nursing 2-newborn, Nursing 2 unit 2
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
