Maternal Newborn - Assessment of the Newborn

APGAR scoring determines the need for ____resuscitation
APGAR score measures what 5 thingsRespiration, Muscle, Tone, Reflex, and color
How often are the APGAR scoring doneFirst minute after birth and again in five minutes if resuscitated.



The APGAR score is between 0-10, what is considered normal8-10
Name the 5 things APGAR scoresSkin color, Heart rate, Reflex irriability, muscle tone, & breathing
In the APGAR rating of skin what does score of 0,1,&2mean?0=blue alll over, 1=blue a extremities, 2=no blue cyanosis body palms and soles may be blue)
In the APGAR rating of Heart rate, what does 0,1&2 mean0=absent, 1=below 100, 2=over 100
In the APGAR rating of reflex irriability what does 0,1,&2 mean0=no response to stimulation, 1=grimace/feeble cry when stimulated, 2=sneeze/cough/pulls away when stimulated
In the AA=PGAR rating of muscle tone what does 0,1,&2 mean0=none 1=some flexion, 2=active movement
In the APGAR rating of breathing what does 0,1&2 mean0=absent, 1=weak or irregular, 2=strong
2nd assessment is within 1-4 hours after birth includes: progress of newborn's adaptation to extra-uterine life, _____ & _____determination of gestational age and ongoing assessment for high-risk problems
Prior to discharge the physiial, nurse practitioner or nurse midwife carries out a ____ assessment and a complete physical examination as well as a general assessmentBehavioral
What two areas are covered when estimating gestational agephysical characteristics and neuromuscular maturity
Sole creases are reliable indicators of gestational age in the first 12 hours of life, a term newborn has creases on the ____ area of the soleheel, premies have slick soles
By compressing the breast tissue between the middle and index fingers, a measurement of 10mm breast tissue is what gestational age40-44 weeks. (7.5mm is 38 weeks.
T/F, the amount of lango increases with gestational ageFalse - amount of lano is greatest at 28-30 wks then disappears
Cartilagnous development of the ear, premies (34 weeks) incurving in only upper __/__ of earupper 2/3, The pina doesn't go back as quick in premies after bent forward
A preterm newborn's pea size testes are not within the ____, and the scrotal surface has few ____scrotum, few rugae
At 40 weeks gestation, the labia majora cover the ____ & ____labia minora and clitoris
As term approaches, the skin appears opaque because of increased ____ tissuesubcutanous tissue
Resting posture flexation at 31 weks flextion of the ____, as gestational age increases, flexion is seen in all ____extremities, full term exhibits hypertonic flexion in all extremities
The square window sign is the angle of flexation of the wrist, the amount of flexation increases or decreases with gestational ageincreases (90 degrees 28-30 wks, 30 degrees 39-40 weeks, and 0 degrees 40-42 weeks)
Preterm infants have less recoil because they have less ____muscle tone
____ angle - the thigh is flexed on the chest and the heel is pulled forward until resistance is met, the more premature, the less resistancepopliteal angle (degree of knee flexion)
____ sign - place the arm around the neck, the elbow is past the midline in a premieScarf sign (at midline 30-4- wks, will not reach midline after 40 wks)
Heel to ear extention - with advancing gestational age, the newborn demonstrates increasing ____resistance
The routine discharge assessment include a complete head to toe phyical assessment and what 4 thingsNutritional status (ablity to breastfeed or bottle feed), behavior state organization abilities, bonding/attachment, and parent learning needs in raltion to newborn care
Newborn range of blood pressure80-60 / 45-40 (about half of adult normal)
What is the normal range of a newborn's heart rate120-160 BPM
What are the normal respirations of a newborn30-60/min (diaphragmatic and abdominal, may have periods of transient tachypnea)
Normal temperature of a newborn97.7 - 99.4 (last vital to take b/c babies cry. Put temp sensor on top of liver)
Crying should be strong, lusty and ____consolable. Cocaine babies have high pitch cat cry
Average weight of newborn2400-4000g or 5 lb 8 oz -13lbs with 8 lb average
How much weight does a newborn lose in the first 3-4 days5-10%
Average length of a newborn18-22 inches (48-52 cm)
posture of term newbornbody is flexed, hands clenched, neck appears short
breech full term babies, the feet are usually ____dorsiflexed
Chest circumfrence is across the ____nipple line
head circumference is above theeyebrow
head circumference is ____ larger than chest circumference2cm
Routine assessment includes lab work: what lab work is done?Mother's Rh factor, direct coombs test (detects antibodies bound to surface of RBC), ABO, billiruben levels, bood sugar for hypoglycemia (under 40), Mother B Beta Strep (If in vagina baby can get it in their lungs caled sepsis neonator)
Assessment colorshould be pink. Acrocyanosis is bluish discoloration of hands and feet and mottling is a lacy pattern of dilated blood vessles under the skin, jaundice
Not normal in the first 24 hours, after first 24 hourse due to immature liver breakdown of billirubinjaundice - from head to toe, blach over cartaliage (nose) & turn yellow.
Other than immature liver, jaundice is caused from:breastfeeding, hematomas, bruises, blood incompatibility, oxytocin augmentation, or severe hemolysis
____ toxicum is a perifollicular eruption of lesions that are firm, vary in size 1-3mm, consists of a white or pale yellow paule or pustule with erythematonus baseErythema toxicum (newborn rash) peak 24-48 hrs
____ is white sebaceous glands on face, especially across the noseMilia
Skin tugor is assessed to determine ____ status, need to initiate early feedings, and presence of infectious processes. Usually assessed wherehydration status. abdomen or thigh - elastic
____ caseosa is a whitish cheeselike substance, covers the fetus while in utero and lubricates the skinVernix caseosa - post term has less
___ nevi, also called stork bites appear pale pink or red spots on eyelids, nose, lower occiptal bone and nape of neckTelangiectatic nevi
____ spots are macular areas of bluish black or blue-grey pigmentation on the dorsal area and bottoxMongolian spots (they are not bruises)
What is the difference between a Nevus flammeus (port wine stain) and Nevus vasculosus (strawberry mark)port-wine stain is non elevated
Head circumference at term is between ____ - ____cm32-37 cm or 12.5 - 14.5"
____ is an opening at juncture of cranial bonesFontanelle
How large is the anterior and posterior fontanelle'santerior fontanelle 3-4cm x 2-3cm diamond shaped. posterior fontanelle 1-2 cm triangular shaped
____ is overriding of cranial bonesMolding (conehead). easily visable in premies and diminishes a few days after birth
____ is a colection of blood resulting from reptured blood vessles between the surface of a cranial bone and periosteal membrane caused from suctioning or foreceptsCephalohematoma - unilateral
____ succedaneum is caused by a long and hard labor or use of suctioning, consisting of tissue fluids, an edematous swellingCaput Succedaneum - bilateral
Newborn hair is normally ____ and ____ in texturesmooth and fine, if not may have hypothyroidism
a face that is not symmetric in movement is called facial ____paralysis. Usually disappears in a few days to 3 weeks but may be permanent
Eyes should be bright and clear with even placement. Eyes with drainage may indicate the mother having ____ or ____Chlamydia or Syphilis
The newborn's nose should be ____patent - they are nose breathers for the first few months.
The mouth should be checked forsucking reflex, roof of mouth for cleft palet, precocious teeth (if loose should be pulled) and Epstein's pearls on the gums
Ears - check for drainage of ___. Lowset (below outter canthus) could indicate ___CSF - low set could indicate kidney problems or chromosomal abnormalities
Neck - check for webbing, fracture to ____, moro reflex and symmetrical shouldersclavicals fracture that can occure with a difficult birth
T/F the chest is 1:1 ratio anterior:lateralTrue - cylindrical
Chest expansion and ____ are not normalretraction
breast hypertrophy is caused bymaternal hormone influences and may last up to 2 weeks
The heart is positioned whereHigh in the chest (apex between 4th and 5th intercostal - point of maximal impulse)
T/F functional murmers in a newborn are okayTrue - 90% are transient and normal , they should be monitored by the physician
The abdomen should be distended, soft and ____round
ausculation of bowle sounds can be heard how long after birth30-60 minutes
The umbilicus has how many arteries and veins2 arteries and 1 vein
T/F An umbilicus hernia does not go away, needs to be surgically removedFalse - usually goes away, if not then surgery
If femoral pulses are not palpaable but brachial pulses are this is caused fromaortic coartion
If the penis meatus is not on the tip, but on top, it is refered to ashyperspadious
____ is a collection of fluid surrounding the testes in the scrotum, can be seen with a pinlightHydrocele
The ____ is prominate in a femaleclitoris
First few weeks, vaginal discharge composed of thick whitish cucus is normal, when it beomes tinged with blood it is called ____ and is caused frompseudomenstration cused from withdrawal of maternal hormones
____ is white, cheeselike substance often present between the labiasmegma, removing it may traumatize tender tissue
If the newborn does not pass meconium in the first 24 hours it may be due toAtresia of the GI tract or meconium ileus (obstruction)
extremeties normally appear ____, flexible and move symmetricallyshort
___ is the presence of extra digitspolydactyly
____ referes to fusion (webbing) of fingers or toessyndactyly
____ is a single palmer creasesimian line (frequently present in children with Down syndrome)
____ palsy is paralysis of portions of the arm results from trauma to the brachial plexus during birthBrachial palsy
____ maneuver is done to rule out the possibility of developmental dysplastic hip.Ortolani's maneuver - positive when makes a cluck noise and can be felt
____ or clubfoot, intrauterine position caused feet to appear to turn inwardtalipes deformity - tx needd if the feet can not be easily returned to midline by manipulation
____ of the hip is asymmetry of gluteal and thigh fat foldsdevelopmental dysplasia of the hip - best seen if newborn is in prone position
____ reflex is stimulated by a flash of lightBlink
____ reflex is stimulated by flash of light and the pupil constrictsPupillary reflex
____ reflex is a response to sudden movement or loud noise and should be one symmetric extension and abduction of arms with fingers extendedMoro response
____ reflex is when the newborn turns in direction of stimulus to cheek or mouth and opens mouth and begins to suck rhythmically when finger or nipple is inserted into mouthrooting and sucking reflex
____ reflex is a grasp of adult finger when palm is stimulatedPalmar grasp
____ reflex is when toes curl downard when sole of foot is stimulatedPlantar grasp
____ reflex is when held upright and one foot touching a flat surface, will step alternatatelystepping reflex
____ reflex is fanning and extension of all toes when one side of sole is stroked from heel upward across ball of footBabinski reflex
____ reflex is the fencer positionTonic neck
____ reflex is while on abomen, the newborn pushes up and tries to crawlprone crawl reflex
____ reflex also called Galant is prone position, stroking of spine causes pelvis to turn to stimulated sideTrunk incurvation
____ scale is to assess state changes, temperament, and individual behavior patternsBrazelton's scale
first temperature is taken ____ then auxiliaryrectal
nursing diagnosis if presence of mucus in lungrisk for ineffective airway clearance R/T presence of mucus and retaining lung fluid
Nursing diagnosis for heat lossRisk for altered body temperature related to evaporation, radiant, conductive and convective heat losses
place the newborn on their back unless they have ____mucus
Use mechonium aspirator suction if mechonium is present at birth and newborn is not ____ at time of birthvigorous
_____ given 0.5 - 1 mg IM is given within one hour of birth to prevent hemorrhagic disease of newbornVitamin K - prophylactic (Phytonadione)
respond immediately to signs of respiratory problems by doing whatnasal & oral suctioning and position with vigorous fingertip stroking of spine
If risk factors are present, how soon should blood sugars be done1 hr
care of circumcisionsqueeze soapy water over once a day, rine with warm water and pat dry. apply petroleum jelly with ea diaper change, let plastibell fall off by itself check for foul smelling drainage, light sticky yellow drainage normal
check circumcision for bleeding and patency of urination, can be blocked with ____edema
You are the nurse assinged to attend the birth & care for baby smith. you noticed as soon as he is born his extremities are blue and he is not crying immediately. you tap his foot and he grimaces. What apgar score will you assign him at 1 min of birth?No crying means no respiration zero cardiac 2 muscle tone not given assume norm 2 grimecing 1 extremities blue 1 total 6 need to hyperventilate with ambu bag
Baby boy smith has leathery cracked skin and deep scrotal ruggae with thick ear cartilage, no vernix and has very long fingernails. What gestational age would these characteristics be of?PAST FULL TERM

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