthy newborns able to produce their own vitamin K?
Introduction of bacteria begins with first feeding Age of 7 days they produce their own
What is so different about brown fat?!
It has a richer vascular & nerve supply than ordinary fat (this is why it's brown) Heat produced by intense lipid metabolic activity in brown fat can warm the newborn by increasing heat production by as much as 100%
When is amylase produced? What is it?
It is produce by the salivary glands after approx. 3 months & pancreas at approx. 6 months It's necessary to convert starch into maltose occurs in high amounts in colostrum
Signs of hypocalcemia in the infant:
Jitteriness High-pitched cry Irritability Apnea Intermittent cyanosis Abdominal distention Laryngospasm Some may be asymptomatic
What are the female infants external genitalia like?
Labia majora & minor are usually edematous with increased pigmentation Labia may protrude past majora Vaginal or hymenal tags are common--- no clinical significance
What causes breastfeeding-associated jaundice?
Lack of effective breastfeeding If the infant is not feeding effectively, there is less caloric & fluid intake & possible dehydration ---Hepatic clearance of bilirubin is reduced Less intake = fewer stools Result = bilirubin is reabsorbed from the intestine back into the bloodstream and must be conjugated again so it can be excreted
How is phototherapy delivered?
Lamp Blanked Pad Cover-body devices
On what side of the heel should you give a heelstick?
Lateral side
What 2 types of skull fractures are typically identified in newborns?
Linear fracture Depressed fracture
What are the nursing interventions for the following nursing diagnosis in the newborn: Risk for Imbalanced Body Temperature related to larger body surface relative to mass
Maintain neutral thermal environment Monitor axillary temp frequently bathe neonate efficiently when temp is stable, using warm water, drying carefully, & avoid exposing neonate to drafts Report any alterations in temp findings promptly
Where is the apex ausculated in the newborn?
Mitral valve
While evaluating the reflexes of a male newborn, the nurse notes that with a loud noise, the newborn symmetrically abducts and extends his arms, his fingers fan out and form a "C" with the thumb and forefinger, and he has a slight tremor. The nurse documents this finding as a positive: Tonic neck reflex response Glabellar (Myerson) reflex response Babinski reflex response Moro reflex response
Moro reflex response
Is it common to have severe soreness or painful, abraded, cracked, or bleeding nipples? What could cause this?
NO often result from poor positioning, incorrect latch, improper suck, or infection
What is the most serious complication of an infant heelstick? How do you prevent it?
Necrotizing osteochondritis resulting from lancet penetration of the bone To prevent, the puncture is made on the outer aspect of the heel & penetrates no deeper than 2.4 mm
What pain assessment tools are used in neonates?
Neonatal Infant Pain Scale (NIPS) Premature Infant Pain Profile (PIPP) Neonatal Pain Agitation and Sedation Scale (NPASS)
What factors influence tooth development in the baby?
Neonatal or infant illness & medication Illness or medication taken by mother during pregnancy Fluoride level in water supply
Significance of Rh-negative fetus
No danger because it has the same Rh factor as mother If fetus is Rh neg at mom is Rh pos it is still not in danger
What should be done to prevent SIDS?
No smoking! Firm mattress! Prone! No crib bumpers! Don't cover with blankets!
Does the diaper go over the cord stump?
No, it is folded down & away from the stump
After feeding, can you save the formula left in the bottle?
No. It must be thrown away because saliva from the baby's mouth can cause the formula to spoil
What is pain in postpartum breastfeeding mothers most safel managed with?
Nonopioid analgesics such as ibuprofen
How do infants produce heat in leu of shivering? (answer = a single mechanism, not long explanation)
Nonshivering thermogenesis
What is neonatal acne?
Normal resembles pimples & can appear at 2 to 4 weeks of age, resolving without treatment by 6 to 8 months
Should infants be bathed daily?
Not necessary and can do harm by disrupting the integrity of the newborn's skin
What hormone is responsible for the milk ejection reflex (MER), or let-down reflex? How is this hormone stimulated?
Oxytocin As the nipple is stimulated by the suckling infant, the posterior pituitary is prompted by the hypothalamus to produce oxytocin.
What 2 disorders are included in the universal screening for all provinces?
PKU Congenital hypothyroidism
When palpating sutures, what should be noted?
Palpable & separated sutures
What to do during the head assessment of a newborn:
Palpate skin Inspect shape, size Palpate, inspect, & note size & status of fontanels Palpate sutures Inspect pattern, distribution, amount of hair; feel texture
Antidepressant medication is the mainstay treatment for maternal depression, with selective serotonin reuptake inhibitors (SSRIs) being the first line of pharmacotherapy. Reports of cardiac defects have been associated with the use of which SSRI? Citalopram Fluoxetine Sertraline Paroxetine
Paroxetine
When does physiologic jaundice peak? When does it usually resolve?
Peaks at about 3-5 days Resolves after 1-2 weeks
When placing a newborn under a radiant heat warmer to stabilize temperature after birth, the nurse should: Place the thermistor probe on the left side of the chest. Cover the probe with a nonreflective material. Recheck temperature by periodically taking a rectal temperature. Perform all examinations and activities under the warmer.
Perform all examinations and activities under the warmer.
Telangiectases
Permanently enlarged and dilated blood vessels. "stork bites" or capillary hemangiomas
What is the Apgar score used for?
Permits a rapid assessment of the newborn's transition to extrauterine life
___ has been associated with exposure to maternal SSRIs after 20 weeks of gestation
Persistent pulmonary hypertension in the newborn (PPHN)
Magnent reflex
Place infant in supine position, partially flex both lower extremities, & apply light pressure with fingers to soles of feet. Normally, while examiner's fingers maintain contact with soles of feet, lower limbs extend. Both lower limbs should extend against examiner's pressure Absence suggests damage to central nervous system. Weak reflex may be seen after breech presentation without extended legs or may indicate sciatic nerve stretch syndrome. Breech presentation with extended legs may evoke exaggerated response.
Truncal incurvation (Galant) reflex
Place infant prone on flat surface; run finger down back about 4-5 cm lateral to spine, first on one side & then down the other. Trunk is flexed, and pelvis is swung toward stimulated side. Response disappears by 4th week. Response varies but should be obtainable in all infants, including preterm. Absence suggests general depression of nervous system. With transverse lesions of cord, no response below level of lesion is present.
What might be given to infants with IgA deficiency who are not breastfed?
Processed donor milk
____ and _____ have been called the "mothering hormones" because they affect the postpartum woman's emotions and her physical state
Prolactin & oxytocin
What are risk factors for facial palsy?
Prolonged second stage of labor Forceps-assistedbirth
What is the purpose of the vernix caseosa?
Protective covering Has emollient & antimicrobial properties Prevents fluid loss through skin Antioxidant properties
What type of injury can cause cranial & peripheral nerve injuries of the infant?
Radial nerve palsy Medial nerve palsy Sciatic nerve palsy Laryngeal nerve palsy Diaphragmatic paralysis Facial nerve palsy
What is normal when assessing hearing of newborns?
Responds to voice & other sounds Passes universal newborn hearing screening
What are the 3 newborn "zones," traditional referred to as newborn states?
Resting zone Ready zone Rebooting zone
What are the nursing interventions for the following nursing diagnosis in the newborn: Risk for Infection related to immature immunologic defenses and environmental exposure
Review maternal record for evidence of any risk factors Monitor temp & other vital signs Have all care providers, including parents, perform proper hand hygiene before handling newborn Provide prescribed eye prophylaxis Keep genital area clean & dry Keep umbilical stump clean & dry If infant is circumsized, keep site clean & apply diaper loosely Teach parents to keep neonate away from crowds & environmental irritants
In terms of Rh incompatibility, which situations would cause a potential problem? Select all that apply: Rh-negative mom having an Rh-positive baby Rh-negative mom having an Rh-negative baby The infant of an Rh-negative mom with Rh-positive father who is homozygous for the trait Rh-positive baby born to an Rh-positive mom
Rh-negative mom having an Rh-positive baby The infant of an Rh-negative mom with Rh-positive father who is homozygous for the trait
What is crepitus?
Rice crispy feeling
Findings of thorax (chest) assessment of normal term infant:
Rounded thorax Prominent ribs & xiphoid process Apical pulse, 4th intercostal space, 110-160bpm when awake Nipple placement equal Crackles (fine) are common right after birth
What might cause retinal & subconjunctival hemorrhage in a newborn? What are the interventions / outcomes?
Rupture of capillaries caused by increased pressure during birth Usually clear with 5 days & present no further problems Explain that these injures are hermless
When are infants considered at risk for hypoglycemia?
SGA or LGA Infants of mothers with diabetes Late preterm infants
How do you properly swaddle an infant?
Safe swaddling involves wrapping the infant snugly in a blanket with the arms extended legs flexed, & hips in neutral position without rotation. The hips in slight flexion & abducted & allowing freedom of movement of the knees. There should be space for 2 to 3 adult fingers between the infant's chest and the swaddle. In the early newborn period, nurses often swaddle infants with the arms flexed
Where is the aortic valve located in the newborn?
Second intercostal space, right of sternum
Where is the pulmonic valve located in the newborn?
Second interspace, left of sternum
Nipple placement in newborn:
Should be symmetric Breast tissue & areola size increase with gestation Areola appears slightly elevated at 34 weeks By 36 weeks a breast bud of 1-2mm is palpable; this increased to 12mm by 42 weeks
What is the hypotonic neonate like?
Show little resistance Can feel like a "rag doll"
If an infant is overheated because of environmental facts, which sings of heat-losing mechanisms may they exhibit?
Skin vessels dilate Skin appears flushed! Hands & feet are warm to touch Infant assume a posture of extension
What is SGA?
Small for gestational age (Less than 10th percentile) Can be presumed to have grown at a restricted rate during intrauterine life
What is the normal finding when assessing the vaginal discharge of the newborn?
Smegma
What can cause SIDS?
Smoking Crib bumpers Laying on belly Covering baby with blankets
What is the normal finding when assessing the soles of the feet of the newborn?
Soles well lined (or wrinkled) over 2/3 of foot Plantar fat pad giving flat-footed effect
What happens after hemoglobin is broken down into Heme?
Some iron is reused for RBCs The porphyrin is converted to bilirubin, which binds to albumin to go into the liver Once in the liver, UDP converts bilirubin to conjugated bilirubin to be excreted
When is vitamin K administration given to the newborn?
Soon after birth Can wait until after first breastfeeding in birthing room
What is the normal finding when assessing bowel sounds & stools of the newborn?
Sounds present within minus after birth Meconium stool passing within 24-48 hr after birth
What is in place to prevent infant abduction?
Special limited-entry systems Teach mothers & families to check identity of any person who comes to remove the baby from their room Personnel usually wear picture identification badges Some units may wear matching scrubs or special badges Some units use closed-circuit television, computer monitoring systems, fingerprint identification pads, or infant bracelet security systems that alarm if newborn is separated from mother or taken outside boundaries of the unit
What could a pilonidal dimple with a sinus & nevus pilosis indicate?
Spina bifida
______, a collection of blood in the subdural space, most often is produced by the stretching and tearing of the large veins in the tentorium of the cerebellum, the dural membrane that separates the cerebrum from the cerebellum
Subdural hemorrhage (hematoma)
In a _____ the scalp is pulled away from the bony calvarium; the vessels are torn, and blood collects in the subgaleal space.
Subgaleal hemorrhage
What is nonnutritive sucking (NNS)?
Sucking on a pacifier -- it's a common comfort measure used for newborns Oral sucrose in small amounts given with a syringe with or without a pacifier for sucking is safe and effective in reducing neonatal pain during painful procedures such as venipunctures or heelsticks
Caloric intake during lactation?
Sufficient to achieve the goal of balancing energy intake & expenditure Adding 450-500 calorie per day
How is supplemental feeding provided?
Supplemental nursing devices Spoon Dropper Cup Syringe Bottles with slow flow nipple
Nursing care for infants with ICH
Supportive Monitoring ventilatory & IV therapy Observing & managing seizures Preventing increased ICP
What is involved in the nursing care of drug-dependent neonates?
Supportive therapy for fluid & electrolyte balance Nutrition Infection control Respiratory care
What factors are included in the newborns response to environmental stimuli?
Temperament Habituation Consolability Cuddliness Irritability Crying
What vital signs are always obtained in the infant?
Temperature HR! RR!
What are the factors that influence heat loss to the environment?
Temperature & humidity of the air The flow & velocity of the air The temperature of surfaces in contract with & around the infant
What is the normal finding when assessing the cremasteric of the newborn?
Testes retracted, especially when newborn is chilled
What is "state modulation"
The ability of the infant to make smooth transitions between states in the sleep-wake cycle
If breatfeeding is painful, what error could be occurring?
The baby might not be taking enough of the breast into the mount, and the tongue is pinching the nipple
Mothers who give birth by cesarean often prefer what hold when nursing?
The football or clutch hold
With regard to hemolytic diseases of the newborn, nurses should be aware that: Rh incompatibility matters only when an Rh-negative offspring is born to an Rh-positive mother. ABO incompatibility is more likely than Rh incompatibility to precipitate significant anemia. Exchange transfusions are frequently required in the treatment of hemolytic disorders . The indirect Coombs test is performed on the mother before birth; the direct Coombs test is performed on the cord blood after birth.
The indirect Coombs test is performed on the mother before birth; the direct Coombs test is performed on the cord blood after birth.
What must be assessed during phototherapy?
The irradiance of the light via radiometer Eyes assessed periodically & during feedings Temperature q1h (hypo/hyperthermia) I&O --urine for hydration & feces for excretion of bilirubin --Can cause insole water loss -- dehydration Turn q2-3h Rash is normal
What is molding?
The shaping of the fetal head by overlapping of the cranial bones to facilitate movement through the birth canal during labor Only lasts a few days
With regard to umbilical cord care, nurses should be aware that: The stump can easily become infected. A nurse noting bleeding from the vessels of the cord should immediately call for assistance. The cord clamp is removed at cord separation. The average cord separation time is 5 to 7 day
The stump can easily become infected.
Why is a bad odor of the cord stump not always a good indictor of infection?
The stump deteriorates through the process of dry gangrene
What is a key factor in evaluating the cause and determining if treatment is needed for newborn jaundice?
The time of onset
why might an infant appear pale & molted with cool skin?
Their temp may have dropped, which caused vasoconstriction to conserve heat
____ is the maintenance of balance between heat loss and heat production
Thermoregulation
How is cabbage used for breast engorgement?
They are washed, dried, chilled in the refrigerator or freezer, crushed slightly to break up the veins in the leaves, & then placed over the breasts for 15 to 20 minutes Frequent application can decrease milk supply
What physiologic characteristics of neonates place them at risk for heat loss?
Thin layer of subcutaneous fat Blood vessels are close to the surface of the skin Changes in environmental temperature alter the temp of the blood Newborns have larger body surface-to-body weight (mass) ratios than children & adults
Neonates respond to painful stimuli with release of __________________
epinephrine norepinephrine glucagon corticosterone cortisol 11-deoxycorticosterone lactate pyruvate glucose
How often is the mother instructed to breast feed at first?
ever 2 hours, softening at least one breast & pumping the other as needed to soften it
Why is vitamin K given to newborns?
To prevent hemorrhagic disease
Plantar grasp
Touch thumb to ball of foot --- toes curl down response lessens by 8 months
Posterior fontanel characteristics
Triangle Smaller than anterior
What is the normal finding when inspecting the umbilical cord after birth?
Two arteries, one vein Whitish gray Definite demarcation between cord & skin, no intestinal structures within cord Dry around base, drying Odorless Cord clamp in place for 24-48h
Deep tendon reflex
Use finger instead of percussion hammer to elicit patellar, or knee jerk, reflex; newborn must be relaxed. Reflex jerk is present; even with newborn relaxed, nonselective overall reaction may occur. It is usually more difficult to elicit upper extremity reflexes than lower extremity reflexes.
What is the New Ballard Score?
Used to measure gestational ages in infants as young as 20 weeks gestation Assess 6 external physical & 6 neuromuscular signs--- each sign has a numeric score & the cumulative score correlates with a maturity rating (gestational age)
How do you clean bottles for formula-fed infants?
Using warm soapy water, wash hands, arms, & under nails; rinse well. Clean and sanitize the surface where preparing the bottles. Thoroughly wash bottles, nipples, rings, caps, can opener, & other preparation utensils in hot soapy water & rinse thoroughly. Squeeze water through nipples to make sure holes are open. • Place bottles, nipples, rings, & caps in pot & cover with water; boil for 5 minutes; remove items from pot with sanitized tongs & allow them to air dry. (Do this before using items the first time; thereafter you can continue to do this or place items in the dishwasher.)
What are transitional stools?
Usually appear by third day after initiation of feeding Greenish brown to yellowish brown; thin and less sticky than meconium; can contain some milk curds
What is the normal finding when assessing the clitoris of the newborn?
Usually edematous
What is pseydomenstruation in infants?
Uterine bleeding without the typical premenstrual endometrial changes. An increase in estrogen during pregnancy followed by a drop after birth results in a mucoid vaginal discharge and even some slight bloody spotting
How often is axillary temperature checked in a newborn?
every hour until temp is stabilized
What could severe nipple pain be related to?
Vasospasm Raynaud's phenomenon
What muscle is the preferred injection site for newborns?
Vastus lateralis
Congenital heart defects (CHDs) are anatomic abnormalities in the heart that are present at birth, although they may not be diagnosed immediately. The most common type of CHD is: Tetralogy of Fallot . Ventricular septal defect (VSD). Pulmonary stenosis. Transposition of the great vessels.
Ventricular septal defect (VSD).
What does the newborns skin look like?
Vernix Erythematous for a few hours, then normal in color (pink) Blotchy or mottled, esp over extremities Acrocyanosis caused by vasomotor instability & capillary stasis
What type of injury can cause spinal cord (cervical) injuries of the infant?
Vertebral artery injury Intraspinal hemorrhage Spinal cord transection or injury
Average finding for infant posture
Vertex formation (arms & legs in moderate flexion; fists clenched) Resistance to having extremities extended for examination or measurement, crying possible when attempted Cessation of dying when allowed to resume curled-up position (lateral) Normal spontaneous movement bilaterally asynchronous (legs moving in bicycle fashion) but equal extension in all extremities
If the infant is hyperthermic because of sepsis, what might they look like?
Vessels in skin are constricted Color is pale Hands & feet are cool
A nurse caring for a newborn should be aware that the sensory system least mature at the time of birth is: Vision. Hearing. Smell. Taste.
Vision.
SCENARIO (this is going by figure 24-1 chart) If the infant is NOT term gestation, not breathing or crying, OR has bad tone, what does the nurse do?
Warm Clear airway if necessary Dry Stimulate
The nurse taught new parents the guidelines to follow regarding the bottle feeding of their newborn. They will be using formula from a can of concentrate. The parents would demonstrate an understanding of the nurse's instructions if they: Wash the top of can and can opener with soap and water before opening the can. Adjust the amount of water added according to weight gain pattern of the newborn. Add some honey to sweeten the formula and make it more appealing to a fussy newborn. Warm formula in a microwave oven for a couple of minutes prior to feeding
Wash the top of can and can opener with soap and water before opening the can.
In helping the breastfeeding mother position the baby, the nurse should keep in mind that: The cradle position is usually preferred by mothers who had a cesarean birth. Women with perineal pain and swelling prefer the modified cradle position. Whatever the position used, the infant is "belly to belly" with the mother. While supporting the head, the mother should push gently on the occiput.
Whatever the position used, the infant is "belly to belly" with the mother.
When does Rh incompatibility occur?
When an Rh-negative mother has an Rh-positive fetus who inherits the dominant Rh-positive gene from the pather
Mixing powder formula
When first opening the container of powder, write the date on the lid. Using the scoop from the container, add 1 scoop of powdered formula for each 2 ounces of boiled, cooled water in a clean bottle. For example, if 6 ounces of water is in the bottle, add three scoops of powder. Add nipple and ring and shake well.
What causes jaundice?
When levels of unconjugated bilirubin exceed the ability of the liver to conjugate it, plasma levels of bilirubin increase, and jaundice appears
When does ABO incompatibility occur?
When maternal blood type is O
What is the asymmetric latch technique?
When the baby's mouth opens widely, the mother moves the baby in toward her body so the chin and lower mandible make contact with the breast first, followed by the top lip. When the baby is latched on, the nose is tilted slightly away from the mother's breast, & the chin is pressed into the underside of the breast. The infant's mouth placement is asymmetric on the areola; the lower part is covered by the baby's mouth, but the top is clearly visible above the top lip.
When does the nipple-erection reflex occur?
When the infant cries, suckles, or rubs against the breast This aids in the propulsion of milk through the ducts to the nipple pores
Tonic neck or "fencing" reflex
With infant in supine neutral position, turn head quickly to one side With infant facing left side, arm and leg on that side extend; opposite arm and leg flex (turn head to right, and extremities assume opposite postures). Disappears by 3-4 months
Crossed extension reflex
With infant in supine position, examiner extends one leg of infant & presses down knee. Stimulation of sole of foot of fixated limb should cause free leg to flex, adduct, and extend as if attempting to push away stimulating agent. Opposite leg flexes, adducts, and then extends. This reflex should be present during newborn period.
When does infant follow-up care after hospital discharge usually occur?
Within 72 hours at the clinic or HCP office
When does early-onset hypocalcemia usually occur in infants?
Within the first 24-48 hours after birth
When is eye prophylaxis given to the newborn?
Within the first hour after birth Can be delayed up to 2 hours until after the first breastfeeding so that eye contact & parent-infant attachment & bonding are facilitated
If the baby was born via C-section, is eye prophylaxis required?
YES - it is required without regard to mode of birth
What can be used to protect the infant's skin from moisture & further excoriation? (r/t diapers)
Zinc oxide ointments
Why might there be eye discharge for the first 2-3 days
a discharge can result from the reaction of the conjunctiva to the substance (erythromycin) used as a prophylactic measure against infection.
What is a hydrocele?
a fluid-filled sac surrounding a testicle that causes swelling in the scrotum Can be easily transilluminated with a light Usually resolves without treatment
what is the subgaleal compartment?
a potential space that contains loosely arranged connective tissue; it is located beneath the galea aponeurosis, the tendinous sheath that connects the frontal and occipital muscles and forms the inner surface of the scalp
What is the Period of PURPLE Crying?
a program to educate new parents about infant crying and the dangers of shaking a baby. Each letter in the acronym PURPLE represents key concepts: P = Peak of crying. Your baby may cry more each week—the most in month 2, then less in months 3 to 5. U = Unexpected. Crying can come and go and you don't know why. R = Resists soothing. Your baby may not stop crying no matter what you try. P = Pain-like face. Crying babies may look like they are in pain, even when they are not. L = Long lasting. Crying can last as much as 5 hours a day, or more. E = Evening. Your baby may cry more in the later afternoon and evening
What is erythema toxicum?
a transient rash, is also called erythema neonatorum, newborn rash, or flea bite dermatitis. It first appears in term neonates during the first 24 to 72 hours after birth and can last up to 3 weeks of age The rash is thought to be an inflammatory response. Eosinophils, which help decrease inflammation, are found in the vesicles. Although the appearance is alarming, the rash has no clinical significance & requires no treatment.
An important consideration in skin cleansing is the preservation of the skin's ______, which is formed from the uppermost horny layer of the epidermis, sweat, superficial fat, metabolic products, and external substances such as amniotic fluid and microorganisms.
acid mantle
What is a key factor in preventing & minimizing local reactions to IM injections in infants?
adequate deposition of the medication deep within the muscle; therefore, muscle size, needle length, and amount of medication injected should be carefully considered.
If the infant is >/= 2000g, and the mothers HepB status is unknown, what actions are taken?
administer HepB vaccine within 12 hours; if mother's HepB results are positive, give HBIG by 1 week of age
How do you confront the baby during a heelstick?
allow mom to hold skin-to-skin nonnutritive sucking (with/without oral sucrose) Swaddling
If the skin is dry or cracking, what can be applied?
an emollient (lotion) once or twice daily. Check with your pediatric health care provider about the type of emollient to use
How should you wash the hair of an infant?
begin by wrapping the infant in a towel with the head exposed. Hold the infant in a football position (under the arm) with one hand, using the other hand to wash the hair.
What does the American Academy of Pediatrics (AAP) suggest in regards to iron supplements?
breastfed infants should receive a daily oral iron supplement (1 mg/kg) beginning at 4 months until feeding includes iron-fortified cereal or other foods fortified with iron Formula-fed infants should receive a formula that contains supplemental iron
Pulse oximetry testing can detect some _______ that present with hypoxemia in the absence of other physical symptoms.
critical congenital heart defects
When is the initial bath given?
deally the initial bath is delayed for at least 2 hours after birth until the neonate has reached thermal and cardiorespiratory stability
Once the infant is feeding well and gaining weight adequately, going to ___________ is appropriate, in which case the infant determines the frequency of feedings.
demand feeding
The most common cause of spinal cord injury in the neonate is a ___
difficult breech birth.
How can a parent help the baby to stay asleep?
don't pick up during active/light sleep.
How warmly should a parent dress their child?
dress the child for the environment as they dress themselves, adding no more than one layer more than they would be wearing as adults
SCENARIO (this is going by figure 24-1 chart) If the infant is of term gestation, is breathing or crying, & has good tone, what are the interventions?
let the baby stay with mama! Provide routine care --Provide warmth --Clear airway if necessary --Dry --Ongoing evaluation
Distended, small, white sebaceous glands noticeable on the newborn face are known as _______.
milia
What is wharton's jelly?
muscous CT found in embryonic umbilical cord
Withdrawal symptoms in infants are described as ____
neonatal abstinence syndrome (NAS)
The goal of care is to provide a ______ for the neonate in which heat balance is maintained.
neutral thermal environment
What physiologic effects occur in the cold-stressed infant?
oxygen consumption and energy are diverted from maintaining normal brain & cardiac function and growth to thermogenesis for survival If the infant cannot maintain an adequate oxygen tension, vasoconstriction follows & jeopardizes pulmonary perfusion. As a consequence the PO2 is decreased, and the blood pH drops Surfactant synthesis can be altered Decreased pulmonary perfusion and oxygen tension can maintain or reopen the right-to-left shunt across the ductus arteriosus.
What is done for the ABR test?
performed by attaching sensors to the baby's forehead and behind each ear. An earphone is placed in the baby's outer ear and sends a series of quiet sounds into the sleeping baby's ear. The sensors measure the responses of the baby's acoustic nerve. The responses are recorded and stored in a computer.
How is screening for critical congenital heart disease (CCHD) done?
performed using pulse oximetry to measure oxygen saturation for the purpose of detecting hypoxemia
The purpose of _____ is to reduce the level of circulating unconjugated bilirubin or keep it from increasing.
phototherapy
What is the definition of "latch?"
placement of the infant's mouth over the nipple, areola, and breast, making a seal between the mouth and breast to create adequate suction for milk removal
How can a parent get the baby to sleep?
put baby down for sleep while he or she is still awake.
How often should the newborn infant be formula fed?
q3-4h
How often should every newborn be assessed for jaundice?
q8-12h
What indicates infection after circumcision?
redness swelling discharge odor Notify HCP
What is kernicteruis?
refers to the irreversible, long-term consequences of bilirubin toxicity such as hypotonia, delayed motor skills, hearing loss, cerebral palsy, and gaze abnormalities
Approximately 45% of brachial plexus injuries occur with ______
shoulder dystocia
Infants are positioned at a 45-degree angle in a car seat to prevent _____
slumping and subsequent airway obstruction
What is done for the EOAE test?
soft rubber earpiece that makes a soft clicking noise is placed in the baby's outer ear. A healthy ear will "echo" the click sound back to a microphone inside the earpiece
What are the distinct long & short term effects of early skin-to-skin contact?
temperature stabilization Reduced crying improved breatfeeding initiation & duration Maternal attachment
What is acute bilirubin encephalopathy?
the acute manifestations of bilirubin toxicity that occur during the first weeks after birth
How is the Barlow test performed?
the examiner places the middle finger over the greater trochanter & the thumb along the midthigh. The hip is flexed to 90 degrees & adducted, followed by gentle downward pushing of the femoral head. If the hip can be dislocated with this maneuver, the femoral head moves out of the acetabulum, & the examiner feels a "clunk."
Describe radiation (form of heat loss)
the loss of heat from the body surface to a cooler solid surface not in direct contact but in relative proximity.
Describe conduction (form of heat loss)
the loss of heat from the body surface to cooler surfaces in direct contact.
What is mastitis characterized by?
the sudden onset of influenza-like symptoms, including fever, chills, body aches, & headache.
What is jaundice?
the visible yellowish color of the skin and sclera, is caused by elevated serum levels of unconjugated (indirect) bilirubin
Why does fresh, raw cabbage over the breasts between feedings help relieve engorgement?
thought that the effect of the cabbage leaves is related to the coolness of the leaves and phytoestrogens within them.
What is pathologic jaundice?
unconjugated hyperbilirubinemia that is either pathologic in origin or severe enough to warrant further evaluation and treatment Appears within 24h after birth Total serum bilirubin increases by more than 6mg/dL in 24h Exceeds 15mg/dL at any time
How does phototherapy work?
uses light energy to change the shape & structure of unconjugated bilirubin, converting it into a conjugated form that can be excreted through urine & stool
It is best to avoid bottles until breastfeeding is well established. When is this?
usually after 3 or 4 weeks.
What is the mother advised to do if there is a break in the skin on the nipple?
wipe the nipples with water after feeding to remove the baby's saliva A thin coating of a topical antibiotic may help reduce the risk of infection and promote healing (the antibiotic cream or ointment should be removed before breastfeeding)
When can an infant discriminate colors
within 2-3 months
What suggestions should be made to parents of infants with a respiratory illness?
• Feed smaller amounts more often to prevent overtiring the infant. • Hold the baby in an upright position to feed. • For sleeping, raise the infant's head and chest by raising the mattress 30 degrees (do not use a pillow). • Avoid drafts; do not overdress the baby. • Use only medications prescribed by a pediatric health care provider. Do not use over-the-counter medications without provider approval. • Use nasal saline drops in each nostril and suction well with bulb syringe to decrease and relieve secretions
What feeding-readiness cues may an infant exhibit when they are hungry?
• Hand-to-mouth or hand-to-hand movements • Sucking motions • Rooting reflex—infant moves toward whatever touches the area around the mouth and attempts to suck • Mouthing
Signs of effective breastfeeding in the mother?
• Onset of copious milk production (milk is "in") by day 3 or 4 • Firm tugging sensation on nipple as infant sucks but no pain • Uterine contractions and increased vaginal bleeding while feeding (first week or less) • Feels relaxed and drowsy while feeding • Increased thirst • Breasts soften or feel lighter while feeding • With milk ejection (let-down), can feel warm rush or tingling in breasts, leaking of milk from opposite breast
What fetal/newborn factors could cause pathologic hyperbilirubinemia in neonates?
• Prematurity • Hepatic cell damage by infection or drugs • Neonatal hyperthyroidism • Polycythemia • Intestinal obstruction such as meconium ileus • Pyloric stenosis • Biliary atresia • Sequestered blood (e.g., from cephalhematomas, ecchymosis, or hemangiomas) • Maternal blood swallowed by neonate • Glucose-6-phosphate dehydrogenase (G6PD) deficiency • Thalassemia
How to parents decrease stimulation & increase support when the baby shows a sign of stress?
• Quiet one's voice.! • Glance away from baby. • Encourage baby to suck a finger or mother's breast. • Swaddle baby. • Place baby skin-to-skin.!
What maternal factors could cause pathologic hyperbiliruinemia in neonates/
• Rh and ABO or other blood group incompatibilities! • Maternal infections • Maternal diabetes • Oxytocin administration during labor • Maternal ingestion of sulfonamides, diazepam, or salicylates near time of birth
What signs may indicate that milk ejection has occurred?
• The mother may feel a tingling sensation in the nipples and breasts, although many women never feel when milk ejection (let-down) occurs. • The baby's suck changes from quick, shallow sucks to a slower, more drawing sucking pattern. • Audible swallowing is present as the baby sucks. • In the early days the mother feels uterine cramping and can have increased lochia during and after feedings. • The mother feels relaxed or drowsy during feedings. • The opposite breast may leak.
Where is the apical impulse (PMI) located in the newborn?
the 4th intercostal space & left of the midclavicular line
What happens to the umbilical cord once clamped?
the umbilical arteries, the umbilical vein, and the ductus venosus are functionally closed; they are converted into ligaments within 2 to 3 months
The nurse is preparing to listen to the apical heart rate of a newborn. The nurse performs the procedure and should note that the heart rate is normal if which rate is noted? 1.A heart rate of 100 beats/min 2.A heart rate of 140 beats/min 3.A heart rate of 180 beats/min 4.A heart rate of 190 beats/min
.A heart rate of 140 beats/min
The nurse is assessing the reflexes of a newborn infant. In eliciting the Moro reflex, the nurse should perform which action? 1.Make a loud, abrupt noise to startle the newborn. 2. Stimulate the ball of the foot of the newborn by firm pressure. 3. Stimulate the perioral cavity of the newborn infant with a finger. 4. Stimulate the pads of the newborn infant's hands by firm pressure.
1.Make a loud, abrupt noise to startle the newborn.
Which are modes of heat loss in the newborn? Select all that apply. 1.Radiation 2.Urination 3.Convection 4.Conduction 5.Evaporation
1.Radiation 3.Convection 4.Conduction 5.Evaporation
Characteristics of the newborn heart rate
120-160 Irregular heart rate is not uncommon in first few hours of life Sinus dysrhythmia is common Murmurs are common in the first few days of life because of fetal shunts
The nurse weighing a term newborn during the initial newborn assessment determines the infant's weight to be 4325 g. The nurse determines that this infant may be at risk for which complications? Select all that apply. 1.Retinopathy 2.Hypoglycemia 3.Fractured clavicle 4.Hyperbilirubinemia 5.Congenital heart defect 6.Necrotizing enterocolitis
2.Hypoglycemia 3.Fractured clavicle 5.Congenital heart defect Any newborn weighing more than 4000 g at birth is defined as being large for gestational age (LGA). Because of their size, LGA infants are also at risk for hypoglycemia. LGA infants also have a higher incidence of birth injuries (fractured clavicle), asphyxia, and congenital anomalies (heart defect).
The nurse develops a plan of care for a woman with human immunodeficiency virus infection and her newborn. The nurse should include which intervention in the plan of care? 1.Monitoring the newborn's vital signs routinely 2.Maintaining standard precautions at all times while caring for the newborn 3.Initiating referral to evaluate for blindness, deafness, learning problems, or behavioral problems 4.Instructing the breast-feeding mother regarding the treatment of the nipples with nystatin ointment
2.Maintaining standard precautions at all times while caring for the newborn
Rho(D) immune globulin (RhoGAM) is prescribed for a client after delivery and the nurse provides information to the client about the purpose of the medication. The nurse determines that the woman understands the purpose if the woman states that it will protect her next baby from which condition? 1. Having Rh-positive blood 2. Developing a rubella infection 3. Developing physiological jaundice 4. Being affected by Rh incompatibility
4. Being affected by Rh incompatibility
An infant is born to a mother with hepatitis B. Which prophylactic measure would be indicated for the infant? 1.Hepatitis B vaccine given within 24 hours after birth 2.Immune globulin (IG) given as soon as possible after delivery 3.Hepatitis B immune globulin (HBIG) given within 14 days after birth 4.Hepatitis B immune globulin (HBIG) and hepatitis B vaccine given within 12 hours after birth
4.Hepatitis B immune globulin (HBIG) and hepatitis B vaccine given within 12 hours after birth
The staff nurse in a neonatal intensive care unit is aware that red electrical outlets denote emergency power and will function in the event of an outage. There are only two red outlets in the room of a 4-day-old male newborn being treated for physiological jaundice and to rule out sepsis from group B streptococcal exposure. Which pieces of equipment requiring power would the nurse select to be plugged into the red outlets in case of a power outage? Select all that apply. 1.Call bell 2.Feeding pump 3.Vital sign machine 4.Phototherapy lights 5.Intravenous (IV) pump
4.Phototherapy lights 5.Intravenous (IV) pump
The nurse administers erythromycin ointment (0.5%) to the eyes of a newborn and the mother asks the nurse why this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis? 1.Protects the newborn's eyes from possible infections acquired while hospitalized. 2.Prevents cataracts in the newborn born to a woman who is susceptible to rubella. 3.Minimizes the spread of microorganisms to the newborn from invasive procedures during labor. 4.Prevents an infection called ophthalmia neonatorum from occurring after delivery in a newborn born to a woman with an untreated gonococcal infection.
4.Prevents an infection called ophthalmia neonatorum from occurring after delivery in a newborn born to a woman with an untreated gonococcal infection.
The nurse is performing Apgar scoring for a newborn immediately after birth. The nurse notes that the heart rate is less than 100, respiratory effort is irregular, and muscle tone shows some extremity flexion. The newborn grimaces when suctioned with a bulb syringe, and the skin color indicates some cyanosis of the extremities. The nurse should most appropriately document which Apgar score for the newborn? 3 5 7 10
5
What is the average blood volume in the term newborn?
85mL/kg
The nurse is checking a newborn's 1-minute Apgar score based on the following assessment. The heart rate is 160 beats/min; he has positive respiratory effort with a vigorous cry; his muscle tone is active and well-flexed; he has a strong gag reflex and cries with stimulus to the soles of his feet; his body is pink, with his hands and feet cyanotic. Which is the newborn's 1-minute Apgar score? 7 9 8 10
9
What does clamping of the umbilical cord cause after birth?
A rise in BP, which increased circulation & lung perfusion
What could the presence of jaundice in a newborn indicate?
ABO or Rh factor incompatibility problems
Why does the fetus in utero need additional RBCs?
Because fetal circulation is less efficient at oxygen exchange than the lungs, the fetus needs additional RBCs for transport of oxygen in utero.
What is acrocyanosis?
Changes in the infants color --Blush around hands, fingernails, & feet Normal for first 24h after birth Can indicate respiratory distress
What are common respiratory complications that may affect neonates?
RDS Meconium aspiration Pneumonia Persistent pulmonary hypertension of newborn (PPHN)
What might indicate upper airway obstruction in newborns?
Suprasternal or subclavicular retractions with stridor or grasping
What could persistent tachycardia in an infant be associated with?
Anemia hypovolemia hyperthermia sepsis
The nurse in the newborn nursery is performing admission vital signs on a newborn infant. The nurse notes that the respiratory rate of the newborn is 50 breaths per minute. Which action should the nurse take? 1. Document the findings. 2. Contact the health care provider. 3. Apply an oxygen mask to the newborn infant. 4. Cover the newborn infant with blankets and reassess the respiratory rate in 15 minutes.
1. Document the findings. The normal respiratory rate for a normal newborn is 30 to 60 breaths per minute.
An initial assessment on a large-for-gestational age (LGA) newborn infant is being done. Which physical assessment technique should the nurse assist in performing to assess for evidence of birth trauma? 1.Palpate the clavicles for a fracture. 2.Auscultate the heart for a cardiac defect. 3.Blanch the skin for evidence of jaundice. 4.Perform Ortolani's maneuver for hip dislocation.
1.Palpate the clavicles for a fracture.
The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings would alert the nurse to the possibility of this syndrome? 1.Tachypnea and retractions 2.Acrocyanosis and grunting 3.Hypotension and bradycardia 4.Presence of a barrel chest and acrocyanosis
1.Tachypnea and retractions
What is surfactant? What is its function?
Surfactant is a protein manufactured in lung cells that lines the term infants lungs It lowers surface tension Reduces the pressure required to keep the alveoli open with inspiration Prevents total alveolar collapse on exhalation Helps to maintain overall alveolar stability
The nurse is reviewing the record of a newborn infant in the nursery and notes that the health care provider has documented the presence of a cephalohematoma. Based on this documentation, what should the nurse expect to note on assessment of the infant? 1.A suture split greater than 1 cm 2.A hard, rigid, immobile suture line 3.Swelling of the soft tissues of the head and scalp 4.Edema resulting from bleeding below the periosteum of the cranium
4.Edema resulting from bleeding below the periosteum of the cranium
The nurse is preparing to administer an injection of vitamin K to a newborn. Which injection site should the nurse select? 1.The gluteal muscle 2.The lower aspect of the rectus femoris muscle 3.The medial aspect of the upper third of the vastus lateralis muscle 4.The lateral aspect of the middle third of the vastus lateralis muscle
4.The lateral aspect of the middle third of the vastus laterals muscle This muscle is the preferred injection site because it is free of major blood vessels and nerves and is large enough to absorb the medication.
What sensory factors are involved in the initiation of respirations in newborns?
Handling of infant by physician Suctioning of mouth & nose Drying by the nurse Pain associated with birth Lights, sounds, & smells of the new environment Surfactant lines lungs of infant at term -- it is a protein that is necessary for the alveoli to open up They are nose breathers
What are paradoxical respirations?
exaggerated rise in abdomen with respiration as the chest fall Not normal in infants
Which would be considered abnormal findings in a newborn less than 12 hours old? Select all that apply. 1.Grunting respirations 2. Presence of vernix caseosa 3. Heart rate of 190 beats/minute 4. Anterior fontanelle measuring 5.0 cm 5. Bluish discoloration of hands and feet 6. A yellow discoloration of the sclera and body
1.Grunting respirations 3. Heart rate of 190 beats/minute 6. A yellow discoloration of the sclera and body
The nurse is preparing to bathe a 1-day-old newborn. Which action should the nurse avoid when performing the procedure? 1.Immersing the newborn in water 2.Supporting the newborn's body during the bath 3.Ensuring that the water temperature is warm 4.Ensuring that the water temperature does not exceed 100° F
1.Immersing the newborn in water Newborn infants may be immersed in water after the umbilical stump has healed
What occurs during the period of decreased responsiveness?
Sleeps or marked decreased in motor activity Infant is pink Respirations are rapid & shallow (up to 60 breaths/min) but unlabored Bowl sounds are audible Peristaltic waves may be noted over the rounded abdomen
What happens to the ductus arteriosus after birth?
Smooth muscles constrict in the ductus arteriosus in the first few hours of life because they sense that the oxygen levels are high When prostaglandin levels decrease (after placenta removal), the ductus arteriosus closes more With auscultation of the chest a patent ductus arteriosus can be detected as a heart murmur
What chemical factors are involved in the initiation of respirations in newborns?
The activation of chemoreceptors in the carotid arteries & aorta ---- this results from the relative state of hypoxia associated with labor Clamping of the cord causes a drop in levels of prostaglandins-- this can inhibit respirations
Blood pressure & newborns
Usually not obtained on a normal infant Average term systolic BP = 60-80mmHg Average term diastolic BP = 40-50mmHg MAP should be equivalent to the weeks gestation BP increases by second day of life Drop in systolic BP (about 15mmHg) is common in first hour of life
What mechanical factors are involved in the initiation of respirations in newborns?
Chest compression during vaginal birth causes changes in antrathoracic pressure --- helps stimulate respirations Crying increases the distribution of air in the lungs & promotes expansion of the alveoli (positive pressure of crying helps keep alveoli open)
What could cause polycythemia in newborns?
Delayed cord clamping! Maternal hypertension Maternal diabetes Intrauterine growth restriction
What happens to the foramen ovale after birth?
It closes due to the lower pressure on the right side of the heart (more pressure one the left [lungs] side than the right) Happens in the first few minutes after birth uring the first few days of life crying can temporarily reverse the flow through the foramen ovale and lead to mild cyanosis
List some signs of respiratory distress in a newborn:
Nasal flaring Intercostal or subcostal retractions Grunting with respirations Bradypnea Tachypnea Abnormal breath sounds <95% Cyanosis Seesaw or paradoxical respirations
Why is it so important for the newborn to have patent nares?
Newborns are nose breathers The reflex response to nasal obstruction is opening mouth to maintain airway--- infants DO NOT have this response until 3 weeks after birth----- therefore cyanosis or asphyxia can occur with nasal blockage
