Maternity Exam #1
When giving a postpartum client self-care instructions in preparation for discharge, the nurse instructs her to report heavy or excessive bleeding. How should the nurse describe "heavy bleeding?"
saturating 1 pad in 1 hour
taking hold phase:
second phase characterized by dependent and independent maternal behavior
best way to warm newborn?
skin to skin contact covered with a blanket on mom
The nurse is assessing the abdomen of the neonate. When inspecting the umbilical cord area of a newborn, the nurse would expect which finding?
two arteries and one vein
A postpartum client reports urinary frequency and burning. What cause would the nurse suspect?
urinary tract infection
A postpartum woman is experiencing subinvolution. When reviewing the client's history for factors that might contribute to this condition, which factors would the nurse identify? Select all that apply.
uterine infection prolonged labor hydramnios
The nurse is making a home visit to a woman who is 4 days postpartum. Which finding would indicate to the nurse that the woman is experiencing a problem?
uterus 1 cm below umbilicus
lochia:
vaginal discharge after childbirth •Rubra-deep red mixture of mucus, tissue debris, blood. Occurs for first 3-4 days after birth •Serosa-pinkish brown 3-10 days after birth •Alba-final stage, creamy white or light brown, 10-14 days up to 3-6 weeks
The prenatal health nurse is conducting an educational session focusing on alcohol use during pregnancy. The nurse feels the session was a success when a participant makes which statement?
"Alcohol use could cause my baby to be intellectually disabled."
The infant has Apgar scores of 7 at 1 minute and 9 at 5 minutes. What is the indication of this assessment finding?
adjusting to extrauterine life
when does the Foramen Ovale close?
after birth
what does the Foramen Ovale do?
allows blood to bypass pulmonary circulation and go to left atrium. after it closes, it causes an increase in pulmonary blood flow
Which finding would lead the nurse to suspect that a woman is developing a postpartum complication?
an absence of lochia
After a class for expectant parents on the various forms of birth control after the birth of their infant, the nurse realizes more training is needed when a participant makes which comment?
"I'm going to be breastfeeding occasionally, so we won't need to use any other birth control for at least six months."
APGAR scoring
A= appearance (color all pink, pink and blue, blue [pale]) P= pulse (>100, < 100, absent) G= grimace (cough, grimace, no response) A= activity (flexed, flaccid, limp) R= respirations (strong cry, weak cry, absent)
NEC (necrotizing enterocolitis):
Abbreviation for the condition that is an acute inflammatory disease of the GI Mucosa, complicated by bowel necrosis and perforation. Can be deadly.
A postpartal woman has a history of thrombophlebitis. Which action would help the nurse determine if she is developing this postpartally?
Assess for calf redness and edema
A woman is bottle-feeding her baby. When the nurse comes into the room the woman says that her breasts are painful and engorged. Which nursing intervention is appropriate?
Assist the woman in placing ice packs on her breasts
A nurse is assessing a newborn's reflexes. The nurse strokes the lateral sole of the newborn's foot from the heel to the ball of the foot to elicit which reflex?
Babinski
transient tachypnea of the newborn:
Condition of rapid respirations caused by inadequate absorption of fetal lung fluid.
The nurse places a newborn with jaundice under the phototherapy lights in the nursery to achieve which goal?
Decrease the serum bilirubin level.
Palmer/Planter (reflex):
Digits curl when foot or hand palm touch
A nurse is caring for a client who has had a vaginal birth. The nurse understands that pelvic relaxation can occur in any woman experiencing a vaginal birth. Which should the nurse recommend to the client to improve pelvic floor tone?
Kegel exercises
Epstein pearls:
Milia in newborns mouth and gums
During a physical assessment of a newborn, the nurse observes bluish markings across the newborn's lower back. The nurse interprets this finding as:
Mongolian spots
The nurse administers vitamin K intramuscularly to the newborn based on which rationale?
Promote blood clotting
What is the primary rationale for monitoring a new mother every 15 minutes for the first hour after delivery?
To check for postpartum hemorrhage
During pregnancy a woman's cardiovascular system expands to care for the growing fetus. After birth, during the early postpartum period, the woman eliminates the additional fluid volume she has been carrying. What is one way she does this?
Urinary elimination
rooting reflex:
a baby's tendency, when touched on the cheek, to turn toward the touch, open the mouth, and search for the nipple
when does the ductus venosus close?
a few days after birth, after the liver is activated
Twenty minutes after birth, a baby begins to move his head from side to side, making eye contact with the mother, and pushes his tongue out several times. The nurse interprets this as:
a good time to initiate breast-feeding.
stepping reflex:
a neonatal reflex in which an infant lifts first one leg and then the other in a coordinated pattern like walking
Which newborn would be a priority for the nurse to monitor for thermal regulation difficulties?
a preterm newborn with cyanotic hands, feet, and tongue, feeding poorly.
difference in acquired disorder v. congenital disorders:
acquired: typically occur at, or soon after, birth problems or conditions experienced by woman during pregnancy or at birth possibly no identifiable cause or disorder congenital: present at birth; usually due to some type of malformation occurring during antepartasl period; inheritance majority with complex etiology
Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress?
asymmetrical chest movement
A primipara client gave birth vaginally to a healthy newborn girl 12 hours ago. The nurse palpates the client's fundus. Which finding would the nurse identify as expected?
at the level of the umbilicus
Erythromycin is given for:
bactericidal and bacteriostatic actions to prevent gonorrhea and chlamydia conjunctivitis
cervix after birth:
closure; now appearing as jagged slit-like opening returns to prepregnant state in ~6 weeks
The nurse is caring for a large-for-gestational-age newborn (also known as macrosomia). What maternal condition is the usual cause of this condition?
diabetes
Harlequin sign:
dilation of blood vessels on one side of body; looks like clown suit. distinct mid-line demarcation; pale on non-dependent side and red on other side.
genitals, ballard scale:
males: evidence of testicular descent and appearance from scrotum (smooth to covered with rugae) females: appearance and size of clitoris and labia; prominent clitoris with flat labia is premature, clitoris covered by labia is more mature
Assessment of a newborn reveals tiny white pinpoint papules on a newborn's nose. The nurse documents this finding as:
milia.
Which sign would indicate dehydration in a newborn?
sunken fontanels
What medication does the nurse anticipate administering to the preterm newborn as an inhalant to improve the lungs' ability to mature?
surfactant
what are the three closing ducts of a newborn?
foramen Ovale Ductus alteriosus ductus venosus
what causes transient tachypnea?
lack of thoracic squeezing that occurs during cesarean birth or diminished respiratory effort if mother received CNS depressant medications.
The nurse assesses a postpartum woman's perineum and notices that her lochial discharge is moderate in amount and red. The nurse would record this as what type of lochia?
lochia rubra
radiation:
loss of body heat to cooler, solid surfaces in close proximity, but not in direct contact
evaporation:
loss of heat when a liquid is converted to vapor
Signs of hypoglycemia in newborn:
most are asymptomatic, though it could display as jitteriness, lethargy, cyanosis, apnea, seizures, high-pitched or weak cry, hypothermia, and poor feeding
Milia:
multiple pearly white/yellow sebaceous glands found on newborn's nose, chin and forehead. disappear after few weeks
Truncal incurvation (Galant) reflex:
newborn in prone position or held in ventral suspension, apply firm pressure and run finger down either side of spine. will cause pelvis to flex towards stimulated side. indicates T1-T2 innervation.
what is the APGAR test for?
newborns ability to acclimate to extrauterine life.
What would be appropriate for the nurse to document in a child suffering from meconium aspiration syndrome?
respirations as increased and high
common risk factors of jaundice:
fetal-maternal blood incompatibility prematurity asphyxia at birth insufficient intake of mild during breast-feeding some medications maternal gestational diabetes infrequent feedings male gender birth trauma ethnicity (asian/native american)
A new mother who is breastfeeding her son asks the nurse, "How do I know if my son is getting enough fluids?" Which response by the nurse would be most appropriate?
"The best way is to check the number of diapers he wets. If he wets 6 to 8 times a day, he's getting enough."
A client who is breast-feeding her newborn tells the nurse, "I notice that when I feed him, I feel fairly strong contraction-like pain. Labor is over. Why am I having contractions now?" Which response by the nurse would be most appropriate?
"The baby's sucking releases a hormone that causes the uterus to contract."
The nurse is assessing the respirations of several newborns. The nurse would notify the health care provider for the newborn with which respiratory rate at rest?
68 breaths per minute
Which information would the nurse emphasize in the teaching plan for a postpartal woman who is reluctant to begin taking warm sitz baths?
Sitz baths increase the blood supply to the perineal area
The nurse teaches a postpartum client that her neonate's first stool will be meconium, which consists of intestinal secretions and cells. Which colors and consistencies should the nurse use to best describe the typical appearance of meconium?
Sticky, greenish black
Based on the nurse's knowledge about the postpartum period and an increase in blood coagulability during the first 48 hours, the nurse closely assesses the client for which condition?
thromboembolism
taking in phase:
time immediately after birth when client needs others to meet her needs and relives the birth process
cunduction:
transfer of heat from one object to another when they are in direct contact
babinski reflex:
Reflex in which a newborn fans out the toes when the sole of the foot is touched
how to treat for FAS:
educate pregnant women on effects assist in finding treatment
The nurse is admitting a 12-month-old to the medical unit. During the admission process the parents tell the nurse that their child is very advanced because he says "ball" when he picks up a football. How should the nurse respond?
"That is great that he is recognizing objects and is able to name them. He is right on target for language skills."
A mother is concerned because her 2-day-old newborn's birth weight was 8 lb (3584 g) and his current weight is 7 lb 8 oz (3360 g). What would be the nurse's response to the mother's concern?
"The weight loss is a normal finding, since newborns lose 5% to 10% of their birth weight in the first few days after birth."
Tonic neck reflex (fencer position):
-elicited by turning an infant's head to one side -infant extends arm and leg on that side and flexes arm and leg on the opposite side -birth to 3 to 4 months
when does APGAR scoring occur?
1 minute 5 minutes 10 minutes (if necessary)
heart rate of newborn
110-160
decreased average heart rate of newborn:
120-130
Neonatal screening is done before the infant leaves the hospital. Blood is drawn through a heel stick and tested for several disorders that can cause lifelong disabilities. When is the ideal time to collect this specimen?
24 hours after the newborn's first protein feeding
After the birth of a newborn, which action would the nurse do first to assist in thermoregulation?
Dry the newborn thoroughly
The nurse is preparing discharge teaching for a client who is 2 days postpartum. Which action should the nurse prioritize to encourage prevention of constipation?
Encourage fiber-rich foods
When doing a health assessment, at which location would the nurse expect to palpate the fundus in a woman on the second postpartal day and how should it feel?
fundus two fingerbreadths below umbilicus and firm
marconium stools:
greenish-black tarry stool composed of amniotic fluid, shed mucosal cells, intestinal secretions, and blood.
what effect does FAS have on newborn?
growth restriction (prenatal and postnatal), craniofacial structural anomalies, and CNS dysfunction.
A newborn that has a surfactant deficiency will have which assessment noted on a physical exam?
grunting
One of the nurse's responsibilities is to educate new parents on the best method to prevent infections in the newborn environment. Which method would the nurse identify as best to control infection?
handwashing
microcephaly:
head circumference more than 2 standard deviations below average or less than 10% of normal parameters for age, caused by failure of brain development.
A woman with diabetes has just given birth. While caring for this neonate, the nurse is aware that the child is risk for which complication?
hypoglycemia
skin variations:
vernix caseosa stork bites/salmon patches mila Mongolian spots erythema toxicum harlequin sign nevus flammeus nevus vasculosus
When teaching new parents about the sensory capabilities of their newborn, which sense would the nurse identify as being the least mature?
vision
A mother asks the nurse why her newborn is getting a Vitamin K injection in the birth room. The nurse explains that the injection is necessary because:
vitamin K is needed for coagulation, and the newborn does not produce vitamin K in the few days following birth
how does a newborn present with jaundice?
with a yellowing of skin, sclera, and mucous membranes
when does the ductus arteriosus close?
within the first breath and clamping of the umbilical cord.
A nurse is assigned to care for a newborn with an elevated bilirubin level. Which symptom would the nurse expect to find during the infant's physical assessment?
yellow sclera
breast fed stools:
yellow-gold, loose, stringy to pasty, SEEDY, sour smelling
The nurse describes the changes in stool that a new mother would see when feeding her newborn formula. Which description best indicates what the mother would observe after several days?
yellow-green, pasty, unpleasant-smelling stool
formula-fed stools:
yellow-yellow/green, loose, pasty or formed, unpleasant
While trying to decide whether to bottle feed or breastfeed her newborn infant, a new mother questions the lactation specialist concerning the greatest benefit of breastfeeding her infant. What would be the best response?
immunity against many different bacteria
A nurse is teaching a postpartum client how to do muscle-clenching exercises for the perineum. The client asks the nurse, "Why do I need to do these exercises?" Which reason would the nurse most likely incorporate into the response?
improves pelvic floor tone
typical length of newborn:
44 - 55 cm, from head to heel unclothed
Typical weight of newborn:
5 lb 8 oz - 8 lb 14 oz
After teaching a postpartum client about postpartum blues, the nurse determines that the teaching was effective when the client makes which statement?
"I might feel like laughing one minute and crying the next."
After teaching a group of pregnant women about the skin changes that will occur after the birth of their newborn, the nurse understands there is a need for additional teaching when one of the women makes which statement?
"I can't wait for these stretch marks to disappear after I give birth."
When assessing a new father's adaptation to his new role, which statement would indicate that he is in the reality stage?
"I didn't realize all that went into being a dad. I wasn't prepared for this."
A postpartum client who is bottle feeding her newborn asks, "When should my period return?" Which response by the nurse would be most appropriate?
"It varies, but you can estimate it returning in about 7 to 9 weeks."
A nursing student observes that the babies in the nursery are wrapped up warmly and are wearing knit caps. Which explanation by the nursery staff would be correct?
"Newborns lose body heat easily and need to be kept warm until their body temperature stabilizes."
The nurse is documenting the relationship between a postpartum mother and her infant. Which observation would demonstrate attachment?
"The mom is talking to the infant while breast-feeding the infant."
A new mother is changing the diaper of her 12-hour-old newborn and asks why the stool is black and sticky. Which response by the nurse would be most appropriate?
"This is meconium stool and is normal for a newborn."
Stacy is going to visit her son in the intensive care unit. She has been pumping breast milk and storing it in the fridge. Stacy is making her son's bottle for his feeding and goes to warm the breast milk. What option should the nurse give the mom to prepare the bottle?
"You can use the hot water tap to get warm water to warm the bottle."
postpartum pain goal:
0-2 on scale
enzymes are limited until what age?
4-6 months. infants cannot digest cereal prior to this time.
typical chest circumference of a newborn:
30-36 cm (12-14 in) at nipple line
typical head circumference of newborn:
32 - 38 cm (13-15 in) at widest diameter
how does a newborn lose heat?
4 mechanisms of heat exchange
APGAR scale:
8-10: normal 4-7: moderate difficulty 0-3: severe distress
normal newborn temperature:
97.7 - 99.7
very low birth weight:
> 3.5 lbs
extremely low birth weight:
>2.5 lbs
low birth weight:
>5.5 lbs
If the nurse manages a new infant with low blood sugar, which intervention would be appropriate to prevent hypoglycemia?
Feed the infant
Postpartum: Vital Signs
HR: 40-80 BPM BP: falls in first 2 days, increased 3-7 days, and returns to normal by 6 weeks Temp: elevated; hydrate Resp: normal; 16 - 20 / min
One hour after birth the nurse is assessing a neonate in the nursery. The nurse begins by assessing which parameters?
Inspecting posture, color, and respiratory effort
Which action would most make the nurse believe that a postpartum woman is accepting a child well?
She turns her face to meet the infant's eyes when she holds her.
A client with diabetes gives birth to a full-term neonate who weights 10 lb, 1 oz (4.6 kg). While caring for this large-for-gestational age (LGA) neonate, the nurse palpates the clavicles for which reason?
One of the neonate's clavicles may have been broken during birth.
Which teaching is most helpful in preventing Sudden Infant Death Syndrome (SIDS)?
Place the infant on his or her back for sleep.
A nurse is caring for a 5-hour-old newborn. The primary care provider has asked the nurse to maintain the newborn's temperature between 97.7° F and 99.5° F (36.5° C and 37.5° C). Which nursing intervention would be the best approach to maintaining the temperature within the recommended range?
Place the newborn skin-to-skin with the mother
A first-time mother is nervous about breastfeeding. Which intervention would the nurse perform to reduce maternal anxiety about breastfeeding?
Reassure the mother that some newborns "latch on and catch on" right away, and some newborns take more time and patience.
sucking reflex:
Reflex that causes a newborn to make sucking motions when a finger or nipple if placed in the mouth
A nurse is assessing a postpartal woman. Which behavior would the nurse interpret as an indication that the woman is entering the taking-hold phase of the postpartal period?
She did her perineal care independently
Moro reflex (startle reflex):
Sudden loud noise will cause symmetric abduction and extension of the arms followed by adduction and flexion of the arms over the body. Disappears by 3 to 4 months. ■ Absence on one side: Rule out brachial plexus injury, fracture, shoulder dystocia. ■ Absence on both sides: Rule out spinal cord or brain lesion. ■ Older infant: Persistence of Moro reflex abnormal. Rule out brain pathology.
stork bites/salmon patches:
Superficial vascular areas found on nape of neck, eyelids, between eyes & upper lip. Normal variant, disappear w/in first year.
A nurse is providing care to a postpartum woman. The nurse determines that the client is in the taking-in phase based on which finding?
The client states, "He has my eyes and nose."
During the birth of a post-term infant, the nurse suspects that meconium aspiration may have occurred in utero. What findings would correlate with this suspicion? Select all that apply.
The newborn has green staining of the fingernails. The newborn has labored abdominal respirations. The newborn makes bearing down movements. Green amniotic fluid is present at birth.
Mongolian spots:
benign blue or purple splotches on lower back and buttocks of newborns. can also occur over legs and shoulders. occur in dark skinned newborns of all races. caused by concentration of pigmented cells; disappear within 4 years of life.
The nurse places a warmed blanket on the scale when weighing a newborn to minimize heat loss via which mechanism?
conduction
The nurse is making a follow-up home visit to a woman who is 12 days postpartum. Which finding would the nurse expect when assessing the client's fundus?
cannot be palpated
what causes regurgitation?
cardiac sphincter and nervous control of stomach are immature. gut doesn't stretch to hold milk so most of it comes right back up
involution:
contraction of muscle fibers; catabolism; regeneration of uterine epithelium
A newborn's axillary temperature is 97.6° F (36.4° C). He has a cap on his head. His T-shirt is damp with spit-up milk. His blanket is laid over him, and several children are in the room running around his bassinet. The room is comfortably warm, and the bassinet is beside the mother's bed away from the window and doors. What are the most likely mechanisms of heat loss for this newborn?
convection and evaporation
Because the newborn's red blood cells break down much sooner than those of an adult, what might result? a. Anemia b. Bruising c. Apnea d. Jaundice
d. jaundice
When describing the hormonal changes that occur after birth of a newborn, the nurse would identify a decrease in which hormone as being associated with breast engorgement?
estrogen
cold stress:
excessive heat loss that requires a newborn to use compensatory mechanisms (non-shivering thermogenesis and tachypnea) to maintain core body temp.
signs of NEC:
feeding intolerance, abdominal distention, and bloody stools in a preterm infant receiving enteral feedings. As the disease worsens, the infant develops signs and symptoms of septic shock (respiratory distress, temperature instability, lethargy, hypotension, and oliguria)
difference in hepatic portal circulation in fetus vs. newborn:
fetus: ductus venosus bypasses; maternal liver performs filtering functions newborn: ductus venosus closes (becomes a ligament); hepatic portal circulation begins
difference between heart circulation in fetus v. newborn:
fetus: pressures in right atrium are greater than in the left, encouraging blood flow through the foramen ovale newborn: pressures in left atrium are greater than in the right, causing the foramen ovale to close
Erythema toxicum:
idopathic generalized transient rash that occurs in up to 70% of newborns for first week of life. looks like flea bites. found on face, chest, and back; no pattern
breastfeeding advantages:
immune system positive bacteria in digestive tract reduces stomach upset, diarrhea, colic bonding lower risk of constipation lower risk of obesity less food allergies lower cost
voiding issues after birth:
incomplete emptying, bladder distention, difficulty voiding, urinary retention due to: perineal lacerations generalized swelling and bruising of perineum and tissue hematomas decreased tone diminished sensation of bladder pressure
what causes jaundice?
increased bilirubin production (more than twice rate in adults) from breakdown of RBCs. live fails to break down the bilirubin.
sweating postpartum:
increased. mechanism to reduce amount of fluids retained during pregnancy and restore prepregnant body fluid levels
changes that occur in the respiratory system after birth:
initiation of respirations: in the intrauterine environment, fluid causes lungs to expand, during and after birth this fluid is removed and replaced with air. vaginal birth helps remove the fluid from baby's body role of surfactant: surface tension reducing lipoprotien that prevents alveolar collapse respirations: 30-60 per minute; irregular, shallow, unlabored; short periods of apnea (<15 seconds); symmetrical chest movements
How is jaundice treated?
phototherapy
FAS (fetal alcohol syndrome):
physical and cognitive abnormalities in children caused by a pregnant women's heavy drinking
When conducting an assessment, the nurse observes fine, downy hair covering the newborn's shoulders and back. The nurse interprets this finding as:
lanugo
When caring for a mother who has had a cesarean birth, the nurse would expect the client's lochia to be:
less than after a vaginal birth.
caput succedaneum:
localized edema on scalp that occurs from pressure of the birth process. prolong labor. soft tissue swelling that crosses suture lines. pitting edema and overlying petechiae and ecchymosis are noted . NO BLOOD
A client expresses concern that her 2-hour-old newborn is sleepy and difficult to awaken. The nurse explains that this behavior indicates:
normal progression of behavior
how to care for cord:
observe for bleeding, redness, drainage, foul odeor avoid tub baths until cord has fallen off and healed expose to air fold diapers below level of cord monitor for changes don't pull cord
when breast feeding, what chemical is released that stimulates afterpains?
oxytocin
During the birth, the primary care provider performed an episiotomy. The client is now reporting discomfort. To reduce this discomfort and increase hygiene to the perineum, the nurse would encourage the client to use which intervention?
peribottle and warm water
difference between physiological jaundice and pathologic neonatal jaundice:
physiological jaundice is harmless and occurs in most infants between 3rd and 8th day of life pathologic jaundice can be conjugated or unconjugated and is typically a symptom of an underlying disease
When palpating for fundal height on a postpartal woman, which technique is preferable?
placing one hand at the base of the uterus, one on the fundus
Nevus flammeus:
port wine stain on face or other body parts.
other ways to minimuze the effects of cold stress for neutral thermal environment:
prewarming blankets/hats keep infant transporter fully charged and heated drying newborn completely after birth early breast-feeding for non-shivering thermogenesis fuel radiant warmers and double wall isoletts to prevent heat loss from radiation defer bathing until newborn is medically stable; radiant heat source while bathing
How to treat transient tachypnea of newborn?
provide supportive care: giving O2, warmth, monitor respiratory status, allowing time for pulmonary capillaries to remove fluid
When assessing a newborn's reflexes, the nurse strokes the newborn's cheek, and the newborn turns toward the side that was stroked and begins sucking. The nurse documents which reflex as being positive?
rooting reflex
A nursing student observing newborns in the nursery is amazed that a crying infant put her fingers in her mouth, instantly stops crying, and then falls asleep. This behavior can best be explained as:
self-quieting ability
A postpartum client comes to the clinic for her 6-week postpartum check up. When assessing the client's cervix, the nurse would expect the external cervical os to appear:
slit-like
___, ___ feedings are the best way to feed a newborn.
small, frequent
lanugo, ballard scale:
soft downy hair, disappears
breastfeeding complications:
sore nipples/cracking engorgement mastitis
skin texture, ballard scale:
sticky to transparent to smooth; some peeling, cracking, wrinkling
possible concern with marconium stool:
stool passed in utero, resulting in the baby's ingestion of marconium
A client who has just given birth to a baby girl demonstrates behavior not indicative of bonding when she performs which action?
talks to company and ignores the baby lying next to her
what signifies that the baby is well nourished/hydrated?
the newborn seems satisfied, wets 6 to 10 diapers daily, produces several stools a day, sleeps well, and is gaining weight regularly, then he or she is probably receiving sufficient breast milk or formula.
vernix caseosa:
thick white substance that protects skin of fetus. found few days after birth in body creases and hair; will be absorbed by skin
breast tissue, ballard scale:
thickness and size of breast tissue and areola; imperceptible to full and budding
why does newborn have trouble with thermoregulation?
thin skin; blood vessels close to surface lack of shivering ability; limited stores of metabolic substrates (glucose, glycogen, fat) limited voluntary muscle activity large body surface relative to body weight lack of subcutaneous fat; little ability to conserve heat inability to adjust own clothing or blankets cannot communicate that they are cold
letting go phase:
third phase in which woman reestablishes relationships with others
what age should spoon feeding begin?
4-6 months, around the time the baby can hold up his/her own head and sit to feed.
A nurse is educating the mother of a newborn about feeding and burping. Which strategy should the nurse offer to the mother regarding burping?
Hold the newborn upright with the newborn's head on the mother's shoulder.
During assessment of the mother during the postpartum period, what sign should alert the nurse that the client is likely experiencing uterine atony?
boggy or relaxed uterus
Bonding v. attachment:
bonding: close emotional attraction to newborn by parents. develops 30-60 MINUTES after birth attachment: development of strong affection between infant and family
Vitamin K is given for:
coagulation
3 positions for breast feeding:
cradle football side laying
plantar creases, ballard scale:
creases on soles of feet, the more the more maturity
signs of respiratory distress:
cyanosis, tachypnea, expiratory grunting, sternal retractions, nasal flaring
A nurse is preparing a couple and their newborn for discharge. Which instructions would be most appropriate for the nurse to include in discharge teaching?
demonstrating comfort measures to quiet a crying infant
the baby is at a higher risk of developing food allergies during the first 4-6 months. why?
due to an immature immune system. (early intro to solids increases the risk)
When developing the plan of care for the parents of a newborn, the nurse identifies interventions to promote bonding and attachment based on the rationale that bonding and attachment are most supported by which measure?
early parent-infant contact following birth
molding:
elongated shaping of the fetal head to accommodate passage through the birth canal. cone head. resolves after a week w/o intervention
A nurse is making a home visit to a postpartum woman who gave birth to a healthy newborn 4 days ago. The woman's breasts are swollen, hard, and tender to the touch. The nurse documents this finding as:
engorgement
treating NEC:
enteral antibiotics, judicious administration of parenteral fluids, human milk feedings, antenatal corticosteroids, enteral probiotics (Lactobacillus acidophilus), and slow continuous drip feedings
A nurse is conducting a class for expectant parents about newborns and the changes that they experience after birth. The nurse discusses the neonatal period, describing it as which time frame?
first 28 days of life
convection:
flow of heat from body surface to cooler surrounding air or air circulating over body
eyes and ears: ballard scale:
fused or open, the greater the ear cartilage with stiffness, the grater the maturity
cephalhematomais:
localized subperiosteal collection of BLOOD of the skull which is always confined by one cranial bone
Which factor places newborns at risk for ongoing health problems?
perinatal asphyxia
how to treat hypoglycemia:
rapid acting source of glucose, IV glucose for acute, severe cases. monitoring of levels, physical examination, body measurements, screening ONLY on at risk infants.
A thin newborn has a respiratory rate of 80 breaths/min, nasal flaring with sternal retractions, a heart rate of 120 beats/min, temperature of 36° C (96.8° F) and persisting oxygen saturation of <87%. The nurse interprets these findings as:
respiratory distress
anocutaneous reflex (anal wink):
stimulate perianal skin close to anus. sphincter will constrict S4-S5 innervations
Nevus vasculosus:
strawberry mark. benign capillary hemangioma in dermal and sub-dermal layers. raised, rough, dark red, and demarcated. found in head region a few weeks after birth. go away after few months.
