week 2 Newborn Assessment (lab day 4)
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A term baby is any baby delivered between ____ and ____ weeks gestation.
A term baby is any baby delivered between 37 and 42 weeks gestation.
A preterm baby is defined as < _____ weeks.
A postterm baby is defined as > _____ weeks.
- A preterm baby is defined as < 37 weeks.
- A postterm baby is defined as > 42 weeks.
The initial assessment of the newborn's cardiopulmonary adjustment after birth is called ________.
True or false... the apgar score is performed by the nurse at 1 and 3 minutes.
false, the apgar score is performed by the nurse at 1 and 5 minutes.
A final apgar score of ____ means no intervention.
8 or higher
An apgar score of < ___ requires intervention
< 8 requires intervention
The apgar score is based on what 5 criteria?
- 1. HR
- 2. resp
- 3. muscle tone
- 4. reflex response
- 5. color
A newborns axillary temperature range should be _____________.
axillary temperature of a newborn should be between 97.7 - 99.1
specify the newborn apical pulse range
Newborn apical pulse range is 120-160 bpm
A newborns respirations should range ______/min ?
newborn respirations = 30-60/min
True or false... The newborns blood pressure is always obtained at birth
false, the newborn's blood pressure varies with gestational age and is not routinely taken on well babies. That said, the range is systolic 65-95 and diastolic is 30-60
When obtaining vitals from a newborn (TPR), which order are they done?
- 1. respirations
- 2. apical pulse
- 3. temperature
How do you perform an axillary temp on a newborn?
- 1. hold thermometer lengthwise against the baby and place into the armpit
- 2. hold the arm firm against the baby's body
- 3. do not force into the armpit
- 4. do not hold thermometer upright
A newborn has an elevated temperature. What should you do?
- 1. assess for s/s of infection
- 2. Is the baby dressed too warmly?
- 3. Is the warmer too hot?
A newborn has a low temperature. What should you do?
- 1. If low at first, take again
- 2. if temp is 97.6 take interventions like wrapping the baby in 2 blankets
- 3. recheck in 1/2 hour
- 4. if it remains low, put baby in a warmer
- 5. check blood glucose for hypoglycemia
- 6. check for s/s of infection
- 7. check for s/s of a CNS deficit
A newborn baby is hypOglycemic. What would the blood glucose level be?
hypoglycemic newborn would have a blood glucose level <= 40 (blood obtained by a heel prick).
hypoglycemia in a newborn could mean infection, CNS problem, or a cold room.
True or false... When counting respirations on a newborn, count for 30 seconds and x 2
- false, count for a full minute
- observer color of lips and tongue, any blue report immediately
what should you assess for regarding a newborns respirations?
- 1. color of lips and tongue, any blue should be reported immediately
- 2. chest movements for symmetry
- 3. respiratory distress - nares flaring, grunting, chest retractions
- 4. tachypnea > 60 bpm (could be due to labor)
- 5. apnea - due to the baby being cold, or due to infection/sepsis
what are the s/s of respiratory distress of a newborn?
- nares flaring
- grunting sounds
- chest retractions
What pulse point should be used on a newborn?
what is the normal pulse range for a newborn?
true or false... when a newborn cries, his pulse goes up
take the newborns pulse apically at the ___ intercostal space
A newborn with tachycardia has > ____ bpm which could be an indication of what 3 things?
- > 160 bpm
- could mean the newborn is experiencing
- 1. respiratory problems
- 2. anemia
- 3. infection
a newborn experiencing bradycardia has < ____ bpm and could be a sign of what?
- < 120 bpm
- could be a sign of
- 1. asphixia
- 2. increased ICP
- 3. sometimes the baby's HR just goes down if he's sleeping
Which pulse point is easiest to palpate on a newborn?
The weight of a newborn that is APA (appropriate for gestational age) is ?
5 lbs 8 oz - 8 lbs 13 oz (2500 - 4000 grams)
What does AGA, LGA, and SGA mean with regards to a newborn's weight?
- AGA - appropriate for gestational age
- LGA - large for gestational age
- SGA - small for gestational age
true or false... the first 3 - 5 days the baby loses 15% of weight
false, the baby loses 10% of weight in the first 3 - 5 days because the baby is still adapting and learning how to survive on it's own. The baby is losing fluids while learning.
This weight should be regained by 2 weeks.
A. Head circumference: ________
B. Chest circumference: ________
C. Length: _________
- A. head circumference: 32 - 38 cm
- B. chest circumference: 30 - 36 cm (measured at the nipple line)
- C. length: 45 - 55 cm
- D. Abdominal girth (not normally done) 17 3/4 - 21
In the newborn posture, the extremities should be ______, the hands should be ______, the movements should be ___________ and when the baby cries, they should have slight ______.
flexed, clenched, symmetrical, tremors
A preterm baby that is flacid may be caused by
A newborn baby that is shaking may have low _____ or low ______.
- low calcium or
- low blood glucose
true or false... the newborn baby should recoil immediately when stretched out
true or false... the newborn baby should have a strong lusty cry
true or false... the newborn cry should be high pitched or shrill like cry
false! this could indicate increased intracranial pressure or a neuro deficit
true or false... a bluish color to hands and feet is of concern
false, this is due to sluggish circulation and will disappear in aprox. 12 hours of life
The cheeselike substance that protects teh baby from the amniotic fluid is called ______
the ________ is to help the _____ adhere to the skin
the hairs on the newborn's skin is called ______
What is acrocyanosis?
a bluish color on the periperhal (hands and feet)
What is the term for a bluish color on the periperhal (hands and feet) of the newborn?
The term baby will have
a. small amounts of vernix in creases
b. small amounts of lanugo in shoulders, sides of face, forehead, upper back
c. small amounts of desquamation
d. all of the above
d. all of the above
dry, cracking and peeling of the skin.
true or false... you should put lotion on the newborns dry, cracking skin
false, lotion will not help desquamation and will resolve itself
white cysts found on the nose, chin, forehead. these are distended sebaceous glands and disappear in about a month.
define erythema toxicum
- this is also known as "newborn rash", or "etox"
- it is benign
- appears as blotchy, red with papules in the center
- they appear in 2-3 days and disappear by day 6
- usually found on the trunk of the newborn
this is also known as "newborn rash", or "etox", it is benign, appears as blotchy, red with papules in the center they appear in 2-3 days and disappear by day 6 usually found on the trunk of the newborn
white cysts found on nose, chin, and forehead. distended sebaceous glands. disappear within a month.
true or false... mongolian spots are common in light skinned babies
false... mongolian spots are common in dark skinned babies
true or false... mongolian spots disappear within a couple months
false, they disappear within a couple years
this is another name for "stork bites"
____________ is due to dilation of the capillaries commonly on the forehead, between the eyes, or on the eyes. they usually disappear by age ____
telangietic nevi, aka "stork bites"
usually disappear by age 2
The ___________ of the newborn's head are separated and needed for birth and brain growth.
the __________________ fontanel is diamond shaped and _____ cm
the __________________ fontanel is triangular shaped and _____ cm
the anterior fontanel normally closes in _____ weeks
the posterior fontanel normally closes in _____ weeks
true or false... the nurse should run fingers through the baby's hair checking the scalp for problems.
___________ of the sutures, aka "conehead", usually goes away in 1 - 2 days
molding of the sutures, aka "conehead", usually goes away in ____ days
1 - 2 days
Define Caput Succedaneum
An area of fluid/edema in scalp tissues that crosses over the suture line
True or false... caput succedaneum is caused by trauma
false, caput succedaneum is caused by birthing pressure on the skull
when palpated, caput succedaneum is hard or soft?
caput usually disappears by _____
within 12 hours
a blood pocket between the periostomy and skull; it is due to trauma; It does not cross the suture line.
What are the characteristics of Cephalhematoma?
- does not cross the suture line
- firm to touch
- slow bleeding
- caused by trauma
- develops at 24 - 48 hours
- reabsorbs slowly on its own over a couple weeks
Define the characteristics of a healthy newborn's ears
- 2 well formed, symmetrical ears
- s/b exactly located at level of inner/outer canthus of eye (measure where ear meets head)
- firm cartilage
report anything abnormal at all as this could be a sign of kidney disease (because the ears and kidneys develop at the same time in utero)
Define characteristics of a healthy newborns face
any transient asymmetry should be reported
- The face should be symmetrical in appearance and movement
- parts proportional and appropriately placed
Define characteristics of a healthy newborn's eyes
- scant or absent tears (first 2-4 weeks)
- sclera bluish white
- follows object 180 degrees
- transient strabismus (cross eyed) - due to loss of control of the eye muscles, usually resolves itself in 3-4 months
- edema in eyelids normal
How do you test the nose of the newborn?
test patency of nares by pressing against on nostril at a time; the newborn should breath without difficulty.
define characteristics of the newborn mouth
- mouth, gums, tongue pink
- tongue size normal
- tongue moves freely
- lips and palate intact
- sucking pads
Define precocious teeth?
a newborn is sometimes born with teeth, these should be removed to prevent aspiration
define epstein pearls
small white hard cysts in the newborns gums, they disappear without treatment
Define the characteristics of the newborns neck and clavicles
- short neck
- turns head easily from side to side
- raises head when prone posture
- clavicles intact
what are the indications of a fractured clavicle in a newborn?
- the clavicle should be straight and flat but if it's fractured it may not be.
- It may feel like sandpaper or crepatus which could indicate a fracture.
- limp arm
- crying when arm is moved
- no treatment but to immobilize the arm.
Crepitus: A clinical sign in medicine characterized by a peculiar crackling, crinkly, or grating feeling or sound under the skin, around the lungs, or in the joints.
true or false... webbing or large fat pad could indicate a chromosomal disorder
define characteristics of a healthy newborn's chest
- cylindrical, symmetrical
- xiphoid process may be prominent
- nipples and breast buds are present (feels like a frozen pea)
- breast engorgement, white nipple discharge are normal and due to maternal hormones
abnormal presence of air in the pleural cavity resulting in the collapse of the lung; may be spontaneous (due to injury to the chest) or induced.
free air in the chest outside the lung
What could chest asymmetry indicate?
collapse of an expanded lung (especially in infants); also failure of pulmonary alveoli to expand at birth
absent breath sounds in the newborn could indicate what?
true or false... c-section babies have more fluid in their lungs?
true. you may hear rales or crackles
Define characteristics of the healthy newborn's abdomen
- s/b round and soft
- should have positive bowel sounds within the first hour after birth
- umbilical cord - 3 vessels, bluish-white color, no drainage
true or false... in the umbilical cord you will see 2 veins and 1 artery
false, you will see 2 arteries and 1 vein
When does the umbilical cord dry up?
dries up, turns brown and falls off within 7 - 10 days
define characteristics of a healthy newborn female genitals
- the labia majora is dark; covers clitoris and labia minora
- smegma present - white cheesy found around labia minora - do not wash off, it protects the fragile skin
- clear/white vaginal discharge present
- urinary meatus and vagina present
true or false... pseudo menstruation is a normal variation in a newborn female
true, this vaginal bleeding is normal
true or false... hymenal tags are a normal variation in the newborn female
- true, these tissues protrude from vagina usually in the 1st week of life
- no treatment
- they disappear
Describe characteristics of the normal newborn male genitals
- tested descended into the scrotal sac - palpate (feels like a cooked pea)
- rugae should completely cover the scrotum in term babies
- prepuce is nonretractable - do not force
- meatus is at the tip of the penis
Hypospadias is when the meatus is on the underside of the penis
epispadias is when the meatus is on the upper side of the penis
true or false... hypospadias and epispadias can usually be corrected with surgery
- hydrocele is a collection of fluid around the scrotum
- it usually resolves on it's on but can develop into an inguinal hernia so monitor
true or false... circumcision is no longer recommended
- true, it is the parents choice
- they should weigh the pros and cons
true or false... clear yellow around the penis is normal after circumcision
How do we assess urinary output in a newborn?
count wet diapers
When will the first void usually occur in the newborn?
within 12 - 24 hours
How many we diapers per day would you expect in the newborn?
6 -- 10 after day 6
What are urate crystals on the diaper?
reddish or orange stained urine due to immature kidneys. this should resolve in a couple of days.
- it is the first stool of the newborn, usually within 12 - 48 hours
- black, dark green, sticky, hard to wash off, important to record
- "he mec'd" is a common phrase in OB unit
What is the normal stool output for the newborn?
- breast fed: yellow, sweet smelling, soft stool, 2-3 stools/day
- formula fed: brown, more formed stool, 1-2 stools/day
Define characteristics of the newborn extremities
- flexed, good muscle tone
- equal and bilateral in movement
- correct number of digits
- nail to end of each digit
- palms - 2 transverse creases
- legs equal in length
- gluteal and thigh creases equal
- knee height equal
When folds don't match up on the knees or gluteal & thigh, what could this indicate?
dislocated hip or hip dysplasia
what is simian crease?
just one transverse crease across the hand. it indicates a chromosomal disorder.
webbing between fingers - surgically corrected
what is ortolani's maneuver?
checking the newborns hip/leg sockets - RN's do not do this - only the doctor!
Define characteristics of a healthy newborn back
- no openings observed or palpated in the vertebral column
- anus patent
- sphincter tightly closed
how would you assess the newborns back?
- run fingers down the spinal column (should be straight and flat) looking for openings or tufts of hair. This could indicate spina bifida.
- pylanidal dimple or sinus should be reported
what is pylanidal dimple?
a sinus on the newborns base of the spine
Define palmer grasp
the newborn grasps your finger, makes a c-shape with fingers and thumb
define moro reflex
when the baby is startled, arms fan outward and inward
define tonic neck
- aka, fencing posture
- the baby will flex the opposite arm and leg when in supine position and neck is turned.
define the babinski reflex
stroke foot from the heal up to the toes and this will cause the toes to fan out
when the baby's feet touch a hard surface, the baby lifts leg, looks like they are stepping
what is the rooting reflex?
turning the head towards the stimulation
define plantar grasp
putting pressure on the feet will cause the toes to curl. do this after the babinski test.
What are some steps taken to ensure newborn safety and identification?
- alarms built into the clamp on the cord or attached on the ID bracelet
- ID bands to ensure the right baby to the right mother - check every time they are separated/reunited
- nurses wear badges
- baby footprints are taken
true or false... the baby should be put into the crib supine
- true, babies should sleep on their backs to prevent/decrease SIDS.
- The slogan "back to sleep" is used to encourage this.
if baby just ate, elevate head of bed to prevent aspiration
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