nursing 2-newborn, Nursing 2 unit 2

Lakukan tugas rumah & ujian kamu dengan baik sekarang menggunakan Quizwiz!

The Apgar score indicates...

-how well the baby is doing physically at birth

To provide for the normal neonate's nutrition and growth needs, which of the following approximate calories are need

. 50-55 cal per pound per day/105-108 Kcal/Kg./day

Following a circumcision, the most common protection used to cover the penis is a sterile dressing to which

. A liberal amount of Vaseline has been added

Which nursing action is a priority for the nurse caring for a newborn with slight yellow tinged skin:

. Teach the mother to breast feed at frequent intervals

A one day old newborn diagnosed with intrauterine growth retardation is observed by the nurse to be restless, irritable, fist sucking and having a high pitched shrill cry. Based on this data, the nurse should:

. Tightly swaddle the infant in a flexed position

1.Prematurity 2.small for gestational age 3.intrauterine growth retardation

1. Before 37 weeks gestation 2. Smaller than normal for G. Age 3. Below 10% intrauterine growth restriction: poor growth of the fetus in which the fetus is unable to achieve its genetically determined size

Results of normal respiratory transition

1. Blood flows to lungs, not placenta 2. Surfactant production is maintained 3. Residual volume is established 4. Metabolic acidosis is resolved 5. Baby becomes pink (from blue, gray, white)

Hazards of cold stress to newborns

1. Increased oxygen need, 2.decreased surfactant production (impedes long expansion and further exacerbates respiratory distress), respiratory distress, 3.hypoglycemia (due to using glycogen stores for temperature maintenance), 4.metabolic acidosis (metabolism of brown fat releases fatty acids resulting in metabolic acidosis), 5.jaundice (due to the elevated fatty acids in the blood which interfere with transportation of bilirubin to the liver-it builds up in the blood)

At birth, the newborns body temperature... Normal 97.5-99

1. May drop 1 to 2° despite external heat application 2. May return to normal in about eight hours 3. Will respond to environmental temperatures

surfactent should be present in a newborn at what age?

35 weeks

The neonates skin is expected to be

- mottled when undressed -Color consistent with genetic background -Reaction to tactile sensation is present -May have tiny pearly white raised bumps on the face-milia (Sweat and sebaceous glands are not yet functioning)

Polyhydramnios oligohydramnios

- too much amniotic fluid for gestational age -too little amniotic fluid for gestational age

Breast-feeding can be...

-A distasteful experience to some mothers even though they love their babies -cannot be satisfying for mother or baby unless a mother really wants to feed a baby this way

The process of infant discharge includes

-Check the wrist/ankle band number of the infant with that of the mother -give feeding instructions to the mother -cut one of the babies ID bands off and attach it to the permanent record -assess the presence of an infant car seat

Signs of respiratory distress in the newborn

-Expiratory grunting -cyanosis -flaring of nostrils

Apgar score of 5 at 1 minute, the nurse would expect to...

-Suction the nasopharynx -place the baby on a warmer -administer oxygen

Why does the normal newborn require frequent small feedings

-The stomach is small at birth and will stretch -the Gastro esophageal sphincter is immature

Factors involved in the initiation of newborn respirations

1. Need for O2 (mild hypoxia and metabolic acidosis) 2. Fluid filled airways empty (vaginal squeeze)and fill with air when chest recoils 3. PCO2 partial pressure of carbon dioxide in blood rises and stimulates respiration center causing baby to take first breath. Surfactant stabilizes alveoli and prevents collapse) 4. The temperature change-sensors in the skin respond by sending impulses to the Medulla that stimulate the respiratory center and breathing

Hispanics African-Americans Native Americans

1. Often late, traditional roles 2.distrust majority race - us. Often unrelated people in house 3.Elders, avoid eye contact, many don't seek prenatal care

Newborns six behavioral states

1. Quiet sleep 2.active sleep 3.drowsy 4.quiet alert 5.active alert 6.crying

A sign that a full-term infant may have an abnormality could be

1. The lack of a sucking reflex 2. Body temperature of 36°C

Why are infants predisposed to heat loss?

1. Thin skin with little subcutaneous white fat 2. Blood vessels close to the surface 3. Large skin surface area-lose heat by evaporation, conduction, convection and radiation

Normal newborn heart rate-apical

100 to 180 bpm

neonatal hr

120-160 apical

Nuclear family

2 parents plus children. Traditional but also includes blended families.

keep ambient air ____warmer than infant-- isolette

2-3 F

Normal newborn weight range

2500 g - 4000 g 5 lbs. 8 oz. - 8 lbs. 13 oz. It is normal during the first week of life, for the infant to lose up to 10% of their birthweight. They normally regain their birthweight by 14 days of life and then gain approximately 30 g per day in early months

newborn normal rr

30-60

Normal newborn length

48-53 cm 19 to 21 inches

Maximum normal weight loss during the first few days of life?

5 to 10%

How many calories are necessary for the normal neonates nutrition and growth needs

50-55 calories per pound per day 105 to 108 cal per kilogram per day

Normal Newborn Temp:

97.5-99.0 º F Axillary

Coining in Vietnamese culture

A cultural practice to rid the body of disease

Mongolian spotting

A harmless blue or gray pigmented birthmark. Typically appear on the buttocks or lower back but could be found on arms or legs. They usually fade by adolescence

Why is vitamin K routinely given to newborns

A lack of intestinal flora to synthesize vitamin K exists at birth

Following circumcision, the most common protection used to cover the penis is a sterile dressing to which...

A liberal amount of Vaseline has been added (want to avoid the dressing sticking to the penis)

APGAR Activity (muscle tone); pulse; grimace (reflex irritability); appearance (skin color); respirations

A test given at one minute and again at five minutes. For each of the five categories, the newborn can receive a score of 0, 1 or 2. The maximum score is 10. Is score of 7 to 10 indicates no breathing assistance will be necessary, A score of 4 to 6 indicates that some assistance for breeding maybe necessary and a score of less than four indicates lifesaving measures must be implemented immediately. At the five-minute mark, a score of 7 to 10 is normal

Phimosis

A tightening of the prepuce (foreskin)of the penis which develops when he is older-it is normal for the prepuce to be tight ( and unretractable )at birth

Molding

A transitory condition of a pointed looking head, returns to a nice round shape quickly after birth

What must the nurse remember when feeding a newborn with a cleft palate:

A. Adequate fluid intake is necessary to prevent dehydration . Burping is unnecessary D. Patience is needed E. The mother will need teaching and encouragement to breast feed.

Thrush is an infection of the mouth. Which of the following statements are true:

A. It is caused by the organism Candida Albicans B. It is caused by the organism which causes Monilial Vaginitis in the mother C. The infant may acquire the infectIon as it passes through the birth canal

Paulmar grasp

Expect fingers to crawl tightly and toes to curl forward when finger is pressed against base of infants fingers or toes.

Caput succedaneum

The swelling or edema of a newborns scalp soon after delivery. Appears as a lump or bump on the head caused by prolonged pressure from the dilated cervix during delivery. Usually goes away on its own within a few days

Head and chest circumference

Head circumference-32 to 38 cm or 13 to 15 inches. May be affected by molding and will be remeasured again later. The chest is measured at the nipple level and is usually 2 to 3 cm smaller than the head

Conduction

Heat loss by direct contact with cool surfaces in the nursery

Stepping reflex

Hold infant so feet touch solid surface, expect infant to lift alternate feet as if walking

When feeding a new born with a cleft palette...

Adequate fluid intake is necessary to prevent dehydration, burping frequently is necessary as they take in a lot of air, Patience is needed, the mother will require teaching an encouragement to breast-feed

Thrush

An infection of the mouth. Caused by Candida albicans, the same organism which causes Monilial vaginitis in the mother. The infant may acquire this infection as it passes through the birth canal

Umbilical cord that is red and, moist and foul smelling at four days after birth

Assess for other signs of infection, isolate the infant, report the findings of infection to the physician

If a newborn has tremors of his extremities and seems jittery, the nurse should

Assess his blood glucose level

What might make you suspect interference with oxygenation requirements in an infant

Becoming cyanotic when crying, seeming hungry, but taking a long time to feed, having a weak cry

Non-physiologic/pathologic jaundice

Begins within the first 24 hours and often requires treatment with phototherapy. A result of abnormalities causing excessive destruction of RBCs or problems in bilirubin conjugation. These include incompatibilities between mother and infant blood types, infection and metabolic disorders

mongolian Spots

Blue-black coloration of skin on back and buttocks of infants of Mediterranean, African, Asian ethnicity Should be documented so presence is established

Urine of a normal newborn...

Can be rust colored, indicating uric acid crystals

Newborn stomach

Capacity of less than 30 to 90 cc (mL)

The incubator provides ideal levels of

Humidity and heat

Which of the following is part of the infant discharge process?

Check the wrist/ankle band number of the infant with that of the mother B. Give feeding instructions to the mother D. Cut one of the baby's identification bands and attach it to the permanent record E. Assess presence of a safe infant car seat

Binuclear family

Child is part of 2 blended families

Care of an uncircumcised newborn includes

Clean the penis with warm water while not pulling back on the foreskin

The first step in nurse should take at birth...

Clear the baby's air passages

Family system theory

Emphasis on the interaction among family members and their environment. Change (eg. Illness) in one part affects all other parts. Try to help families by keeping as much normalcy as possible

If the nurse gets a low axillary temperature on the newborn what is an appropriate intervention?

Encourage the mother/father to do skin to skin

phenylketonuria (PKU)

Enzyme to break down amino acid phenylalanine is missing Results in buildup of phenylpyruvic acid Accumulation in brain

A hasty/precipitous birth in the emergency department requires what initial action by the nurse?

Establish an airway for the baby

Hemangiomas or stork bites appear between the eyes are at the base of the skull in the newborn and Will be expected to

Fade with age

Golden hour

First hour after birth-first reactive.-Intently awake.perfect time to breastfeed

Convection

Flow of heat from warm body surface to cooler air

Hepatic -newborn liver

Immature. Slow to break down bilirubin end product of hemoglobin breakdown.

Cold stress in newborn

Increases in metabolic rate, respiration rate, and O2 consumption. Increase in glucose metabolism to fuel metabolic rate can lead to metabolic acidosis

Excretory assessments

Infant should void within 24 hours. Infrequent voids, stools, or brick red urine is caused by uric acid. This indicates a need for higher fluid intake-breast milk and formula, NOT water

Normal respirations in newborns

Irregular, 40 to 60 breaths per minute

Hyperbilirubinemia

Jaundice becomes visible when the bilirubin level is greater than 5 mg/dL. The serum bilirubin level is the most important value to know

when using a bulb syringe babies should suctioned from what position

Keep head lower than body to promote drainage of secretions (Trendelenburg position)

Excretory-kidney newborn

Kidneys have been functioning in utero making amniotic fluid. Baby voids adding to amniotic fluid volume-amniotic fluid volume is an important indicator to renal health.

Radiation

Loss of heat from body to cooler solid surface in relative proximity to infant. Crib placement

Evaporation

Loss of heat that occurs when a liquid is converted to a vapor-important to dry baby

factors that are involved in the initiation of the newborn's respiration.

Need for oxygen, Fluid filled airways empty and fill with air; PCO2 in blood rises and stimulates respiratory center, causing baby to take its first breath.

Cardiovascular transition of fetus

O2 rich blood returns to fetus via umbilical cord. Enters thru Umbilical vein and enters inferior vena cava and the RIGHT ATRIUM. Blood is shunted right to left in heart thru special structure of fetal circulation FORAMEN OVALE. These special structures close within 24 hrs. R to L to L to R

Physiologic jaundice

Occurs in normal newborns after the first 24 hours of life as a result of hemolysis of red blood cells and immaturity of liver. More common in Asian infants as their bilirubin levels rise higher and fall more slowly

What should the newborn be cleansed with

Plain warm water and soap, no soap on the eyes or face obviously

Cephalohematoma

Pooling of blood from damaged blood vessel's between the skull and inner layers of the skin. A collection of blood between the periosteum and skull bone, present for several hours after birth. This places a baby at higher risk of jaundice because as the blood breaks down, the levels of Bilirubin increase

Neonates most at risk for hypoglycemia

Preterm, small for gestational age, large for gestational age, born to diabetic mothers or exposed to stressors

In Massachusetts, when must a hearing screening of a newborn be conducted

Prior to discharge from the hospital

Habituation

Process of becoming familiar with worlds noises, light etc.

Since shivering is not possible for a newborn, they may have difficulty

Regulating their body temperature

If newborn temperature is below 97.5...

Report! Retake rectally if needed. We were an infant gradually if too cold. Isolette is 2 to 3°F warmer

FORAMEN ovlae

Special fetal structure that shunts blood from right side of heart to left. Flap between R atrium and LA so blood can bypass non functioning lungs and go directly to LVentrical and aorta. It then bypasses the pulmonary artery and goes directly into the aorta via the DUCTUS ARTERIOSUS (also a fetal structure). From there it is dispersed to the body "head to toe".

Family stress theory

Stress is inevitable and any positive or negative event can be stressful it has a cumulative effect. Wide range of coping mechanisms. For adaptation to occur, a change in family structure or interaction is necessary

Babinski reflex

Stroke lateral sole of foot from heel across to base of toes and expect toes to flair with dorsiflexion of big toe

Nursing action that is a priority for the nurse caring for a newborn with slight yellow tinged skin

Teach the mother to breast-feed at frequent intervals. When a breast-fed baby shows signs of jaundice, the reason is usually insufficient intake so frequent feedings-8 to 12 feedings in 24 hours increases infant intake and the mothers production of milk

Moro reflex

The "embrace" position. Let the infants head dropback 30° and expect sharp extension and abduction of arms followed by flexation to embrace position. disappears at 5 to 6 months

Tonic neck

The reflex that causes the baby to extend his arm and leg on the side to which the head is turned and flex the arm and leg on the opposite side

Conjugate

The liver must conjugate Bilirubin-change from fat to water soluble form. If conjugation is slow, John this is the result

Apgar score does not determine

The need for recessitation . Resuscitation of newborn always begins within 10 to 30 seconds after birth

Newborn water distribution

The newborns body is composed of a greater percentage of water, with more located in the extracellular compartment, and fluid is more easily lost.

A one-day old is diagnosed with intrauterine growth retardation and is restless, irritable, fist ****ing and having a high-pitched cry. What should you do?

Tightly swaddle the infant in a flexed position

Rooting reflex

Touch or stroke from side of mouth towards cheek, expect infant to turn head to the side that is touched

Harlequin coloring

Unilateral erythema with striking contrast at midline. An unequal skin coloring. Think of the Harlequin masks that are black on one side and white on the other. The mechanism of this phenomena is not known but it usually occurs between the second and fifth day of life and resolves itself.

NEWBORN INJECTION TECHNIQUE

Use vastus lateralis site Middle third of lateral aspect of thigh Max volume 0.5 mL 25 gauge, 5/8 in needle Wash thigh before cleansing with alcohol Stabilize leg so infant does not inadvertently move

The nurse assesses a normal new born and expects to find the following:

Vernix B. Milia C. Lanugo D. Phimosis E. Smegma

During assessment of a normal newborn, the nurse expect to find

Vertex, Milia, lanugo, smegma

vs parameters after birth

Vital signs every 30 min for first 2 hrs after birth BP not usually taken on otherwise healthy newborn Temp -axillary, rectal or by skin probe Respirations and apical pulse counted for 1 full minute at rest

To prepare for a baby is imminent arrival what supplies should you have ready?

Warm blankets, oxygen and suction, name bands

sx-CARDIOPULMON ARY DISTRESS

absent or weak cry despite stimulation Floppy Labored breathing: retractions, flaring, grunting on expiration, stridor Bradypnea or tachypnea nl 30- 60/ min at rest, irregular, periodic breathing Bradycardia 120-160/min at rest (apical) Central or circumoral cyanosis Asymmetrical chest expansion Paradoxical (seesaw) abdominal/thoracic breathing Crackles persisting beyond 1-2 hrs or other abnormal breath sounds

vitamin k

administered 12hrs after birth

erythromycin or tetracycline

administered within 2hrs of birth (gonorhea or chlamydia prevention)

kernicterus

bilirubin deposits in brain. sx-cns, lethargy, irritability, seizures, bilirubin greater than 20

premature baby definition

born less then 37 weeks

The urine of the normal newborn is:

can be rust colored, indicating uric acid crystals

phototherapy

changes bili to water

_________ and _________ are not uncommon in the first 1-2 hours after birth

crackles and tachypnea

the anterior fontanel is ________ shaped and _________ cm from bone to bone

diamond, 4-5

BETAMETHASONE

enhances lung development in premature newborns

a water ring in the stool is caused by

formula intolerance or infection

middle 3rd of bone, limited motion, crepitus, abscence of moro reflex

fractured clavicle

hep b vaccine

given within 12hrs of birth

a normal Apgar score is

greater than 7

radiation

heat tranfered to proximate objects

conduction

heat transfered through direct contact

convection

heat transfered to surrounding air

evaporation

heat travels from wet surface to air

bsl less than 45

hypoglycemia

difficult births and increased metabolism can cause _______ and_______ _

hypoglycemia, metabolic acidosis

breach

inspect for symmetry of gluteal and thigh folds assess for limited hip abduction when leg is flexed leg (femur) length discrepancy tx-ultraSound, Splinting with Pavlek Harness for 3-6 months Gentle ROM exercises to make hip more abducted Skin traction or hip spica cast. Frejka Pillow maintains abduction, extention, and internal rotation (frog-like position)

pressing the infants skin and assessing its color is used to uncover

jaundice

epispadias

located on the upper side of the penis

hypospadias

meatus located on the underside of the penis

hypospadias

meatus on ventral side of penis circumcision not done,

Which of the following best describes the neonate's skin?

mottled when undressed B. Color consistent with genetic background C. The sweat and sebaceous glands are present and functioning D. Reaction to tactile sensation is present E. May have tiny pearly-white raised bumps on the face

transient tachypnea

rr-50-100, c-sectioned babies, grunting and resp distress

jaundice

not present first 24hrs, peaks 5-6 days. pathological persists after 2 weeks, preveted by rhogam

thrush is treated with

nystatin

Breast-feeding jaundice

often caused by insufficient intake. True breastmilk jaundice begins later than physiologic jaundice and maybe caused by substances in the milk

meningoceles

protrusions of spinal fluid or spinal cord

erythema toxicum

red blotchy areas with white/yellow veiscles. often disappears after 10 days

simian crease

single crease that crosses the palm without a break or line, indicative of downs syndrome

diaphramatic hernia

sunken appearance of abdomen

vernix caseosa

thin white film present at childbirth

Phimosis

tight foreskin which can not be pulled over glans

cleft palate feeding

use of special feeding devises (Haberman Nipple-Breck feeder) to facilitate feeding feed in upright position

hip displasia may be indicated

when one knee is lower than the other

lanugo

white fine hair on newborn, more visible on premature births

milia

white spots on newborn forehead, disappear after a few weeks, plugged sebaceous glands around infants nose


Set pelajaran terkait

Evolve: Psychobiological Disorders

View Set

Hanson earth and space ch 17 exam

View Set

Systems Analysis Chapter 7 Sequence Diagrams

View Set

Georgia Constitution & Government Study Guide

View Set