Nursing 2700: Newborn Assessment and Nursing care
The appropriate for gestational age (AGA) infant falls between the 10th and 90th percentiles for gestational age when birth weight and gestational age determination (Ballard assessment) are considered together. Weight, head circumference, and length are all between the 10th and 90th percentiles.
What does AGA mean?
Accurate assessment of gestational age Assessment for potential birth trauma: fractured clavicle as a result of shoulder dystocia or fractured femur if the fetus was in breech presentation or a cesarean section was performed. Monitoring for hypoglycemia, polycythemia, and hyperbilirubinemia.
What does nursing care include for LGA babies?
any type of difficult labor
What is dystocia?
Heart rate - a heart rate less than 100 bpm calls for immediate resuscitation.
What is the most critical part of the apgar scoring system?
was developed to accurately assess the gestational age of infants born between 20 and 28 weeks gestation in response to the increased survival rate of immature infants.
What is the new ballard assessment?
occurs 4-8 hours after birth
What is the second period of reactivity?
SAFETY
What is the top priority for nurses when caring for the newborn?
Vernix caseosa natural lubricant
What is the white goopy stuff on baby when baby is born and why do we leave it on?
Neuromuscular characteristics may be affected by interventions during the birthing process, such as anesthesia or analgesia provided to the mom within 4 hours of birth, and unplanned interventions, such as cesarean section or use of forceps or vacuum extraction
What might effect neuromuscular characteristics of the newborn?
Repeat the scoring every 5 minutes up to 20 minutes, and resuscitation measures may need to be instituted.
What must the nurse do if the apgar score is less than 7 at 5 minutes?
Decrease in motor activity followed by 60-100 minutes of sleep
What occurs after the first period of reactivity?
Tachycardia Tachyapnea Meconium passes Increased muscle tone, changes in skin color, and mucous production
What occurs during the second period of reactivity?
30 min
Axillary temperatures are usually taken at what interval until the baby is stable?
yellow and seedy
Breast fed infants have stools that are...
crying
Breathing patterns increase with...
sleeping
Breathing patterns slow with...
Large head Prominent abdomen Rounded chest with the center of the body at the umbilicus Flexed position.
During the head-to-toe assessment 2 hours after birth, what should the physical appearance of the newborn be?
Promote weight gain. Continuously assess for complications of SGA: polycythemia, cold stress, asphyxia, hypothermia and hyperbilirubinemia. Assess parent size; it might be an expected familial trait.
For VSGA and SGA babies, the plan of care should focus on?
every 2-3 hours.
How frequently should newborns feed when breastfeeding?
their gestational age.
Infants are classified by their size in relation to?
born between 34 and 36 (6/7) weeks
Late preterm
intrauterine growth restriction.
Most babies born SGA are a result of?
Square window sign Recoil of the legs and arms Determination of the popliteal angle The scarf sign Heel-to-ear extension Ankle dorsiflexion Head lag Ventral suspension Reflexes (Moro, sucking, rooting, Babinski).
Neuromuscular characteristics will be assessed to determine infant maturity; these include:
24; usually void after each feeding
Newborns usually have a wet or soiled diaper after each feeding. The nurse must document each void and bowel movement. Newborns will usually void within how many hours?
48
Newborns usually have their first bowl movement within how many hours?
pallor and cyanosis - mainly looking for normal skin tone & blue coloring
Newborns with dark skin color will not be pink. How are they assessed for the apgar test?
6-8 hours, or according to facility policy
Until discharge, the newborn's vital signs are taken every...
born between 38 and 42 weeks of gestation
Term
By 5:30 pm Rationale The assessment of the newborn should be performed within 2 hr of birth. It can be completed within 1 hr, but with an uncomplicated delivery it is not necessary. The 2 hr after delivery can be used as beneficial bonding time with the parents. It is not appropriate to wait until the nurse's change of shift to complete the assessment.
The nursery has been informed of the completion of an uncomplicated vaginal delivery at 3:30 p.m. The nurse prepares for her assessment of the newborn. When should this assessment be performed? By 6:30 p.m. By 5:30 p.m. At change of shift By 4:30 p.m.
when they are at rest
Vital signs should always be obtained on infants when?
Heart rate Respiratory effort Muscle tone Reflex irritability Skin tone
What are the assessment components of the apgar scoring system?
The cause is often unknown, but most often it is associated with maternal diabetes, genetic predisposition, multiparity, erythroblastosis fetalis, Beckwith-Widemann syndrome, or transposition of the great vessels.
What are the associated causes for LGA babies?
The large for gestational age (LGA) infant falls above the 90th percentile for gestational age when birth weight and gestational age determination (Ballard assessment) are considered together. Weight, head circumference, and length are all above the 90th percentile.
What are LGA babies?
Very small for gestational age (VSGA) infants are below the 3rd percentile
What are VSGA babies?
forceps injuries Vacuum cup Accidental lacerations during a cesarean birth
What are common issues secondary to dystocia?
Soft tissue injuries: Subconjunctival and retinal hemorrhages Erythma, ecchymoses, petechiae, abrasions, or edema.
What are common newborn problems?
polycythemia (increased RBC's) cold stress asphyxia hypothermia hypervilirubinemia
What are complications of SGA?
Symmetry
What is the nurse looking at in general when assessing physical characteristics?
Weight below the 10th percentile Length below the 10th percentile Rationale Characteristics of infants who are small for gestational age include weight, head circumference, and length all below the 10th percentile. Difficulty feeding and no passage of meconium for 48 hr are not characteristics of a baby who is small for gestational age.
The nurse is receiving the change of shift report from the night nurse, and one newborn she will be caring for has been determined small for gestational age (SGA). Which data obtained during the physical assessment supports this diagnosis? (Select all that apply.) Weight below the 10th percentile Length below the 10th percentile No passage of meconium for 48 hr Head circumference below the 20th percentile Difficulty feeding
110-160 beats/min in a term newborn.
What is the normal apical pulse for a newborn?
17-22 inches
What is the normal length for a newborn?
2500-4000 g
What is the normal range of weight for a newborn?
30-60 per minute; irregular; periods of apnea less than 20 seconds is normal
What is the normal respiratory rate for a newborn?
12.5-14.5 inches
What is the normal size of the head for a newborn?
The normal axillary temperature range for a newborn is 97.7°-98.6°F (36.5°-37.0°C).
What is the normal temperature for a newborn?
Respiratory effort - apnea to good crying
What is the second most critical component of the apgar scoring system?
no, immediate resuscitation needs to be initiated
Is the apgar an appropriate assessment to complete if an infant is has absent heart rate or respiration?
During the first 24 hr, a newborn makes the critical transition from the intrauterine to the extrauterine life. As with any client, assessment is ongoing based on the client's condition. Assessments are performed as the client's status changes.
What is the time frame where the risk for complications greatest for the newborn?
Assessing and documenting the newborn's intake, output, and weight are a vital part of the ongoing assessments. The newborn's weight is usually obtained once every 24 hr at the same time to promote accurate comparisons. It is normal for newborns to lose up to 10% of their birth weight during the first week of life. Parents should be assured that the weight will be regained within 2 weeks of birth, as long as the newborn feeds well.
What is vital for the nurse to assess for in the newborn regarding weight, nutrition, and elimination?
External Chest Abdomen Neurological Genitourinary Other observations
What other things should be included in the initial neonatal assessment besides the apgar scoring?
At 1 min after birth At 5 min after birth As part of the routine admission, within 2 hr of birth Routinely thereafter based on the protocols of the institution At discharge from the institution.
When are the assessments of the newborn performed?
the amount of formula taken and the feeding quality in terms of the newborn's sucking ability. The nurse also assesses for vomiting or regurgitation.
If the newborn is formula-fed, the nurse assesses:
the respiratory, cardiac, and thermoregulation functions.
When assessing the newborn, what functions are the nurses primary concern?
day 8
When do healthy infants produce vitamin K on their own?
identification bands are placed on the mom and baby. The information on this set of bands is identical. The newborn baby is banded on one wrist and one ankle. The mom is banded on her wrist. In some institutions, the partner or support person is also banded on the wrist.
In the delivery room, immediately after the birth and stabilization of the newborn, what is done?
This assessment is normally done on the third day after birth, because the infant's behavior is not organized enough to assess before then.
When is the Brazelton Neonatal Behavioral Assessment scale performed?
Counts respirations and apical heart rate for 1 min. Counts respirations before stimulating the infant. Respirations are easier to count and more accurate if the infant is not crying. Listens to the heart and lung sounds when the infant is quiet to ensure accuracy. To calm a crying infant, the nurse may place a moistened, gloved finger in the infant's mouth for suckling.
When the newborn is observed in the resting position, the nurse should?
COLD BABY DRUG WITHDRAWL
When you think neonatal hypoglycemia think...
at the junction of the umbilical cord and the skin.
Where is heart rate palpated on the skin of a newborn?
caused by the buildup of unconugated bilirubin, which is a breakdown product of Hgb released from destroyed RBC's.
Jaundice
raised white spots across the nose
Milia
Resting posture Skin appearance Amount of lanugo Development of plantar creases Amount of breast bud tissue Recoil of the pinna and cartilage development Development of the genitalia .
Physical maturity characteristics that the nurse will assess to determine the gestational age of the infant include:
Signs of respiratory distress Core temperature readings Gestational age determination Rationale Accurate assessment of the gestational age of the preterm newborn is imperative to anticipate special needs and problems. Gestational age assessment should be performed on all newborns. Premature infants may exhibit alterations in thermoregulation, are more prone to hypothermia, and need core temperature readings. Premature infants may exhibit alterations in all body systems and are more likely to encounter respiratory issues than term infants. Blood glucose monitoring and a complete blood count may be done but are not part of the essential assessments that need to be performed initially.
A preterm infant arrives in the nursery. Which initial assessments will the nurse make on this infant? (Select all that apply.) Complete blood count Signs of respiratory distress Core temperature readings Gestational age determination Blood glucose monitoring
neonatal mortality
A score of 3 on the apgar after 5 minutes is associated with what?
infants with suspected cardiac anomalies, infants in distress, or premature infants.
The blood pressure of healthy, term newborns may not routinely be measured. However, blood pressure should be measured on babies with what condition(s)?
Habituation Orientation to stimuli Motor activity Variations of alert states State changes or color changes Self-quieting activity Cuddliness or social behaviors
The brazelton assessment should be done in a quiet, dimly lit room and typically takes about 20-30 min. The nurse observes what behaviors and the sleep-wake states that they are assessed in?
Soon after birth, before the infant is taken to the nursery Rationale Shortly after birth, the newborn will enter a quiet alert state that provides a great time for parents to bond with the baby. This is the perfect opportunity to initiate breastfeeding. The parents need time for bonding immediately after birth. The nurse should allow time for parental bonding during this time. Medications can be administered after the baby is taken into the nursery for full assessment. There is no specific time for the baby's first bath. It would not be appropriate for the nurse to inform the parents that the baby should be fed before the first bath. The nursing priority after providing a newborn's bath is ensuring the baby is warmed and preventing heat loss. The nurse should encourage feeding as soon as possible after the delivery.
A mother asks the nurse when she can breastfeed her infant who has just been born. Which response by the nurse is the most appropriate? After the first bath After all prophylactic medications have been administered in the nursery Soon after birth, before the infant is taken to the nursery Before the first bath
the newborn is sleeping
A newborn's heart rate is 100 bpm, this is normal if...
the newborn is crying.
A newborn's heart rate is at 180 bpm, this is normal if...
changes in color, such as pallor or cyanosis signs of respiratory difficulty (nasal flaring, grunting, or retractions). **These signs may indicate problems with thermal regulation or glucose stability.***
Along with vital signs, what should the nurse continually assess for in the newborn until discharge?
30 minutes
An apical pulse and respiratory rate are taken at what intervals until the baby has been stable for two hours?
The amount of breast tissue is part of the physical characteristics of the Ballard Gestational Assessment. The scarf sign, rooting reflex, and Babinski reflex are part of the neurological characteristics of the Ballard Gestational Assessment.
The nurse is performing a Ballard gestational age assessment for baby boy Jefferys, born 1.5 hr ago. Which will the nurse assess during the physical characteristic portion of this examination? Babinski reflex Rooting reflex The amount of breast tissue Scarf sign
The newborn's identity must be verified before giving the newborn to his mother. It is not uncommon to find a bracelet inside a blanket where it has come off of the newborn's wrist or ankle. If a bracelet is found to be missing, the institution's policy for replacing it should be followed. The nurse should also check that the newborn's anti-abduction device is in place. This is a bracelet or clamp with a sensor that is placed on the newborn's ankle or umbilical cord. An alarm will sound if the newborn is taken beyond specified boundaries in the nursing unit.
Before giving the newborn to its mother, what must be verified?
have transitional stools that are greenish brown and more formed.
Bottle-fed babies usually have stools that are...
Appropriate for gestational age The appropriate for gestational age (AGA) infant falls between the 10th and the 90th percentiles for gestational age when birth weight and gestational age determination (Ballard assessment) are considered together. The combination will plot out on the classification of newborns by birth weight and gestational age between the 10th and 90th percentiles. Weight, head circumference, and length are all between the 10th and 90th percentiles. The large for gestational age (LGA) infant falls above the 90th percentile for gestational age when birth weight and gestational age determination (Ballard assessment) are considered together. The combination will plot out on the classification of newborns by birth weight and gestational age above the 90th percentile. Weight, head circumference, and length are all above the 90th percentile. The small for gestational age (SGA) infant is identified by having weight below the 10th percentile for gestational age when birth weight and gestational age determination (Ballard assessment) are considered together. The combination will plot out on the classification of newborns by birth weight and gestational age below the 10th percentile. A premature (preterm) infant is defined as an infant born after 20 weeks and before the completion of 37 weeks' gestation
During the initial exam, a newborn estimated at 40 weeks gestation weighs 7 lb 8 oz (3,550 g). Which classification is most appropriate for this newborn based on birth weight and gestational age? Large for gestational age Appropriate for gestational age Small for gestational age Premature
Gynecomastia Pseudo menstruation neonatal hypoglyemia, but this is not normal
Endocrine system manifestations include:
60 seconds
For how long is the apical pulse auscultated in the newborn?
A normal newborn presents with elbows and hips flexed, with knees positioned up towards the abdomen.
How does a normal infant present for muscle tone?
Newborn's heart rate increases to 160-180 bpm Decreases after 30 minutes Respirations are irregular at 60-80 bpm
How does the first period of reactivity present?
every 3-4 hours
How frequently should newborns feed when on formula?
A premature (preterm) infant is an infant born alive before the completion of 37 weeks of gestation.
How is a premature infant defined?
feeding phototherapy exchange transfusion parent education home photo therapy
How is hyperbilirubinemia treated?
it is determined by evaluating the degree of flexion and resistance to straightening of the extremities.
How is muscle tone evaluated for the apgar scoring test?
stroking of the spine or flicking of the soles of the feet.
How is reflex irritability evaluated for the apgar scoring system?
20 seconds or less
How long is a normal period of apnea for a newborn?
the number of times the newborn nursed and the ease with which the mother was able to achieve latch-on.
If breastfeeding, the nurse assesses:
reassess in 24 hours
If neuromuscular assessment and physical assessment are vastly different, what is the implication for the nurse?
Never leave their newborn unattended in their room, even if they are going to the bathroom or taking a shower. They should ask for assistance when planning to take a shower. Give their newborn only to staff wearing appropriate identification, and if they are unsure, they should ask for their nurse. Call for assistance if they are feeling weak or faint. They should not attempt to pick up or carry their newborn when feeling unwell. Maintain good hand hygiene to protect their newborn from infection. Keep a hand on their newborn when out of the crib, to prevent falls.
Nurses should also assess the parents' understanding of measures they can implement to keep their newborn safe while in the hospital. Parents should be instructed as follows:
Parents should be informed that newborns will have 6-8 wet or soiled diapers by the end of the first week of life. They should also understand that a lack of voids or bowel movements might indicate a poor feeding pattern.
What is important education for the parents regarding soiled diapers within the first week of life, and that lack of these may indicate what?
fine hair that covers the fetus
What is lanugo?
born after 42 weeks with effects of placental insufficiency
Postmature
born after the completion of 42 weeks
Postterm (postdate)
the first six hours after birth, in which the newborn is adapting to extra-uterine life.
What is neonatal transition?
erythema toxicum - looks like a big whitehead zit
What is newborn rash called?
the type, amount, and quality of the feeding.
The newborn's intake is assessed and documented in regard to...
the number of days old of the newborn; up to one week
The number of voids/bowel movements per day typically match up with...
For example, a newborn will turn toward a parent's voice and will focus on the parent's face. This may facilitate eye contact. The nurse can promote attachment between the newborn and the parents by using the Brazelton Neonatal Behavioral Assessment content to guide the parents in learning the behaviors of their newborn.
The nurse can use aspects of the Brazelton scale to identify certain behaviors of the infant as he or she responds to the parents. What is an example of this?
Central cyanosis Rationale Central cyanosis is a sign of severe respiratory distress and would require immediate intervention by the nurse. Nasal flaring, grunting, and retractions may indicate respiratory distress and may require close monitoring by the nurse, but not, perhaps, immediate intervention.
The nurse is assessing a newborn infant. Which assessment finding would indicate the need for immediate intervention? Retractions Grunting Central cyanosis Nasal flaring
The newborn's Apgar score Rationale The initial Apgar score will be most helpful to the nurse in determining the newborn's risks because it reveals information about movement, respiratory effort, muscle tone, skin color, reflexes, and pulse rate. The newborn's color is a useful assessment, but color along with the other assessments in the Apgar score will give more information. The mother's pregnancy history will give the nurse some information about the newborn, but the Apgar score will give the nurse more information about the infant's risk factors. Respiratory effort is an important aspect of the Apgar score, but if all information from the Apgar scoring is used, the nurse will have much more information about the possibility of complications.
The nurse is assessing a newborn right after birth. Which assessment will be most helpful initially in identifying an at-risk newborn? The newborn's respiratory effort The newborn's color The mother's pregnancy history The newborn's Apgar score
Respirations 78 breaths/min Rationale The normal temperature range for a newborn is 97.5° to 99°F. The nurse should not report this temperature as an abnormal finding of concern. Normal respiratory rate is 30dash-60 breaths/min. Seventy-eight respirations per minute could represent a less-than-expected transition. The nurse should notify the healthcare provider of this pattern of breathing. It is normal for the newborn to exhibit brief periods of apnea lasting less than 15 seconds. This should not be reported to the healthcare provider unless the periods of apnea last longer or the infant's vital signs become unstable. This heart rate is within the normal range of 110dash-160 beats/min.
The nurse is assessing a sleeping, 1-hr-old newborn. Which data would necessitate the need to notify the healthcare provider? Respirations 78 breaths/min Brief periods of apnea lasting less than 5 seconds Temperature 97.9°F Heart rate 122 beats/min
Full term Rationale One to two creases appear at approximately 32 weeks gestation. By 36 weeks gestation, creases cover the anterior two thirds of the foot. At term, creases cover the entire foot. For extremely preterm infants, the nurse measures the foot length from the tip of the great toe to the back of the heel.
The nurse is assessing baby boy Henry, who is 2 hr old. She notes that Henry's plantar creases cover his entire foot. Based on this information, what does the nurse determine Henry's gestational age to be? Full term 36 weeks 32 weeks Preterm
Grunting The nurse will assess the newborn for signs of respiratory distress. These may include nasal flaring, grunting, or retractions. These signs may indicate problems with respiration in the newborn. The normal respiratory rate for newborns is between 30 and 60 breaths/min. It is normal for the newborn to have brief periods of apnea lasting less than 15 s.
The nurse is assessing newborn baby Thomas, who is 1 hr old. Which assessment finding does the nurse report to the healthcare provider? Grunting Brief periods of apnea Nasal secretions Coughing
a gestational age assessment tool that assesses the neuromuscular maturity and physical maturity of the newborn using a point system.
What is the Ballard assessment?
it is used to evaluate the physical condition of the newborn at birth. It is completed one minute after birth, and then again at 5 minutes after birth, then receives a total apgar score of 0-10.
What is the apgar scoring system?
lasts up to 30 minutes after birth
What is the first period of reactivity?
Posture at rest Relationship of head size to body Rationale The newborn should be observed in the resting position. Observing the relationship of the size of the head to the body is a component of assessing the general appearance of the newborn. Newborns have a large head when compared to their body. Assessment of general appearance requires observation techniques. Assessing rectal temperature requires the use of a thermometer, insertion of the device into the rectum, and positioning of the newborn to prevent harm, which involves the nurse disturbing the newborn's natural position and emotional state. Assessment of lung sounds is a component of the physical assessment, not a component of the newborn's general appearance. Apgar scoring is performed immediately after birth to determine the need for resuscitation or other interventions; it is not a component of assessing the general appearance of the newborn.
The nurse is assessing the general appearance of a newborn. Which data will the nurse document as part of this assessment? (Select all that apply.) Posture at rest Relationship of head size to body Lung sounds Rectal temperature Apgar scoring
The newborn may have suffered from intrauterine growth restriction (IUGR). The newborn's weight falls below the 10th percentile. Rationale Infants classified as small for gestational age (SGA) may have intrauterine growth restriction (IUGR), which can be related to multiple etiologies, although the terms SGA and IUGR are not necessarily interchangeable. Infants whose weight is below the 10th percentile are diagnosed as SGA. Babies can weigh less than 5 lb 8 oz (2,500 g) because of gestational age and still be classified as appropriate for gestational age or large for gestational age. Infants whose head circumference is below the 10th percentile are diagnosed as SGA. Intrauterine exposure to bacteria is not associated with infants who are SGA.
The nurse is caring for a newborn who is small for gestational age (SGA). The newborn's parents ask the nurse how this happened. Which rationales will the nurse use to respond to these parents? (Select all that apply.) The newborn may have suffered from intrauterine growth restriction (IUGR). The newborn weighs less than 2,500 g (5.5 lb). The newborn's weight falls below the 10th percentile. The newborn's head circumference is in the 50th percentile. The newborn had intrauterine exposure to bacteria.
The Babinski reflex response is elicited by stroking the lateral aspect of the sole from the heel upward and across the ball of the foot. Startling the infant elicits the Moro reflex. The sucking reflex is elicited when an object is placed in the infant's mouth or touches the infant's lips. The rooting reflex is elicited by touching the side of the infant's mouth or cheek.
The nurse is completing the assessment of the gestational age of baby girl Samuels. Which action is appropriate for the nurse to take when assessing the Babinski reflex for this newborn? Place a gloved finger in the infant's mouth Stroke the infant's cheek Startle the infant while on the warmer Stroke the lateral aspect of the infant's sole from the heel upward
Plantar creases present on anterior two thirds of the sole Areas for assessment for physical maturity include lanugo, plantar creases, breast tissue, ears, and genitalia. Head-to-toe physical assessment includes examination of the umbilical cord, fontanelles, and the presence of milia.
The nurse is conducting a gestational age assessment on a newborn. Which physical assessment finding would the nurse record during this assessment? Plantar creases present on anterior two thirds of the sole Milia present on bridge of nose Anterior and posterior fontanelles not bulging Umbilical cord moist to touch
Small for gestational age infants are identified by having weight below the 10th percentile for gestational age. Weight, head circumference, and length all fall below the 10th percentile. Large for gestational age infants fall above the 90th percentile for gestational age. Weight, head circumference, and length all fall above the 90th percentile. Appropriate for gestational age infants fall between the 10th and the 90th percentiles for gestational age. Weight, head circumference, and length all fall between the 10th and 90th percentiles. Postterm infants are newborns born after 42 weeks gestation.
The nurse is conducting a newborn assessment for baby girl Roper, born 2 hr ago. The newborn's weight, head circumference, and length all fall below the 10th percentile. Which classification will the nurse document in the medical record for this newborn? Appropriate for gestational age Small for gestational age Large for gestational age Postterm
Keep a hand on the newborn when out of the crib. Ask hospital staff for identification if they are not wearing it. Avoid leaving the newborn in the hospital room alone. Wash hands often to protect the newborn from germs. Rationale Nurses should educate parents about safety precautions. Parents should avoid leaving the newborn alone in the room to prevent injury from falls or infant abduction. Parents should only allow staff with proper identification to care for their baby. If a staff member is not wearing identification, parents should ask to see it. Maintaining good hand hygiene helps prevent the newborn from getting an infection. To prevent falls, parents should always be in close contact with and touching the infant when outside of the crib. Parents should not attempt to carry a newborn if they feel weak or faint. They should place the newborn in a crib and call the nurse.
The nurse is educating the parents about safety precautions for their newborn while in the hospital. Which topics should the nurse discuss with the parents? (Select all that apply.) Keep a hand on the newborn when out of the crib. Ask hospital staff for identification if they are not wearing it. Bring the newborn to the nurses' station if parent feels weak or faint. Avoid leaving the newborn in the hospital room alone. Wash hands often to protect the newborn from germs.
Neuromuscular Rationale The rooting reflex is a neuromuscular characteristic and is elicited when the side of the newborn's mouth or cheek is touched. In response, the newborn turns toward that side and opens the lips to suck. Neuromuscular characteristics evaluate the physiological maturity of the newborn. The Apgar score is used to evaluate the physical condition of the newborn and determine the need for immediate resuscitation. Physical characteristics are objective, clinical criteria used to determine gestational age. Vital signs include respirations, apical heart rate, temperature, and blood pressure, if indicated.
The nurse is evaluating a new mother following a teaching session. The mother gently brushes the infant's cheek with her nipple and the newborn turns toward that side and opens the lips to suck. This demonstration of the rooting reflex is part of which assessment? Vital signs Neuromuscular Physical maturity assessment Apgar score
Opaque skin and plantar creases on the anterior two thirds of the newborn's sole are indications of a term infant. A large amount of lanugo over the back and minimal ear cartilage are indications of a premature infant. The heart rate assessment is not part of the gestational age assessment.
The nurse is performing a newborn assessment to determine gestational age. Which assessment findings does the nurse expect for a full-term infant? (Select all that apply.) Plantar creases on the anterior two thirds of the sole A large amount of lanugo over the back Heart rate greater than 100 beats/min Minimal ear cartilage Opaque skin
Plantar creases present on anterior two thirds of sole Rationale When determining newborn gestational age, points are given for each area of assessment, with a low of -1 or -2 for extreme immaturity to as high as 4 or 5 for postmaturity. Areas of assessment include skin texture, lanugo, plantar creases, breast tissue, eyes and ears, and genitalia.
The nurse is trying to determine whether a newborn is appropriate for gestational age (AGA). Which data collected during the physical assessment will help the nurse determine this classification for the newborn? Umbilical cord moist to touch Anterior and posterior fontanels nonbulging Plantar creases present on anterior two thirds of sole Milia present on bridge of nose
Counts respirations and apical heart rate for 1 full minute Rationale Respirations and apical heart rate should be counted for 1 full minute for all newborn assessments. The newborn should first be assessed in the resting position, and vital signs should be taken while the newborn is at rest. The blood pressure on healthy, term newborns may not routinely be measured. However, blood pressure should be measured on infants with suspected cardiac anomalies, infants in distress, or premature infants. The nurse listens to the heart sounds and lung sounds when the infant is quiet to ensure accuracy
The nurse is working with a student nurse during assessment of a 2-hr-old healthy newborn. Which action of the student nurse demonstrates an understanding of the neonatal assessment? Counts respirations and apical heart rate for 1 full minute Stimulates the newborn so the newborn will be alert for the assessment Obtains a blood pressure first Listens to lung sounds when the newborn is crying
type (meconium or transitional stool), color, and consistency
The nurse must document each void and bowel movement. Bowel movements should be assessed for...
Sole creases Rationale Physical characteristics generally include sole creases, amount of breast tissue, amount of lanugo, cartilaginous development of the ear, testicular descent, and scrotal rugae or labial development. The scarf sign, the Moro or startle reflex, and the square window sign are all components of neuromuscular development.
The nurse performs a gestational age assessment, as part of the newborn assessment, to evaluate physical characteristics. Which data will the nurse collect as part of the gestational assessment for this newborn? Square window sign Scarf sign Startle reflex Sole creases
2
The nurse performs a head-to-toe assessment of the stable newborn within how many hours after birth?
Length Ballard assessment Weight Head circumference Rationale Determination of size for gestational age includes weight, length, head circumference, and the Ballard assessment. Vital signs are a part of the newborn assessment, but are not used for determination of gestational age.
The student nurse is assessing a newborn to determine whether the newborn is small for gestational age (SGA), appropriate for gestational age (AGA), or large for gestational age (LGA). Which items included in the physical examination of the newborn reflect appropriate understanding of this assessment process? (Select all that apply.) Length Ballard assessment Vital signs Weight Head circumference
prevent or decrease risk of hemorrhage and infection umbilical cord = ideal for bacterial growth clean with plain soap and water falls of in 10-14 days
What is the goal of umbilical care?
openings at the juncture of cranial bones ARE THEY PRESENT? Anterior - palpated as 5 cm diamond Posterior - small triangle
What are fontanels and how are they assessed?
Airway maintenance - clear secretions with bulb syringe Maintaining adequate oxygen supply - clear airway, effective establishment of respirations, adequate circulation, perfusion, effective cardiac function, adequate thermoreguation.
What are important interventions for the newborn?
Blood glucose Bilirubin levels Drug levels Newborn screening tests PKU Sickle cell disease Galactosemia Heel stick, venipuncture, urine collection
What are important newborn labs?
macular areas of bluish black pigmentation on the dorsal area and buttocks, common in dark skinned races
What are mongolia spots?
any newborn birthmark
What are nevi?
baby covered - hat when doing assessment, use radiant warmer Keep infant dry, avoid placement on cool surfaces, avoid drafts.
What are nursing regulations related to thermoregulation?
Vital signs Weight and length Head Newborn body Respiratory System GI system Urinary System Endocrine Musculoskeletal Newborn Reflexes
What are the basic components of a newborn head-to-toe assessment?
Resting posture Square window sign Arm recoil Popliteal angle Scarf sign Heel-to-ear extension
What are the neuromuscular maturity components that the ballard assessment looks at?
Babinski Moro reflex Tonic Neck Reflex Palmar grasp Stepping reflex Rooting reflex
What are the newborn reflexes that are assessed?
Skin appearance Amount of lanugo Development of plantar creases Amount of breast bud tissue Recoil of the pinna and cartilage development Development of the genitalia
What are the physical maturity components that the ballard assessment looks at?
nasal flaring intercostal/subcostal retractions grunting out of range vitals
What are the symptoms of RDS?
edges should not be joined general symmetric shape
What are you assessing for in regards to the newborn sutures of the cranial bones?
born before 37 completed weeks of gestaion
What does pre-term or premature refer to?
behaviors and sleep-wake states of the newborn.
What does the Brazelton Neonatal Behavioral Assessment Scale assess?
cyanosis and skin pallor
What does the skin assessment component of the apgar look for?
Infants who have weight below the 10% percentile are considered to be small for gestational age (SGA) when birth weight and gestational age determination (Ballard assessment) are considered together. Most infants born SGA are a result of intrauterine growth restriction. In these infants, weight, head circumference, and length are all below the 10th percentile.
What is SGA?
a score of 7-10 indicates a newborn in good condition who requires only nasopharyngeal suctioning and maybe some oxygen near the face (blow by oxygen)
What is a "normal" apgar score?
edematous area on scalp, usually from a long labor when sustained pressure of the head against the cervix compresses local blood vessels and slows venous return. ***Crosses suture lines****
What is a caput succedaneum?
collection of blood from ruptured blood vessels between the surface of a cranial bone and the periosteal membrane. **does NOT cross suture lines***
What is a cephalohematoma?
pink body, blue extremities. Scored as a 1 on the apgar test. Present in 85% of newborns, and is deemed normal in newborns 1 minute after birth.
What is acrocyanosis?
Normal positioning (flexed) Limited extension (barlow/ortalani's maneuvers) Feet - flat sole, dry & flaky skin Symmetry of gluteal forls
What is assessed during the neuromuscular assessment of a newborn?
Replace it according to policy. The nurse should regularly assess the newborn's anti-abduction bracelet. It is not uncommon to find a bracelet inside a blanket that has accidentally come off. If this occurs, the nurse should follow the agency policy for replacing it. The nurse would not notify security unless there was suspicion of newborn abduction. It is not advisable for the nurse to leave the bracelet off for security reasons. Unless agency policy requires completing an incident report, it is not reasonable to assume this would be an action required of the nurse.
Which action is most appropriate if a newborn's anti-abduction bracelet accidently comes off? Leave it off for comfort. Replace it according to policy. Complete an incident report. Notify hospital security.
Ear cartilage remains folded over, lanugo present over much of the body, some flexion of arms and legs at rest Ear cartilage remains folded over, lanugo present over much of the body, and some flexion of arms and legs at rest are signs of a premature infant. Full sole creases, nails extending beyond fingertips, testes deep in rugae covered scrotum, 1-cm breast bud, peeling skin without visible veins, and rapid recoil of legs and arms are signs of a postterm infant.
Which characteristics does the nurse anticipate when assessing a newborn infant born at 33 weeks gestation? Testes located deep in the scrotum, rugae cover the scrotum, vernix covering the entire body Ear cartilage remains folded over, lanugo present over much of the body, some flexion of arms and legs at rest Full sole creases, nails extending beyond fingertips, scarf sign shows elbow beyond the midline One-centimeter breast bud, peeling skin and veins not visible, rapid recoil of legs and arms to extension
Late preterm: 34 - 36 6/7 Risk for respiratory distress, temperature instability, feeding difficulties, hyperbilirubinemia (jaundice)
Which classification range of gestation have risk factors because of physiologic immaturity even though they are often the size and weight of a term infant?
Chest circumference 31.5 cm, head circumference 33.5 cm At birth, the circumference of the newborn's head is 32dash-37 cm. The average circumference of the chest is 32 cm and ranges from 30 to 35 cm. At birth, the circumference of the head is approximately 2 cm greater than the newborn's chest. Next Question
Which data would be considered normal during an initial nursing assessment of a term newborn? Chest circumference 31.5 cm, head circumference 33.5 cm Chest circumference 32.5 cm, head circumference 36 cm Chest circumference 38 cm, head circumference 31.5 cm Chest circumference 30 cm, head circumference 29 cm
Heel-to-ear extension Neuromuscular assessment of the newborn includes heel-to-ear extension. Skin appearance, breast bud tissue and genitalia are parts of the physical assessment, not the neuromuscular assessment.
Which element will the nurse include when assessing the neuromuscular maturity of an infant who is 4 hours old? Skin appearance Development of the genitalia Heel-to-ear extension Amount of breast bud tissue
It is normal for the newborn to lose up to 10% of birth weight during the first week of life. The nurse should reassure the parents this is usually regained in a period of 2 weeks as long as feeding goes well. Newborns may lose more than 5% of their birth weight without concern. A loss of 15dash-20% of the birth weight in the first week of life indicates a problem. The nurse should assess feeding patterns of the newborn and complete a health assessment. Findings should be reported to the healthcare provider.
Which percentage of weight loss does the nurse anticipate for a newborn during the first week of life? 5% 15% 20% 10%
don't want to document that the infant is completely fine
Why do you never give a score of 10 to a newborn on the apgar?
to avoid gonorrheal or chlamydia infection; erythromycin, tetracycline or silver nitrate
Why is eye prophylaxis mandatory in the united states?
Vitamin K IM, prevents hemorrahgic disease; newborns do not produce their own clotting factors because they do not have bacteria to produce vitamin K in the GI tract
Why is vitamin K prophylaxis mandatory in the united states?