Newborn clinical assessment

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Newborn clinical assessment
2013-04-10 00:06:14
nursing newborn

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  1. NST?
    nonshivering thermogenesis - burn brown fat to produce heat - can increase need for O2 and cause resp distress
  2. Erythrocytes and HgB of newborns?
    have more RBC and HgB than adults, hemolysis can cause jaundice b/c rbc don't live as long, have fetal HgB with greater affinity for O2
  3. WBC count of baby at birth?
    9100 to 34000
  4. Why do newborns get vit K injection?
    they don't have normal intestinal flora to synth vit K
  5. Stomach capacity of a newborn?
  6. Gastrocolic reflex?
    stim when the stomach fills, causing increased intetinal peristalsis -
  7. Normal newborn BG?
    day 1 - 40 - 60

    after day 1 - 50-90
  8. Bilirubin cycle?
    released from hemolyses RBC -> conjugated to water soluble form by the liver -> excreted in urine and stool
  9. Major diff b/t pathologic and physiologic (nonharmful) jaundice?
    pathologic can occur in the first 24 hours after birth
  10. 2 factors that coagulation factors need?
    liver function to create them and Vit K to activate them
  11. Where is iron stored during pregnancy?
    liver and spleen
  12. Kidney filtering ability is like adults at what age?
    1 to 2 years
  13. newborns are at risk for what pH imabalance?
    metabolic acidosis b/c they lose more bicarb and decreased ability to reabsorb it
  14. If a newborn has an infection what may occur?
    may not have fever or increased WBC because immune system is immature
  15. Assessment imm after birth?
    assessed for cardiopulm probs and obvious anomalies
  16. Perferred site and normal temp of NB?
    axillary - 36.5-37.5
  17. Normal NB heart rate?
    120-160 BPM
  18. PMI of NB heart?
    3rd to 4th intercostal space lateral to the midclavicular line
  19. 3 pulses to check for with NB?
    brachial, femoral, and pedal
  20. Normal resp rate for NB?

    AVg resp rate?
    30-60 BPM

    avg is 40-49 BPM
  21. Normal respirations in NB?
    irregular, shallow, unlabored, symmetrical,
  22. Avg BP for NB?
    65/30 - 95/60
  23. Why may a NB have white discharge from nipples?
    mother's hormones withdrawing from them
  24. When should meconium and first urine be passed?
    meconium in first 12 - 48 hours and urine in 12 -24 hours
  25. Respiratory assessment frequency?
    assess q 30 minutes until stable for 2 hours after birth
  26. Apnea?
    pause that lasts more than 20 sec., or that is accompanied by cyanosis, pallor, bradycardia, or decreased muscle tone
  27. Breath sounds in first couple of hours?
    may have wet sounds b/c of amnio fluid
  28. S/S of resp distress in NB?
    • 1. tachypnea - may occur for short periods but should not be prolonged
    • 2. retractions
    • 3. nasal flaring
    • 4. cyanosis - lips, tongue, mm, and trunk
    • 5. grunting
    • 6. seesaw or paradoxical respirations - chest and stomach don't move together
    • 7. asymmetry
  29. Choanal atresia?
    nasal passages blocked by bone or tissue

    NB is nasal breather for first 4 to 6 weeks and this can cause resp distress
  30. Pallor may indicate ___ or____.
    hypoxia or anemia
  31. Ruddy color indicates ____.
    polycythemia which causes increased risk for jaundice
  32. HR assessment frequency?
    should assess q 30 minutes until NB has been stable for 2 h

    Once stable check q 8 to 12 h or according to agency policy
  33. BP cuff for NB?
    should be 40-50% of the circumference of the leg or 25% - 50% wider than the diameter of the limb
  34. Assessing cap refill in NB?
    press skin over chest, abd, or extremeity until it blanches - color should return in 3 to 4 sec
  35. Assessment frequency of temp?
    q 30 min until stable for 2 h after birth then at 4 h after that then q 8 h
  36. Craniosynostosis?
    premature closure of the sutures
  37. How to palpate fontanels?
    infants head should be elevated

    anterior should be 4 to 5 cm and

    should be soft and flat or slightly depressed
  38. Caput succedaneum?
    area of localized edema that appears over vertex of head due to pressure against mother's cervix in labor
  39. When may cephalhematoma occur?
    24 to 48 h after birth - has clear edges that end at suture lines (caput succedaneum crosses suture lines)
  40. Assessment of infant hips?
    Place fingers over infant's greater trochanter and thumbs over femur and flex knees and hips

    2. barlow test:  adduct hips and apply gentle pressure down and bakc with the thumbs - will feel move out of acetabulum if displaced

    3. ortolani test - abduct the thighs and apply gently pressure forward over the greater trochanger - will feel clunking if dysplasia
  41. Assessment of ear placement?
    horizontal line from outer canthus of eye should be even with area where the ear jhoins the head
  42. Hearing assessment?
    infants reaction to sudden noise
  43. What eye prob may occur but be normal?
    transient strabismus- eye crossing due to weak eye muscles
  44. Normal NB response to bright lights?
    blink or close eyes
  45. 3 causes of tremors in infants?
    • 1 hypoglycemia
    • 2 low calcium
    • 3 drug use of mom
  46. Moro reflex?
    AKA startle reflex - when infant's head and chest are allowed to drop 30 degrees arms are thrown out and fingers fan out and make a c
  47. Palmar grasp reflex?
    touching palm below fingers should cause baby to close hand around object
  48. Plantar grasp reflex?
    same as palmar but with toes
  49. Babinskin reflex?
    stroke up from heel on outside of foot and across ball of foot- toes should fan out and big to should dorsiflex
  50. Rooting reflex?
    cheek is touched near the mouth the head turns toward the side that has been stroked
  51. sucking reflex?
    when mouth or palate is touiched by nipple or finger the infant begins to suck

    assess for presence and strength
  52. Tonic neck reflex?
    posture assumed by newborns when in a supine position - infant extneds arm and leg on side where head is turned & flexes extremities on the other side - AKA fencing reflex - looks like they are fencing
  53. Stepping reflex?
    infant is held upright with feet toucing surface - will lift one foot then other like they are trying to walk
  54. Cry that indicates neuro disorder?
    catlike or high pitched
  55. How to assess for jaundice?
    press on end of nose or sternum

    will begin at head and move down so areas affected should be documented
  56. Normal NB position?
    flexed hips, knees, and ankles
  57. Square window test?
    flex palm toward forearm- closer palm gets to forearm closer to full term baby is- if can't get close = preterm
  58. Arm recoil test?
    hold arms fully flexed at the elbows for 5 seconds and then pull hands straight down to the sides & quickly release them - degree of flexion is measured as arms return to normally flexed posotion

    preterm infants may move arms slowly or not at all

    full term = quick return
  59. Popliteal angle test?
    newborn's lower leg is folded against the thigh with thigh on the abd .  Then lower leg is straghtened just until resitance is met.  angle at popliteal space is scored when resitance is first felt

    preterm will extend leg farther than full term
  60. Scarf sign test?