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Glossary of Medical 2-Labor Process Lecture 1

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Nursing diagnoses for a mother who has a baby who
says "This baby's ugly. I don't know that I can take it home". My husband can't take this fact." What is an appropriate response?
Ineffective individual coping
What is an appropriate nursing diagnosis for a family who is screaming in the hallway?
?
Make sure to look at jaundice stuff, COOMBS, appropriate interventions. There will be nursing diagnosis. There will be nursing interventions.
?
What is an appropriate nursing diagnosis for in labor nursing?
Alteration of comfort
Anxiety
Nursing diagnosis for epidural would be?
high risk for injury related to epidural
What is a direct and indirect Coombs and how do I utilize it?
?
What is membrane stripping?
The doctor goes in to check woman's dilation and if he thinks you're near enough date, he'll do an aggressive grooming to see if he can pull out the mucus plug to stimulate labor.
Define FETAL ductus arteriosus?
large with no tone; blood flow from pulmonary artery to aorta
Define NEWBORN ductus arteriosus?
reversal of blood flow; now from aorta to pulmonary artery because of increased left atrial pressure; ductus is sensitive to increased oxygen and body chemmicals and begins to constrict
Define FETAL foramen ovale?
patient with large blood flow from right atrium to left atrium
Define NEWBORN foramen ovale?
increased pressure in left atrium attempts to reverse blood flow and shuts one-way valve
Define FETAL pulmonary blood vessels?
constricted with very little blood flow; lungs not expanded
Define NEWBORN pulmonary blood vessels?
vasocilation and increased blood flow; lungs expanded; increased oxygen stimulates vasodilation
During transition from fetal to newborn....there is initiation of respiration (expansion of lungs) which leads to increased _______ levels.
P02
Explain steps leading up to closure of foramen ovale in newborn when P02 levels are increased following expansion of lungs?
decreased pulmonary vascular
resistance
increased pulmonary blood
flow
increased pressure in left
atrium
closure of foramen ovale

(there is also decreased right atrial pressure which also assists in closure of foramen ovale)
Explain steps leading up to closure of ductus venosus following expansion of lungs in newborn?
expansion of lungs
increased PO2 levels
increased systemic vascular
resistance
decreased systemic venous
return
cessation of umbilical
venous return
closure of ductus venosus
Explain steps leading up to closure of ductus arteriosus?
Expansion of lungs
increased P02 levels
increased systemic vascular
resistance
systemic resistance greater
than pulmonary
closure of ductus arteriosus

(there is also pulmonary resistance less than systemic...leads to left-to-right shunt)
Name the five major areas of change in cardiopulmonary adaptation?
increased aortic pressure and
decreased venous pressure
increased systemic pressure
and decreased pulmonary
artery pressure
closure of foramen ovale
closure of ductus arteriosus
closure of ductus venosus
Explain increased aortic pressure and decreased venous pressure in newborn?
Clamping of umbilical cord eliminates the placental vascular bed and reduces the intravascular space. Then, aortic (systemic) b.p. increases. At same time, blood return via the IVC decreases, resulting in decreased right atrial pressure and a small decrease in pressure within the venous circulation.
Explain increased systemic pressure and decreased pulmonary artery pressure in newborn?
With the loss of the low-resistance placenta, systemic resistance increases, resulting in greater systemic pressure. At the same time, lung expansion increases pulmonary blood flow, and the increased blood P02 associated with initiation of respiration dilates pulmonary blood vessles. The combo of vasodilation and increased pulmonary blood flow decreases pulmonary artery resistance. As the pulmonary vascular beds open, the systemic vascular pressure increases, enhancing perfusion of the other body systems.
Explain closure of foramen ovale in newborn?
Closure of the foramen ovale is a function of changing atrial pressures. In utero, pressure is greater in the right atrium, and the foramen ovale is open after birth. Decreased pulmonary resistance and increased pulmonary blood flow increase pulmonary venous return into the left atrium, thereby increasing left atrial pressure slightly. The decreased pulmonary vascular resistance and the decreased umbilical venous return to the right atrium also cause a decrease in right atrial pressure. The pressure gradients across the atria are now reversed, with left atrial pressure greater, and the foramen ovale is functionally closed 1 to 2 hours after birth. However, a slight right-to- left shunting may occur in the early neonatal period. Any increase in pulmonary resistance or right atrial pressure, such as occurs in crying, acidosis, cold stress, or induced hypoxia, may cause the foramen ovale to reopen, causing a right- to-left shunt. Permanent closure of the foramen oval occurs within 6 months.
Explain closure of ductus arteriosus?
Initial elevation of the systemic vascular pressure above the pulmonary vascular pressure increases pulmonary blood flow by reversing the flow through the ductus arteriosus. Blood now flows from aorta into pulmonary artery. Also, although the presence of oxygen causes the pulmonary arterioles to dilate, an increase in blood P02 triggers the opposite response in the ductus arteriosus--it constricts.
Functional closure is done within 15 hours of birth, and fibrosis of ductus occurs within 3 weeks after birth.
Explain closure of ductus venosus in newborn?
Although the mechanism of initiating closure of ductus venosus is not known, it appears to be related to mechanical pressure changes that result from severing of the cord, redistribution of blood, and cardiac output. Closure of the ductus venosus forces perfusion of the liver. Fibrotic closure occurs within 2 months.
What is the purpose of the DeLee mucus trap?
to remove excess secretions from the mouth and nares due to possible depressed respirations or if amniotic fluid was meconium stained
What is the preparation for performing nasal pharyngeal suctioning using the DeLee mucus trap?
Tighten DeLee lid or other suction device collection bottle to avoid spillage of secretions and prevent air from leaking out of lid.
Connect one end of DeLee tubing to low suction.
Procedure for performing nasal pharyngeal suctioning using DeLee or other suction device?
*gloves
*suction turned off
*insert free end of DeLee tubing 3 to 5 inches into newborn's nose or mouth
*place thumb over suction control and begin to apply suction; continue to suction as you slowly remove the tube, rotating it slightly
*continue to reinsert tube and provide suction for as long as fluid is aspirated
*if it is necessary to pass tube into newborn's stomach to remove meconium secretions that newborn swallowed before birth, insert tube through the newborn's mouth into stomach; apply suction and continue to suction as you withdraw tube
*document completion of procedure and amount and type of secretions
What is the rationale behind inserting free end of DeLee tubing 3 to 5 inches into newborn's nose or mouth?
applying suction while passing the tube would interfere with smooth passage of the tube
What is the rationale behind placing thumb over suction control and beginning to apply suction; continue to suction as you slowly remove the tube, rotating it slightly?
Suctioning during withdrawal removes fluid and avoids redepositing secretions in the newborn's nasopharynx
What is the rationale for continuing to reinsert tube and provide suction for as long as fluid is aspirated and not excessively aspirating?
Excessive suctioning can cause vagal stimulation, which decreases the heart rate.
What is the rationale behind
passing tube into newborn's stomach to remove meconium secretions that newborn swallowed before birth, insert tube through the newborn's mouth into stomach; apply suction and continue to suction as you withdraw tube?
Because the newborn's nares are small and delicate, it is easier and faster to pass the suction tube through the mouth
Explain the rationale behind documenting the completion of the procedure and the amount and type of secretions?
This documentation provides a record of the intervention and the status of the infant at birth.
Define physiologic jaundice?
Tabors: caused by accelerated destruction of fetal RBCs, impaired conjugation of bilirubin, and increased bilirubin reabsorption from intestinal tract...not pathologic...a normal biologic response to newborn...there are six factors giving rise to it

lecture notes: newborn has too many RBC's, with a shorter lifespan than adults..the RBCs are dying off... and an immature liver that can't handle the metabolic breakdown

text: occurs after first 24 hours of life
during first week of life, bilirubin should not exceed 13 mg/dL;
some pediatricians allow levels up to 15 mg/dL;
bilirubin levels peak at 3 to 5 days in term infants
Six factors (H & S)which give rise to physiologic jaundice are?
*increased amounts of bilirubin delivered to liver
*defective uptake of bilirubin from plasma
*defective conjugation of bilirubin
*defect in bilirubin excretion
*inadequate hepatic circulation
*increased reabsorption of bilirubin from intestine
Define kernicterus?
*a form of jaundice occurring in newborns during the second to eighth day after birth
*the basal ganglia and other areas of the brain and spinal cord are infiltrated with bilirubin, a yellow substance produced by the breakdown of hemoglobin. The disorder is treated by phototherapy and exchange transfusion to limit neurological damage. The prognosis is quite poor if the condision is left untreated.
(per lecture, kernicterus is when the byproduct adheres to the meninges of the brain and causes mental retardation)
Physiological jaundice and lecture notes.
baby has excessive amount of RBCs...liver is immature...typically the RBC's break down....they are metabolized through the liver...but they can't be metabolized efficiently in the immature liver...typically, the break down of a RBC results in bilirubin...it's part of that conjugation of the RBC...the bilirubin is what gives us the yellow tint and we have a problem...since the etiology of physiological jaundice has to do with longevity of the RBCs, we find that these babies end up getting yellow, lethargic, and at a certain level of above 20, they can possibly become kernicterus.
Kernicterus is gotten when the mother smokes a lot, so there's a hypoxic environment and malnutrition...so baby creates an excessive amount of RBC's whose break down can't be metabolized because of it's immature liver...hence jaundice..

Again...there's an increased amount of bilirubin in the liver...the newborn RBC's go to his liver, become conjugated and becomes excreted...how is jaundice/bilirubin excreted? In the stool.

What helps the baby's stool?
Eating...so instead of eating every 3-4 hours...eat every two hours.
One way to treat physiologic jaundice is to assist newborn with?
eating frequent meals, about every 2 hours instead of every 4 hours...not with water but with something that increases peristalis...a food of some sort...whether it's breastfeeding colostrum or the bottle feeding.
Why does breast feeding in a physiologic jaundice case have an advantage over bottle feeding?
breast feeding metabolizes faster and it has a cathartic or laxative effect...so it stimulates peristalsis much faster than formula does. More stools are eliminated more frequently which helps eliminate more of the bilirubin.
Phototherapy is used in physiologic jaundice cases when?
the bilirubin is excessively high...usually 14 at birth...15...but they don't want bilirubin to hit 20...damage doesn't typically occur until it hits 20...can cause brain damage, mental retardation. It can also cause hearing loss.
Babies that get physiologic jaundice but who's bilirubin may not get high enough (borderline) to get Mental retardation may still have some loss of ?
hearing
Lecture: Diagram
bilirubin going into liver and hepatic system begins to conjugate it and begins to eliminate it. What isn't eliminated is absorbed back into the circulatory system and as it is circulated, it becomes unconjugated and you cannot elim
okay
Inteventions for physiologic jaundice?
push fluids
If for some reason, the baby is placed under phototherapy treatments, then you have to do things to protect the baby from phototherapy injury which includes:
*protect eyes by patching...it's like sunbathing...so the baby bronzes which is not a good thing
*expose as much skin surface as possible even if it means having the baby naked
*turn babies frequently to avoid bronzing
*protect baby from dehydration...light dehydrates...like being out in the sun
*don't impair the bonding process most of all
Phototherapy works in jaundice cases by?
breaking down bilirubin and
helps unconjugated bilirubin become conjugated so that it can be eliminated...unconjugated won't eliminate
When operating a phototherapy session, make sure you are
calibrating the machine properly
that you know how much it's putting out so that you're using effective phototherapy.
What can cause physiologic jaundice?
ABO incompatibilities can cause bilirubin...
Rh incompatibilities can cause elevated bilirubin...
those are the abnormal ones...

breast milk on some babies can cause bilirubin (this is a late onset)...
babies mom's who have been induced with ptosin increases bilirubin...
babies who get overdoses of aquamethycin? get bilirubin..
How was phototherapy discovered?
babies who are next to the window have a lower bilirubin count than those who aren't...that's how phototherapy was discovered
What may lead to an increased bilirubin count?
delayed cord clamping
leading to increased blood
volume
use of forceps causing trauma
to newborn
inadequate ingestion of
calories by newborn
hypothyroidism
fatty acids in breast milk
vs albumin competing for
binding sites
bacterial flora and decreased
intestinal motility
congenital infection
decreased oxygen due to
mother smoking or
congenital heart disease
reduced bowel motility
intestinal obstruction
delayed passage of meconium
What is the Coombs test?
a lab test for presence of antibodies, usually blood type antibodies, in serum.
The patient's serum is incubated with RBCs with known antigenic markers; if antibodies to the antigen are present in the serum, they bind with RBCs. When antihuman globulin is added, RBC clumpong occurs. The test is used for crossmatching blood before transfusion to ensure that no antigen antibody reaction will occur and to test for the presence of specific antibodies to RBCs
What is indirect Coombs?
?
What is direct Coombs?
?
There's a direct and indirect Coombs...one is for mom..one for baby. which one indicates there's an ABO or Rh problem? Which one indicates it's a regular physiological jaundice and to go ahead and proceed?
Know for bilirubin as well as for RH incomp
?
What is breast milk jaundice?
Bilirubin levels begin to rise about the fourth day after mature breast milk comes in.
Peak of 5-10 mg/dL is reached at 2 to 3 weeks of age
It may be necessary to interrupt breastfeeding for a short period when bilirubin reaches 20 mg/dL
Newborns don't have enough vitamin K to heal their cord and keep them from being at risk for bleeding so we give them?
AquaMEPHYTON
or AquaNephatin??
Vitamin K 0.1 mg always in the vastus lateralus (outside of foot)
use 5/8" syringe, one time shot
(make sure to give 0.1 mg because if 1 mg given, the baby will be at risk for hyperbilirubinemia)
How does a nurse minimize the exposure of the newborn to mother's AIDS before giving Vitamin K shot?
Babies should not get Vitamin K shot until after their initial bath because mother's who have AIDS can infect the baby during pregnancy, during delivery, during breastfeeding, or during exposure to fluids afterwards. We don't know when it occurs.
Meds on hand for hospital nursery are minimal and might include?
AquaMEPHYTON (vitamin K)
something to treat eyes
something to treat bleeding
circumcision (epinephrine,
topical)
(just a few stocked drugs, because nursery looks for healthy babies)
When first assessing baby
measure their length by measuring from?
the tip of the head to the heel. A slide may be used and a pencil. Some meaasure from the crown to the rump and down (which is not as accurate)
Measure the circumference of head from?
Lecture: Just over the eyebrows, just above the ears.
Text: Because of molding, the circumference of newborn's head should be measured immediately following birth and about 3 days later
breech born and cesarean births circumference is not affected
Measure the chest by?
measure under the arms, across the back and across the nipple line
When assessing cord, make sure there is?
one vein
two arteries
Check placenta for all of it's?
condylile ??? part in it and not fragmented
Weight loss in newborn in first week attributable to?
fluids that are moved from the intracellular to extracellular. This is when we get them urinating more frequently. We also get some dehydration and add that to phototherapy...more insensible loss...
How much is stomach capacity of newborn?
50 to 60 mls
(not good to start off with an 8 ounce bottle...use 4 ounce bottle to prevent regurgitation)
Cardiac sphincter which holds the food in newborn stomach is immature so they'll spit up, so?
burp them frequently until the food settles below the air and that they won't have projectile vomiting.
Bottle feeders should burp their babies about?
every ounce
Newborns will usually pass meconium no later than?
8 - 24 hours or doctor wants to investigate typically...there may be some abnormal problem like Hirsprung's disease, megacolon...maybe no connection from colon to rectal sphincter (surgical procedure possibly)
The nurse should anticipate a messy black tarry stool in healthy newborn.
Define phenylketonuria?
Tabors: a congenital, autosomal recessive disease marked by failure to metabolize the amino acid phenylalanine to tyrosine.
Results in severe neurological deficits in infancy if it is unrecognized or left untreated
Phenylalanine
an amino acid...food products must tell the consumer that it contains phenylalanine because it converts to tyrosine and it doesn't convert in people with PKU who are unable to break it down to a usable amino acid that can be absorbed (gum is another source)
It it contains phenylalanine
(almost all cooked products, premade products).
It really makes a problem because kids can't break it down so there's an increase of phenylalanine in their blood. That's why in 3 weeks they go back to the pediatrician for this test to detect whether or not they have the PKU...
How does phenylalanine affect children throughout growth?
Children who can't break down phenylalanine have to avoid it during their whole growth process.
Every increase in phenylalanine can cause bilirubin and kernicterus and possible mental retardation. This occurs because phenylalanine and its byproducts accumulate in the body, esp. nervous system where it can cause MR.
How to test newborns for PKU?
Tabors: heel-stick specimen of blood, which is allowed to dry on blottingn paper before being sent to the lab; confirm high levels with additional test

Lecture: 24 hours after eating...make sure heel is nice and warm, squeeze it enough to be able to wipe off first drop of blood with alcohol...saturate strip...put it in assay tray and check thyroid (Cretenism), PKU, thalacemia, and others not done in Texas...PKU usually done 2-3 weeks after birth (AFTER 24 HOURS and FOOD intake) in doctor's office.
don't bruise the baby when doing PKU...be kind and gentle
Recommended newborn screening for PKU is?
Tabors: before discharge from nursery or in first 2 weeks of life
The PKU test is most accurate if performed no sooner than?
Tabors: 24 hours after birth
Lecture: to get an adequate test, the baby needs to have eaten at least 24 hours to cause a change in their blood...so if there's a baby that's not eating well...you could get a false negative if you take the test too early.
Some women with PKU who are childbearing ability, should avoid phenylalanine during pregnancy or keep it low amounts which will prevent _____ _______ in the fetus.
Tabors: fetal malformation
Congenital hypothyroid?
an inborn enzyme deficiency...can be from lack of dietary iodine...especially in Africa where they use salt without iodine...there's an increase of goiters and congenital hypothyroidism.
the check is done at birth for both in Texas. Also done for thalacemia (Mediterranean blood dyscrasia) and there's a whole list of tests that can be done at the same time that are not done in Texas.
NCLEX focuses on universal.
Kids will receive thyroid their whole life.
All newborn's have a _____
tinge to their skin regardless of genetic background.
pink
What is choanal atresia?
*congenital blockage of the passageway between nose and pharynx
*newborn will be cyanotic at rest and pink only with crying
*if crying increases cyanosis, heart or lung problems may be suspected
Very pale newborn may indicate?
anemia
hypovolemia (low b.p.)
What is acrocyanosis?
bluish discoloration of the hands and feet
What is acrocyanosis due to?
poor peripheral circulation, which results in vasomotor instability and capillary stasis, esp when the baby is exposed to cold;
if central circulation is adequate, blood supply should return quickly to extremity after blanching
Don't use blue hands and nails to assess?
oxygenation of newborn
Face and mucous membranes should be pink and are the best indicatior for assessing?
adequate oxygenation
Define mottling?
lacy pattern of dilated blood vessels under skin
Mottling occurs as a result of?
general circulation fluctuations
How long may mottling last?
several hours to several weeks or come and go periodically; may be related to chilling or prolonged apnea
What is Harlequin sign?
clown
a deep color develops over one side of the newborn's body while the other side remains pale, so that the skin resembles a clown's suit
How does Harlequin sign develop?
results from a vasomotor disturbance in which blood vessels on one side dilate while the vessels on the other side constrict; usually lasts from 1 to 20 minutes; may be single or multiple episodes, are transient and not of clinical significance
Define jaundice?
first detectable on face (where skin overlies cartilage) and mucous membranes of mouth
How is jaundice evaluated primary to sclera?
by blanching tip of nose, forehead, or gum line under proper lighting
yellowish cast following blanching is indicator
Besides face, what other area can indicate jaundice?
sclera
Jaundice may be related to?
Text:
breastfeeding
hematomas
immature liver function
bruises from forceps
blood incompatibility
oxytocin (pitocin)
severe hemolytic process
Define erythema toxicum?
perifollicular eruption of lesions that are firm, vary in size from 1-3 mm, and consist of a white or pale yellow papule or pustule with an erythematous base;
often called "newborn rash" or "flea bite" dermatitis
Define milia?
*exposed sebaceous glands
appear as raised white spots
on face, esp. across nose
*no treatment necessary because they clear up
*transient neonatal pustual melanosis in Africans
How to assess newborn skin turgor?
*used to assess hydration,
initiate early feedings, infectious processes
*asess over the abdomen or thigh
*skin should be elastic and return rapidly
Define vernix caseosa?
*whitish cheeselike substance which covers fetus while in utero and lubricates skin of newborn
*skin of term or postterm newborn has less vernix and is frequently dry
*peeling is common, esp. hands and feet
What is the birthmark telangiectatic nevi (stork bites)?
pale pink or red spots and are frequently found on eyelids, nose, lower occipital bone, nape of neck
*lesions common in light-complexioned newborns and are more noticeable during periods of crying; have no clinical significance and usually fade by second birthday
What are Mongolian spots?
*macular areas of bluish black or gray-blue pigmentation found on the dorsal area and the buttocks (base of spine)
*common in newborns of Asian and African descent and other dark-skinned races
*may be mistaken for bruises and should be documented in
newborn's chart
IT'S NORMAL!
What is nevus flammeus (port wine stain)?
*a capillary angioma directly below the epidermis
*nonelevated, sharply demarcated, red to purple area or dense capillaries
*Africans may appear as a purple-black stain..size and shape varies...commonly appears on face...does not grow in size...does not fade with time...does not blanch; may be concealed by cosmetic cream
Define nevus vasculosus (strawberry mark)
capillary hemangioma
consists of newly formed and
enlarged capillaries in
dermal and subdermal layers
raised, clearly delineated,
dark red, rough-surfaced
birthmark commonly found
in head region
What is lanugo?
fine downy hair covering body..if born prematurely, they will have more lanugo than if full-term.
covers ears, shoulders, arms which wears away with time
Respirations of newborn are?
Lecture: fast, irregular,
abdominal and obligatory nose breathers; apnea no longer than 10 seconds okay; color changes should not be apparent
Text: 30-60 respirations per minute
predominantly diaphragmatic but synchronous with abdominal movements
respirations are counted for 1 full minute
The newborn's head is large, about _____-______ of body size with soft pliable skull bones.
one-fourth
What is molding?
asymmetry in vertex presentation
What causes molding?
overriding of cranial bones during labor and birth
When does molding go away?
within a few days after birth and then suture lines become palpable
Any extreme differences in head size may indicate?
microcephaly
hydrocephalus
Define fontanelles?
useful indicator of newborn's condition
soft spots
openings at the juncture of the cranial bones measured with fingers in cms
appear smaller at birth because of molding
How is the measurement of fontanelles carried out?
sitting position
not crying
anterior fontanelle 3-4 cm by 2-3 cm; closes in 18 months
posterior fontanelle 0.5 cm by 1 cm; closes in 8-12 wks
The anterior fontanelle may _____ when the newborn ________ or passes a stool or may pulsate with ________
which is normal
swell
cries
heartbeat
A bulging fontanelle usually signifies increased ___________ _____________
intracranial pressure
A depressed fontanelle usually indicates _________
dehydration
The newborns head has a?
recedingn jaw
small mouth
reflexes that are intact and are to be checked for
frenulum (dip in lip) if it's
absent, it's abnormal
may have a blister on upper
lip from sucking thumb or
lip throughout utero.
they don't normally have teeth, but occasionally one is born with a tooth
What is a rooting, sucking, and gagging reflex?
stroke the cheek
baby will open it's mouth and turn toward the side of the stimulus
when baby searches for finger, then quickly check for soft palate...while finger is being sucked on, advanced finger slightly so baby gags to check gag reflex
What is caput succedaneum?
a localized, easily identifiable soft area of scalp, generally resulting from a long and difficult labor or vacuum extraction
What happens to newborn in caput succedaneum?
*there is compression of local blood vessels
*venous return is slowed
*causes increase in tissue fluids...edematous swelling....occasional bleeding under periosteum
How long does it take the fluid from caput s. to reabsorb?
within 12 hours to a few days after birth
The difference between caput s. and cephalhematoma is?
caput overrides suture lines and cephalahematoma never crosses a suture line
Define cephalahematoma?
collection of blood between cranial (usually parietal) bone and periosteal membrane...
doesn't cross suture lines...
doesn't increase in size with crying...appears on firrst and second day...disappears after 2-3 weeks ormay take months
What is the pre-auricular hole?
Sometimes when ear forms it forms a false indentation dimple right in front of the ear (preauricular hole)
The abdomen is _________
rounded.
Describe nipples?
With boy or girl, breast buds may be slightly swollen or inflamed due to female hormone, estrogen.
chest and abdomen and respiration
the chest will not have as much respiratory motion as abdomen...there should be no intercostal retraction...check clavicle
Ophthalmascope eye check for?
*cataracts
*transient strabismus
*red reflex should be symmetric in both eyes...either offset to one side...but they should be symmetrical
The base of the spine should have a indention called?
sinusoidal dimple
it is sometimes considered spina bifida
it can develop into a cyst later on in life because of the many hairs in it
just document it and don't do anything about it
What is the step reflex?
Standing a newborn up will make him take a slow step..pick up other foot and take another slow step
Trunk and head are disproportionately long compared to ______
legs
Genitalia on males?
Lecture: may have enlarged scrotum again from the hormones;
breech babies have larger scrotums because of the trauma of being born breech.
What is hypospadias?
occurs when the urinary meatus of male infants is located on the ventral surface of penis
What is phimosis?
a condition occurring in newborn males in which the opening of foreskin (prepuce) is small, and foreskin cannot be pulled back over glans at all...may interfere with urination, so adequacy of urinary stream should be evaluated
Female genitalia on fullterm?
will have enlarged labia majora...labia minora should not be visible in fullterm or barely visible...
clitoris may or may/not be enlarged due to hormone...
Female genitalia on preterm?
very minor labia majora and labia minora will be more present
The arms and legs of newborn are typically?
flexed...they like the fetal position and warmth.
Hands of newborn are typically?
closed, fist-like, palmar grasp
What is the plantar response?
newborn's toes curl when fingers placed under them
What is Babinski reflex or plantar reflex?
Lecture: flaring of toes

Tabors: dorsiflexion of great toe when sole of foot is stimulated; normal in infants under age 6

Text: fanning and hyperextension of all toes, occurs when the lateral apsect of the sole is stroked from the heel upward across the ball of foot..in adults, by contrast, the toes flex
Define Ortolani maneuver?
rules out congenital hip dysplasia
place quiet newborn on firm surface
What angle are hips and knees at with Ortolani maneuver?
90 degree
With Ortolani maneuver, what does nurse grasp?
text: infant's thigh with middle finger over greater trochanter
With Ortolani maneuver, how does nurse lift infant's thigh?
text: to bring femoral head from its posterior position toward acetabulum
With Ortolani's maneuver, what happens after abducting thigh?
text: the femoral head is returned to the acetabulum and examiner feels a sense of reduction or a "clunk"; the reduction is palpable and cannot be heard
What is Ortolani's maneuver per lecture?
take baby, lay on back, bring knees up to a parallel position and push back toward table...when pushing back toward table, rotate hips outward and down, and feel a click (abnormal) or give (abnormal) in the hip socket that isn't well-formed...they will monitor that hip and start doing treatments to keep that hip aligned in the socket as the hip continues to grow...a minimally invasive treatment is to double-diaper them...the double-diaper will deep seat it.
Don't let small children sit in front of television on floor with legs behind them, because that rotates them too much. They can also put them in braces at night with shoes and brace across the two feet to keep the legs splayed so that the hips stay more aligned. If surgical intervention called for, they'll spika cast them.
A spika cast goes from just above the waist down to the knee on one side and usually down past and a cutout for elimination. They stay in that for months. Can't put him in a carseat...mom has to carry child and a 50 pound cast, dressing them, feeding them, skin break down.
What is talipes?
Lecture: Hold knee of baby, and see whether the foot stays turned in or whether he gets into alignment...
newborn can exercise those muscles to help (physical therapy)...soft shoes are better than hard shoes of yesterday

Tabor: any of several deformities of the foot, esp. those occurring congenitally; a nontraumatic deviation of the foot in the direction of one or two of the four lines of movement
Assessing back?
*baby prone
*spine should appear straight and flat because lumbar and sacral curves don't develop until infant begins to sit
What is the text's dermal sinus called nevus pilosus?
(Same as sinusoidal dimple in lecture.)
*look for dermal sinus
*nevus pilosus ("hairy nevus") may be found at base of spine in newborns, but significant in association with spina bifida; examine to make sure no connection with spinal canal
Possible nursing diagnosis? (6)
Ineffective airway
Ineffective thermoregulation
Risk for altered nutrition
Risk for infection
Risk for injury
Altered family
Do initial temperature of newborn by rectum, not axillary because?
to see if rectum is patent...care must be taken not to damage rectum if it's not patent...what is the hospital's protocol...some are getting away from rectal temperatures because of perforation...just check patency by stool
Warm room important because we don't want the newborn to lose heat through?
evaporation
convection
conduction
radiation
When assessing head to toe, do quiet things first. Don't start with blood pressure. Start with _____.
Do palpations last.
Measure the newborn head and length, talk softly.
respiration
What is motor or startle reflex?
take the crib and lift and drop...babies arms will go outward like they're falling...fingers and thumbs will go into C shape. That's a good thing.
What is the tonic neck reflex?
text: fencer position
elicited when the newborn is supine and the head is turned to one side; in response, the extremities on the same side straighten, whereas on the opposite side they flex; this reflex may not be seen during the early newborn period, but once it appears, it persists until about the third month
lecture: lay baby on back, turn him to one side, he's going to extend the arm out on the side he's turning into and he'll put his other arm over his head...it eventually goes away...it's normal.
Nursing diagnosis for newborn cleft palate might be?
risk for altered nutrition
Nursing diagnosis for newborn with mother with PKU is?
risk for altered nutrition
Nursing diagnosis for mother with beta-hemolytic strip that was positive and they didn't have time to treat her because she delivered rapidly?
risk for infection
Nursing diagnosis for ruptured membrane?
risk for infection
Nursing diagnosis for 14 yo mother with lack of maternal experience?
risk for injury related to 14 yo mother and lack of experience
Nursing diagnosis for male mental IQ equal to 6 yo?
risk for injury
History of previous pregnancy important because?
she may be a gravida six, and a para 2 so what has she gone through to have this baby...maybe she's not experienced as you anticipated...maybe she has complications...maybe newborn came out with complications...2 vessels, an artery and a vein...instead of 2 arteries and a vein...how fast does she normally delivery...
The most important information concerning prenatal history is?
immunizations
If she didn't have prenatal care and we don't know what her status or lifestyle has been. Is she immune to measles, does she have Rh factor? Has she taken prenatal vitamins? What's her weight gain? Low iron?
okay
Parent-child relationships or bonding
okay
Reba Rubin?
she discusses stages of bonding. Look her up!
Maslow?
where does sense of belonging fall in hierarchy of needs?
Erickson? What is the first stage of development?
trust vs mistrust
What is the grasping reflex?
elicited by stimulating the newborn's palm with a finger or object...
newborn will grasp and hold the object or finger firmly enough to be lifted momentarily from the crib
What is the Moro's reflex?
elicited when the newborn is startled by a loud noise or is lifted slightly above the crib and then suddenly lowered...
in response the newborn straightens arms and hands outward while the knees flex...
slowly the arms return to the chest, as in an embrace..
fingers spread, forming a C, and the newborn may cry...this reflex may persist until about 6 months of age
What is the rooting reflex?
elicited when the side of the newborn's mouth or cheek is touched. In response the newborn turns toward that side and opens the lips to suck (if not fed recently)
What is the sucking reflex?
elicited when an object is placed in the newborn's mouth or anything touches the lips...newborns suck even while sleeping; this is called nonnutritive sucking,and it can have a quieting effect on the baby
What is trunk incurvation or Galant reflex?
seen when the newborn is prone...stroking the spine causes theh pelvis to turn to the stimulated side
Arteries are delivering _______ blood back to mother and the vein is delivering __________ blood
unoxygenated
oxygenated
What is the state of newborn's oxygen when born?
When the newborn is born, it looks somewhat blue...it's in a hypoxic state...just enough to survive...we couldn't survive
Discuss clamping?
Some doctors like to wait until the cord stops pulsating to clamp it and cut it. That used to be one of the old thinkings. They felt at that point, the baby has converted over to extrauterine circulation and it was safe to go ahead and clamp. Other doctors thought that delaying that allowed too much blood from the placenta to pass to the baby and increased the risk for hyperbilirubinemia...
Now it's common knowledge that sudden clamping of the cord helped the baby transition faster.
Where is the clamping of umbilical cord done?
One is close to the baby with a Hollister clamp because it's a plastic clamp that when it's clamped (Hollister's who made it)..it doesn't come undone...it stays locked. It has to be cut or broken. The other is a Kelly forcep and you cut between the two clamps. If you didn't clamp on the other side, when you cut it, everything would come out of the placenta, blood would continue to flow, and there'd be a puddle of mush. So clamp both ends.
So after flow stops from umbilical vein, you get started closure of patent ductus arteriosus which comes from the aortic arch and goes across to pulmonary.
This is transient in nature. It takes anywhere from 24 to 72 hours to close completely. Once
okay
What is PFC?
persistent fetal circulation
causes hypertension in pulmonary vessels..and the more resistance and hypertension in the pulmonary vessels, the less oxygen is picked up...the more it continues to stimulate the fetal circulation and it's a self-fulfilling prophecy.
What is done in the case of PFC or persistent fetal circulation?
give medication to keep PDA open...because newborn won't survive if it's closed
What are the drugs used to treat PFC?
phenobarbitol??
indomethycin??
others?
Once these closures happen, pulmonary circulation is increased because of resistance that was in the pulmonary circulation decreases. If for some reason, the baby has what we used to term as hyland membrane disease?? which is now immature fetal surfactan
okay
Transitory murmurs. These are associated with PDA. Listen to newborn hearts...they're so fun to listen to....murmurs, clicks, are normal.
okay
Take blood pressure in ankle or thigh. Normal systollic will be greater than _____.
40
Hypotension condition will be less than _____?
40
So newborns will have a higher _____ _____ and a lower ______ _______.
heart rate
blood pressure
Why do newborns have a rapid loss of heat loss?
*there is a great amount of body surface to body mass index newborn have
*limited amount of insulating subcutaneous fat ...out of shower...infant is bathed in warm fluid and then out into a cold environment all wet
*there is heat loss internally and externally
*it's not impaired heat production, IT'S excessive heat LOSS!
How does heat transfer occur in newborn?
*increase in oxygen consumption
*depletion of glycogen stores
*metabolizing of brown fat
What is convection?
text:
*loss of heat from warm body surface to cooler air currents
*air-conditioned rooms, air currents with a tem. below infant's skin temp, oxygen by mask, and removal of infant from an incubator for procedures increase convective heat loss of newborn

lecture:
loss of heat to air...so if surrounding air is cooler than you...you'll lose heat
Define radiation?
Losses occur when body heat rises to cooler surfaces and objects not in direct contact with the body...the walls of a room or an incubator are potential causes of heat loss by radiation, even if the ambient temp. of the incubator is within the neutral thermal range for the infant...placing cold objects (such as ice for blood gases) onto the incubator or near the infant in the radiant warmer will increase radiant heat losses
Define evaporation?
loss of heat incurred when water is converted to a vapor...the newborn is particularly prone to heat loss by evaporation immediately after birth, when the baby is wet with amniotic fluid, and during baths; thus drying the newborn is critical
Define conduction?
loss of heat to a cooler surface by direct skin contact...chilled hands, cool scales, cold examination tables, and cold stethoscopes can cause heat loss by conduction...even if objects are warmed to the incubator temperature, there still may be a significant temperature difference between the infant's core temperature and the ambient temperature...this results in heat transfer
Which two of the four avenues result in the highest heat losses?
radiation
convection
Explain shivering in newborn?
rarely seen in newborn...
means the newborn metabolic rate has already doubled...
extra muscular activity does little to produce needed heat
Define brown adipose tissue (BAT)?
uniquie and assists in nonshivering thermogenesis in newborn...
primary source of heat in newborn..
first appears in fetus 26 to 30 weeks gestation...
continues to increase until 2 to 5 weeks afer birth of term infant, unless depleted by cold stress
Where is brown adipose tissue BAT found?
midscapular area
around neck
axillas
deeper placement around trachea
esophagus
abdominal aorta
kidneys
adrenal glands
How much of newborn's total body weight is BAT and why is it called BAT?
2% to 6%
receives name from its dark color, which is due to its enriched blood supply, dense cellular content, and abundant nerve endings
How about BAT and preterm babies?
have less BAT
Newborn is considered hypoglycemic if blood sugar heel stick is less than _____?
45???
(if this low, probably okay to give 5% sugar or dextrose water...babies who have not had a tried esophageal gag and swallow, makes it easier on the lungs if it's aspirated) also can put baby to breast because colostrum has some glucose
Don't heel stick the inner part of the foot because?
there are arteries and nerves there and easily bruised
(use lateral part of heel and warm it up)
In cases of hypoglycemia, the baby is using up oxygen and glucose, they're also using up calories...so they're at risk for?
metabolic acidosis and ketoacidosis
(like adults who get on diet and start exercising)
it also reduces the amount of surfactant production they continue to make...
this is a normal risk for normal babies...it typically doesn't become a big problem
How big is a US male baby?
female baby?
about 7.5 pounds
about 7.2 pounds
What is the average length of US Caucasian male baby?
female baby?
19-21 inches?
Baby sleeps about ______ to _____ per day for first 2 weeks.
16-20
(this depends on if breastfeeding or bottle feeding...because breastfed babies are satified more quickly but eat more often, because they break down the food more quickly...whatever mother eats, happens...if mom ingest caffeine, baby feels effects...baby wired)
Describe shapes of fontanelles of newborn?
back fontanelle is a triangle, it's very small, should not be able to put whole fingertip into it, just feel it...
the front fontanelles where the 3 or 4 plates come together is a diamond...should be able to put 2-3 fingertips to palpate it...they should be flat and have some spring to them...check when not crying or fontanelles will bulge...
if fontanelles are sunken, it may indicate dehydration...check in sitting up position, not laying down
What is normal for umbilical cord?
2 arteries and 1 vein...if one artery and 1 vein then at risk for kidney or heart defects
About the 26th week, the baby might experience respiratory effort, because baby breathes in amniotic fluid...there might be less surfactant in those arterioles by the 35th week.
What diagnostic test can be done?
can do amniocentesis to determine whether the baby can be born or not...if there's a problem going on...and that's because the baby breathes amniotic fluid in and it bathes the lungs and comes back out and causes respiratory effort...picking up materials
When there is decreased surfactant, there's nothing to keep the balloon inflated when it empties of air and it reinflates. Surfactant gives it elasticity and causes it not to stick. When a baby has meconium and has stool that's in utero, so when alveoli
okay
Baby's are obligatory nose breathers. So which does the nurse suction first, nose or mouth?
suction nose first...first one nares then the other
(baby won't switch to mouth breathing)
Within first minute of life, the nurse would expect from newborn?
loud lusty cry
no respiratory distress
no retractions of intercostal
muscles
no grunting or sighing
respiratory rate less than
60
there will be a seesaw
diaphragmatic abdominal
movement for breathing
Apnea in newborn may last about ____ _____. This is normal. Baby's have paradoxical pulses...
they increase and decrease with the inner thoracic pressure...heart rate fluctuates
10 seconds
(if 10 seconds exceeded, baby at risk for SIDS; males at greater risk than females; twins are a risk)
O2 consumption in newborn is increased with what condition?
lecture:
hypothermia leading to metabolic acidosis
Hematocrit of infant is _____
than adult
higher
because they have a higher number of RBCs, because their RBCs only live about 90 days...adults live 120 days...they're in a hypoxic environment so body makes more RBCs to compensate...they're thrombocytopenic or hypocytopenic by nature...
babies will have high hematocrit...if hematocrit is higher than 70, what kind of workload is that for the baby?...it increases viscosity
What is phospholipid substance which is phospho-sincomyelin that lines alveoli??? (lecture)
allows lungs to expand when baby takes a breath
Having a stool in utero is an abnormal sign. If the baby has recently stooled, there needs to be aggressive resuscitative efforts done while the baby is still in the?
birth canal.
(dr will aggressively suction the baby's head at perineum before delivering the chest...this is to avoid the big gasp that baby makes when he emerges...don't want to bring the meconium back down into the lungs any more than necessary.
Meconium will arrive in first ______ hours and it will be black
24
Fetal hypoxia can occur?
up to a few days before delivery. There's a lot of things that can cause fetal hypoxia...parents may have done something to cause it too...not just medical staff
Discuss acceleration and deceleration?
Watch fetal activity...accelerations are a good sign, followed by deceleration, which is return to baseline...it can become a concern of hypoxia especially if it occurs over and over....or a slowing of the fetal heart rate where it can become bradycardic...
Discuss decreased variability?
lecture:
could be asleep or medicated, or if hypoxic...if it occurs longer than 15 minutes...if not medicated...something's wrong if baby's hypoxic for over 15 minutes.
Meconium staining at birth?
baby has already inhaled fluid while in utero...won't pink up real well...turn to a paleness instead of pink...have lower APGAR scores...aggressively go in and suction with a DeLee suction
Nursing diagnosis for presence of mucus or meconium?
ineffective airway clearance

so suction prn
place in side-lying position
observe for respiratory
distress: grunting, nasal
flaring, sternal
retractions
Nursing diagnosis for immature nervous system?
ineffective thermoregulation

so...provide appropriate heat source, hat and blankets, monitor room and infant's temperature frequently, avoid cold stress
Nursing diagnosis for limited food intake or poor sucking reflex?
risk for altered nutrition

so...weigh infant daily, assess mother-infant success at breast feeding and teach accordingly, assess bottlefeeding, monitor I&O
Nursing diagnosis for immature immune response?
risk for infection

so...proper handwashing

eye prophylaxis..use
erythromycin..kills
chlamydia and gonorrhea;
ointment is given in
conjunctival sac not on
sclera...will decrease
visual bonding between
newborn and mom...let mom
know...lasts couple hours

keep away from sick people

provide daily hygiene and skin care

does baby need daily bath?
not necessary

diaper changes - how often?
6 or more wet diaper per
day indicates adequate
nutrition as long as baby
is not just taking in water
*1 gram equals 1 ml of
fluid; weigh diaper
of output is normal

cord care - diaper under umbilicus so cord doesn't stay moist...try to keep cord dry...will turn black in 10-14 days and fall off...don't pull on it...use alcohol at the base or soap and water and keep it dry and clean...a smell coming from the cord is abnormal...avoid tub baths until cord falls off
Nursing diagnosis for immature blood clotting mechanism
risk for injury so...administer and chart vitamin K
Nursing diagnosis for immature liver function
risk for injury
so...monitor skin and scalp for jaundice...press nose for blanching
Nursing diagnosis for circumcision
risk for injury

so care for circumcision; very little care...just change diaper frequently...be careful not to pull on plastibell or ring that's left on...if using more traditional surgery with just a piece of foreskin left that hasn't epithelialized and it's mucosa...then use vaseline gauze to keep it from sticking and adhering to diaper and tearing skin...

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