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
