NURSING ASSESSMENT FOR NEWBORN Flashcards by Patricia dignam

ASSESSMENT OF PHYSICAL MATURITY CHARACTERICS

*THE COMMON PHYSICAL CHARACTERISTICS
  INCLUDED IN THE GESTATIONAL AGE
  ASSESSMENT ARE:
   -RESTING POSTURE
   -SKIN
   -LANUGO-FINE HAIR (MOST ON BACK)
   -SOLE (PLANTAR) CREASES (MOST 
    ACCURATE IN FIRST 12 HRS)
   -BREAST TISSUE
   -EAR FORM AND CARTILAGE DISTRIBUTION
   -MALE GENITALIA

How well did you know this?

Not at all

Perfectly

NEUROMUSCULAR COMPONENTS

*EXAMINE POSTURE, MUSCLE TONE, SQUARE
 WINDOW SIGN (HAND FLEXION), POPLITEAL
 ANGLE, ARM RECOIL (FLEXION DEVELOP-
 MENT), HEEL TO TOE EXTENSION, SCARF SIGN
*NURSE DETERMINES GESTATIONAL AGE OF
 NEWBORN AND IDENTIFIES NEWBORN AS
 SMALL FOR GESTATIONAL AGE (SGA), 
 APPROPRIATE FOR GESTATIONAL AGE (AGA)
 OR LARGE FOR GESTATIONAL AGE (LGA) AND
 PRIORITIZE NEEDS

How well did you know this?

Not at all

Perfectly

ASSESSMENT

*DO WITHIN FIRST 2 HRS
*MONITOR BP IN CASES OF DISTRESS, PRE-
MATURE BIRTH, AND ANOMOLY
*ASSESS FOR CAPILLARY REFILL (<2SEC)
*EVALUATE FOR COLD STRESS
NOTIFY DR OF ELEVATION OR DROP IN TEMP
*EVALUATE FOR RESP DISTRESS

How well did you know this?

Not at all

Perfectly

WEIGHT

*AVG BIRTH WT. 7LB 8OZ
*5% WT LOSS NORMAL FIRST 3-4 DAYS
*PLOT WT AND GESTATIONAL AGE ON
GROWTH CHART
*ASCERTAIN BODY BUILD OF PARENTS
*FEED INFANT EARLY POST BIRTH
*CALCULATE FLUID INTAKE AND LOSSES

How well did you know this?

Not at all

Perfectly

TEMP

*INITIAL TEMP IS CRITICAL, HEAT CONSERVA-
TION MEASURES ARE A MUST
*MONITOR EVERY 30 MN UNTIL STABLE FOR 2
HRS. THEN EVERY 8 HRS

How well did you know this?

Not at all

Perfectly

POSTURE, SKIN, HAIR

*RECORD SPONTANEITY OF MOTOR ACTIVITY
 AND SYMMETRY OF MOVEMENTS
*EVALUATE SKIN TEXTURE, TURGOR,
 PIGMENTATION VARIATIONS, AND BIRTH-
 MARKS
*ASSESS LOCATION AND TYPE OF RASH:
    EXAMINE FOR PETECHIAE
*EXAMINE THE TEXTURE AND DISTRIBUTION 
 OF HAIR
*RECORD SIZE AND SHAPE OF BIRTHMARKS

How well did you know this?

Not at all

Perfectly

SKIN

*ACROCYANOSIS (BLUISH DISCOLORATION OF
 THE HANDS AND FEET)
*MOTTLING (LACY PATTERN OF DILATED 
 BLOOD VESSELS UNDER THE SKIN)
*JAUNDICE
*ERYTHEMA TOXICUM (RED RASH)
*MILIA (POSTULA RASH)
*SKIN TURGOR
*VERNIX CASEOSA
*FORCEPS MARKS (EDEMA, HEMATOMA)
*BIRTHMARKS

How well did you know this?

Not at all

Perfectly

HEAD

*HEAD CIRCUMFERENCE SHOULD BE 2 CM 
 GREATER THAN CHEST CIRCUMFERENCE
*ASSESS FONTANELLES AND SUTURES
   OBSERVE FOR SIGNS OF HYDROCEPHALUS
   AND EVALUATE NEUROLOGIC STATUS
*MOLDING
*NEWBORN INFANT SHOULD HAVE A HEAD 
 THAT APPEARS LARGE FOR ITS BODY

How well did you know this?

Not at all

Perfectly

POSITION AND BEHAVIOR

*NEWBORNS TEND TO STAY IN FLEXED 
 POSITION AND WILL RESIST STRAIGHENING
*HANDS REMAIN CLENCHED
*INFANT WILL SLEEP MAJORITY OF TIME AND
 WAKE FOR FEEDING
   *EASILY CONSOLED WHEN UPSET
*HIGH PITCHED CRY: NEUROLOGICAL?

How well did you know this?

Not at all

Perfectly

CEPHALOHEMATOMA

COLLECTION OF BLOOD BETWEEN THE SURFACE OF CRANIAL BONE AND ITS PERIOSTEAL MEMBRANE.  
*SHOULD DISAPPEAR WITHIN 2-3 WKS.
*CAN CAUSE JAUNDICE
*CAUSED BY PROLONGED SECOND STAGE OF 
 LABOR OR INSTRUMENTAL DELIVERY

How well did you know this?

Not at all

Perfectly

CAPUT SUCCEDANEUM

IS A COLLECTION OF FLUID (SERUM) UNDER THE SCALP.  
*SOFT HEAD MAY ELONGATE
*SHOULD REABSORB WITHIN 12 HRS
*MORE LIKELY TO FORM DURING A LONG AND
 HARD DELIVERY

How well did you know this?

Not at all

Perfectly

FACE, MOUTH, EYES AND EARS

*ASSESS AND RECORD SYMMETRY
*ASSESS FOR SIGNS OF DOWN
*LOW-SET EARS
*ASSESS FOR HISTORY FOR RISK FACTORS
FOR HEARING LOSS
*TEST FOR MORO REFLEX

How well did you know this?

Not at all

Perfectly

CRY

*THE NEWBORNS CRY SHOULD BE STRONG, LUSTY AND OF MEDIUM PITCH
*HIGH-PITCHED, SHRILL CRY IS ABNORMAL &
MAY INDICATE NEUROLOGIC DISORDERS OR
HYPOGLYCEMIA

How well did you know this?

Not at all

Perfectly

RESPIRATIONS

NORMAL BREATHING PATTERNS FOR A TERM NEWBORN IS 30-60 RESP PER MIN AND IS PREDOMINANTLY DIAPHRAGMATIC, W/ASSOC
W/RISING AND FALLING OF THE ABDOMEN DURING INSPIRATION AND EXPIRATION
*CHEST & ABDOMEN RISE W/INSPIRATION
*CHEST WALL RETRACTS & ABDOMEN RISES
W/INSPIRATION

How well did you know this?

Not at all

Perfectly

HEART AND LUNGS

*ASSESS AND MAINTAIN AIRWAY
*ASSESS HR, RHYTHM - 110-160 PM
-EVALUATE MURMUR:LOCATION,TIMING AND
DURATION
-EXAMINE APPEARANCE & SIZE OF CHEST
-NOTE IF THERE IS FUNNEL CHEST, BARREL
CHEST, UNEQUAL CHEST EXPANSION
-AUSCULTATION IS PERFORMED OVER THE
ENTIRE HEART REGION (PERCORDIUM)
BELOW THE LEFT AXILLA, AND BELOW THE
SCAPULA. APICAL PULSE RATES ARE
OBTAINED BY AUSCULTATION FOR A FULL
MINUTE, PREFERABLE WHEN THE
NEWBORN IS ASLEEP
*BILATERALLY PALPATE THE FEMORAL
ARTERIES FOR RATE & INTENSITY OF THE
PULSES. PRESS FINGERTIP GENTLY AT THE
GROIN. COMPARE THE FEMORAL PULSES
TO THE BRACHIAL PULSES BY PALPATING
THE PULSES SIMUTANEOUSLY FOR
COMPARISON OF RATE AND INTENSITY(PEDAL

How well did you know this?

Not at all

Perfectly

ABDOMEN

Study These Flashcards

*ABDOMEN APPEARS LARGE IN RELATION TO
 PELVIS
   *NOTE INCREASE OR DECREASE IN 
    PERISTALSIS
   *NOTE PROTRUSION OF UMBILICUS
*MEASURE UMBILICAL HERNIA BY PALPATING
 THE OPENING & RECORD
    *NOTE ANY DISCHARGE OR OOZING FROM 
     CORD
    *NOTE APPEARANCE & AMT OF VESSELS
*AUSCULTATE & PERCUSS ABDOMEN
   *ASSESS FOR SIGNS OF DEHYDRATION
   *ASSESS FEMORAL PULSES
   *NOTE BULGES IN INGUINAL AREA
   *PERCUSS BLADDER 1-4 CM ABOVE 
    SYMPHYSIS
   *VOIDS WITHIN 3 HRS OF BIRTH OR AT TIME
     OF BIRTH

GENITALS

Study These Flashcards

*EXAMINE LABIA MAJORA, LABIA MINORA, AND
 CLITORIS (NOTE SIZE OF EACH FOR 
 GESTATIONAL AGE ASSESSMENT
*OBSERVE FOR PSEUDOMENSTRUATION
*INSPECT PENIS TO DETERMINE WHETHER
 URINARY MEATUS IS CORRECTLY POSITION
*CHECK FOR PHIMOSIS (CHEESY MATERIAL 
 WHEN YOU PULL BACK FORSKIN)
 UNCIRCUMSIZED
*WARM HANDS WHEN INSPECTING SCROTUM
*PALPATE TESTES SEPARATELY
*ASSESS FOR HYDROCELE ( FLUID-FILLED 
 SACK IN THE SCROTUM
*NOTE DISCOLORATION & EDEMA (COMMON
 IN BREECH BIRTHS)

ANUS

Study These Flashcards

*INSPECT ANAL AREA TO VERIFY THAT IT IS 
 PATENT AND HAS NO FISSURE
*DIGITAL EXAM BY DR. OR NURSE PRACTION
 IF NEEDED
*NOTE PASSAGE OF MECONIUM

EXTREMITIES

Study These Flashcards

*EXAMINE EXTREMITIES FOR GROSS 
 DEFORMITIES
  *NOTE POSITION & CONDITION OF
   EXTREMITIES & TRUNK
*EXAMINE MORE CLOSELY WHEN INFANT IS
 RELUCTANT TO MOVE AN EXTREMITY
   *NOTE IF THERE IS BRACHIAL PALSY OR
    ERB DUCHENNE PARALYSIS
*CHECK FOR DEVELOPMENTAL DYSPLASIA OF 
 THE HIP:
   PERFORM ORTOLANI'S MANEUVER OR
   BARLOWS MANEUVER
*EXAMINE THE BACK FOR ASSOCIATIONS 
 W/ANY NEURAL TUBE DEFECTS

CLUBFOOT

Study These Flashcards

*NURSE EXAMINES FEET FOR EVIDENCE OF
 TALIPES DEFORMITY (CLUBFOOT)
*INTRAUTERINE POSITION CAN CAUSE FEET TO
 APPEAR TO TURN INWARD
     -POSITIONAL CLUBFOOT
*TO DETERMINE PRESENCE OF CLUBFOOT,
 NURSE MOVES FOOT TO MIDLINE
     -IF PERSISTS, IT IS TRUE CLUBFOOT

TEACHING

Study These Flashcards

DURING PHYSICAL & BEHAVIORAL 
ASSESSMENT, IDENTIFY FAMILYS NEED FOR
TEACHING
  -INVOLVE FAMILY EARLY IN CARE OF INFANT
  -PROCESS ESTABLISHES UNIQUENESS &
   ALLAYS CONCERN

NEWBORN VITAL SIGNS

Study These Flashcards

HR: 120-160 BPM
RESP: 30-60 BPM
BP AT BIRTH: 80-60/45-40 mm Hg

NEUROLOGICAL STATUS

Study These Flashcards

*ASSESSMENT BEGINS W/PERIOD OF
 OBSERVATION
*OBSERVE BEHAVIORS:
    NOTE:
       STATE OF ALERTNESS
       RESTING POSTURE
       CRY
    NOTE:
        QUALITY OF MUSCLE TONE
        MOTOR ACTIVITY
        JITTERINESS
        DIFFERENTIATE CAUSATIVE FACTORS

REFLEXES

Study These Flashcards

*IMMATURE CNS OF NEWBORN IS 
 CHARACTERIZED BY VARIETY OF REFLEXES
   *SOME REFLEXES ARE PROTECTIVE, SOME
    AID IN FEEDING, OTHERS STIMULATE
    INTERACTION
   *ASSESS FOR CNS INTEGRATION
   *PROTECTIVE REFLEXES ARE BLINKING,
    YAWNING, COUGHING, SNEEZING, DRAWING
    BACK FROM PAIN
*ROOTING AND SUCKING REFLEXES ASSIST
 W/FEEDING

TONIC NECK REFLEX

FENCER POSITION ELICITED WHEN THE NEWBORN IS SUPINE AND THE HEAD IS TURNED TO ONE SIDE. THE RESPONSE IS WHEN THE EXTREMITIES ON THE SAME SIDE STRAIGHTEN; THE OPPOSITE SIDE FLEXES. IT MIGHT NOT APPEAR IN THE EARLY MOMENTS BUT WHEN IT APPEARS IT PERSIST UNTIL THE THIRD MONTH

PALMER GRASPING REFLEX

ELICITED BY STIMULATING THE NEWBORNS PALM W/A FINGER OR OBJECT; THE NEWBORN GRASPS AND HOLD THE OBJECT OR FINGER FIRMLY ENOUGH TO BE LIFTED MOMENTARILY FROM THE BED

MORO REFLEX

ELICITED WHEN THE NEWBORN IS STARTLED BY A LOUD NOISE OR LIFTED SLIGHTLY ABOVE THE CRIB AND THEN SUDDENLY LOWERED. IN RESPONSE THE NEWBORN STRAIGHTENS ARMS AND HANDS OUTWARD WHILE THE KNEES FLEX.SLOWLY THE ARMS RETURN TO THE CHEST LIKE AN EMBRACE. THE FINGERS SPREAD, FORMING A C AND THE NEWBORN MAY CRY. THIS REFLEX MAY PERSIST UNTIL 6 MONTHS

ROOTING REFLEX

ELICITED WHEN THE SIDE OF THE NEWBORNS MOUTH OR CHEEK IS TOUCHED. IN RESPONSE THE NEWBORN TURNS TOWARD THE SIDE AND OPENS THE LIPS TO SUCK (IF NOT FED RECENTLY)

STEPPING REFLEX

WHEN HELD UPRIGHT WITH ONE FOOT TOUCHING A FLAT SURFACE, THE NEWBORN PUTS ONE FOOT IN FRONT OF THE OTHER AND WALKS. THIS REFLEX IS MORE PRONOUNCED AT BIRTH AND IS LOST IN 4-8 WEEKS

SUCKING REFLEX

ELICITED WHEN AN OBJECT IS PLACED IN THE NEWBORNS MOUTH OR ANYTHING TOUCHES THE LIPS. NEWBORNS SUCK EVEN WHILE SLEEPING, THIS IS CALLED NONNUTRITIVE SUCKING, AND IT CAN HAVE A QUIETING EFFECT ON THE BABY. DISAPPEARS BY 12 MONTHS.

NEWBORN BEHAVIORAL ASSESSMENT

``` *PARENTS MAY HAVE CONFLICTING PERCEPTIONS OF THEIR NEWBORN -NURSES CAN HELP PARENTS TO IDENTIFY SPECIFIC BEHAVIORS OF THEIR INFANT *OBSERVATIONS OF NEONATAL BEHAVIORS PROVIDE IMPORTANT DATA ABOUT WELL- BEING OF NEWBORN AND INDIVIDUALIZED PATTERNS OF ACTIVITY AND SLEEP ```

NURSING ASSESSMENT FOR NEWBORN Flashcards

(31 cards)