PC test 3

wink reflex

Anal sphincter responds to touch by opening and closing

tetanus antitoxin

(horse serum) used for wound management; passive immunity

how many calories to infants require a day?

108 calories to thrive

chest circumference of newborn

12-13 inches, measure at nipple line

head circumference

13-14 inches, measure right above eyebrows

normal length

18-22 inches

the urine output of a newborn

30-60 ml/day or approximately 180 mls for an 8 lb baby. 6-8 wet diapers a day

normal newborn's blood sugar

50-90 mg/100 ml <30 is strict hypoglycemia

babies at risk for wet lungs:

C-section babies preemies newborn asphyxia

stepping (walking)

Hold infant vertically alowing on foot to touch table surface- alternates flexion and extension of feet

polio

OPV = oral polio vaccine (live virus, SABIN) IPV = inactivated polio virus (killed virus, Salk)

crossed extension

Place infant in a supine position. Then extend one leg, press knee downward, and stimulate bottom of foot; opposite leg flexes, adducts and then extends

moro

Place infant supine on flat surface and make a loud abrupt noise; symmetric abduction and extension of arms, fingers fan out, thumb and forefinger form a C; arms are then adducted into an embracing motion and return to relaxed flexion and movement

tonic neck (fencing)

Place sleepy infant in a supine position, turn head quickly to one side-- arm and leg extend on side to which head is turned while opposite arm and leg flex.

glabellar (myerson sign)

Tap over forehead, bridge of nose, or maxilla when eyes are open; blinks for first four or five taps

yellowish tinge in sclera and on face, blood glucose level of 35 mg/dl

a breast fed full term newborn girl is 12 hours old and being prepared for early discharge. If present, which assessment findings could delay discharge?

during a home visit, the mother of a 1 week old infant son tells the nurse the she is very concerned about whether her baby is getting enough breast milk. The nurse should tell this mother that at 1 week of age a well nourished newborn should exhibit:

a minimum of three bowel movements each day of soft, yellow, seedy stools

increased mucus production, passage of meconium, heart rate of 160 beats/minute

a newborn, at 5 hours old, wakes from a sound sleep and becomes very active and begins to cry. Which signs, if exhibited by this newborn, indicate expected adaptation to extrauterine life?

3 degrees of dysplasia

acetabular, subluxation (the largest percentage), dislocation seen more in girls than in boys 1 in 500-1000 births

Brazelton assessment scale

allow assessment of individual strengths of a newborn and to allow staff and parents to view the newborn as an individual

the nurse should teach breastfeeding mothers about breast care measures to preserve the integrity of the nipples and areola. What should the nurse include in these instructions?

apply modified lanolin to both dry and sore nipples

a newborn male has been scheduled for a circumcision. Essential nursing care measures following this surgical procedure include:

applying petroleum ointment to the site with every diaper change until the site is healed

AGA

appropriate for gestational age

a breastfeeding woman asks the nurse about a reliable and safe method of birth control she should use during the postpartum period. The best recommendation for a safe yet effective method during the first 6 weeks after birth is:

barrier method using a combination of a condom and spermicide foam

cephalophematoma

bleeding between the cranial bone and the periosteum in periosteal space. does not cross suture lines

habituation

decreasing responsiveness with repeated stimulation. As infants gain familiarity with repeated exposure to a visual stimulus, their interest wanes and they look away sooner.

a woman has determined that bottle feeding is the best feeding method for her. Instructions that the woman should receive regarding this feeding method include:

expect a 2 week old newborn to drink approximately 90-150 mL of formula at each feeding

d

given as a single antigen

pertussis

given for kids 6 weeks to 6 years, whole cell inactivated, current form is acellular inactivated, fewer side effects.

DTP

given to children under 7 years of age

DT

given to children under 7 years of age who can't take pertussis

the nurse evaluates the laboratory test results of a newborn who is 4 hours old. Which results require notification of the pediatrician

glucose 34 mg/dL calcium 7 mg/dL

a newborn male has been designated as large for gestational age. His mother was diagnosed with gestational diabetes late in her pregnancy. The nurse should be alert for signs of hypoglycemia. Which assessment finding is consistent with a diagnosis of hypoglycemia?

jitteriness

LGA

large for gestational age, above normal, >90%, (gestational diabetes)

increased metabolic rate

leads to increased use of glucose and production of surfactant. this can lead to hypoglycemia and respiratory distress

vasoconstriction

leads to pale, mottled skin and shut down of pulmonary vessels, which leads to fetal circulation patterns

breast fed babies

loose BM golden yellow color non-irritating no odor

non-shivering thermogenesis

metabolism of brown fat, leads to increased production of free fatty acids, which leads to metabolic acidosis and jaundice

a physician has ordered that a newborn receive a hepatitis B vaccine prior to discharge. In fulfilling this order the nurse should:

obtain parental consent prior to administering the vaccine, inform the parents that the next vaccine in the series needs to be given at 1-2 months, administer the injection into the vastus lateralis muscle

convection

occurs when heat is transferred to air that surrounded the nb

conduction

occurs when the nb comes in direct contact with objects that are cooler than their skin

radiation

occurs when there is a transfer of heat to cooler objects that are not in direct contact with the infant

evaporation

occurs when wet surfaces are exposed to air

As part of thorough assessment, the newborn should be checked for hip dislocation and dysplasia. Which of the following techniques would be used? a. Check for syndactyly bilaterally b. Stepping or walking reflex c. Magnet reflex d. Ortolani's maneuver

ortolani maneuver

molding

overriding sutures, resolves quickly

grasp

place finger in palm of hand or at base of toes; infant's fingers curl around examiner's fingers or toes curl downward

magnet

place infant in a supine position and apply pressure to soles of the feet with fingers when the lower limbs are semi-flexed, legs extend against examiners pressure

truncal incurvation

place infant prone on flat surface, run finger down side of back first on one side and then down the other side 4 to 5 cm lateral to spine; trunk flexes and pelvis swings towards stimulated side

extrusion reflex

placement of things on the anterior third of the tongue causes the tongue to protrude, prevents baby from swallowing incredible things gone by about 4 months

a woman is trying to calm her fussy baby daughter in preparation for feeding. She exhibits a need for further instruction if she:

removes all clothing from the infant except the diaper

SGA

small for gestational age, below normal, < 10%

caput succedaneum

soft tissue edema from birth trauma, crosses suture lines

bottle fed babies

soft, formed BM pale yellow color irritating odor

when assessing a newborn after birth, the nurse notes flat, irregular, pinkish marks on the bridge of the nose, nape of the neck, and over the eyelids. The areas blanch when pressed with a finger. The nurse documents this finding as

telangiectatic nevi

cremasteric

testes retract when infant is chilled

Td

tetanus and diphtheria vaccine for kids over 7 years (lesser concentration of diphtheria)

a newborn male is estimated to be at 40 weeks gestation following an assessment using the new ballad scale. New Ballard scale findings consistent with this newborn's full term status are

thinning of lanugo with some bald areas, testes descended into the scrotum, elbow does not pass midline when arm is pulled across the chest

rooting

touch infant's lip, cheek, or corner of mouth with nipple or finger; turns head toward stimulus and opens mouth ready to take hold and suck

extrusion

touch or depress tip of tongue; tongue is forced outward

tonic neck reflex

turn infant's head to one side, causing infant to extend am/leg on the side and flex arm/leg on opposite side, helps prevent baby from rolling over

a radiant warmer will be used to help a newborn girl to stabilize her temperature. The nurse implementing this care measure should:

undress and dry the infant before placing her under the warmer

Babinski reflex

use finger to stroke sole of foot beginning at heel, upward along lateral aspect of sole, then across ball of foot; all toes hyperextend, with dorsiflexion of big toe "positive response"

tetanus toxoid

used for primary immunity, gives antitoxins for 10 years or more

tetanus immunoglobulin

used for wound management; passive immunity

a new breastfeeding mother asks the nurse how to prevent nipple soreness. The nurse tells this woman that the key to preventing sore nipples is:

using correct technique for latch-on and removal from the breast

approved live vaccines

viral: MMR, oral polio, varicella, yellow fever bacterial: BCG for tb Recombinant: typhoid

inactivated whole cell vaccines

viral: influenza, IPV, Rabies, hep A bacterial: pertussis, typhoid, cholera, plague

medications in delivery room

vitamin K (aquamephyton) blood clotting erythromycin ointment for gonorrhea and chlymydia

at a home visit 1 week after birth, a nurse is evaluating a woman's breastfeeding technique. Which actions indicate that the woman needs further instruction regarding breastfeeding to ensure success?

waits to feed her baby until he wakes up and begins to cry, squeezes her nipple and areola between her thumb and forefinger and then inserts her nipple into the baby's mouth, positions her baby, supporting back and shoulders securely, and then brings her breast toward the baby, putting the nipple in the baby's mouth

a nurse is preparing to administer erythromycin ophthalmic ointment 0.5% to a newborn after birth. Which nursing actions are appropriate ?

wear gloves, cleanse the eyes if secretions are present, wipe away excess ointment after 1 minute, apply the ointment from the inner to outer canthus

documents the finding as erythema toxicum

when assessing a newborn boy at 12 hours of age, the nurse notes a rash on his abdomen and thighs. The rash appears as irregular reddish blotches with scattered papule. The nurse: