Flashcards in Test 3 Blueprint (3) Deck (57):
How much weight is normal for an infant to lose on day 3 or 4?
above 90th percentile
below 10th percentile
How many kcal/day is normal for a newborn?
What do you suction first? Why?
mouth before nose, removes the substances from the mouth/throat area so they won't be aspirated when the nose is suctioned
Localized swelling of the soft tissues of the scalp caused by pressure on the head during labor. An expected finding that may be palpated as a soft edematous mass and may CROSS OVER THE SUTURE LINE.
Caput succedneum usually resolves in ___ to ___ days. Does it require treatment?
3 to 4 days
doesn't require treatment
Extravasation of blood from ruptured vessels between a skull bone and its external covering, the periosteum. Swelling is limited by the margins of the cranial bone affected (usually parietals).
AGA: appropriate for gestational age --> btwn 10th & 90th percentile
SGA: small for gestational age --> below 10th percentile; grown at restricted rate during intrauterine life
LGA: large for gestational age --> more than 90th percentile; grown at accelerated rate during intrauterine life
What are the 4 ways a baby loses heat?
What is evaporation?
conversion of liquid to vapor
(ex/ infant covered with amniotic fluid, wet gown)
directed contact with objects cooler than skin
(ex/ infant place on cold scale)
What is convection?
transfer of body heat to air surrounding infant
(ex/ uncovered in cool room)
What is radiation?
heat loss to cooler objects not in direct contact with body
(ex/ walls of nursery near bed or warmer)
Characteristics of neonate that lead to heat loss:
- little subQ fat
- thin epidermis/blood vessels close to surface
- body mass (heat-producing tissue such as muscle/adipose) --> small in relation to surface area
- position of extension contributes to rapid heat loss
- cannot shiver to generate heat
Characteristics of neonate that encourages thermoregulation:
- flexed position --> conserves heat
- nonshivering thermogenesis from metabolism of brown fat & metabolic activity of brain, heart, liver
What are the 2 types of infant jaundice?
physiologic & pathologic
Describe physiologic jaundice:
Benign, appears after 24 hrs of age
From normal newborn physiology of increased bilirubin production due to the shortened lifespan and breakdown of fetal RBCs and liver immaturity
Describe pathologic jaundice:
Result of underlying disease, appears BEFORE 24 hrs of age or is persistent after day 7
Usually caused by a blood group incompatibility or an infection, but may be the result of RBC disorders
How can we treat jaundice?
Feed early & often...helps with excretion of bilirubin in urine & feces
Phototherapy...breaks down bilirubin into an excretable form
Phenylalanine is an essential ____ ____.
What does an infant need before the PKU test can be performed?
adequate amounts of milk (24 hrs)
Accumulations of phenylalanine can result in what?
severe mental retardation (but early treatment can avoid this)
Education for mother who is receiving the rubella vaccine:
- receive vaccine after birth and again 1 month following
- don't get pregnant for 1 month after vaccination
- may cause rash
- safe for breastfeeding
- made from duck eggs, allergy my develop hypersensitivity to rubella vaccine
Normal HR of a newborn:
Where can you best hear the neonate's heart sounds immediately after birth?
Where can you best hear the neonate's heart sounds 24 hours after birth?
PMI is found at 4th ICS to left MCL day after delivery
Normal RR of newborn?
What is characteristic of a newborn's breathing?
- shallow, irregular breathing
- short periods of apnea (
What is normal cord blood bilirubin level?
Skin staining may be noticed with serum bilirubin levels of ___ to ___ mg/dl.
4 to 6 mg/dl
Number one cause of infant stress...
Strike flat surface that newborn is lying on, or allow head and trunk to fall back to an angle of 30 degrees. Arms and legs extend then abduct, fingers spread to form a "C".
Stroke cheek or edge of mouth, newborn turns to that side and starts to suck.
Stroke outer edge of sole of foot, moving up toward toes. Toes will fan upward & out.
Characteristics of gestational newborn maturity (length, weight, L/S ratio):
Length: 17.7 - 21.7 in
Weight: 5.5 - 8.8 lb
L/S ratio: 2:1
Characteristics of FIRST PERIOD OF REACTIVITY:
- lasts up to 30 min after birth
- HR increased at first but gradually falls back to btwn 100-120
- RR high = 60-80/min
- Audible grunting, nasal flaring, chest contraction can be present (should clear within one hour)
- may have fine crackles
- infant is alert
Characteristics of SECOND PERIOD OF REACTIVITY:
- starts 2-8 hrs after birth, lasts 10 min to several hrs
- tachycardia, tachypnea
- increased muscle tone...really jumpy
- increased mucus production...watch for gag & choking
- meconium usually passed during this time
What is considered a normal APGAR score? What is indicative of a need for resuscitation?
3-4 needs resuscitation
APGAR heart rate scores:
0 - absent
1 - 100
APGAR respiratory rate:
0 - absent
1 - weak, irregular
2 - good, crying
APGAR muscle tone:
0 - flaccid
1 - arms & legs flexed
2 - well flexed
APGAR reflex irritability:
0 - no response
1 - grimace
2 - cough or sneeze
APGAR skin color:
0 - blue, pale
1 - hands & feet blue
2 - completely pink
What can cold stress result in?
- hypoxia (cold stress uses up O2)
- hypoglycemia (glucose depleted in efforts to raise core temp)
- metabolic acidosis
- bilirubin level increased r/t excessive fatty acids released and displace bilirubin from binding sites
How can hypoxia lead to metabolic acidosis?
hypoxia --> hypoglycemia --> metabolic acidosis
How can cold stress increase bilirubin level?
because fatty acids are released and displace bilirubin from binding sites --> jaundice and potential for kernicterus
What nursing interventions are done when baby is too cold?
- dry quickly, put on cap
- attach transistor probe over upper quadrant of abdomen to keep infant's temp 36.5-37 C
- position crib away from walls or windows
- perform exams/procedures under heat panel
- delay bath until temp is stable (36.5/97.7)
- skin to skin with mother, cover with blanket
- swaddle in double warm blankets
- radiant warmer
- observe for resp. distress
- observe for signs of hypoglycemia
What is bigger, the head or the chest? By how much?
Head, by approx. 0.5in
What type of cry may be noted in a baby with hypoglycemia?
shrill, high-pitched cry
What should be done for a hypoglycemic baby?
- check glucose (
Diffuse swelling that crosses suture lines on the neonate's head.
Swelling confined to an area between suture lines:
How does cephalhematoma contribute to increased bilirubin level?
Blood between skull and periosteum, blood pools under skull and not getting to liver to remove toxins
Normal bilirubin levels:
serum: 0-1 mg/dl
Signs of Down Syndrome?
- small, low set ears
- simian hand crease; broad hands; 5th finger with only 1 flexion crease
- oblique palpebral fissures or upward slant of eyes; epicanthal folds
- flat facial profile with depressed nasal bridge and small nose
- protruding tongue
- hyperflexibility; hypotonic muscles
3 ways to determine the presence of congenital hip dislocation of newborn:
1) positve Ortoloni sign
2) unsymmetrical gluteal folds
3) uneven level of knees (Allis sign)