objective 6 Flashcards by Kaitlyn Dominie

what are the 3 transition periods?

period of reactivity
period of decreased responsiveness
second period of reactivity

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30 mins to 1hr
best time to initiate BF and bonding

period of reactivity

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1 to 3 hrs
infant either sleeps or becomes less active

period of decreased responsiveness

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3 to 8 hrs
infant becomes responsive and alert again

second period of reactivity

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how do we maintain cardiorespiratory function?

Once umbilical cord is clamped & cut, lungs take on function of breathing
Full expansion does not occur for several days
Face, nose, & mouth are gently wiped
Gentle bulb suctioning to clear airways
Infant may be cyanotic at birth
ACROCYANOSIS
Sternal retractions, grunting, flaring nostrils, or resp >60 → requires 02 via face mask and report immediately

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how do we maintain thermoregulation?

Neonate has unstable heat-regulating system
Hypothermia can lead to cold stress
Hypoglycemia and resp distress
Sweat glands do not function during neonatal period
Risk of elevated temp if overdressed or placed in overheated env
Essential nursing care:
Dried after birth, and placed skin to skin or BF
First bath after 24hrs
Place in warmer, wrap in warm blankets
Place hot on infants head

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____ of liquids from skin
skin wet from amniotic fluid

evaporation

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_____ caused by direct contact with a cold surface
cold hands, stethoscopes, scales

conduction

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_____ caused by heat drawn away from the body by drafts
AC, windows, O2 admin

convection

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caused by being near a cold surface, although not in direct contact
cold env of walls, windows, placing ice on incubator

radiation

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Standardized method of evaluating newborns condition immediately after birth

APGAR scoring

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what are the 5 factors evaluated in APGAR scoring?

HR
Respiratory effort
Muscle tone
Reflex response to suction or gentle stimulation
Skin color

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no action (continued observation & support)

8-10

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gentle stimulation (rubbing back)

4-7

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active resuscitation required

less than 3

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May not urinate for as long as 24 hrs
Document if infant urinates in birthing room
May be cloudy in color after first void
Should see one wet diaper in first 24 hrs
Diaper count every shift (should be 6-8 wet diapers by day 5-6)

urination

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This is the first newborn stool
Dark greenish, black thick & tarry
Mixture of amnotic fluid & secretions of intestinal glands
Should be passed before 24hrs post birth
Most pass it within 12 hrs
Meconium should be passed before discharge

meconium

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usually taken by the axilla (hold arm against side), should be between 36.5-37.5, report any variations

temp

count before taking temp as infant may cry when disturbed, count for 1 full min
Newborns pule is irregular and rapid 110-160bpm
Resps are 30-60 breaths/min
Blood pressure is low; averaging 65 to 95 mm Hg systolic over 30-60 mm Hg diastolic

pulse
resps rate
BP

what is average length and weight?

Average length
45-55cm
Average weight
2500 to 4000g

what is the average head circumference?

33-35cm

how do we do cord assessment?

assess 3 vessels
AVA

what is normal for pre and post term for skin?

Preterm: thin, transparent
Post-term: peeling

what is normal for vernix, pre, term, and post term?

Preterm: covers most of skin;
Term: only in creases
Post-term: absent

what is normal for hair pre and post term?

Preterm: heavily covered Post-term: hair in few places

what is normal for ears pre and term?

Preterm: spring back slowly Term: quickly

what is normal for breast tissue pre and term?

Preterm: minimal or none Term: palpable mass

what is normal for genitalia preterm?

Preterm: scrotum smooth and small, labia majora and minora nearly equal in size

what is normal for sole creases pre, term, and post?

Preterm: ⅓ foot Term: ⅔ foot Post-term: whole foot

what are the reflexes that the full-term infant is born with?

Blinking Sneezing Gagging Sucking Grasping crying swallowing

when startled, the infant draws their legs up and the arms fan out and then come toward midline in an embrace position

moro reflex

what is the abnormal moro reflex?

note the clenches fist of one hand that does not follow a symmetrical embracing motion. This infant requires follow-up care

Stroke the side of the foot; big toe dorsiflexes, and the toes flare out

babinski reflex

Place object in hand of the newborn and newborn will grasp it tightly

palmar grasp

Causes the infants head to turn in the direction of anything that touches the cheek, in anticipation of food

rooting

The infant turns the head to one side, and the arm and leg are extended on that side. The opposite arm and leg flex (fencing position)

tonic neck reflex

Prancing movements of the legs, seen when an infant is held upright on the examining table

dancing/stepping reflex

fetal head conforms to size and shape of birth canal May have swelling of the soft tissues of the scalp, called caput succedaneum May see a cephalohematoma: a collection of blood beneath the periosteum of the cranial bone Does not cross the suture line Fontanels (soft spots) protect the head during delivery & allow further brain growth

molding

Newborn is born with ability to control the head in some positions normally occur when the newborn is raised for the bed in a supine position If lasts past 6 months- follow up care required

head lag

Yellow tinge to skin Caused by rapid destruction of excess RBCs Becomes evident between 2nd and 3rd day of life and lasts 1 week Treated with phototherapy Normal process; not harmful to infant Assessed: transcutaneous bilirubin measurement (TcB) followed by blood work

icterus/hyperbilirubinemia

what are the S&S of hypoglycemia?

Jitteriness Poor muscle tone Sweating Respiratory difficulty Low temp Poor sucking High pitched cry Lethargy Seizures

Test for PKU is mandatory If infant has this disorder, special formula is started in 1st months of life preventing disability and severe intellectual and development delays PKU test done on day of discharge

phenylketonuria (PKU)

what are the areas of teaching before discharge?

Basic infant care Bath, diapers, cord care Safety measures Suction with bulb syringe, SIDS, safe sleep Immunization Follow up appointments Proper, use of a car seat S&S of health concerns, & who to contact

parents should contact someone if...?

Temp greater the 38 by axilla Refusal to two feedings in a row Two green watery stools Frequency or forceful vomiting Lack of voiding or stooling A change in usual behaviour