OB Week 4
Pulse
110-160 bpm
If baby is blue around lip
central cyanosis not normal
Acrocyanosis
1 point on APGAR does not mean anything is wrong Means hands or feet are blue
Dry baby right away after washing them
They can lose heat through evaporation
A nurse is caring for a new mother who is concerned about her babys eyes crossing, which therapeutic response?
This occurs because newborns lack control to regulate eye movement
Normal weight
2500-4100g
Respirations
30-60 per min
Temp
363.5-37.2 C
The nurse is taking care of e newborns, which should be assessed first.
A baby who has redness and swelling around his umbilical cord
Hepatitis B protocol
All women are screen pre birth Infants born when mom has Hep B have to get the HepB vaccine and HBIG within 12 hours of birth
A nurse is checking several newborn reflexes on a 2 day old neonate. Which reflex would require further investigation?
Asymmetrical abduction
The nurser isn assessing a neonate 1 hour after birth which requires further eval?
Axillary temp of 97.1F 36.2C
The nurse is performing a physical assessment on a 40-week neonate, which assessment should the nurse document as normal. SATA
Breast buds Overriding sutures Acrocyanosis of the hands and feet Equal gluteal folds
The nurse is assisting with care of a normal newborn. Which meds should nurse anticipate admin?
Erythromycin Ointment Vitamin K injection Hep B vaccine
The nurse is performing an assessment on baby. sShe notices localized edema in soft tissue. The area feels spongy and crosses suture lines. which of the following should nurse expect?
Caput succedaneum
A nurse is assessing a newborn the day after delivery. The nurse noted a raised bruised area scalp that does not cross suture line. How does nurse document finding?
Cephalhematoma
A nurse places a newborn under a radiant heat warmer after birth. The purpose is to prevent which of the following in the newborn?
Cold stress
A nurse is caring for a newborn and auscultates a heart rate of 110bpm, which action should the nurse take?
Document as expected
A nurse is assessing a newborn who was born at 42.5 weeks which of the following should the nurse expect?
Dry cracked skin
A nurse on the labor and d unit is caring for newborn, which action reduces evaporate heat loss?
Drying the newborn's skin thouroughly
Newborn circulation 3 major changes?
Ductus venosus Foramen Ovale Ductus Arteriosus need to close
After deliuvery, the left atrial pressure is higher than right atrial pressure, this causes the ------- to close.
Foramen ovale
Water-soluble vitamin K injection
Given IM vastus lateralis (outer thigh)
A nurse is teaching the parent of newborn about bottle feeding. which of the following statements by parent indicates a need for further teaching?
I will tip the nipple so air is present as my baby sucks
Cephalohematoma
Looks like an egg on head Does not cross suture line
Caput Succedaneum
Looks like swollen head Crosses suture lines
Cold stress occurs when
Low environmental temp Causes Low body temp, high HR and RR, increase O2 consumption, depletion of glucose, low surfactant Respiratory distress
The educator is teaching a class about risk of infection. Which newborn is at highest risk?
Newborn with a circumcision
A. day shift nurse gives a report to the night sift nurse four newborns. which newborn should be assessed first?
Newborn with clear breath sounds and grunting
A nurse is caring for a newborn and observes signs of diaphoresis, jitteriness, and lethargy. Which of the following actions should the nurse take?
Obtain blood glucose by heel stick
Reflexes Grasp
Palmar grasp = hand grasp Plantar grasp = foot grasp
A nurse is caring for a newborn and assessing reflexes, to elicit moron reflex, which action?
Perform a sharp handclap near infant
A nurse is providing teaching to mom for baby who is SGA, whidh should nurse include as a possible cause for this condition?
Placental Insufficiency
The nurse is assessing. newborn who has trisomy 312 (down syndrome) which of the following are common characteristics of trisomy 21?
Protruding tongue Transverse palmar creases
Chemical Stimuli
Relaxation of pulmonary vessels resulting in a decrease of pulmonary vascular resistance
The nurse is assessing a newborn in the immediate post delivery period. She notices baby has sacral dimple with a patch of hair, nurse would suspect which of the following?
Spina bifida
5 symptoms of respiratory distress
Tachypnea Cyanosis Nasal flaring Grunting Chest retractions = skin looks like it being pulled in
Which of the following vitals in a 2-day-old newborn is abnormal?
Temp 37C, pulse 120, resp 30
The nurse is reviewing a physiological changes that occur in a newborn after birth. Which of the statements are true about transitioning to extrauterine life. SATA
The ductus venosis closes with cessation Cold stress can cause hypoglycemia Surfactant decreases the surface tension
What is the most critical change that occurs in the transition from fetus to neonate?
The establishment of extrauterine respirations
A nurse is preparing to admin vitamin K by IM injection, the nurse should admin med into which muscle?
Vastus lateralis
The mother baby educator is performing a skill check off on neonatal heel sticks with a recently hired nurse graduate on orientation. Which method is correct for collecting blood by heel stick?
Warm the foot, clean with alcohol and puncture side of heel
A nurse is performing an assessment on a 12 hour old neonate, which assessment needs further investigation and should notify MD?
Yellow coloring of the skin
Pseudomenstruation
also normal Means baby has pink or red discharge Means moms hormones are circulating in baby's body
Check baby's PMI
femoral and brachial murmurs
Epstein pearl
harmless and do not require treatment Bump of keratin looks like a white pimple on gums Notify MD
Reflexes Stepping/dancing
hold baby in standing position, baby will try to take step
Birthmarks Erythema toxicum
innocuous, pink, papular rash
Reflexes Moro/startle
loud clap makes it happen, baby stretches arms and legs out
Birthmarks Pigmentation
mongolian spots (looks like bruising), last 6 months to a year
Ortolani maneuver
move hips do you feel cracking? Sign of hip dysplasia
The nurse is assessing a baby who was born 30 min ago, which findings indicate respiratory distress?
nasal flaring retractions grunting
Plastibell method
no lubricant
If baby is cross eyes
normal do not worry, does not need to be reported
If ears are low set compared to eyes on baby?
sign of down syndrome
Reflexes Rooting
stroke mouth or cheek, baby will turn head in that direction
Birthmarks Millia
unopened sebaceous glands, tiny white pinpoint papules on nose etcv
Birthmarks Hemangiomas
vascular tumors of skin red patch
A nurse is caring for newborn who is SGA, which finding is associated?
wide skull sutures