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normal term newborn
characteristics of, full systems assessment of, and breastfeeding,
| Question | Answer |
|---|---|
| changes in the shape of the head that allow it to pass through the birth canal | molding, caused by overrriding of the cranial bones at the sutures and is common after a long second stage. parietal bones often override the occipital and frontal bones, and a ridge is felt; resolves in days to one week. |
| caput succedaneum | swelling that crosses the suture line, results from pressure against mother's cervix, local edema, resolves within12 hours to several days, may result from the use of a vacuum extractor |
| persistant, widened suture lines | indication of intracranial pressure |
| what are abnormal signs at the newborn cranium? | bulging, full, depressed fontanelles |
| cephalohematoma | bleeding between the periosteum and skull, in 1% to 2% of newborns and is the result of pressure during birth. does not cross suture lines, resolves in weeks to months due to breakdown of rbc's infants at greater risk for jaundice |
| assessing the face: | symmetry, facial feature position, movement, expression, transient asymmetry from pressure may occure lasting a few weeks to months |
| eye exam | s/s inflammation, size, symmetry, transient strabismus, color, pupils, tears, eyelid edema, hemorrhage, visual acuity |
| Ear | placement, overall appearance/maturity, position hearing, |
| nose | patency, discharge and septal deviation |
| mouth | palpate, visualize, inspect pink mouth, gums, epstein's pearls- |
| epstein's pearls | small white or yellow cystic vesicles (1 to 3 mm in size) often seen in the median palatal raphe of the mouth of newborn infants |
| neck/clavicles | visually, check for clavicle fx |
| integumentary | assess every inch of skin, pink/tan, acrocyanosis (feet and hands), cyanosis may occur in the face |
| vernix caseosa | thic white cream cheese like substance, lipids protein, preterm/postterm, most vernix is removed during the first bath and remaining vernix is absorbed by the skin |
| lanugo | fine hair that covers the fetus in utero, as fetus nears term, lanugo thins, dark skinned infants have more |
| milia | white cystes 1 to 2 mm in size, face over the forehead, nose, cheeks, and chin, resulting from distentio of sebaceous glands not yet functional |
| cardio respiratory assessment | transitional changes take place in both systems. paying attention to SOB is important b/c newborn cannot verbalize chx pain |
| Airway | asses once every 30 minutes, note abnormalities, lung sounds, resp distress |
| what are signs/symptoms of resp distress | tachypnea (breaths above 60 per min-abnormal after first two hours) , retractions, nostril flaring, cyanosis, grunting, seesaw respirations, asymmetry, choanal atresia |
| retractions | substernal, intercostal, supraaclavicular: chest muscles used to draw air into the lungs pulling soft tissue in with effort of pulling air |
| nostril flaring | reflexive widening of the nostrils occurs when the infantis receiving insufficient oxygen, it decreases airway resistance, increases amount of air intake, continued flaring indicates serious problem (more than the first hour after birth) |
| cyanosis | purplish blue discoloration, indicating that the infant ins not getting enough oxygen, preceded by dusky/gray hue to skin, centrally involves lips, tongue, mucosa, trunk, not enough O2 reaching vital organs, |
| false indication of cyanosis | bruising of face from tight nuchal cord or pressure during birth and may look like central cyanosis |
| Central cyanosis vs acrocyanosis (peripheral) | central cyanosis with dark skin, assess color of mucosa, |
| bruising vs cyanosis | cyanotic area will blanch, pulse oximeter measures 02 saturation |
| cyanosis occurs when? | whenever the infant's breathig is impaired, difficulty coordinating sucking, swallowing, and breathing during breast feeding, on exertion or crying may indicate congenital heart defect, shortly after birth may dissipate when infant begins to breathe |
| grunting | noise on expiration of air over partially closed vocal cords, causes increase in pressure wihtin the alveoli, which keeps them open and enhances the exchange of gases in the lungs, may be mild heard with stethoscope, persistent is common sign of RDS |
| seesaw respirations | seesaw respirations -indicates sever resp difficulty (chx falls when abd rises) normallly chx/abd rise/fall together during resp, in the infants without other signs of respiratory difficulty should not cause alarm |
| Asmmetry: | chx expansion should be = bilat, |
| choanal atresia | one or both nasal passages blocked or narrowed by bone or membrane protrusion. Assessed by closing infant's mouth and occluding one nostril each. significant b/c they r preferential nose breathers for 1st 3 wks. bilat= resp distress, needs surgery |
| auscultate | rate rhythm, presence of murmurs or abnormal sounds, listen at apex 3rd or 4th ics, medial to mcl, assess once q 30 min |
| brachial/femoral pulses | =, strong, bilat |
| bp is taken when? | not normal assessment only during focused assessment for unequal pulses, murmurs, or cardiac complications, takenon extrem x4 when infant is quiet |
| cap refill | dtermns adequate perfusion, color returns under 3 seconds after blanching |
| GI system: initial feeding | assess the infants ability to suck swallow breath in a coordinated manner |
| abdomen | soft round protrudes, not distended, auscultate bs |
| stools assessfor: | color, type, consistency, (meconium-dark greenish-black/tarry/odorless/tenacious; transitional-loose/greenish/-brown on 2nd or 3rd day; breast fed-pass very soft, seedy, mustard-yellow stools after transitional stools; formula fed-solid yellow/lt brown) |
| when is Urine first voided and how much volume is voided?; | newborn voids within first 12 hours, record first void, by 4th day of life, at least six wet diapers can be expected |
| what are normal signs of infant female genitalia? | Edema of the labia and white mucous vaginal discharge are normal. In the full term infant, the labia majora should be large and completely cover the clitoris and labia minora. |
| what happens in infant female interaction with maternal hormones/?infant male interaction? | A small amount of bleeding (pseudomenstration) may occur from sudden w/d of maternal hormones at birth. Labia may be darker than the surrounding skin, a normal response to maternal hormones before birth; in male infant scrotum may be dark brown |
| Male infants need cleansing of the meatus how often? | Routine retraction of the foreskin of the newborn for cleansing is not recommended as it can cause damage. |
| Neuro checks? | Rooting. Sucking. Moro Reflex. Palmar Grasp Reflex. Plantar Grasp Reflex. Tonic Neck Reflex. Babinski.Dance or Stepping Reflex. |
| rooting is when what happens after the infant is Stimulated by touching the side of the newborn's cheek near the mouth. | Infant turns head toward that side and opens the lips. |
| sucking is stimulated how? | placing a nipple or gloved finger into the infant's mouth. Suck reflex is assessed for presence and strength. |
| tonic neck reflex is performed in suppine position how? | the infant's head is quickly turned to one side, arm and leg will extend on that side, and opposite arm and leg will reflex; posture resembles a fencing position. |
| what happens in the babinski test? | Elicited by stroking the lateral sole of the infant’s foot from the heel forward and across the ball of the foot. Causes the toes to flare outward with dorsiflexion of big toe. |
| how are signs of neuro checks interpreted? | Note the strength and symmetry of reflexes. Absence of reflexes may indicate a serious neurological problem. Asymmetric responses may indicate that trauma during birth caused nerve damage, paralysis, or fracture. |
| Other assessments of newborn | length 19-21 inches (48-53 cm). Weight 5 lb 8 oz to 8 lb 13 oz (2500-4000 gm). drops 10% birth weight 1st 7 to 10 days. Head circumference. 33-35.5 cm (13-14 inches). Chest 12 to 13 inches (30.5 to 33 cm). |
| temperature normal values are? | Axillary: 36.5-37.5 C (97.7-99.5 F). Rectal 36.5-37.6 C (97.7-99.7 F). Axilla is the preferred site. |
| heart rate | Normal rate 120 to 160 beats/minute with normal activity. May rise to 180 beats/minute when the infant is crying, or drop to 100 beats/minute during deep sleep. Count apical pulse for a full minute. |
| resp rate | Normal rate is 30 to 60 breaths/minute. Chest should move symmetrically, although pattern and depth of respirations are irregular. Respirations should not be labored. Count rate for 1 full minute for accuracy. |
| nursing early care | Occurs after immediate stabilization and initial assessment of the newborn. Administering Vitamin K. One dose IM within the first hour after birth. Providing Eye Treatment. Erythromycin 0.5% ointment most commonly used. |
| ongoing assessment care | Perform cord care. Preventing infant abduction. Nutritional Needs of the infant |
| different stages of breastfeeding begin with what stage of breastfeeding known as colostrum | A thick yellow substance high in protein, minerals, fat soluble vitamins and immunoglobulins, which transfers some immunity to the infant. Its laxative effect speeds the passage of meconium |
| transitional milk | Appears as the milk changes from colostrums to mature milk. Immunoglobulins and protein decrease, whereas lactose, fat, and calories increase. |
| mature milk | Established by two weeks after delivery. Bluish in color and not as thick as colostrum |
| formulas, aka bottling is defined by what types? | modified cow's milk, unmodified cow's milk, soy, ready to feed, powdered, concentrated; |
| when is soy formula indicated? | Soy formulas may be given to infants with allergies, galactosemia, or lactase deficiency or whose families are vegetarian. Examples are ProSobee and Isomil. |
| what newborn characteristics predispose them to body temperature loss? | Skin is thin and blood vessels are close to the surface. Little subcutaneous or white fat is present to serve as a barrier to heat loss. Percentage of subcutaneous fat is only half that of an adult. Newborns have x3 more surface area than adults |
| explain different methods heat loss : Evaporation | Evaporation: Occurs when wet surfaces are exposed to air. Drying the infant, especially the head, as quickly as possible at birth and after bathing helps prevent excessive heat loss. |
| conduction | Occurs when newborns come in direct contact with objects that are cooler than their skin. Placing infants on cold surfaces or touching them with cool objects causes this type of heat loss. |
| convection | Occurs when heat is transferred to air surrounding the infant. Air currents from A/C or people moving around increase loss of heat. |
| radiation | Transfer of heat to cooler objects that are not in direct contact with the infant. For example, infants placed near cold window lose heat by radiation. |
Created by:
redhawk101
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