A baby with neonatal abstinence syndrome may have a wide range of symtoms including CNS, metabolic, vasomotor, respiratory, and GI. These include:
(list
... [Show More] 3 or more for each) - CORRECT ANSWER CNS:
-increased wakefulness
-high-pitched cry, incessant crying
-irritability
-tremors
-hyperactive w/increased Moro reflex
-increased DTRs
-increased muscle tone
-abrasions and/or excoriations on the face & knees
-convulsions
Metabolic, Vasomotor, Respiratory:
-nasal congestion w/flaring
-frequent yawning
-skin mottling
-tachypnea >60/min
-sweating
-temp >than 37.2 C (99 F)
GI:
-poor feeding
-regurgitation (projectile vomiting)
-diarrhea
-excessive uncoordinated constant sucking
Hypoglycemia in the newborn findings: - CORRECT ANSWER -poor feeding
-jitteriness/tremors
-hypothermia
-diaphoresis
-weak shrill cry
-lethargy
-flaccid muscle tone
-seizures/coma
-irregular respirations
-cyanosis
-apnea
normal newborn blood glucose=
normal infant (up to 2 yrs) blood glucose= - CORRECT ANSWER 40-80 mg/dl
50-80 mg/dl
newborn dehydration s/s: - CORRECT ANSWER -urine output less than 1 mL/kg/hr
-urine specific gravity more than 1.015
-weight loss
-dry mucous membranes
-absent skin turgor
-depressed/sunken fontanels
postterm infant s/s: - CORRECT ANSWER -wasted appearance, thin w/loose skin
-peeling, cracked, dry skin, also leathery
-long, thin body
-meconium staining of fingernails and umbilical cord
-long hair and nails
-may be more alert
-hypoglycemic
-macrosomic
-cold stress
Birth injuries: subarachnoid hemorrhage s/s - CORRECT ANSWER -seizures within the 1st 72 hours
-decreased levels of consciousness
-irritability
Birth injuries: facial paralysis s/s - CORRECT ANSWER -facial flattening
-unresponsiveness to grimace that accompanies crying or stimulation
-eyes remaining open
Sun-setting sign is common with this newborn complication, in which the whites of the eyes are visible above the iris and the head is enlarged and fontanels are bulging: - CORRECT ANSWER Hydrocephalus
Manifestations include murmurs, abnormal heart rate or rhythm, breathlessness, and fatigue when feeding: - CORRECT ANSWER patent ductus arteriosus
Manifestations include respiratory difficulties, cyanosis, tachycardia, tachypnea, and diaphoresis: - CORRECT ANSWER Tetralogy of Fallot
How to suction with a bulb syringe for a newborn: - CORRECT ANSWER 1. compress bulb before insertion into 1 side of the mouth
2. Avoid center of the mouth to prevent stimulating gag reflex
3. Aspirate mouth 1st, one nostril, then 2nd nostril
Maternal Adaptation
Dependent: Taking in Phase - CORRECT ANSWER -first 24-48 hours
-focus is on meeting personal needs
-rely on others for assistance
-excited, talkative, need to share experience
Maternal Adaptation
Dependent-Independent: Taking-Hold Phase - CORRECT ANSWER -begins on day 2-3
-focus on baby & improving care-giving competency
-wants to take charge but needs acceptance from others
-wants to learn and practice
Maternal Adaptation
Independent: Letting-Go Phase - CORRECT ANSWER -focus on family as a unit
-resumption of role (intimate partner, individual)
How to relieve breast engorgement: - CORRECT ANSWER -completely empty breasts at each feeding
-nurse often
-massaging during feeding helps w/emptying
-alternate breasts w/each feeding
-apply cool compresses between feedings
-warm compresses (or warm shower) prior to feeding
-nonlactating clients: cold cabbage leaves in the bra, mild analgesics
PMI (point of maximal impulse) refers to the location in which fetal heart tones are best heard based on the position of the fetus. List the location the nurse should place the doppler based on fetal position:
Vertex presentation=
Breech presentation= - CORRECT ANSWER vertex= PMI is either in the right or left-lower quadrant or below the maternal umbilicus
breech=right or left upper quadrant above the maternal umbilicus
The nurse places the doppler in the right or left-lower quadrant or below the umbilicus to auscultate fetal heart tones in a baby that is in the _______presentation. - CORRECT ANSWER vertex
The nurse places the doppler in the right or left upper quadrant above the maternal umbilicus to auscultate fetal heart tones in a baby that is in the ______presentation. - CORRECT ANSWER breech
findings of false labor (braxton-hick's contractions) include: - CORRECT ANSWER -painless, irregular frequency, and intermittent
-decrease in frequency, duration, and intensity w/walking or position change
-felt in the lower back or abdomen above umbilicus
-often stop w/sleep or comfort measures such as oral hydration or emptying the bladder
Breast milk may be stored at room temp in clean conditions for up to: - CORRECT ANSWER 8 hrs
Breast milk may be refrigerated in sterile bottles for use within: - CORRECT ANSWER 8 days
Breast milk may be frozen in sterile containers in the freezer compartment of a 2-door fridge for up to: - CORRECT ANSWER 6 months
Thawing the breast milk in the refrigerator for ______is the best way to preserve the immunoglobulins in it. DO NOT... - CORRECT ANSWER -24 hours
DO NOT refreeze thawed milk
Used portions of breast milk must be... - CORRECT ANSWER discarded
Prepared formula can be refrigerated for up to: - CORRECT ANSWER 48 hr
Teach parents to do what with the formula can prior to opening it? - CORRECT ANSWER wash the lid of a can of concentrated formula with hot soapy water
Expected changes during the second trimester: - CORRECT ANSWER -skin changes (stretch marks, hyperpigmentation) (chloasma, linea nigra, striae gravidarum)
-breast & abdomen enlargement
-fatigue
-BP decreases 5-10 mmHg for both diastolic & systolic
-heartburn
-constipation
-hemorrhoids
-backaches
-shortness of breath & dyspnea
-varicose veins & lower-extremity edema
-braxton hicks contractions
-gingivitis, nasal stuffiness, epistaxis (nose bleeds)
Safe Immunizations for Pregnancy: - CORRECT ANSWER -Tdap (given at 27-36 weeks)
-influenza (1st or 2nd trimester)
How to perform a heel stick on a newborn: - CORRECT ANSWER 1. Don clean gloves
2. Warm the newborns heel 1st to increase circulation
3. Cleanse the area w/an appropriate antiseptic & allow to dry
4. A spring-ac [Show Less]