SPECIAL POP EXAM 2

The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings should alert the nurse to the possibility of this syndrome? Select all that apply 1.Cyanosis 2.Tachypnea 3.Hypotension 4.Retractions 5.Audible grunts 6.Presence of a barrel chest

1.Cyanosis 2.Tachypnea 4.Retractions 5.Audible grunts

The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care? A. Avoid stimulation. B. Decrease fluid intake. C. Expose all of the newborn's skin. D. Monitor skin temperature closely. E. Reposition the newborn every 2 hours. Cover the newborn's eyes with eye shields or patches.

Monitor skin temperature closely. Reposition the newborn every 2 hours. Cover the newborn's eyes with eye shields or patches.

What does APGAR stand for?

Appearance, pulse, grimace, activity, respiratory effort

The nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is most appropriate? 1.Apply gentle pressure. 2.Reinforce the dressing. 3.Document the findings. 4.Contact the primary health care provider (PHCP).

3.Document the findings.

The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which findings should the nurse expect to note during the assessment of this newborn? Select all that apply. 1.Lethargy 2.Sleepiness 3.Irritability 4.Constant crying 5.Difficult to comfort 6.Cuddles when being held

3.Irritability 4.Constant crying 5.Difficult to comfort

serum bilirubin

5-6mmhg

What is immediate care for newborn

Clear airway Maintenance of body temp identification before baby leaves room

Infants at risk for hypoglycemia

Premature, S.G.A. L.G.A . Diabetic mom. Babies who suffered hypoxia in labor.

Nonphysiologic jaundice

- requires further investigation - may occur in the first 24hrs - rises higher and more rapidly than expected or stays elevated longer - requires treatment to prevent severe hyperbilirubinemia - causes can include: blood incompatibility, infection, and metabolic disorders - treated with phototherapy

Newborn physical assessment-face

-Edema around eyes, face, and scrotum or labia -acrocyanosis normal for 24 hours -Vernix Caseosa: -lanugo: more premature =equal prescene -monogolian spots -Mila: white/yellow pinpoint spot

hypothermia in newborn

-Prevent cold stress by swaddling, put on hat, skin-to-skin, dry off, delay bathing, dress them, warmer -Risk factor of jaundice -Causes hypoxia, metabolic acidosis, and hypoglycemia -check temp frequently -food/IV fluid should be warm

newborn head assessment

-anterior fontanel close b/w 12-18 months -posterior fontanel close by 2 months -eye- -absent of tears and blinking reflex present -ear- -low set ears = renal and mental impairment -tongue- -ankyloglossia: tongue tied and cause feeding and speech problems caput succedaneum and Cephalohematoma may be present

hypoglycemia in newborn

-blood glucose of less than 40 -jitteriness (first sign), twitching, weak high pitched cry -irregular RR -cyanosis -lethargy -seizures -eye rolling - decrease glucose to brain irreversible ands severe neurologic impairment

caput succedaneum

-edematous swelling and ecchymosis of the presenting -part of the head caused by birth crosses the suture lines -reabsorbs with 12 hours or few days

Second period of reactivity

-last about 2-5 hours -baby alert and responsive - Increased heart rate, resp, gastric secretion -meconium commonly occurs -skin color begins Following second stage can last months

Cephalhematoma

Bleeding between the periosteum and skull from pressure during birth; does not cross suture lines. Doesn't not increase in size hen crying. appears on the 1 or 2 days. disappears after 2-3 weeks.

The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast-fed. The nurse should provide which instruction to the mother? A. Feed the newborn less frequently. B.. Continue to breast-feed every 2 to 4 hours. C. Switch to bottle-feeding the infant for 2 weeks. D. Stop breast-feeding and switch to bottle-feeding permanently.

Continue to breast-feed every 2 to 4 hours.

The nurse assisted with the birth of a newborn. Which nursing action is most effective in preventing heat loss by evaporation? 1. Warming the crib pad 2. Closing the doors to the room 3. Drying the infant with a warm blanket 4. Turning on the overhead radiant warmer

Drying the infant with a warm blanket

Group B Beta Strep

Early onset or infection baby could have pneumonia, respiratory distress, shock, apnea , meningitis Late onset 3-4 days after births bacteremia, meningitis, may occur in LBW infants acquired: perinatally, intrapartum antibiotics decrease early onset but not late onset. risk factors: preterm births, maternal GBS thats untreated, chrioamnionitis treatment: admin ampicillin plus aminoglycoside. mother is cultured at 36 week prenatal appointment

The nurse is caring for a term newborn. Which assessment finding should alert the nurse to suspect the potential for jaundice in this infant? A. Presence of a cephalhematoma B. Infant blood type of O negative C. weight of 8 pounds, 6 ounces (3800 gm) D. A negative direct Coombs' test result

Presence of a cephalhematoma

Physiologic Jaundice of the Newborn

appears 2-3 days later and then decline 5-7 days no treatment needed

modalities of losing body temp

evaporation: internal energy turns to liquid conduction: direct contact b/w body surface and cooler solid object. ex child on cold surface ' Convection: exposure to an infant to direct source or air draft. ( air hitting child) radiation: distant object that are cooler than skin temp

Admission care for newborn

interpersonal communication with patients Take complete history of mom and prenatal history ID band and form complete physical assessment Admin Vitamin K

first period of reactivity in newborns

stage 1 -During the first 3 hours -Physiologically unstable. -very alert, cries vigorously, may suck at first greedily -interested in surroundings -best time to begin breastfeeding Stage 2 -last 2-4 hours -mucus production are decreased/stable -sleepy and calm -bad time to begin breastfeeding