MCN Final Reviewer 2 Flashcards
(91 cards)
1
Q
Eyes: usually baby cries tearlessly
A
because of immature lacrimal duct * until 3months
2
Q
distance of sight
A
6-8in
3
Q
iris color usually
A
gray and blue
4
Q
permanent color assume at
A
3-12months of age
5
Q
eye ointment against gonorrhea for 24hours of life
A
erythromycin and theramycin
6
Q
white pupil - indicate
A
congenital cataract
7
Q
Ears: When you assess Ears it must be
A
symmetrical
8
Q
Pinna could be fold easily
A
True
9
Q
Pinna should be aligned with the
A
outer cantus of the eye
10
Q
pinna is lower than outer cantus ex. down syndrome (trisomy 21)
A
Chromosomal abnormality
11
Q
3 Possible Indications of eye problem
A
- Chromosomal abnormality
- Kidney diseases
- Cranio-facial lesions
12
Q
how to assess the ears
A
using bell - 6in away from the ear
13
Q
Nose: Neonatal is
A
Obligatory nose breather
14
Q
Blockage at the rear of the nose
A
Choanal Atresia
15
Q
How to assess Choanal Atresia
A
By closing the mouth and press the one nares or nostril
16
Q
Indication of Respiratory distress
A
Nasal Flaring
17
Q
Mouth: one side of the mouth moves more than the other
A
cranial nerve injury
18
Q
Nerves that are affected
A
CN7 and CN5
19
Q
assess palate
A
cleft palate
20
Q
white glistening cyst seen at the newborn gums and palate which is cause by extra load maternal calcium
* disappear in a week time
A
Eptein’s Pearl
21
Q
is a candida infection usually appears on the tung and sides of the chicks or mouth as white gray patches
A
Oral trash or Oral moniliasis
22
Q
causative agent of Oral Trash or Oral Moniliasis
A
candida albicans
23
Q
Unusual to have two teeth erupted after birth
A
Natal Teeth
24
Q
Short and often chubby with creased or wrinkle skin folds
A
Neck
25
what to observe in assessing neck
ROM- range of motion
26
stiff neck
Nuchal Rigidity
27
Indication of Nuchal Rigidity
indication of Meningitis - inflammation of meninges of the brain
28
Chest: What to assess in the chest
Symmetry
29
how many yrs when chest measurement exceed or more than the head circumference
2yrs
30
normal assessment to chest
breast are engorge
| clavicle must be straight
31
secretes a thin watery fluid
| * influence of the mother's hormone
witch milk
32
assess for abnormal sound
wheezing, reputes, granting, strigur
| * respiratory distress
33
observe chest retraction
drawing-in of he chest wall with inspiration
| * during inhalation / inspiration
34
Abdomen: Observe the contour of the abdomen
slightly protuberant
35
Assess shape
Dome-shape
| * normal
36
protrusion of the abdominal organ outside the abdomen *nursing intervention - cover with sterile saline dressing
Gastrochisis
37
protrusion of the abdominal organ though the umbilicus
Omphalocele
38
the presence of palpable olive shape mass in the infant abdomen
Pyloric Stenosis
39
presence of the palpable sausage - shaped mass in the infant abdomen
Intussusception
40
Access the umbilical cord :1st hour
white gelatinous
41
Assessment of umbilical cord after one hour
dry and shrink and turns brown
42
Assessment of umbilical cord after 2nd to 3rd day
black
43
Assess the kidney: which one is higher L or R
Left Kidney
44
left is harder to palpate because
of the intestines are bulkier on the left side
45
kidney can easily palpated because it is lower
Right Kidney
46
Anogenital Area
Anal and Genital
47
Test the potency of the anal area
by lubricated thermometer
48
expect urine and feces(meconium) within
24 hours
49
Types of Stool
1. Meconium
2. Transitional
3. Milk Stool
50
- first stool pass by the newborn
- greenish - black , sticky, and odorless
- expected to pass at least 4x in the first 24hours
Meconium
51
Indications for the failure of the meconium to pass out within the 24hours
1. Inperforate Anus
2. Hirschsprung's disease
3. Cystic Fibrosis
52
- pass by the newborn beginning 2nd day to the 10th day after delivery
- greenish yellow, odorless, slimy
- pass 6x or more in a day
Transitional
53
- breast fed baby stool or bottle fed baby stool
Milk Stool
54
- golden color, mushy, soft, sweet smelly
| - pass by the newborn every after breast feeding
breast fed stool
55
- pale and yellow, hard and formed, and with an offensive odor
- pass once a day
bottle fed stool
56
Observe for the testes both should be present in the
Scrotum
57
an descended testes
Cryptorchidism / undescended testes
58
male: urinary meatus is located at the dorsal or above the penis
Epispadia
59
male: urinary meatus is located at the ventral surface or below the penis
Hypospadia
60
male: Absence of organ
Agenesis
61
Genital size of a male
2cm
62
Usually the vulva (external structure of the female reproductive system) is _________
due to maternal hormones
swollen
63
presence of vaginal secretion with blood tinged and this is due to maternal hormones
Pseudomenstruation - Pseudo (false)
64
white mucus discharges presence at the genital of newly born
Smegma
65
Spine: Usually the spine is flat from
lumbar and sacral area
66
The arms and legs are flex on
the abdomen and chest
67
dimpling at the base of the spine
Spina Bifida
68
Extremities: The arms and the legs are
short, full range of motion
69
Usually the fingernails are
soft and smooth
70
Observe diffects on the legs
bow legged - (Genu - varum)
| knocked - knee ( Genu- valgum)
71
bow legged
Genu - varum
72
knocked - knee
Genu - valgum
73
Observe diffects on the feet
1. Equinus or plantar flexion
2. Varus or inversion
3. Valgus or eversion
4. Calcaneus
5. Syndactyl or Fuse digits or webbing
6. Polydactyl
74
toes lower than the heel
Equinus or plantar flexion
75
toes points inwardly
Varus or inversion
76
the toes points outwardly
Valgus or eversion
77
the toes points upward, toes are higher than the heel
Calcaneus
78
Fuse digits or webbing
Syndactyl
79
Extra finger or toes
Polydactyl
80
is a simple method to quickly assess the health of the newborn child
APGAR Score
81
assessment done twice
1 min and 5 mins after birth
82
develop the APGAR * anesthesiology
Virginia Apgar
83
5 Parameters in APGAR
1. Heart Rate
2. Respiration
3. Muscle Tone
4. Reflex Irritability
5. Color
84
APGAR
```
A- appearance (Color)
P- ulse (HR) * most important to assess
G- rimace ( reflex irritability)
A- ctivity ( Muscle Tone)
R- espiration ( Respiration)
```
85
Score APGAR
```
1. Appearance
0- pale and blue (cyanotic)
1- body pink but extremities are blue (acrocyanosis)
2- completely pink
2. Pulse (auscultation) * most important assessment
0- no pulse
1- below 100bpm
2- above 100bpm
3. Grimace
0- no response
1- weak cry and grimace
2- vigorous or strong cry or cough and sneeze
4. Activity
0- limp or flaccid
1- some flexion of extremities
2- active movement or motion
5. Respiration
0- no RR
1- weak, slow and irregular
2- good, strong or vigorous crying
```
86
0-2 score
- indicates poor and serious and severely dippers newborn
| - it requires intensive resuscitation
87
Nursing Intervention on 0-2 score
1. clear the airway
2. suction secretions
3. administer oxygen
4. initiate full CPR CardioPulmunaryResuscitation
5. maintain body temperature
88
3-6 score
- fair guarded or moderately dippers newborn
- it needs further evaluation and observation
- requires resuscitation
89
Nursing Intervention on 3-6 score
1. suctioning
2. quickly dry
3. maintain warm
4. provide oxygen
90
7-10 score
- indicates that the newborn is in good and healthy condition
- it rarely needs resuscitation
91
APGAR score
the higher the score the better the condition of the newborn
