Exam 4

Dry, peeling skin is seen in...

postmature newborns

Taking-in Phase

time immediately after birth, pt needs sleep, depends on others to meet her needs, & relives events of birthing process *24-48 hrs

A multigravida client has given birth to a large-for-gestational age infant with Apgar scores of 8 and 9. The priority nursing assessment for this infant is for:

hypoglycemia

Immediately after birth what does lochia look like?

bright red & consists mainly of blood, fibrinous products, decidual cells, & red and white blood cells

When do newborns have their first bowel movement?

up to 24 hrs for first meconium stool

A client has admitted use of cocaine prior to beginning labor. After the infant is born, the nurse should anticipate the need to include which action in the infant's plan of care?

urine toxicology screening

Jaundice

aka icterus. yellowing of the skin, sclera, & mucous membranes

A diabetic postpartum client plans to breastfeed. The nurse determines that the client's understanding of breastfeeding instructions is sufficient when she states:

"Breastfeeding will assist in lowering maternal blood glucose."

The nurse has provided health teaching about physiologic changes that can be expected during the postpartum period to a postpartum client who is bottle-feeding her neonate. Which client statement indicates that this teaching has been effective?

"My menstrual flow should resume in approximately 6 to 10 weeks."

After the birth of her first neonate, a mother asks the nurse about the reddened areas at the nape of the neonate's neck. How should the nurse respond?

"They're normal and will disappear as the baby's skin thickens."

How do you care circumcision?

*Apply petroleum jelly gauze to penis, except if plastibell is used * clean after each void with warm water * milky covering is normal, don't disrupt

Postpartum/puerperium period

*begins after delivery of placenta until about 6 wks (varies) *womens body begin to return to prepregnant state

Lochia

*vaginal discharge that occurs after birth *decidua (spongy layer) of uterus is shed to give the lochia

When is APGAR assessed?

1 min, 5 min of birth *If below 8 @ 5 min, they require a 10 min score

Engrossment(father or significant other's development of a bond w/ newborn)

1. visual awareness of newborn-attractive, pretty, beautiful 2. tactile awareness- touch or hold newborn 3. Newborn is perfect- doesn't see imperfections 4. Strong attraction to newborn-focuses all attention on newborn 5. awareness of distinct features- distinguish newborn from others 6. extreme elation- "high" 7. Increased sense of self-esteem--feels proud, more mature, and older

HR for newborn:

120-160 * up to 180 if crying

How does the uterus change after birth?

1st week- shrinks by 50%, wt 1 lb. 6 wks- 2 oz. approx. wt prior to pregnancy 1st few day it descends from level of umbilicus at a rate of 1cm(1 fingerbreadth) per day. 3 days, lays 2-3 cm below umbilicus. End of 10 days, fundus can't be palpated

Breastfeed every...

2-3 hrs

Newborns first void:

24-48 hrs post delivery *usually doc is notified if babe hasn't voided after 24 hrs.

Formula feed every...

3-4 hrs

How many bowel movement do newborns have in one day?

3-5 daily on average up to 10 May have 1 every 5-7 days after a couple of weeks

Resp. for newborn

30-60 breaths/min

When are bowel sounds present in newborn?

30-60 min after birth

When are kidney's developed in newborn?

34-36 wks gestation

A nurse assigns to a neonate an Apgar score of 8 at 5 minutes. The nurse understands that this score indicates:

A neonate who is in good condition.

A male neonate underwent circumcision. What nursing intervention is part of the initial care of a circumcised neonate?

Apply petroleum gauze to the site for 24 hours.

The liver is responsible for conjugation of what?

Bilirubin (yellow to orange bile pigment produced by the breakdown of red blood cells)

On examination of an African newborn, the nurse notes a macular, blue-black area of pigmentation near the buttocks. Which of the following actions of the nurse is appropriate?

Consider the finding as normal in Africans.

Harlequin sign

Deep pink or red color develops over one side of newborns body while the other side remains pale or normal color * may indicate shunting of blood that occurs w/ cardiac problem or may indicate sepsis

How often should the newborn's body temp. be assessed?

Every 30 min. for the first 2 hrs. or until the temp. has stabilized. THEN every 8 hrs. until discharge

In the newborn, the liver stores what?

Iron

4 mechanisms stimulating respiration:

Mechanical- vaginal squeeze, first gasp initiates the removal of fluid to clear little sacs (doesn't occur in c-sections) Chemical- stimulation; clamp cord, no oxygen from mother, systems kick into gear Sensory- "shock" they go from comfortable to not. It's now noisy, bright, big change. Mom's chest is most zen place, skin to skin calms babe. Mom's temp. adjusts to warm babe Thermal- it's a temp. change, cold stress or hypothermia could result if active measures aren't taken. If preterm bump up the heat

What is milia on a neonate?

Milia are white papules from plugged sebaceous ducts that disappear by age 2 to 4 weeks.

Which action would be most appropriate after assessing a neonate's cry as infrequent, weak, and very high pitched?

Notify the primary care provider because this may indicate a neurologic problem.

Postpartum depression

S/Sx: restless, worthless, guilty, hopeless, moody, sad, overwhelmed

Stomach capacity of newborn:

about 50-60 mLs

Erythromycin

administered within 1 hr after birth to prevent ophthalmia neonatorum

How long is cord clamped?

at least first 24 hrs. *can be removed when the cord is dried & occluded & is no longer bleeding

"maternal blues" aka "baby blues"

characterized by mild depressive symptoms, anxiety, irritability, mood swings, tearfulness, increased sensitivity, & fatigue *peak on postpartum days 4 & 5, may last hours to days, resolve by day 10

Lochia rubra

deep-red mixture of mucus, tissue debris, & blood. first 3-4 days

Capet Succedaneum

edema of head (from birth) (crosses over suture line) *normal finding, subsides w/ in few days

Lochia alba

final stage. creamy white or light brown Consists of leukocytes, decidual tissue, & reduced fluid content Occurs from days 10-14, can last 3-6 wks

What does lochia smell like?

fleshy. If its an offensive odor it usually indicates infection

An increased left atrial pressure causes what to close?

foramen ovale, thus allowing the output from the R. ventricle to flow entirely to the lungs.

Clavicles should be palpated to assess for...

fractures

Transitional stool is..

greenish brown & of looser consistency than meconium

Torticollis

head inclined to one side as a result of contraction of muscles on that side of the neck

When obtaining a blood sample to screen a neonate for phenylketonuria (PKU), the nurse should obtain the sample from the:

heel

Vitamin K is administered IM to newborn to prevent what?

hemorrhagic disorders

After teaching the mother about the neonate's positive Babinski's reflex, the nurse determines that the mother understands the instructions when she says that a positive Babinski's reflex indicates which condition?

immaturity of the central nervous system

A client who used heroin during her pregnancy gives birth to a neonate. When assessing the neonate, the nurse expects to find:

irritability and poor sucking.

Stage 3: Transition to Mastery (father)

makes conscious decision to take control & be at the center of newborns life regardless of preparedness *similar to mother's letting-go phase

Taking-hold Phase

maternal adaptation, dependent & independent maternal behavior. Starts 2nd to 3rd day postpartum & may last several weeks

Oxytocin acts so that...

milk can be ejected from alveoli to the nipple

In the newborn, what is suctioned first?

mouth & then nares with a bulb syringe

One hour after receiving nalbuphine for pain during labor, a primigravida gives birth to a full-term neonate with symptoms of respiratory depression. The nurse anticipates that the neonate will require the administration of which drug?

naloxone

Formula-fed newborns stools become...

pale yellow to light brown

Lochia serosa

pinkish brown 3-10 days Contains leukocytes, decidual tissue, red blood cells, & serous fluid

Stage 1: Expectations (father)

preconceptions about home life & what it will be like with a newborn *eye opening experience

Parents who bring a 3-week-old neonate to the hospital report that he's been "throwing up after every feeding." A nurse notes projectile vomiting while assessing the neonate. X-rays confirm:

pyloric stenosis.

Stage 2: Reality (father)

realize expectations aren't realistic, become sad, ambivalent, jealous, & frustrated, they want to be more involved

The newborn has increased energy needs after birth, so the liver does what?

releases glucose from glycogen stores for the 1st 24 hrs.

If nasal flaring occurs, what can this indicate?

respiratory distress

Why aren't rectal temp.'s done anymore?

risk of traumatizing the rectal lining

Breast-fed newborns stools become...

seedy, yellow

What are Epstein's Pearls?

small,white cysts on hard palate

Cephalhematoma

swelling due to bleeding into an area between bone & periosteum (doesn't cross over suture line) *absorbed w/ in 6 wks no treatment

Engorgement

swelling of breast tissue as a result of an increase in blood & lymph supply as a precursor to lactation *peaks in 3-5 days postpartum, subsides within 24-36 hrs. * occurs from infrequent feeding or ineffective emptying of the breasts * hard and tender to touch * offer frequent feedings, applying warm compress, cabbage leaf compresses *cold compresses reduce swelling * If not breastfeeding, subsides within 2-3 days

Mucosal barrier protects from what?

the penetration of harmful substances (bacteria, toxins, and antigens) present within the intestinal lumen

Newborn receives passive immunity via...

the placenta (immunoglobulin G) & from colostrum (immunoglobulin A)

Where would you touch to elicit plantar reflex on a neonate?

the sole of the foot near the base of the digits, causing flexion or grasping. This reflex disappears around age 9 months.

Prolactin

triggers the synthesis & secretion of milk

Umbilical cord should have three vessels...

two arteries & one vein *small,thin cord may be associated w/ poor fetal growth

Newborn has a sponge bath for how long?

until the cord falls off (2 wks)

The nurse determines the client has breast engorgement and should instruct the client to:

use her hand or a pump to express a small amount of breast milk before breastfeeding.

Effective breastfeeding release oxytocin, which causes what?

uterine cramping

Involution

uterus returns to its normal size

Physiologic jaundice

very common. Occurs within the 1st 3 days of life

What does thrush look like?

white patchy areas on tongue or gums that cannot be removed w/ washcloth; may be painful

Production of vitamin K occurs when?

within 24 hrs. of age from bacterial colonization of the gut (after oral intake)

When does breast milk typically appear?

within 4-5 days after childbirth

Letting-go phase

women reestablishes relationships w/ others, adapts to parenthood, assumes responsibility & care of the newborn with more confidence

Nursing interventions to help maintain newborn body temp.

•Dry the newborn immediately after birth to prevent heat loss through evaporation.•Wrap the baby in warmed blankets to reduce heat loss via convection.•Use a warmed cover on the scale to weigh the unclothed newborn.•Warm stethoscopes and hands before examining the baby or providing care.•Avoid placing newborns in drafts or near air vents to prevent heat loss through convection.•Delay the initial bath until the baby's temperature has stabilized to prevent heat loss through evaporation.•Avoid placing cribs near cold outer walls to prevent heat loss through radiation.•Put a cap on the newborn's head after it is thoroughly dried after birth.•Place the newborn under a temperature-controlled radiant warmer