Exam 1 - Eval of the neonate & infant Flashcards
(144 cards)
1
Q
What time frame is considered a neonate?
A
First 28 days of life
2
Q
What time frame is considered an infant?
A
29 days - 12 months
3
Q
What time frame is considered a preemie?
A
Birth prior to 37 weeks
4
Q
What are the first 3 things included in immediate care of the baby in the delivery room?
A
- drying the baby
- clearing the baby’s airway
- warming the baby
5
Q
What 3 things should be asked regarding the clinical status of the baby in the delivery room and what should be done if the baby does or does not meet these statuses?
A
- > 35 weeks gestation?
- good muscle tone?
- crying/ breathing?
YES > baby given to mother (skin to skin contact, bonding, early breast feeding)
NO > further eval and intervention
6
Q
What is used to classify the newborn’s neurological recovery after birth and immediate adaptation to extrauterine life?
A
APGAR score (ranges 1-10)
7
Q
What does APGAR stand for and when is it assessed?
A
A- activity (muscle tone) P- pulse G- grimace A- appearance R- respiration 1 minute and 5 minutes (and continues every 5 minutes if needed until score is 7+)
8
Q
What status would result in 0, 1, and 2 points for activity in APGAR?
A
0- absent
1- arms and legs flexed
2- active movement
9
Q
What status would result in 0, 1, and 2 points for pulse in APGAR?
A
0- absent
1- below 100 bpm
2- over 100 bpm
10
Q
What status would result in 0, 1, and 2 points for grimace in APGAR?
A
0- flaccid
1- some flexion of extremities
2- active motion (sneeze, cough, pull away)
11
Q
What status would result in 0, 1, and 2 points for appearance in APGAR?
A
0- blue, pale
1- body pink, extremities blue
2- completely pink
12
Q
What status would result in 0, 1, and 2 points for respiration in APGAR?
A
0- absent
1- slow, irregular
2- vigorous cry
13
Q
What status does a score of 0-3 indicate on the APGAR?
4-6?
7-10?
A
0-3 is severely depressed
4-6 is moderately depressed
7-10 is excellent condition
14
Q
What is the next step if a baby scores < 4 on APGAR at ONE minute?
A
requires immediate resuscitation
15
Q
What is a normal APGAR score at one minute?
A
7-10
16
Q
What is the next step if a baby scores 7+ on APGAR at FIVE minutes?
A
proceed to a more thorough exam (if less, intervention as indicated)
17
Q
What is considered the transitional period and what things are monitored during this time?
A
- First 4-6 hours of extrauterine life
- HR, respirations, temperature, color, tone
18
Q
What might central cyanosis indicate during the transitional period?
A
Respiratory or cardiac disease
19
Q
What might hypotonia be secondary to if observed during the transitional period?
A
Medications given to mother during labor, underlying syndrome, sepsis, neurological impairment
20
Q
What are the most common ways used to determine gestational age?
A
Date of LMP, ultrasound, Ballard scoring system
21
Q
What is the Ballard scoring system useful for and what does it assess?
A
Estimates gestational age to within 2 weeks even in extremely premature newborns; assesses neuromuscular and physical maturity
22
Q
What gestational age is considered full term/ term?
A
37-42 weeks (above or below indicates preterm or postterm)
23
Q
What birth weight is considered normal?
A
2500g +
24
Q
What percentile indicates small for gestational age (SGA)?
A
< 10th
25
What percentile indicates appropriate for gestational age (AGA)?
10-90th (mortality lowest)
26
What percentile indicates large for gestational age (LGA)?
> 90th
27
What are important maternal history components?
Socioeconomic status, family history, maternal history, labor and delivery course
28
What factors are considered with respect to maternal labor and delivery course?
- Duration of rupture of membranes
- Duration of labor
- Mode of delivery
- Mom and newborn's condition @ delivery
- Risk for sepsis
29
What is indicated by a score of 5-6 on APGAR at ONE minute?
some nervous system depression
30
What is indicated by a score of 6 or less on APGAR at FIVE minutes?
high risk for CNS/ organ system dysfunction > intervention as indicated
31
What should be done as part of care of a neonate?
1. Prophylactic erythromycin ophthalmic ointment- prevents gonococcal ophthalmia
2. Vitamin K- prevent vit. K deficient bleeding
3. HepB vaccine
4. Umbilical cord care
5. Monitoring (bilirubin and glucose levels)
6. Newborn screen- heel stick, pulse ox, hearing screen
7. Positioned supine- "back to bed"
32
Why is it important to position a baby supine?
Decreases risk of SIDS
33
What does the heel stick test for and why is it so important that it is done as a newborn?
Metabolic and genetic disorders; early intervention may improve outcomes of life threatening/ long term health issues
34
What is the protocol for the heel stick?
Done twice- 1st @ 24-48 hours old, 2nd at first doctor's visit or between 5-10 days of age (whichever comes first)
35
Why is it important to screen for congenital hypothyroidism?
It is one of the most common preventable causes of mental retardation
36
What is adrenal hyperplasia?
- Endocrine disorder
- In females, can present as ambiguous genitalia with clitoral enlargement and a urethral-vaginal orifice ( normal internal organs)
- In males, there are no overt signs. May have phallic enlargement or scrotal hyperpigmentation
37
What is the result of sickle cell disease?
Hemoglobins formed in sickle shape; leads to pain and issues
38
Why is it important to screen for cystic fibrosis?
Most common life shortening autosomal recessive disease among Caucasians
39
What condition is related to having cystic fibrosis and what percent of newborns will present with CF if they have this condition?
meconium ileus; 80-90%
40
If a newborn screens positive for CF, what important diagnostic test should then be performed?
sweat chloride testing
41
How many core conditions are newborns screened for and what are the top 4 diagnoses?
29; hearing loss, primary congenital hypothyroidism, CF, sickle cell disease
42
Why is a hearing screen performed before discharge?
Early intervention with hearing loss improves speech and language development
43
What two electrophysiologic techniques are used for the hearing screen?
```
Auditory brainstem responses (ABR)
Otoacoustic emissions (OAE)- determines cochlear status/ hair cell function
```
44
What is pulse oximetry used to screen for?
Critical congenital heart disease
45
What is the recommended primary source of nutrition for infants up to 6 months of age?
breastfeeding
46
Why is breastfeeding recommended over formulas?
- Protection against infections (IgA) and allergic conditions
- Improved neurodevelopmental outcomes
- Improved mother-infant bonding
- Maternal benefits
47
What recommendations should a mom who is breastfeeding follow?
- Relax
- Rest while baby sleeps
- Consume extra 350-500 kcal/ day
- Drink plenty of fluids
- Avoid alcohol/ tobacco/ caffeine
* breastfeeding can be stressful & painful early on)
48
What are maternal contraindications to breastfeeding?
- Abuse of street drugs/ alcohol
- HIV infection
- T-cell lymphotropic virus infection
- Untreated miliary TB (can pump and dump)
- Chemotherapy and radiation therapy
- Active herpetic breast lesions
49
What are infant contraindications to breastfeeding?
galactosemia
50
What feeding guidelines should be followed in the first 24 hours after birth?
Breast feeding- feed early and frequently- 8-12x/ 24 hours for 10-15 min/breast and begin vitamin D supplement
Formula feeding-iron containing formula
Do not exceed 4hrs between feeding to avoid hypoglycemia
51
What is considered normal with respect to the weight of a full term infant?
Full term infants may lose 10% of their body weight in the first few days of life; should regain BW by 10-14 days
52
What are considered normal bladder habits of a newborn?
At least 1 wet diaper in the first 24 hours, by day 5 = 6-8 wet diapers/ day of light yellow urine
53
What are considered normal bowel movements of a newborn?
- First 24-48 hours- thick, very dark stools (meconium)
- Transition from black-green to yellow stools
- By day 5: 3-4 yellow, seedy stools/ day
54
What does the Newborns' and Mothers' Health Protection Act (NMHPA) state?
Insurance is required to cover up to 48 hours for vaginal deliveries, 96 hours for c-section deliveries
55
How soon is a f/u well-visit recommended if discharged < 48 hours after birth?
within 48 hours of discharge
56
How soon is a f/u well-visit recommended if discharged > 48 hours after birth?
within 3-5 days
57
What general things are checked at the well-visit exam?
- Size
- Type of respirations (labored, noisy)
- Level of consciousness
- Activity- head and limb movement
58
What vitals are taken at the well-visit exam?
- Temperature- >100.4
- Pulse- 120-160 bpm
- Resp rate- 30-60 breaths/ min
- BP- taken for high risk infants
59
What measurements are taken at the well-visit exam?
Head circumference, length, weight
60
What things are evaluated at the well-visit exam with respect to skin?
- Vernix caseosa
- Texture
- Color
- Skin eruptions/ rashes
- Birth marks/ vascular markings
61
What things are evaluated at the well-visit exam with respect to hair?
Lanugo and midline hair tufts
62
What skin color changes should the newborn be evaluated for?
Jaundice, cyanosis, meconium staining
63
What is lanugo?
fine hair covering
64
What are milia?
smooth, white, raised areas with no surrounding erythema; pinpoint papule
65
Where are milia found on newborns?
nose and cheeks
66
When do milia appear/ disappear?
Appear within the first few weeks and disappears over several weeks
67
What is neonatal acne?
Multiple papules and pustules found primarily on the forehead, cheeks, and upper chest
68
When does neonatal acne typically start/ resolve?
starts 2-3 weeks, resolves 4-6 months
69
What is miliaria rubra?
Scattered vesicles/ non follicular papules on an erythematous base; affects face neck, and trunk
70
What is miliaria rubra often referred to as and when will it disappear?
"Heat rash"; disappears spontaneously within weeks
71
How does erythema toxicum present clinically?
- Erythematous macules with central pinpoint vesicles scattered diffusely
- Progress to pustules
- Unknown etiology
72
When does erythema toxicum typically appear/ disappear?
Usually appears on days 2-3 of life and disappears within 1 week of birth
73
In what population is pustular melanosis more common in?
black infants
74
What are the 3 stages of pustular melanosis?
1. superficial white pustules
2. "unroof"- erythematous macules with surrounding scale
3. hyper pigmented macules that gradually fade
75
How long does pustular melanosis last?
Can last several months
76
What is acrocyanosis and where does it typically present?
Non pathogenic bluish peripheral discoloration around the mouth, hands, and feet. **Mucous membranes are still pink!
77
How long does it take for acrocyanosis take to resolve?
24-48 hours
78
What is it important to differentiate acrocyanosis from?
Central cyanosis - pathogenic bluish discoloration that affects the mucosa (lips, gums, tongue) and trunk
79
What are types of benign birthmarks?
Eyelid patch, "stork bite", Mongolian spots
80
What is a type of birthmark that has significant malignant potential?
congenital hairy nevus
81
What is neonatal "physiologic" jaundice?
Visible jaundice AFTER 24 hours of age; 65% of all newborns, resolves by 2 weeks
82
What is "non-physiologic" jaundice and what does it suggest?
Jaundice WITHIN 24 hours of birth; suggests hemolytic disease of the newborn
83
What is the concern with neonatal jaundice?
severe neonatal hyperbilirubinemia (neurotoxic and can cause death); TB > 25 mg/dl
84
What is the treatment for neonatal jaundice?
phototherapy
85
What are the 3 most important jaundice clinical pearls?
1. jaundice is pathologic within the first 24 hours or after 2 weeks
2. ABO or Rh incompatibility?
3. infants discharged before 48 hours need to be followed up within 2 days
86
What is a suture and what does it feel like upon palpation?
separate the bones from one another; feel like ridges
87
What is a fontanelle and what does it feel like upon palpation?
where the major sutures intersect; feel like "soft spots" = soft concavity of the skull
88
What are the primary differences in sizes and closure time between the anterior and posterior fontanelle?
anterior- birth measures 4-6 cm, closes between 4-26 months
posterior- birth measures 1-2 cm, closes at 2 months
*anterior open much longer than posterior*
89
What are worrisome findings of fontanelles?
- Bulging, tense anterior fontanelle- increased intracranial pressure (hydrocephalus)
- Depressed anterior fontanelle- dehydration
- Early or delayed closure
90
What are the basic characteristics of hydrocephalus?
- Enlargement of the head
- Distended scalp veins
- Thin, shiny, and fragile- looking scalp skin
- Underdeveloped neck muscles
91
What is a cephalohematoma and what is important to know about it?
subperiosteal hemorrhage (trauma from birth); it does not cross the suture line
92
What is craniosynostosis?
premature closure of cranial sutures
93
What things should be evaluated for with respect to skull symmetry and head circumference?
Cephalohematoma, craniosynostosis, positional plagiocephaly, microcephaly, macrocephaly
94
What are microcephaly?
| What is Macrocephaly?
Micro Head circumference <2 SD's below the mean for age and sex
Macro: Head circumference >2 SD's below the mean for age and sex
95
What is positional plagiocephaly?
flattening of the parieto-occipital region
96
What should be evaluated for with respect to the face?
Symmetry, abnormal facies, facial palsy
97
Regarding the eyes, what are visual milestone for a baby at birth and 1 month?
At birth- blinks, regards a face
| At 1 month- fixes on an object
98
What is common visual abnormality immediately following birth that may indicate a problem if it persists?
Nystagmus; persistence may indicate poor vision or CNS disease
99
What is a normal finding of the eyes within the first few months of life?
Intermittent strabismus
100
What should be performed as part of the ophthalmoscopic exam?
bilateral red light reflex
101
What should you check for on an ear exam of a baby?
- Shape, positioning, features- abnormalities may indicate congenital defects
- Acoustic blink reflex- snap 12 inches away from ear
- Visualize tympanic membrane (may not be possible in first few days of life)
102
What should you check for on a nose exam of a baby?
- Shape and size
- Obligate nasal breathers
- Nasal patency (abnormal = choanal atresia = excessive growth of tissue)
103
What should you check for on a mouth and pharynx exam of a baby?
- Inspect and palpate: clefts, natal teeth
- Epithelial (Epstein) pearls: small, white benign inclusion cysts
- Tongue: size, frenulum, oral candidiasis
104
Where is it common to see Epstein's pearls?
clustered at the midpoint of the junction between the soft and hard palate
105
What should you check for on a neck exam of a baby?
Palpate lymph nodes, assess for masses, evaluate for torticollis, clavicular fracture
106
What could torticollis be a result of/ a precipitating factor for?
Position/ injury to the SCM; plagiocephaly
107
What are considered abnormal findings with respect to respirations/ breathing patterns?
Nasal flaring, grunting, retractions, audible wheezing or stridor
108
What abnormal/ adventitious lung sounds may be heard with auscultation?
Wheezes, crackles, rhonchi, lack of breath sounds (obstruction)
109
What should be evaluated with respect to the heart?
Check for cyanosis, palpate peripheral pulses, evaluate heart rhythm, evaluate for murmurs
110
What are normal findings with respect to heart rhythm/ sounds?
sinus dysrhythmia, functional (benign) heart murmurs
111
What is a normal/ abnormal finding of the umbilical cord?
Normal: cord dries up and falls off within 2 weeks
Abnormal: omphalitis- infection of the umbilical stump
112
What are normal/ abnormal findings in the female genitalia exam?
Normal: white/ blood-tinged discharge
Abnormal: imperforate hymen
113
What abnormalities may be seen with respect to the testes?
- Undescended testicle(s) = cryptorchidism (most commonly both descent by 1 year)
- Swelling- hydroceles, inguinal hernias
114
What is hypospadias?
the opening of the urethra is on the underside of the penis instead of at the tip
115
What should be assessed as part of the rectal exam for both males and females?
- Location and patency
- Abnormal = imperforate anus
- Cannot assume patent until newborn has passed meconium (48 hours)
116
What should be assessed for with respect to upper extremities/ hands?
- Syndactyly= webbed fingers
| - Polydactyly= extra fingers
117
What should be assessed for with respect to the spine?
- Spina bifida occulta
| - Hair patches, deep pits, dimple, pigmented spots
118
What should be assessed for with respect to the hips?
- Developmental dysplasia of the hip
- Galeazzi test
- Ortolani and Barlow test
119
What should be assessed for with respect to the legs and feet?
- Symmetry, bowing, torsion
| - Club-foot
120
How will spina bifida occulta present?
- Abnormalities within 1cm of midline
| - May overlie external openings of sinus tracts that extend to the spinal canal
121
How do you perform the Galeazzi test and what does it test for?
Test for femoral shortening
1. place feet together and note difference in knee heights
2. unequal knee heights= positive galeazzi sign
122
How do you perform the Barlow test and what does it test for?
Test ability to sublux or dislocate an intact but unstable hip
1. stabilize with 1 hand
2. with other hand, place thumb medially over less trochanter and index finger laterally over greater trochanter
3. flex and adduct opposite hip while applying posterior force
4. palpable clunk or sensation of movement is felt as the femoral head exits the acetabulum posteriorly = positive Barlow sign
123
How do you perform the Ortolani test and what does it test for?
Test for the presence of a posteriorly dislocated hip
1. flex legs to right angles at the hips and knees
2. place index finger over greater trochanter of each hip, thumbs over lesser trochanters
3. abduct hip (1 hip at a time)
4. positive= feel "clunk" as the femoral head enters acetabulum
124
What is a positive Babinski response?
dorsiflexion of big toe and fanning of other toes
125
How is sensory function assessed?
- Gently flick palm or sole with finger
| - Observe for withdrawal, arousal, change in facial expression
126
What reflex is indicative of a functional CN V?
rooting/ sucking reflex
127
What reflex is indicative of a functional CN VIII?
acoustic blink reflex
128
How do you check for the rooting reflex and when does it resolve?
1. Stroke the perioral skin at the corners of the mouth
2. Mouth will open and baby will turn the head toward the stimulated side and suck
Resolve @ 3-4 months
129
How do you check for the Moro/Startle reflex and when does it resolve?
1. Hold baby supine, supporting head, back legs
2. Abruptly lower entire body about 2 feet
3. Arms abduct and extend, hands open, legs flex
Resolve @ 5-6 months
130
How do you check for the palmar grasp reflex and when does it resolve?
1. Place fingers into baby's hands and press against the palmar surfaces
2. Baby will flex all fingers to grasp your fingers
Resolve @ 4-6 months
131
How do you check for the plantar grasp reflex and when does it resolve?
1. Touch sole at base of toes
2. Toes curl
3. UTD up to 10 months
Resolve @ 6-8 months
132
How do you check for the asymmetric tonic neck reflex and when does it resolve?
1. With baby supine, turn head to 1 side, holding jaw over shoulder
2. Arms/ legs on side to which the head is turned extend while the opposite arms and legs flex
3. Repeat on other side
Resolve @ 2-3 months
133
How do you check for the positive support reflex?
1. Hold the baby around the trunk and lower until the feet touch a flat surface
2. Hips, knees, ankles extend, baby stands up, partially bearing weight, sags after 20-30 seconds
Resolve @ 6 months (starts at birth or 2 months)
134
What does salt losing crisis from adrenal hyperplasia result in?
Hyponatremia, hyperkalemia, and failure to thrive
135
What does non salt losing adrenal hyperplasia result in?
Toddlers with signs of puberty
136
What is congenital hypothyroidism caused by 85% of the time?
Thyroid dysgenesis- minimal to no growth of thyroid, or it grows in the wrong spot
137
Severe neonatal byperbilirubinema increases the risk of what? Acute? Chronic?
Bilirubin induced neurological dysfunction (BIND)
Acute- bilirubin encephalopathy, reversible
Chronic- kernicterus, permanent and irreversible neurological dysfunction
138
What should be evaluated as part of the abdominal exam?
- Protuberant (normal)
- Check for tenderness, distention, masses, bowl sounds
- Inspect umbilical cord for redness/ swelling (2 arteries, 1 vein)
- Umbilical hernias (most disappear by 1 year)
- Palpate all abdominal organs (kidneys, liver, spleen)
139
What should be assessed with respect to female genitalia?
Location and size of labia minora/ majora, clitoris, urethral meatus, vaginal introitus (opening)
140
What should be assessed with respect to male genitalia?
- Penis, testis, scrotum
- Foreskin- non retractable at birth
- Palpate testes
141
What is assessed with respect to the neurologic examination?
- Mental status
- Character of cry
- Motor function/ tone
- DTR (deep tendon reflex)
- Primitive reflexes
- CN's and sensory function
142
What do primitive reflexes assess and what do abnormalities of any of them suggest?
the newborn and infant's developing CNS; abnormalities suggest neurologic disease and require further evaluation
143
What are some important considerations for maternal history?
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Medications used
Diet
Alcohol and tobacco use
Occupation
Previous OB history
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144
What is indicated by a positive pulse ox screen?
Low O2- there is a reason for this and supplemental O2 is needed
