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NCLEX-RN (7) Maternity > Newborn > Flashcards

Flashcards in Newborn Deck (68)
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1

What is an APGAR assessment?

An APGAR assessment is done on the newborn at 1 minute and 5 minutes after birth to assess for immediate complications.

It is done more often if there are complications.

2

What is the highest and best score a newborn can get for an APGAR score?

Highest APGAR score = 10

Many newborns get a 9 due to cyanotic feet or hands.

 

3

What are the 5 categories of an APGAR assessment?

  1. Activity/muscle tone
  2. Pulse
  3. Grimace/response to stimulation
  4. Appearance/skin color
  5. Respiration effort

4

What is the possible score for each APGAR category?

The newborn can be assigned a 0, 1 or 2 for each category of APGAR.

  • 0 is the worst score
  • 2 is the best score

5

What is the scoring for APGAR Activity/muscle tone?

  • 0 = flaccid/limp
  • 1 = minimal flexion
  • 2 = good flexion/active

6

What is the scoring for APGAR Pulse?

  • 0 = absent
  • 1 = < 100 beats/minute
  • 2 = >100 beats/minute

7

What is the scoring for APGAR Grimace/response to stimulation?

  • 0 = absent
  • 1 = grimace to suction or slap on soles of feet
  • 2 = responds promptly with cry or active movement

8

What is the scoring for APGAR Appearance/skin color?

  • 0 = pallor or cyanosis (blue color)
  • 1 = cyanotic extremities
  • 2 = all normal color / pink

9

What is the scoring for APGAR Respiration effort?

  • 0 = absent
  • 1 = slow and weak
  • 2 = vigorous cry and respirations between 30 - 60

10

What are the 2 interventions immediately following the birth of a newborn?

  1. suction mouth and nares with a bulb syringe
  2. dry the newborn and stimulate crying by rubbing the back

11

How is cold stress avoided in a newborn?

  • dry infant immediately
  • place skin-to-skin contact on mom
  • put hat on baby

If client is not available, wrap baby in blankets and place in warmer. 

12

What is a normal heart rate for a newborn?

Heart rate for newborn: 120 - 160

  • if sleeping: down to 80 beats/minute
  • if crying: up to 180 beats/minute

13

What are normal respirations for a newborn?

Respirations for newborn: 30 - 60 breaths/minute

Irregular breathing is common.

14

What is a normal temperature for a newborn?

Normal temperature for a newborn: 96.8oF - 99oF (37oC - 37.2oC)

15

Where is the anterior fontanel of a newborn located?

Anterior fontanel is located on the top of the head.

 

16

Where is the posterior fontanel of a newborn located?

Posterior fontanel is located on the back of the head.

17

When does the anterior fontanel close on a newborn?

The anterior fontanel closes between 12 and 18 months of age.

18

When does the posterior fontanel close on a newborn?

The posterior fontanel closes between birth and 3 months.

19

What is caput succedaneum?

Caput succedaneum is edema of soft tissue over bone on the newborn's head.

It crosses the suture line and subsides within a few days.

20

What is cephalhematoma?

Cephalhematoma is swelling on the head caused by bleeding.

It does not cross the suture line. It is usually absorbed by 6 months and doesn't need treatment.

21

What is thrush?

Thrush is a fungal infection in the newborn's mouth. It looks like white, patchy areas in the mouth.

It may clear up in a few days. If it doesn't, oral antifungal medicine will be given. 

 

22

What is vernix caseosa?

Vernix caseosa is a normal finding of a cheesy-white looking substance covering a newborn's skin.

It's a protective cover over the skin from amniotic fluid.

23

What does a stork bite birthmark look like?

Stork bite birthmark looks like a red patch.

24

What does a port-wine stain birthmark look like?

A port wine stain birthmark looks like a dark red patch.

25

What does a strawberry birthmark (or hemangioma) look like?

Strawberry birthmark (hemangioma) looks like a dark red patch.

 

26

What does a mongolian spot birthmark look like?

Mongolian spot birthmark looks like purple-blue patches usually on the sacrum.

27

What is lanugo?

Lanugo is fine body hair on a newborn.

It is found on term infants (39 weeks and later) and helps to hold vernis caseosa on the skin which protects it from amniotic fluid.

28

How many vessels should the umbilical cord have and what are they?

A normal umbilical cord should have 3 vessels:

  • 2 arteries
  • 1 vein

29

What should be assessed after circumcision?

bleeding and urinary retention

30

What is the first stool of a newborn?

The first stool of a newborn is meconium: it is black and tarry.

 

31

When should the first stool pass (meconium)?

The first stool should pass within 24 hours of being born.

32

What do the baby's first stools look like after the meconium has passed?

The baby's first stools are yellow and look like there are small seeds in it. 

33

What is physiological jaundice?

Physiological jaundice is an increase in bilirubin that causes yellowing of the skin. It is caused by an immature liver.

It occurs after 24 hours and is a mild and common condition.

34
Immediate complication

What is pathological jaundice?

Pathological jaundice is an increase in bilirubin and yellowing of the skin. It is caused by a hemolytic disease such as Rh incompatibility or liver disease.

It occurs before 24 hours and is a serious life-threatening condition.

35

What is the pathophysiology of jaundice in a newborn?

Jaundice is from an increase of bilirubin in the blood. Bilirubin is a waste product of red blood cells and is a yellow color. The liver is unable to get rid of the bilirubin. 

 

36
Lab value:

bilirubin in a newborn born at term (not premature)

< 12 mg/dL (180 mcmol/)

37

What complication can occur if jaundice is not treated?

Brain damage can occur if jaundice in the newborn is not treated.

High levels of bilirubin can enter the newborn's brain and cause toxicity.

38

What are the interventions for jaundice in a newborn?

 

  1. frequent feedings
    • to flush bilirubin out
  2. phototherapy
    • light makes it easier for liver to break down and remove bilirubin
  3. vitamin K injection
    • to prevent bleeding disorders from an immature liver

39

In how many days after birth should the birth weight be regained by the newborn?

10 - 14 days after birth.

40

Do newborns shiver when they are cold?

No 

Newborns do NOT shiver when they are cold. 

41

How do newborns keep warm?

Newborns have brown fat deposits that keep them warm. They also should be wrapped in a blanket with a hat on. 

42

What is the sucking (rooting) reflex?

An automatic response by the newborn when they turn their face toward the stimulus and make a sucking or rooting motion with the mouth when the cheek or lip is touched.

The rooting reflex helps to ensure successful breastfeeding.

43

What is the swallowing reflex?

An automatic response by the newborn to swallow without gagging or coughing.

44

What is the tonic neck (fencing) reflex?

An automatic response by the newborn when the arm is extended and the face points in that direction.

Reflex goes away at about 4 months old.

45

What is the palmar grasp reflex?

An automatic response by the newborn when an object is placed in the infant's hand and they involuntary grasp it tightly.

Reflex goes away between 3 - 6 months old.

46

What is the moro (startle) reflex?

An automatic response by the newborn when the arms go out to the sides if they feel like they are falling.

 

47

What is the babinski reflex?

An automatic response by the newborn when the sole of the foot is firmly stroked. The big toe then moves upward or toward the top surface of the foot. The other toes fan out. 

48

What is the parent teaching on how to bathe a newborn?

  1. keep room warm
    • cold rooms cause too much oxygen demand
  2. use a mild soap
  3. clean from the cleanest spot to the dirtiest spot last
  4. clean eyes from inner to outer area
  5. dress in layers and put a hat on baby

49

How should an uncircumcised baby be cleaned?

  • there is no special cleaning
  • never pull on foreskin or underneath foreskin
  • clean with mild soap and water

50

What are the safety measures for a newborn in a hospital to prevent infant abduction?

  • ID bracelet is applied to both mom and baby
  • every person caring for baby must have ID on
  • baby is wheeled in a bassinet when leaving the room, never carried by staff

51

What is the gestational age for a preterm newborn?

< 37 weeks

52

What is the gestational age for a post-term baby?

> 42 weeks

53

What is the most common complication of a post-term newborn?

The most common complication of a post-term newborn is hypoglycemia.

Infant does not have enough stored glucose at birth.

54
Immediate complication

What can cause respiratory distress syndrome in an infant?

Respiratory distress syndrome is caused by the newborn unable to produce enough surfactant. It can occur in preterm infants.

Surfactant helps open up the lungs to breathe better.

55
Medications:

respiratory distress syndrome in an infant

give surfactant through the ET tube

56
Describe:

Meconium aspiration syndrome

Immediate complication

Meconium aspiration syndrome is when meconium gets into the lungs and causes respiratory distress and/or pneumonia.

57
Interventions:

Meconium aspiration syndrome

  • oxygen
  • antibiotics
  • ventilator if severe

58
Describe:

Dysplasia

Dysplasia is chronic inflammation of the lungs when the newborn has been oxygen dependent for more than a month.

59
Medications:

Dysplasia

  • surfactant
  • bronchodilators
  • steroids

60
Describe:

Erythroblastosis fetalis

Erythroblastosis fetalis is when the red blood cells get destroyed due to an Rh incompatibility.

61
Treatment:

Erythroblastosis fetalis

give Rh-negative blood infusions to the infant

62
Describe:

Addicted newborn and fetal alcohol spectrum disorders

Addicted newborn and fetal alcohol spectrum disorders is when the infant is born addicted to alcohol or other substances.

The infant is highly irritated and has an increase in metabolism.

63
Interventions:

Addicted newborn and fetal alcohol spectrum disorders

  • wrap baby snuggly
  • seizure precautions
  • reduce stimulation
  • let mom express guilt and encourage treatment for mom

64

What are the priority assessments of a newborn from a diabetic mother?

  • assess for respiratory distress
  • assess blood sugar

Increased insulin from mother can cause delayed production of surfactant, which is needed for lung development

65
Lab value:

blood glucose in a one day old infant

40 - 60 mg/dL (2.3 mmol/L)

66
Interventions:

Hypoglycemic newborn

  • feed baby
  • give glucose if needed

67
Immediate complication

What are the steps for CPR on an infant?

  1. check for pulse with brachial artery
  2. use 2 fingers or 2 thumbs for chest compressions
  3. go down 1 1/2 inches (2 cm) for compressions
  • 1 rescuer: 30 compressions then 2 breaths
  • 2 rescuers: 15 compressions and then 2 breaths

Click HERE for an instructional video on infant CPR and Choking

68
Immediate complication

What are the steps for a choking infant?

Steps for a choking infant:

  1. hold infant face down with head lower than feet
  2. support head and jaw
  3. give 5 back slaps
  4. then put baby face up and give 5 chest thrusts
  5. repeat until obstruction clears

Click HERE for an instructional video on infant CPR and Choking