Maternity Assessment of Newborn

A nurse is teaching a client who gave birth to a full-term female neonate how to change the neonate's diaper. Which of the following statement by the client would indicate to the nurse that learning has taken place?

"I will clean and dry the neonate's perineal area from front to back."

After teaching a new mother about the care of her neonate after circumcision with a Gomco clamp, which statement by the mother indicates to the nurse that the mother needs additional instructions?

"I will remove any yellowish crusting gently with water."

Harlequin Sign

(clown suit appearance) a deep color develops on one side and the other side is pale; this color change is due to vasomotor disturbance where vessels dilate on one side and constriction on the other. Usually lasts 1-20 minutes

Popliteal Angle

(degree of knee flexion) is determined with the newborn flat on its back. The thigh is flexed on the abdomen and chest, and the nurse places the index finger of the other hand behind the newborn's ankle to extend the lower leg until resistance is met. The angle formed is then measured. Results vary from no resistance in the very immature newborn to an angle of 80 degrees in the term newborn.

Nevus flammeus

(port wine stain) capillary angioma directly below the epidermis, non elevated and sharply demarcated red to purple area of dense capillaries; Commonly on face If they don't go away, they are usually a good indication of epileptic issues

Telangiectactic Nevi

(stork bites) pale pink or red spots found on eyelids, nose, lower occipital bone and nape of neck, common in light complexion newborn and color increases with crying and usually fades by second birthday.

Nevus Vasculosus

(strawberry mark) a capillary hemangioma; consists of enlarged capillaries in the dermal and subdermal layers. Raised clearly delineated dark red dark surface birthmark found in the head region. Full size by 1-3 months. -Will feel bumpy. Usually will go away on their own

Which of the following newborns is not at risk for respiratory distress syndrome?

-35 week newborn with APGAR of 6&7 -33 week newborn of preeclamptic mother -37 week newborn of gestational diabetic -40 week newborn with APGAR scores of 8&9

Which of the following is NOT a common cause of hemolytic disease in the newborn is?

-ABO incompatibility -Cephalohematoma -Rh isoimmunization

What are some pain relief measures for a newborn?

-Assess for vital sign changes -swaddle -cuddling -rocking -pacifier -quiet environment -oral sucrose for procedures (circumcision) -morphine, fentanyl, topical anesthetics

Which is NOT part of care of an infant in phototherapy?

-Monitor temp -Keep eyes covered -Expose all skin to light except genitalia -Remain under light at all times

Which of the following is NOT a sign of NAS?

-Muscle weakness -tremors -sneezing -excoriation

A nurse is evaluating the return demonstration of cord care by the mother of a neonate. Which actions would the nurse encourage the mother to perform?

-Sponge-bathing the infant until the cord falls off -Placing the diaper below the cord.

What is NOT an inborn error of metabolism?

-congenital hypothyroidism -PKU -Galactosemia -Lofenolac

Spina bifida occulta

-defect not visible -may show as a skin depression or dimple -port-wine angiomatous nevi -dark tufts of hair -soft subcut lipomas -progressive disturbance of gait with foot weakness -bowel and bladder sphincter disturbances

Causes of hydrocephalus

-developmental malformations -neoplasms -infections -trauma

Clinical Manifestations of hydrocephalus

-enlarged or full fontanelles -split or widened sutures -"setting sun" eyes -head circumference greater than 90% on growth chart -transillumination

Nursing interventions for intrauterine growth restriction (IUGR)

-hypoglycemia is the most common problem -asphyxia, hyperviscosity and cold stress may affect the baby's outcome -monitor respiratory status and signs of distress (tachypnea, grunting, flaring, retractions, cyanosis, decreased O2 sat, and abnormal ABGs) -Assess for hypoglycemia (tremors and lethargy, cyanosis or apnea, high pitched cry, pallor and hypothermia) Frequent screening done in the first 4 hours of life -Weight -Keep warm, prevent cold stress

Bottlefeeding teachings:

-low iron formula to 1 year of age -room temp -no microwaves (may cause hot spots in formula) -2-3 oz 6-8 times per day -important to burp after every 15 mL drank (0.5 oz)

Benefits of swaddling

-maintains body temperature -provides protection, feeling of closeness and security; quiets a crying baby

Which is not a type of spina bifida?

-myelomeningocele -chiari malformation -spina bifida occulta -meningocele

During the second period of reactivity:

-newborn is awake and alert -HR and R increase -may develop color changes (cyanotic or mottled with fluctuations) -increased production of mucus and gastric secretions (newborn will gag, choke and regurg, assess airway for patency) -may pass first stool in this period and void -may want to eat

Bonding:

-upright enface position talking to the baby, humming, singing -calling by name -complimenting -cuddling, massage, gently rubbing hands and feet -document evidence of bonding- do not chart bonding well, list signs observed

Circumcision Care:

-vasoline gauze after procedure and with each diaper change -may see yellowish film (normal; indicates healing) -report s/s of infection -keep diaper loose -first void should be noted -baby will not go home until first pee -baby will stay in nursery for 1 hour post op for observation -no vaseline gauze is used with plastibell

Spina bifida cystica

-visible defect with external saclike protrusion -sensory disturbances usually parallel motor dysfunction -Below 2nd lumbar vertebra (flaccid, partial paralysis of LE, varying degrees of sensory deficit, overflow incontinence with constant dribbling of urine, lack of bowel control, rectal prolapse (sometimes)) -Below 3rd sacral vertebra (no motor impairment, may be saddle anesthesia with bladder and anal sphincter paralysis) -Joint deformities (sometimes produced in utero; talipes valgus or vaus contractures, kyphosis, lumbosacral scoliosis, and hip dislocations

Teachings for breastfeeding:

-wash nipples with mild soap and water -may need to feed every 2 hours until routine is established -it should never hurt, if it does, something isn't being done right -baby eats whatever mother eats -It is important to teach the mother to put as much of the areola into the newborn's mouth as she can -newborns will feed on demand -babies suck with the back of the tongue -Should have 6-8 wet diapers a day

By the 10th day of age, the newborn's blood pressure should be around?

100/50

When does the blood from caput succedaneum reabsorb?

12 hours or a few days (depends on how bad the condition is)

Normal pulse for a newborn

120-160 bpm

Babies shoud sleep how much a day?

15-20 hours

The umbillical cord should be left how long?

2 cms from abdomen

Hearing can be evaluated by response to loud noise when?

24 hours post birth; if the baby fails the first test, they will test again within the next 24 hours

If an infant was born at 28 weeks and is now 2 months old, what is the infant's corrected age?

36 weeks

A 6-lb, 8-oz (2,948 g) neonate was born vaginally at 38 weeks' gestation. At 5 minutes of life, the neonate has the following signs: heart rate 110, intermittent grunting with respiratory rate of 70, flaccid tone, no response to stimulus, and overall pale white in color. The Apgar score is:

4

Normal respirations for a newborn

40-60

In the first 3-4 days after birth, the infant loses about ________ of its birth weight

5-10%

The newborn should have about ______ wet diapers per day

6

When is eye color established?

6-12 months of age

At birth, what should the diastolic range be?

60-40

When should the cord fall off?

7-14 days after birth important to teach the family: to not pull it off clean with alcohol assess for signs of infection

At 5 minutes of age, a neonate is pink with acrocyanosis; has flexed knees, clenched fists, a whimpering cry, and a heart rate of 128 beats/minute; and withdraws the foot when slapped on the sole. What 5-minute Apgar score would the nurse record for this neonate?

8

A baby can fix on objects how far out in front of their face?

8-10 inches

The newborn's temperature should stabilize within?

8-12 hours

At birth, what should the systolic range be?

80-45

Axillary termperature of a newborn

97.7 - 98.6

Habituation

Ability to respond to and then inhibit responding to discrete stimuli (light, rattle, bell, pinprick) while asleep

APGAR stands for

Appearance Pulse Grimace Attitude Respirations

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

Apply petroleum gauze to the site for 24 hours.

A neonate begins to gag and turns a dusky color. What should the nurse do first?

Aspirate the neonate's nose and mouth with a bulb syringe.

A certified nurse-midwife places a neonate under the radiant heat unit for the nurse's initial assessment. The initial assessment includes heart rate 110 beats/minute and an irregular respiratory effort. The neonate is moving all extremities and his body is pink. He also has a vigorous cry. The nurse notes copious amounts of clear mucus present both orally and nasally. Based on these assessment findings, what should the nurse do next?

Assign an Apgar score of 9, place the neonate in modified Trendelenburg's position, and suction the neonate's nose and oropharynx

Areola

At term gestation, the tissue will measure between 0.5-1 cm. During the assessment, the nipple should be not grasped firmly because skin and subcutaneous tissue will prevent accurate estimation of size. As gestation progresses, the breast tissue mass and areola enlarge.

What is NOT a defect of TOF?

Atrial septal defect

A nurse is about to give a full-term neonate his first bath. How should the nurse proceed?

Bathe the neonate only after his vital signs have stabilized.

Condition that occurs most commonly in preterm infants requiring mechanical ventilation

Bronchopulmonary dysplasia

What is NOT a characteristic of fetal alcohol syndrome?

Cardiomyopathy

A higher BP in the upper extremities and a lower BP in the lower extremities suggests?

Coarctation of the aorta

What does prolonged exposure to cold do to a newborn?

Depletes glycogen stores and causes acidosis (respiratory distress)

When assessing the legs, there should be symmetric skin folds on back of legs and butt, if not what does this indicate?

Dislocated hip

The nurse recognizes that what is suggestive of necrotizing entercolitis?

Distended shiny abdomen

The heart rate of a newly born neonate is regular at 142 bpm. What should the nurse do next?

Document this as a normal neonatal finding.

When is cord care done?

Done with am care and with each diaper change

Low set ears indicate?

Down syndrome

A neonate born 2 hours ago has just arrived in the nursery. Which nursing measure will prevent the neonate from losing heat by evaporation?

Drying him thoroughly after a bath

Organs that develop at the same time?

Ears and kidneys; usually if there is a problem with one then the other system needs to be checked as well

Refers to the urethral opening on the dorsal side of the penis?

Epispadias

What is the most likely cause of retinopathy of prematurity?

Exposure to high levels of oxygen

Which action is the best precaution against transmission of infection?

Eye prophylaxis with antibiotics for a neonate whose mother has gonorrhea infection

What is doll eyes and how long does it usually last?

Eyes move in the opposite direction of the head's position

Order of washing the baby:

Eyes: -inner to outer canthus, using a different part of the cloth each time Ears: -fold ear and get in behind Rest of face: -no soap, lotions or oils on face Neck: -soap can be used here Chest, back, arms: -do not get cord wet (may take longer to dry out and can increase risk of infection) Legs & Feet: -use lotion if skin is dry Genital area: -front to back If circumcised: -use clear water and squeeze over site, pat dry Wash Head: -use football hold and head titled slightly downward

What is expected with a child with cleft lip and palate?

Feeding difficulties

A preterm infant has a respiratory rate of 65. How should this infant be fed?

Gavage fed

What is the leading cause of neonatal morbidity and mortality in the US?

Group B streptococcus

Breastfeeding contraindications:

HIV Galactosemia (lack of enzyme to metabolize galactose; will need soy free formula) TB active and untreated Cytomegalovirus

If the baby undergoes pain what happens to vital signs?

HR and R go up BP and blood sugar increase

What does the first breath do?

Helps to expand the collapsed lungs

Condition of excess CSF in the ventricles of the brain

Hydrocephalus

What is NOT a risk associated with large for gestational newborns?

Hydrocephalus

What is a sign of infection in a newborn?

Hypothermia

When assessing a neonate 1 hour after delivery, the nurse measures an axillary temperature of 95.6° F (35.3? ° C), an apical pulse of 110 beats/minute, and a respiratory rate of 64 breaths/minute. Which nursing diagnosis is the priority at this time?

Hypothermia related to heat loss

What is the term for a yellow discoloration of the skin associated with hyperbilirubinemia?

Icterus

Which blood test is done on the mother to detect antibodies to the Rh antigen?

Indirect Coombs

Crossed extension

Infant should be supine; extend one leg, press knee downward, stimulate bottom of foot; observe opposite leg. Opposite leg flexes, adducts and then extends

What should a baby wear for the first 24 hours?

It should have a t-shirt, hat and be double wrapped

What would suggest hypoglycemia in a newborn?

Jitteriness that stops when disturbed

What is it called when the mother holds the newborn skin to skin?

Kangaroo care

What is the term for an infant of a diabetic mother who has increased body fat?

Macrosomia

Yellow staining of the skin and is showing signs of respiratory distress, likely cause?

Meconium aspiration syndrome

How do you bulb suction?

Mouth first, then nose

What is the term for the infant experiencing withdrawal symptoms?

Neonatal abstinence syndrome (NAS)

Babinski reflex (plantar)

On sole of foot, beginning at heel, stroke upward along lateral aspect of sole, then move finger across ball of foot. All toes hyperextend with dorsiflexion of big toe, recorded as a positive sign

What does blue sclera indicate?

Osteogenesis imperfecta (brittle bone disease)

A nurse would suspect what abnormality in a premature newborn that is cyanotic and mottling?

Patent ductus arteriosis

Magnet

Place infant in supine position, partially flex both lower extremities and apply pressure to soles of feet. Both lower limbs should extend against examiner's pressure. -Absence suggests damage to spinal cord or malformation. Reflex may be weak or exaggerated after breech birth

Trunk incurvation (Galant)

Place infant prone on flat surface, run finger down back about 4-5 cm lateral to spine, first on one side and then down other. Trunk is flexed and pelvis is swung toward stimulated side. With transverse lesions of cord, no response, below the level of the lesion is present -Response disappears by 4th week. Absence suggests general depression of nervous system. Response may vary but should be obtainable in all infants, including preterm ones.

Crawling

Place newborn on abdomen; Newborn makes crawling movements with arms and legs -Response should disappear about 6 weeks of age

Large for gestational age (LGA)

Plot above 90th percentile curve

What is the most likely cause of ruddy skin color in a newborn?

Polycythemia

Male genitals

Prior to 36 weeks, small scrotum has few rugae, testes are palpable in the inguinal canal. by 36-38 weeks, the testes are in the upper scrotum, and rugae have developed over the anterior portion of the scrotum. by term, the testes are generally in the lower scrotum, pendulous, covered with rugae.

When assessing female genitalia, it is important to teach the family about?

Psuemenstruation, which is discharge that may become tinged with blood; it is caused due to withdrawal of maternal hormones and is normal

Pull-to-sit (traction)

Pull infant up by wrists from supine position with head in midline. Head will lag until infant is in upright position, then head will be held in same plane with chest and shoulder momentarily before falling forward; infant will attempt to right head -response depends on general muscle tone and maturity and condition of infant

Oritentation

Quality of alert states and ability to attend to visual and auditory stimuli while alert

During the first period of reactivity the respirations will be?

Rapid, seen with some retractions, flaring and grunting. This is normal because they are adjusting to changes.

Recoil

Recoil is first tested in the legs. The newborn is placed on its back on a flat surface. With a hand on the newborn's knees and while manipulating the hip joint, the nurse places the baby's legs in flexion, then extends them parallel to each other and flat on the surface. The response to this manuever is recoil of the newborn's legs. According to gestational age, they may not move, or they may return slowly or quickly to the flexed position. Preterm infants have less muscle tone than term infants, so preterm infants have less recoil. Arm recoil is tested by flexion at the elbow and extension of the arms at the newborn's side. While the baby is in the supine position, the nurse completely flexes both elbows, holds them in this position for 5 seconds, extends the arms at the baby's side, and releases them. Upon release, the elbows of the full-term newborn form an angle of less than 90 degrees and rapidly recoil back to the flexed position. The elbows of the preterm newborn have slower recoil time and form a greater than 90 degree angle. Arm recoil is slower in healthy but fatigued newborns after birth; arm recoil is best elicited after the first hour of birth, when the baby has had time to recover from the stress of birth. Assessment of the arms' recoil should be bilateral to rule out brachial palsy.

When is the APGAR scores performed?

Recorded at 1 and 5 minutes If the score is low, will be done again at 10 minutes

Which temperature is taking right after birth and why?

Rectal temperature is assessed first; this checks the baby's core temperature and checks for patency of the anus

Sole (plantar) creases

Reliable indicators of gestational age in the 1st 12 hours of life. Development of sole creases begins at the top (anterior) portion of the sole and as gestation progresses, proceeds to the heel.

What is the most likely complication in a preterm infant?

Respiratory distress

What would be an expected finding with diaphragmatic hernia?

Respiratory distress

How does a newborn respond to inflammation and infection?

Slowly because of the immaturity of the immune system

Which of the following assessments would indicate an Apgar score of 8 for a neonate immediately after birth?

Some muscle tone in the arms and legs, bluish hands and feet

This is the most common defect of the CNS with failure of closure of the neural tube

Spina bifida

When giving a newborn a bath, where should the nurse start?

Start at head and move down. -can wash hair last

After the birth of a neonate, a quick assessment is completed. The neonate is found to be apneic. After quickly drying and positioning the neonate, what should the nurse do next?

Start positive pressure ventilation.

One minute after birth, a neonate has a heart rate of 120, a weak cry and respiratory effort, some muscle tone, and is acrocyanotic. The infant was given an Apgar score of 6. What should the nurse do?

Stimulate breathing by rubbing the neonate's back.

In a premature infant, what medication can be administered to improved respiratory effort?

Surfactant

What is the baby's first bath called?

Surgical scrub

A neonate circumcised with a Plastibell 1 hour ago is brought to his mother for feeding. What should the nurse instruct the mother to do?

Tell the nurse when the neonate voids

If a baby appears cyanotic but is showing no problems, what is an important teaching for the family?

The baby has had limited circulation before its birth, it will begin to pink up within 8-12 hours post birth

Why may c-section babies have difficulty with breathing?

They didn't experience a compression on their chest when they were born. They may experience respiratory issues for up to 24 hours.

The baby should eat during the first period of reactivity because?

They will have a deep sleep and during this sleep, their sugar can drop.

Excessive drooling is a hallmark sign of?

Tracheoesophageal fistula

Deep Tendon

Use finger instead of percussion hammer to elicit patellar, or knee jerk, reflex; newborn must be relaxed. -This reflex should be present during newborn period

What vitamin may be needed to help supplement milk?

Vitamin D

The nurse is preparing to administer vitamin K intramuscularly to a term neonate of a primipara who has just given birth. After explaining the purpose of the drug to the mother, which statement by the mother indicates effective teaching?

Vitamin K will help my baby's blood to clot properly."

Vernix caseosa

White cheese like substance covers fetus and lubricates skin of newborn. Term or post term have less

Cephalhematoma

a collection of blood between the surface of a cranial bone (usually parietal) and the periosteal membrane -unilateral or bilateral -does not cross the suture line -may be associated with physiologic jaundice (because of the extra blood cells destroyed in the cephalhematoma)

Intestinal stenosis

a narrowing of the intestine that causes partial blockage

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

a neonate who's in good condition.

Simian Crease

a single straight palmar crease; an abnormal finding that is associated with Down Syndrome.

During the first period of reactivity, bowel sounds will be?

absent

Physiologic jaundice occurs

after 24 hours of age

If a baby is experiencing tachypnea

an OG tube may be necessary for feeding

Term Skin

appears opaque because of increased subcut. tissue.

Preterm Skin

appears thin and transparent with veins prominent over the abdomen early in gestation

Reflexes

assessment of several neonatal reflexes

Female genitals

at 30-32 weeks, the clitoris is prominent and the labia majora are small and widely separated. at 36-40 weeks, they nearly cover the clitoris. at 40 weeks and beyond, labia majora cover the labia minora and clitoris.

Jaundice can be assessed by?

blanching tip of nose and forehead, observe sclera or gum line

Choanal Atresia

blockage between the nose and pharynx; will cause the baby to become cyanotic and will turn pink when they cry

Acrocyanosis

bluish discoloration of hands and feet and may be present in the first 2-6 hours. -due to poor peripheral circulation.

Radiation is

body heat rises to cooler surfaces, no direct contact (windows)

Skin turgor

check hydration status do over abdomen or thigh

The nurse is preparing to administer erythromycin ophthalmic ointment to a neonate soon after birth. The nurse should explain to the parents that this medication, in addition to preventing blindness caused by gonococcal organisms, also prevents neonatal blindness caused by which organism?

chlamydia trachomatis

Decreased or absent femoral pulses indicate?

coarctation of aorta -important to assess pulse ox and BP in all 4 limbs

Hydrocele

collection of fluid surrounding testes (usually resolves on own); swelling

What stool characteristics vary between breast-fed and formula fed babies?

color amount consistency

Intestinal Atresia

congenital malformation that involves the complete absence or closure of a part of the intestine

Smegma

consistency of vernix (prevents friction and trauma to tissue), found under foreskin

Myelomeningocele

contains meninges, spinal fluid and nerves -associated with varying, often serious neural deficits

How is heat lost?

convection radiation evaporation conduction

Nails

cover the nail bed at about 20 weeks. May extend beyond the fingertips in postterm newborn.

Vernix

covers the preterm newborn. The posterm newborn has none.

Immunoglobulin G (IgG)

crosses the placenta and provides newborn with passive immunity. -Gone and no infection right now.

Erbs Palsy

damage to 5&6th cervical nerve; the arm lies limp and elbow is in extension with forearm pronation, can't elevate the arm. May see statue of liberty splint.

After the first period of reactivity, the activity will?

decrease. HR and R will decrease and the newborn will sleep; this can last 2-4 hours.

Ankle dorsiflexion

determined by flexing the ankle on the shin. -This sign can be influenced by intrauterine position and congenital deformities.

PKU Newborn test

determines the body's ability to break down phenylalanine -done after 24 hours after intitiation of feeding breast or formula -state law that this test must be performed -tests for over 200 congenital disorders now -will need special formula -if breastfed, low PKU diet for mother -if the newborn cannot break down phenylalanine, there is a risk for mental retardation.

Polydactyly

dominant trait; presence of extra digits on either hands or feet

A score of 7

done again every 5 minutes for 20 minutes unless two consecutive 8's

Subconjunctival hemorrhage is caused by

due to changes in vascular tension or ocular pressure during birth, such as long periods of pushing

Square window sign

elicited by flexing the baby's hand toward the ventral forearm until resistance is felt. The angle formed at the wrist is measured

Scarf sign

elicited by placing the newborn supine and drawing an arm across the chest toward the newborn's opposite shoulder until resistance is met. The location of the elbow is then noted in relation to the midline of the chest.

Meningocele

encases meninges and spinal fluid but no neural elements -not associated with neural deficits

What do you give a baby to help prevent eye infections after birth?

erythromycin eye drops

Milia

exposed sebaceous glands looks like white spots on face especially across nose

What is transient strabismus and what causes it?

eye jerking; it is caused by poor neuromuscular control of eyes. This is a normal finding. Gradually regresses in 3-4 months

Cryptorchidism

failure of testes to descend -risk factor for testicular cancer

Swallowing

feed infant, swallowing usually follows sucking and obtaining fluids swallowing is usually coordinated with sucking and usually occurs without gagging, coughing, or vomiting -If response is weak or absent, may indicate prematurity or neurologic defect. Sucking and swallowing are often uncoordinated in preterm infant.

Lanugo

fine hair covering; greatest at 28-30 weeks and then disappears first from the face, then from the trunk and extremities. Decreases as gestational age increases.

What position decreases heat loss?

flexed positions

How long are babies called neonatal?

for the first 28 days of life

Development of muscle controls proceeds from?

head to foot; head and neck muscles are the first ones under control

If a baby has no respiratory distress, but is appearing cyanotic, what could this indicate?

heart problems; may have a shunting issue

A tremor that is related to hypoglycemia

hold hand and tremor will stop, if it is a convulsion it will not

Moro

hold infant in semi-sitting position, allow head and trunk to fall backward to an angle of at least 30 degrees. Place an infant on flat surface, strike surface to startle infant. Symmetric abduction and extension of arms are seen; fingers fan out and form a C with a thumb and forefinger; slight tremor may be noted; arms are adducted in embracing motion and return to relaxed flexion and movement. Legs may follow similar pattern of response. Preterm infant does not complete "embrace", instead arms fall backward because of weakness -Response is present at birth; complete response may be seen until week 8; body jerk is only seen between 8-18 weeks; response is absent by month 6 if neurologic maturation is not delayed. Response may be incomplete if infant is deeply asleep; give parental guidance about normal response. Asymmetric response may connote injury to brachial plexus, clavicle, or humerus. Persistent response after 6 months indicates possible brain damage.

Stepping or "walking"

hold infant vertically, allowing one foot to touch table surface. Infant will stimulate walking, alternating flexion and 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

Regulation of state

how infant responds when aroused

Ear form and cartilage distribution

in a newborn less than 34 weeks gestation, the ear is relatively shapeless and flat; it has little cartilage,s o the ear folds over on itself and remains folded. by 36 weeks, some cartilage and slight incurving of the upper pinna are present and the pinna springs back slowly when folded. By term, the newborn's pinna is firm, stands away from the head, and springs back quickly from the folding

How does a newborn produce heat?

increased BMR, muscular activity and non-shivering thermogenesis (burn up brown fat)

A ruddy hue is related to?

increased RBC concentrations; newborn will appear dark red

Skull firmness

increases as the fetus matures. In a term newborn, the bones are hard, and the sutures are not easily displaced.

Club Feet may be caused by

intrauterine position; called positional clubfoot. Fix with ROM exercises If the foot will not return to midline or realign this is true and may require cast.

Ventral suspension

is evaluated by holding the newborn prone on the examiner's hand. The position of the head and back and degree of flexion in the arms and legs are then noted. Some flexion of arms and legs indicates 36-38 weeks gestation; fully flexed extremities, with head and back even are characteristics of a term newborn.

Head lag

is measured by pulling the baby to a sitting position and noting the degree of head lag. Total lag is common in infants up to 34 weeks gestation, whereas the postmature newborn (42 weeks +) will hold the head in front of the body line. Full term newborns are able to support their heads momentarily.

Mottling

lacy pattern of dilated vessels under the skin, may be related to chilling or prolonged apnea, may occur as a result of general circulation fluctuations

First period of reactivity

lasts 30 minutes after birth; good time to start breast feeding and bond.

Routine measurements of newborn:

length head circumference chest

Epstein's Pearls

lesions on midline of hard palate, caused by collection of epithelial cells

Convection is

loss of heat to air currents (keep away from fans)

Conduction is

loss of heat to cooler surfaces

Mongolian Spots

macular areas of bluish black or gray blue pigmentation on the dorsal area and buttocks. Common in Asian and African descent and other dark skinned races. Will fade by 1st or 2nd year of life.

When assessing the neck, it is important to look for

masses, lymph nodes, webbing (short and wide neck; it is seen with Turner's Syndrome in females and Down syndrome) and ROM

Forcep marks

may be present after difficult delivery, will have reddened area over cheeks or jaws, these will disappear usually in 1-2 adys

Range of state

measure of general arousal level or arousability of infant

If a stool isn't passed in the first 24 hours of life, what should the nurse question?

meconium ileus (no peristalsis or bowel movement)

What does a slushing sound indicate in the heart?

murmur (many are associated to PDA which will close in 1-2 days)

What is associated with spina bifida?

nevus pilosus (hairy nevus) that is occassionally found at the base of spine

Erythema toxicum

newborn rash or flea bites; this is white or pale yellow papule or pustule with erythematous base. Rash may appear suddenly over trunk and diaper area and wide spread, peak time is 24-48 hours and rarely after 5 days. -Will go away on own

What is the primary source of heat in the newborn with cold stress?

non-shivering thermogenesis

An APGAR score of 7-10

notes absence of difficulties

An APGAR score of 4-6

notes moderate distress

An APGAR score of 0-3

notes severe distress

Phimosis

opening of foreskin is small; may interfere with voiding

Formula-fed infants' stool

pale yellow to light brown, are firmer in consistency and have a more offensive odor.

Brachial Palsy

partial or complete paralysis of arm due to trauma to brachial plexus during difficult birth. Portion of arm effected is determined by nerve damage. Check moro reflex

Heel-to-ear extension

performed by placing the newborn in a supine position and then gently drawing the foot toward the ear on the same side until resistance is felt. The nurse should allow the knee to bend during the test. It is important to hold the buttocks down to keep the baby from rolling. Both the proximity of foot to ear and degree of knee-extension are assessed. A preterm, immature newborn's leg will remain straight and its foot will go to the ear or beyond. With advancing gestational age, the newborn demonstrates increasing resistance to this manuever.

Cephalhematoma may be associated with

physiologic jaundice because of the extra blood cells destroyed in cephalhematoma

When assessing the skin, the nurse knows that a healthy newborn will appear

pink

Plantar Grasp

place finger at base of toes, infant's toes curl downward around examiner's fingers -response lessens by 8 months

Palmar grasp

place finger in palm of hand, infant's fingers curl around examiner's fingers -Response lessens by 3-4 months.

The nurse is planning care for a neonate to prevent neonatal heat loss immediately after birth. To conserve heat and help the infant maintain a stable temperature, the nurse should:

place the infant skin to skin with the mother

small for gestational age (SGA)

plot below the 10th percentile

Average for gestational age (AGA)

plot between 10th and 90th percentile curve

What may a shift in heart tones in the mediastinal area to either side indicate?

pneumothorax, dectrocardia (heart on R side of chest), or diaphragmatic hernia

Maternal conditions that may affect gestational assessment

preeclampsia, diabetes, and analgesia & anesthesia

Hair

preterm NB has the consistency of matted wool or fur and lie in bunches rather than in the silky, single strands of the term newborn's hair.

Immunoglobulin A (IgA)

produced after neonatal period (about 1 month) ends -contained in breast milk

Immunoglobulin M (IgM)

produced by the newborn (infected at moment) elevated levels suggest serious infection

Motor performance

quality of movement and tone

Red Reflex

red glow that appears to fill the person's pupil; absent with cataracts. Congentinal cataracts are suspected if mom had a history of rubella, cytomegalic inclusion disease or syphilis.

With male genitalia, what is common with breech delivery?

scrotal edema; bruising may be present

Physiological jaundice

seen as a yellow tinge to the skin; caused by the rapid destruction of excess red blood cells, appears after 24 hours of life

Pathologic jaundice

seen within 24 hours of life and should be reported immediately. Usually caused by underlying disorder (Rh isoimmunization, ABO incompatability, liver disease)

The measurements of the head and chest:

should be about the same

Resting posture

should be assessed as the baby lies undisturbed on a flat surface

Autonomic stability

signs of stress (tremors, startles, skin color) related to homeostatic (self-regulator) adjustments of the nervous system

When assessing the eyes, it is important to look at

size, equal pupils, reaction to light, blink, inflammation and edema of lids

Protective reflexes are

sneeze, blink, yawn or cough

Baby's remove obstructions in their noses by?

sneezing

Caput Succedaneum

soft area of scalp, an edematous swelling and occasional bleeding under the periosteum -does cross the suture lines -may be due to vacuum extraction or long difficult labor (long pressure on presenting part) -reabsorbed within 12 hours or a few days

To measure the length of the newborn:

start at top of head and extend to heel

To measure the chest of the newborn:

start directly over the nipple line and measure the circumference

To measure the head of the newborn:

start just above the eyebrows and measure the circumference

Transitional stools

start to smell; usually appear by the 3rd day; greenish brown to yellowish brown. -may contain some milk curds

When trying to prevent hypoxia, the side lying position helps to

stop aspiration and helps stimulation

When assessing the face, it is important to look at

symmetry of eyes, nose, ears and facial movement (could be an indication of paralysis)

Glabellar (Myerson's sign)

tap over forhead, bridge of nose, or maxilla of newborn whose eyes are open; newborn blinks for first four or five taps -continued blinking with repeated taps is consistent with extrapyramidal disorder

A client is concerned that her 2-day-old, breast-feeding neonate isn't getting enough to eat. The nurse should teach the client that breast-feeding is effective if:

the neonate latches onto the areola and swallows audibly

The top of the ears should be even with?

the outer canthus of the eye

What should the infant's first stool look like?

thick, tarry, sticky, black-greenish with no smell

What is the purpose of the APGAR?

to evaluate physical condition of the newborn at birth and the immediate need for resuscitation.

Sucking & rooting reflex

touch infant's lip, cheek, or corner of mouth with nipple infant turns head toward stimulus, opens mouth, takes hold and sucks If response is weak or absent, consider prematurity or neurologic defect

Extrusion

touch or depress tip of tongue; newborn will force tongue outward -response disappears by 4 months

Epispadis

urinary meatus is located on top, dorsal surface

Hypospadias

urinary meatus is located on ventral surface

Brick dust urine

urine has pink tinge, from urate crystals (kidneys may not be able to filter out); may be normal in 1st four days of life. If seen later, it may be sign of dehydration

A baby's cry is

usually tearless and not functional until 1-3 months

Evaporation is

water converted to vapor (bath, keep body parts covered if not bathing under radiant warmer)

Tonic neck or "fencing"

with infant falling asleep or sleeping, 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 oppoosite postures)\ -complete response by 3-4 months; incomplete response may be seen until 3rd or 4th year. After 6 weeks, persistent response is signs of possible cerebral palsy

Footprints need to be done

with mother's prints before the baby leaves the room

Baby may lose weight because?

withdrawal from maternal hormones, fluid shifts, and the loss of feces and urine

Breast-fed infants' stool

yellow to golden, are pasty in consistency, and have an odor similiar to that of sour milk