Unit 5 jeopardy game
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."
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."
Mastitis
*Candida can be the causative agent in infants with thrus *Enters via fissures or cracks in nipples
Alba
*Creamy white *Not seen in hospital *10-14 days up to 3-6 weeks *may just be a spot on the pad
caput succedaneum
*Soft area of scalp an edematous swelling and occasional bleeding under the periosteum *DOES CROSS 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
Signs and symptoms of mastitis
*nipple pain *Itching *Burning followed by shooting pain throughout or between feedings *Affected nipple will be bright pink or red *Mom will notice yeast odor to milk *fever 101
normal newborn hr
120-160
An infant 5 hours old and weighing 7 lb (3,180 g) has a prescription for gentamicin sulfate 13 mg every 36 hours. The pharmacy sends gentamicin 20 mg/2 mL. How many milliliters should the nurse administer? Record your answer using one decimal place. Record the NUMBER ONLY.
135
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
Recommended caloric addition for breastfeeding mother
500 additional calories per day
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.
Simian crease
Associated with down syndrome *Check palmar crease
Seedy, yellow poop
Breast milk poop
Afterpains
Common in large infants , multifetal or breastfeeeding *If mother breastfeeds causes increase in uterine contractions
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.
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
Which action is the best precaution against transmission of infection?
Eye prophylaxis with antibiotics for a neonate whose mother has gonorrhea infection
What risk factor do babies with cleft lip and palate have?
Feeding difficulties
What happens to a diabetic mom after she has her baby
Her insulin needs are not as great as they use to be
Patient was diagnosed with diabetes during her pregnancy. What do we educate her on insulin use postpartum?
Her insulin needs will typically drop after delivery
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
Vaginal delivery 1 hour ago. Mom is sweaty, skin clammy, T:97.1 , HR: 132, R:28, BP:88/42. What condition is occuring
Hypovolemic shock
Dietary recommendations for nursing moms
Increase calories by 500
Growth chart LGA
Infants whose birth weight falls above the 90th percentile at any week of gestation on intrauterine growth charts *Associated with maternal diabetes, Multipara *Infant has erythroblastosis fetalis or beckwith- wiedeman syndrome *Suffer from fractured clavicle, brachial plexus injury, facial paralysis
Fine hair located on newborns back and shoulders
Lanugo
Tiny white pustules noted on newborns nose
Milia
Red rash over newborn
New born rash or flea bites *White or pale yellow papule or pustule with erythematous base *May appear suddenly over trunk and diaper area and wide spread, peak time is 24-48 hours and rarely after 5 days
Babinksi reflex
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
A three-day-old infant has only had 3 wet diapers in 24 hours
One wet diaper for each day old is normal
Mom calls department stating she isnt good at caring for infant and they would both be better off is she just does what the voices are telling her and kills herself and the baby. What stage of PP depression is she in
Postpartum psychosis
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
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.
Infants first APGAR is 6 what would be a nursing action needed for this infant
Stimulate by drying, rubbing back or soles of feet
Moro in newborn
Strike surface to startle baby *symmetric abduction and extension of arms are seen with fingers fan out and form a C with thumb and forefinger
The nurse obtains the following vital signs on a 24 hour infant. Which is most concerning?
T: 96.9 B/P: 88/41 HR: 155
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 large clot make sure it is not
Tissue (May have retained placenta) *Larger than 1cm is considered abnormal
Meningiocele
Visible defect with external saclike protrusion *Encases meninges & and spinal fluid but no neural elements *Not associated with neural defect
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.
Mom is spraying her peri bottle from back to front what do we teach
always spray from front to back and never forcedly into the vagina
Mom delivered this morning. Shes saturated 3 pads in 1 hour and her fundus is firm @ 1 fb above her umbilicus what would be the best action
assist her to void
Curling then flexing of the toes when the sole of the foot is touched
babinski reflex
How to determine if mom has lacerations after birth
bleeding continues but the fundus is firm
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
Cephalohematoma
collection of blood between surface of a cranial bone and the peristeal membrane **DOES NOT CROSS SUTURE LINES**
gram to kg conversion
divide by a 1000
3 days postpartum with generalized achiness, temp 100.9, B/P 90/48, HR:122 and abdominal tenderness with fundal check
endometritis
Milia
exposed sebaceous glands look like white spots on face especially across nose *No tx will clear up on own
Extending on leg and bending the opposite arm inward
fencing reflex
On assessing a patient a eccyhmosis and hard knot is noted. Patient complains of rectal pain and feeling of fullness and pressure within the vagina. You suspect a
hematoma
Do moms use hot or cold water with Peri care
if swollen use cold as can stand water (hot water will increase the swelling)
Infant born with spina bifida is at what greatest risk
infection from the opening in the spine
*Luekorrhea, backache and foul lochia if
infection is present
Endometritis
infection of the lining of the uterus; most common postpartum infection
Redenned, hard knot on the breast and low grade temperature
mastitis
Thick, sticky green poop
meconium
Extension of the arms and legs away from the body and to the side and then by drawing them together
moro
Infant is sweaty, irritable, vomiting and has facial excoriation. What could be causing these symptoms
neonatal abstinence syndrome
patient calling office with complaints of mastitis. What education do we provide regarding feeding the baby during the illness
never stop breastfeeding due to mastitis
Mom notices red blotchy area over newborns back and chest
newborn rash (Eryhtema toxicum)
Stroking the infants cheek and the head turns to your finger
rooting
When held upright with his or her feet touching a solid surface, infant performs stepping action
stepping reflex
Within 12 hours of delivery the fundus should be at
the umbilicus *Should descend 1 fingerbreath/ day (Involution) *Should not be palpable by day 9-10
Inversion of the uterus
turning inside out *Incomplete (Cant see) *Complete (mass in vagina) *Prolapsed (protrudes out) *S/S shock
Mom delivered three hours ago complaining of severe pain and rectal pressure
vaginal hematoma
Nursing care for Spina bifida
*Early closure within 12-18 hrs of birth to prevent local infection and trauma to exposed tissues, stretching of other nerve roots and further motor impairment *SB is associated with latex allegery *Observe infant behavior to stimulus *Measure urine output *Measure head circumfrence daily
Signs and symptoms of vaginal hematoma present
*Ecchymosis *Edema *Bulging mass *Extreme tenderness on palpation *Pain in perineal area *Feeling of fullness & pressure within vagina *Rectal pain
Symptoms of endometritis
*Fever *increased HR *Pain seropurulent drainage (Get culture) *Foul smelling lochia *Pelvic pain *Uterine tenderness
Subinvolution
*Fundal height is greater than expected *Lochia fails to progress *cause of late postpartum bleeding
what should the nurse monitor for in a baby born of a diabetic mother
*Hypoglycemia *LGA shoulder dystocia
tx for mastitis
*Increase fluid intake *DO NOT stop breastfeeding *Supportive bra *Moist heat and Antibiotics
Nursing actions for phototherapy for newborns
*Infant unclothed with genitals and eyes covered *Monitor vs Q4 hrs , I&O, observe skin for excoriation, rashes , bronzing *Predisposed to dehydration (Loose stools) *Fluid volume should be increased by 25% *Monitor labs *Discontinue phototherapy & remove eyepatches at least once per 8hr and when feeding or parent visit
Uterine atony
*marked hypotonia of uterus ; Major cause of PPH *If inadequate uterine contractions occur the uterus remains flaccid and rapid blood loss can follo w *High parity, Macrosomic baby
Serosa
*pinkish brown *4-10 days *No clots *More watery
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 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.
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.
Acrocyanosis
blueness of the extremities
If steady trickle noted and the fundus is firm check for
perineal laceration and notify HCP
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
to prevent cold stress at risk new borns are
placed skin to skin with mother
If fundus is deviated to one side
the bladder may be distended fundus may get boggy and bleeding could increase *Have mom urinate then reassess
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.
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."
Myelomeningocele (spina bifida)
*Contains meninges, spinal fluid and nerves *Associated with varying often serious neural defects
Post partum hemorrhage risks
*Cumulative blood loss of greater than 100 or bleeding associated with hypovolemia within 24 hours after brith *Retained placenta fragments *Infection *Uterine atony *Laceration of the uterus and cervix *Subinvolution of the uterus
Postpartum psychosis
*Irrational thoughts and behaviors, insomnia *Delusions and hallucinations *Associated with Bipolar *EMERGENCY bc of risk of homicide with delusions and hallucinations feels infant should not be allowed to live and NB may home harm other children *Emergency hospitalization
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? Select all that apply.
*Placing the diaper below the cord. *Sponge-bathing the infant until the cord falls off. *Washing the cord with mild soap and water.
Epiostomy and laceration assessments use REEDA
*Redness *Edema *Ecchymosis *Drainage *Approximation (Episiotomy)
Postpartum depression
*Sadness, frequent crying, insomnia, excessive sleeping, appetite changes *Perisistent anxiety; feels out of control *Feels in a fog *Irritability and hostility toward others including newborn
postpartum blues
*Severe in primiparas *feels overwhelmed, unable to cope, anxious, irritable and oversensitive *Classic sign is tearful or cries with no reason *Let mom know this is a normal adjustment and assist with care and family support is important
Peri care postpartum
*Squirt warm water from front to back (Peribottle) *Stand before flushing *Change pad everytime after voiding/BM *Sitz bath if episiotomy, laceration or hemorrhoids
myelomeningocele sac care
*Sterile, moist non adherent dressing *Change q2-4 hrs * Incubator or warmer to maintain NTE *If overhead warmer dressings require more frequent mositening *Sterile drape attached to sacrum to prevent stool contamination *Prone position to minimize tension on the sac and risk for trauma *Often not diapered: frequent pad changes essential *Often continous passage of stool due to no sphincter tone
Patient teaching for mastitis
*Teach good breast care and hand washing *Wear a supportive bra *Rotate positions *Massage clogged area while the infant sucking *If a clogged area is noted can apply a warm moist pack before feeding *Start with unaffected breast to stimulate let down reflex
Rubra
*dark red *1-3 days *Some clots *Heavy to moderate flow
what skin issues would you expect with a post dates infant
dry, peeling skin creases over entire sole of feet
education after infant has circumcision
vasoline gauze wash with soap and water
cheesy white substance on newborn skin
vernix
