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Maternal Newborn
Assessment of the Newborn
| Question | Answer |
|---|---|
| APGAR scoring determines the need for ____ | resuscitation |
| APGAR score measures what 5 things | Respiration, Muscle, Tone, Reflex, and color |
| How often are the APGAR scoring done | First minute after birth and again in five minutes if resuscitated. |
| The APGAR score is between 0-10, what is considered normal | 8-10 |
| Name the 5 things APGAR scores | Skin color, Heart rate, Reflex irriability, muscle tone, & breathing |
| In the APGAR rating of skin what does score of 0,1,&2mean? | 0=blue alll over, 1=blue a extremities, 2=no blue cyanosis body palms and soles may be blue) |
| In the APGAR rating of Heart rate, what does 0,1&2 mean | 0=absent, 1=below 100, 2=over 100 |
| In the APGAR rating of reflex irriability what does 0,1,&2 mean | 0=no response to stimulation, 1=grimace/feeble cry when stimulated, 2=sneeze/cough/pulls away when stimulated |
| In the AA=PGAR rating of muscle tone what does 0,1,&2 mean | 0=none 1=some flexion, 2=active movement |
| In the APGAR rating of breathing what does 0,1&2 mean | 0=absent, 1=weak or irregular, 2=strong |
| 2nd assessment is within 1-4 hours after birth includes: progress of newborn's adaptation to extra-uterine life, _____ & _____ | determination of gestational age and ongoing assessment for high-risk problems |
| Prior to discharge the physiial, nurse practitioner or nurse midwife carries out a ____ assessment and a complete physical examination as well as a general assessment | Behavioral |
| What two areas are covered when estimating gestational age | physical characteristics and neuromuscular maturity |
| Sole creases are reliable indicators of gestational age in the first 12 hours of life, a term newborn has creases on the ____ area of the sole | heel, premies have slick soles |
| By compressing the breast tissue between the middle and index fingers, a measurement of 10mm breast tissue is what gestational age | 40-44 weeks. (7.5mm is 38 weeks. |
| T/F, the amount of lango increases with gestational age | False - amount of lano is greatest at 28-30 wks then disappears |
| Cartilagnous development of the ear, premies (34 weeks) incurving in only upper __/__ of ear | upper 2/3, The pina doesn't go back as quick in premies after bent forward |
| A preterm newborn's pea size testes are not within the ____, and the scrotal surface has few ____ | scrotum, few rugae |
| At 40 weeks gestation, the labia majora cover the ____ & ____ | labia minora and clitoris |
| As term approaches, the skin appears opaque because of increased ____ tissue | subcutanous tissue |
| Resting posture flexation at 31 weks flextion of the ____, as gestational age increases, flexion is seen in all ____ | extremities, full term exhibits hypertonic flexion in all extremities |
| The square window sign is the angle of flexation of the wrist, the amount of flexation increases or decreases with gestational age | increases (90 degrees 28-30 wks, 30 degrees 39-40 weeks, and 0 degrees 40-42 weeks) |
| Preterm infants have less recoil because they have less ____ | muscle tone |
| ____ angle - the thigh is flexed on the chest and the heel is pulled forward until resistance is met, the more premature, the less resistance | popliteal angle (degree of knee flexion) |
| ____ sign - place the arm around the neck, the elbow is past the midline in a premie | Scarf sign (at midline 30-4- wks, will not reach midline after 40 wks) |
| Heel to ear extention - with advancing gestational age, the newborn demonstrates increasing ____ | resistance |
| The routine discharge assessment include a complete head to toe phyical assessment and what 4 things | Nutritional status (ablity to breastfeed or bottle feed), behavior state organization abilities, bonding/attachment, and parent learning needs in raltion to newborn care |
| Newborn range of blood pressure | 80-60 / 45-40 (about half of adult normal) |
| What is the normal range of a newborn's heart rate | 120-160 BPM |
| What are the normal respirations of a newborn | 30-60/min (diaphragmatic and abdominal, may have periods of transient tachypnea) |
| Normal temperature of a newborn | 97.7 - 99.4 (last vital to take b/c babies cry. Put temp sensor on top of liver) |
| Crying should be strong, lusty and ____ | consolable. Cocaine babies have high pitch cat cry |
| Average weight of newborn | 2400-4000g or 5 lb 8 oz -13lbs with 8 lb average |
| How much weight does a newborn lose in the first 3-4 days | 5-10% |
| Average length of a newborn | 18-22 inches (48-52 cm) |
| posture of term newborn | body is flexed, hands clenched, neck appears short |
| breech full term babies, the feet are usually ____ | dorsiflexed |
| Chest circumfrence is across the ____ | nipple line |
| head circumference is above the | eyebrow |
| head circumference is ____ larger than chest circumference | 2cm |
| Routine assessment includes lab work: what lab work is done? | Mother's Rh factor, direct coombs test (detects antibodies bound to surface of RBC), ABO, billiruben levels, bood sugar for hypoglycemia (under 40), Mother B Beta Strep (If in vagina baby can get it in their lungs caled sepsis neonator) |
| Assessment color | should be pink. Acrocyanosis is bluish discoloration of hands and feet and mottling is a lacy pattern of dilated blood vessles under the skin, jaundice |
| Not normal in the first 24 hours, after first 24 hourse due to immature liver breakdown of billirubin | jaundice - from head to toe, blach over cartaliage (nose) & turn yellow. |
| Other than immature liver, jaundice is caused from: | breastfeeding, hematomas, bruises, blood incompatibility, oxytocin augmentation, or severe hemolysis |
| ____ toxicum is a perifollicular eruption of lesions that are firm, vary in size 1-3mm, consists of a white or pale yellow paule or pustule with erythematonus base | Erythema toxicum (newborn rash) peak 24-48 hrs |
| ____ is white sebaceous glands on face, especially across the nose | Milia |
| Skin tugor is assessed to determine ____ status, need to initiate early feedings, and presence of infectious processes. Usually assessed where | hydration status. abdomen or thigh - elastic |
| ____ caseosa is a whitish cheeselike substance, covers the fetus while in utero and lubricates the skin | Vernix caseosa - post term has less |
| ___ nevi, also called stork bites appear pale pink or red spots on eyelids, nose, lower occiptal bone and nape of neck | Telangiectatic nevi |
| ____ spots are macular areas of bluish black or blue-grey pigmentation on the dorsal area and bottox | Mongolian spots (they are not bruises) |
| What is the difference between a Nevus flammeus (port wine stain) and Nevus vasculosus (strawberry mark) | port-wine stain is non elevated |
| Head circumference at term is between ____ - ____cm | 32-37 cm or 12.5 - 14.5" |
| ____ is an opening at juncture of cranial bones | Fontanelle |
| How large is the anterior and posterior fontanelle's | anterior fontanelle 3-4cm x 2-3cm diamond shaped. posterior fontanelle 1-2 cm triangular shaped |
| ____ is overriding of cranial bones | Molding (conehead). easily visable in premies and diminishes a few days after birth |
| ____ is a colection of blood resulting from reptured blood vessles between the surface of a cranial bone and periosteal membrane caused from suctioning or forecepts | Cephalohematoma - unilateral |
| ____ succedaneum is caused by a long and hard labor or use of suctioning, consisting of tissue fluids, an edematous swelling | Caput Succedaneum - bilateral |
| Newborn hair is normally ____ and ____ in texture | smooth and fine, if not may have hypothyroidism |
| a face that is not symmetric in movement is called facial ____ | paralysis. Usually disappears in a few days to 3 weeks but may be permanent |
| Eyes should be bright and clear with even placement. Eyes with drainage may indicate the mother having ____ or ____ | Chlamydia or Syphilis |
| The newborn's nose should be ____ | patent - they are nose breathers for the first few months. |
| The mouth should be checked for | sucking reflex, roof of mouth for cleft palet, precocious teeth (if loose should be pulled) and Epstein's pearls on the gums |
| Ears - check for drainage of ___. Lowset (below outter canthus) could indicate ___ | CSF - low set could indicate kidney problems or chromosomal abnormalities |
| Neck - check for webbing, fracture to ____, moro reflex and symmetrical shoulders | clavicals fracture that can occure with a difficult birth |
| T/F the chest is 1:1 ratio anterior:lateral | True - cylindrical |
| Chest expansion and ____ are not normal | retraction |
| breast hypertrophy is caused by | maternal hormone influences and may last up to 2 weeks |
| The heart is positioned where | High in the chest (apex between 4th and 5th intercostal - point of maximal impulse) |
| T/F functional murmers in a newborn are okay | True - 90% are transient and normal , they should be monitored by the physician |
| The abdomen should be distended, soft and ____ | round |
| ausculation of bowle sounds can be heard how long after birth | 30-60 minutes |
| The umbilicus has how many arteries and veins | 2 arteries and 1 vein |
| T/F An umbilicus hernia does not go away, needs to be surgically removed | False - usually goes away, if not then surgery |
| If femoral pulses are not palpaable but brachial pulses are this is caused from | aortic coartion |
| If the penis meatus is not on the tip, but on top, it is refered to as | hyperspadious |
| ____ is a collection of fluid surrounding the testes in the scrotum, can be seen with a pinlight | Hydrocele |
| The ____ is prominate in a female | clitoris |
| First few weeks, vaginal discharge composed of thick whitish cucus is normal, when it beomes tinged with blood it is called ____ and is caused from | pseudomenstration cused from withdrawal of maternal hormones |
| ____ is white, cheeselike substance often present between the labia | smegma, removing it may traumatize tender tissue |
| If the newborn does not pass meconium in the first 24 hours it may be due to | Atresia of the GI tract or meconium ileus (obstruction) |
| extremeties normally appear ____, flexible and move symmetrically | short |
| ___ is the presence of extra digits | polydactyly |
| ____ referes to fusion (webbing) of fingers or toes | syndactyly |
| ____ is a single palmer crease | simian line (frequently present in children with Down syndrome) |
| ____ palsy is paralysis of portions of the arm results from trauma to the brachial plexus during birth | Brachial palsy |
| ____ maneuver is done to rule out the possibility of developmental dysplastic hip. | Ortolani's maneuver - positive when makes a cluck noise and can be felt |
| ____ or clubfoot, intrauterine position caused feet to appear to turn inward | talipes deformity - tx needd if the feet can not be easily returned to midline by manipulation |
| ____ of the hip is asymmetry of gluteal and thigh fat folds | developmental dysplasia of the hip - best seen if newborn is in prone position |
| ____ reflex is stimulated by a flash of light | Blink |
| ____ reflex is stimulated by flash of light and the pupil constricts | Pupillary reflex |
| ____ reflex is a response to sudden movement or loud noise and should be one symmetric extension and abduction of arms with fingers extended | Moro response |
| ____ reflex is when the newborn turns in direction of stimulus to cheek or mouth and opens mouth and begins to suck rhythmically when finger or nipple is inserted into mouth | rooting and sucking reflex |
| ____ reflex is a grasp of adult finger when palm is stimulated | Palmar grasp |
| ____ reflex is when toes curl downard when sole of foot is stimulated | Plantar grasp |
| ____ reflex is when held upright and one foot touching a flat surface, will step alternatately | stepping reflex |
| ____ reflex is fanning and extension of all toes when one side of sole is stroked from heel upward across ball of foot | Babinski reflex |
| ____ reflex is the fencer position | Tonic neck |
| ____ reflex is while on abomen, the newborn pushes up and tries to crawl | prone crawl reflex |
| ____ reflex also called Galant is prone position, stroking of spine causes pelvis to turn to stimulated side | Trunk incurvation |
| ____ scale is to assess state changes, temperament, and individual behavior patterns | Brazelton's scale |
| first temperature is taken ____ then auxiliary | rectal |
| nursing diagnosis if presence of mucus in lung | risk for ineffective airway clearance R/T presence of mucus and retaining lung fluid |
| Nursing diagnosis for heat loss | Risk for altered body temperature related to evaporation, radiant, conductive and convective heat losses |
| place the newborn on their back unless they have ____ | mucus |
| Use mechonium aspirator suction if mechonium is present at birth and newborn is not ____ at time of birth | vigorous |
| _____ given 0.5 - 1 mg IM is given within one hour of birth to prevent hemorrhagic disease of newborn | Vitamin K - prophylactic (Phytonadione) |
| respond immediately to signs of respiratory problems by doing what | nasal & oral suctioning and position with vigorous fingertip stroking of spine |
| If risk factors are present, how soon should blood sugars be done | 1 hr |
| care of circumcision | squeeze soapy water over once a day, rine with warm water and pat dry. apply petroleum jelly with ea diaper change, let plastibell fall off by itself check for foul smelling drainage, light sticky yellow drainage normal |
| check circumcision for bleeding and patency of urination, can be blocked with ____ | edema |
| You are the nurse assinged to attend the birth & care for baby smith. you noticed as soon as he is born his extremities are blue and he is not crying immediately. you tap his foot and he grimaces. What apgar score will you assign him at 1 min of birth? | No crying means no respiration zero cardiac 2 muscle tone not given assume norm 2 grimecing 1 extremities blue 1 total 6 need to hyperventilate with ambu bag |
| Baby boy smith has leathery cracked skin and deep scrotal ruggae with thick ear cartilage, no vernix and has very long fingernails. What gestational age would these characteristics be of? | PAST FULL TERM |
Created by:
cgwayland
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