nursing care of the newborn Flashcards
(72 cards)
1
Q
opening of the lungs
A
- squeeze from contraction takes fluid out of lungs
- lungs recoil and first breath also due to it being cold
- hypoxic during pushing
2
Q
abc approach when baby born
A
- bukb syringe mouth @ side of cheek in back
- bulb nose
- after airways clear, do skin the skin
- dry and stimulate baby
- make sure baby dry completely
- apgar score
3
Q
why do babys normally loose points
A
for color, completely normal in first 24 hr
4
Q
APGAR
A
appearance pulse grimace activity respirations
5
Q
less than 7
A
needs resciation
6
Q
how to count pulse right after
A
count at umbillicord for 6 sec x 10
7
Q
Nursing Interventions: Immediate Newborn Period
A
- Maintaining airway patency
- Bulb syringe proper technique?
- Ensuring proper identification
- Administering prescribed medications
- Maintaining thermoregulation
8
Q
medications
A
Vitamin K
Eye prophylaxis
Hepatitis B Vaccine
9
Q
first hour
A
skin to skin
breast feeding
10
Q
after hr
A
head, chest abdominal cirumfrence, weight and legth
11
Q
immediate care
A
dry and stimulate
12
Q
vitamin k action
A
- Provides the newborn with vitamin K (necessary for production of adequate clotting factors II, VII, IX, and X by the liver) during the first week of birth until newborn can manufacture it
- Prevents vitamin K deficiency bleeding (VKDB) of the newborn
13
Q
vitamin k nursing implication
A
- Administer within 1–2 hr after birth.
Give as an IM injection at a 90-degree angle into the outer middle third of the vastus lateralis muscle.
Use a 25-gauge, 5/8-in needle for injection. - Hold the leg firmly and inject medication slowly.
- Adhere to standard precautions.
- Assess for bleeding at injection site after administration.
14
Q
erythromycin action
A
Provides bactericidal and bacteriostatic actions to preventNeisseria gonorrheaandChlamydia trachomatisconjunctivitis
Prevents ophthalmia neonatorum
15
Q
erythromycin nursing implications
A
- Be alert for chemical conjunctivitis for 1–2 days.
- Wear gloves, and open eyes by placing thumb and finger above and below the eye.
- Gently squeeze the tube or ampoule to apply medication into the conjunctival sac from the inner canthus to the outer canthus of each eye.
- Do not touch the tip to the eye.
- Close the eye to make sure the medication permeates.
- Wipe off excess ointment after 1 min.
16
Q
heb b vaccine action
A
The first dose is highly effective in preventing mother-to-baby infection.
The vaccine is well tolerated in infants.
17
Q
heb b nursing implication
A
Administer within 24 hours after birth and complete the series of 3 injections giving #2 at 1-2 mths & #3 at 6-18 mths. of life.
Follow other steps from the Vitamin K injection above
18
Q
indications for injections
A
.5ml
vastas lateralis
righty hepiti lefty Vk
19
Q
respirations
A
30-60
20
Q
heart rate
A
100-160
21
Q
temp
A
97.7-99.5
22
Q
rectal temps
A
should not routinely be performed on a newborn because of the risk for perforation and vagal stimulation.
23
Q
Initiation of respirations:
A
adjusting from a fluid-filled intrauterine environment to gaseous extrauterine environment
24
Q
role of surfactant
A
surface tension reducing lipoprotein that prevents alveolar collapse
Surfactant production begins at 24 wks. Gestation & is in sufficient amounts by 35 wks.
25
respirations
30 to 60 breaths per minute; irregular, shallow, unlabored; short periods of apnea (<15 seconds); symmetrical chest movements
26
issue w c/s
does not have the same benefit of the birth canal squeeze as does the newborn born by vaginal delivery. Closely observe the respirations of the newborn after cesarean delivery.
27
S/S of Newborn Respiratory Distress
- Nasal flaring, chest retractions
- Grunting on exhalation, labored breathing
- Generalized cyanosis, flaccid body posture
- Abnormal breath sounds, abnormal respiratory rates
- Abnormal heart rates, abnormal newborn size
- grunting
28
early s/s of resp distress
nasal flarring, chest retractions
29
late s/s of respiraotry distress
generalized cyanosis, flaccid body posture
30
mechanisms for neonatal heat loss
conduction
convection
evaporation
radiation
31
conduction
Transfer of heat from object to object when the two objects are in direct contact with each other
32
convection
Loss of heat from warm body surface to cooler air current
33
evaporation
Loss of heat when water is converted into vapor
| “Insensible water loss”
34
radiation
Loss of body heat to cooler, solid surfaces in close proximity but not in direct contact
35
cold stress
the newborn can lead to the following problems if not reversed: depleted brown fat stores, increased oxygen needs, respiratory distress, increased glucose consumption leading to hypoglycemia, metabolic acidosis, jaundice, hypoxia, and decreased surfactant production
36
do infants shiver
DO NOT shiver. If an infant appears to be shivering it is either withdrawing from maternal substance use or hypoglycemic.
Neonate will pull limbs in to conserve heat
37
urine
Urine is less concentrated and has lower specific gravity.
| Does not excrete salt, water loads, or medications quickly
38
of wet diapers after birth
Day 1 = 1 wet diaper / Day 2 = 2 wet diapers / Day 3 = 3 wet diapers / Day 5 = 5 wet diapers / Day 6 and on = 6 wet diapers (min)
39
brick dust
“Brick dust” urine in diaper- could mean baby is dry or dehydrated- fairly normal in first few days
40
amount of intake needed
To gain weight the newborn requires an intake of 108 kcal/kg/day from birth to 6 months of age
41
umbilical cord
Umbilical cord should be clamped, will dry within 24 hours and fall out 7-10 days after birth
42
abd and anus
Abd rounded, non-distended, + BS in all 4 quadrants
| Anus should be patent
43
stool
1st stool in 24 hrs (meconium), after milk comes in: 3-4 stools a day is normal (may have variation)
44
modleing baby
spidery looking skin
| normal
45
baby as risk for jaundice
too many red blood cells baby is yed then yellow
46
stork bite
patch of deep pink skin on head or face
| normal
47
new born baby rash (erythema toxicum)
normal on baby skin goes away dont pick at it
48
mongolian spots
normal fade during 1st few years of life
49
hemangioma
strawberry mark
| normal should fade
50
port wine stain nervus flammerus
non reverible red on half of the face
51
vernix
super sticky natural lotion in young baby, most seen in preme
52
dry baby
dry cracked leathery baby: post due, overcooked
53
caput succedenum
normal from baby being birthed vaginnaly
| cross suture lines
54
cranial molding
normal from baby fitting through pelvis
55
cephalhematoma
swelling that doesn't cross the suture line not normal
56
neurological status
alertness, posture, muscle tone, reflexes
57
moro
started lift shoulders, drop and they get startled
58
rooting
tickle side of cheeck turn head and open mouth
59
Gestational age assessment is important because
allows the nurse to plot growth parameters and to anticipate problems related to prematurity, postmaturity, and growth abnormalities.
60
preterm
prior to 37 weeks
61
term
38-42
62
posterm
after 42 weeks
63
postmature
after week 42 placental aging
64
sga
small for gestational age
65
aga
appropirate for gestational age
66
lga
large of gestational age
67
wrong age can lead to
hypoglycemia and other things to do
68
new ballard scale: physical maturity
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Skin texture
Lanugo
Plantar creases
Breast tissue
Eyes and ears
Genitals
```
69
24hr screening
- PKU/Metabolic condition screening
- Hearing tests
- CCHD- critical congenital heart defect screening
- Bilirubin check
- Weight
- Bath (depending on facility policy/parent’s wishes)
70
cotton swabs
no swabs in nares, or inside ear cana;
71
Preoperative circumcision preparation should include confirmation of the following
- Infant is at least 12 hours old or older
- Infant has received standard vitamin K prophylaxis
- Infant has voided normally at least once since birth
- Infant has not eaten for at least an hour prior to the procedure
- Written parental consent has been obtained
- Correct identification of the infant brought to procedure room
72
plastibell
If the Plastibell was used; clean with water, no petroleum jelly, it will fall off by itself in about 1 week.
- the ring will fall off by itself within 1 week, call md if see any bleeding, make sure diaper is loose in the front (don’t need petroleum jelly and shouldn’t clean with soap/water)
