Part IV Flashcards
(25 cards)
When do fontanelles close?
Posterior - around 2 months
Anterior - 12 to 18 months
What is normal when looking at an infant’s Face?
Face: Symmetry, hairline, eyebrows, eyelashes present
What is normal when looking at an infant’s mouth?
Mouth: Symmetry of movement and strength, presence of gag, swallowing, evaluation of the pallet, tongue
What is the difference between Caput and Cephalohematoma?
Caput: (causes by vacuum or after pushing against non-fully opened cervix)
o Collection of fluid (serum)
o Crosses suture line
Cephalohematoma: (increased risk of jaundice- more dead RBC)
o Collection of blood
o Does not cross suture line
What should the nurse notice on a newborn’s eyes, ears, and nose?
· Eyes: General placement and appearance, color, blink, eyelids, drainage?
· Nose: Size, midline, patent nares bilaterally, no flaring
· Ears: Responds to sound, without lesions, cysts or nodules
Is nasal flaring normal in newborns?
No, nasal flaring at rest is not normal
What is a normal Respiratory status of newborns?
CHEST & RESPIRATORY STATUS
· Respiratory rate 30-60 (unlabored)
· Nose breathers
· Abdominal muscles for breathing
· Even chest expansion
· Moist respiration (crackles) not unusual at first… Usually clears with crying
· Irregular rate, depth and rhythm (Should not have apnea for > 15 seconds!)
· Swollen breast tissue and small discharge
What are s/s of respiratory distress?
RESPIRATORY DISTRESS SIGNS & SYMPTOMS
· Tachypnea (rate over 60)
· Apnea (Pauses > 15 seconds)
· Persistent nasal flaring at rest
· Grunting or Humming sound with exhalation
· Retractions
· Central Cyanosis, Mottling or Pallor
true or false - it is normal for female infants to have vaginal discharge (sometime even scant blood noticed)
true - not concerning
What should be assessed on an infant abdomen, genitals, and elimination?
· Abdomen should be soft & rounded
· No cyanosis centrally on the newborn’s body is normal!!
· No protrusion of the umbilicus
· Cord: Two arteries and one vein
· Bowel sounds present
· Irregular peristalsis and BMs initially
· No bulges in inguinal area
· Females: labia majora covers minora (term), pseudomenstruation, some swelling of labia
· Males: testes descended, urinary meatus location
How often should infant’s pee?
· Urinary elimination 1-2 times daily at first, then 6+
Define Polydactyly and Syndactyly
o Polydactyly - Extra digits
o Syndactyly - Webbed digits
What is a way to determine a dislocated hip in an infant?
Buttock and leg fat folds line up side to side when legs are straightened… if not, there may be a dislocation
What are some risk factors for hypoglycemia in infants?
Risk Factors for Hypoglycemia
· Pre/Post maturity
· LGA or SGA
· Low APGAR scores
· Cold Stress
· Maternal Diabetes
What are some s/s of hypoglycemia in infants?
Signs & Symptoms of Hypoglycemia
· Jittery/Lethargic
· Poor tone/suck
· Tachycardia/Tachypnea
· Diaphoretic
· Low Temperature
· No Symptoms
What is the nurses role with known or suspected substance abuse?
· Screen every mother upon admission and watch for “red flags.”
· Follow facility policy for collection of tissues for substance testing (cord segment is common)
· Collaborate closely with the care team caring for the baby! Monitor for withdrawal symptoms, medicate as needed, comfort the baby.
o Work with family in a nonjudgmental fashion
· First Priority is to Protect and Advocate for the newborn!
What is Neonatal Abstinence Syndrome (NAS)?
NEONATAL ABSTINENECE SYNDROME (NAS)
· NAS is a collection of drug withdrawal symptoms that result from chronic intrauterine exposure to a variety of substances.
· Withdrawal signs and symptoms typically begin within 72 hours after birth and can last as long as 6 months.
· Treatment often consists of morphine but can include phenobarbital too with severe seizure activity.
What are some possible NAS s/s related to CNS disturbances?`
Central Nervous System Disturbances
· Excessive crying
· Poor/short sleep-even after feeding
· Hyperactive Moro reflex
· Tonic/clonic jerking
· Tremors
· Increased muscle tone
· Excoriation
· Seizures
What are some possible NAS s/s related to Metabolic/Vasomotor/Respiratory Disturbances?
Metabolic/Vasomotor/Respiratory Disturbances
· Sweating
· Fever
· Skin mottling
· Nasal flaring, stuffiness, RR >60
· Excessive sneezing/yawning >3
What are some possible NAS s/s related to GI disturbances?
GI Disturbances
· Projectile vomiting
· Poor feeding
· Diarrhea/Loose stools, Diaper rash
· Excessive sucking
true or false - *Be cautious because low blood glucose can look very similar to signs of withdrawal!
true!
Also, premature babies may has some similar s/s
How could neonatal sepsis be acquired?
Can be acquired in utero from existing intrauterine infection, during birth, or acquired after birth.
*85% of neonatal infections have their onset in the first 48 hours of life (usually meningitis or pneumonia).
What are some risk factors for neonatal sepsis?
Risk Factors
· Prematurity
· Compromised immune system
· Prolonged ROM
· Group B Strep exposure
· Substance exposure
· Decreased gastric acid
· Exposure to organism before, during, or after birth
What are some s/s of neonatal sepsis?
Signs and Symptoms
· Temperature instability
· Respiratory Distress
· Pallor/Duskiness/Cyanosis/Jaundice
· Poor tone
· Irritability/Seizures
· Poor feeding/Hypoglycemia
· Rash
· Abdominal Distention
