ATI MATERNAL NEWBORN REMEDIATION
1. Management of Care
a. Establishing Priorities
i. Assessment and Management of Newborn Complications:
... [Show More] Priority Finding that
Requires Further Assessment (Chp 27)
• Signs of alcohol withdrawal include jitteriness. Irritability, increased
tones and reflex responses, and seizures. A term newborn’s blood
glucose should be 30-60mg/dL. Hypoglycemia can bring about poor
feeding, jitteriness/tremors, hypothermia, diaphoresis, weak cry, and
lethargy.
• Other reportable findings are respiratory distress which include
tachypnea, nasal flaring, expiratory grunting, retractions, and cyanosis.
Newborn infections like sepsis can cause an infant to have temperature
instability, suspicious drainage, poor feeding, weak suck, vomiting,
diarrhea, hypo or hyperglycemia, respiratory distress, and low BP.
• Hyperbilirubinemia includes yellowish tint to skin, sclera, mucous
membranes, observe the newborns color for yellowish tint as the skin is
blanched, and assess if there is an underlying cause that needs to be
fixed. Look for hypoxia, hypothermia, hypoglycemia, and metabolic
acidosis. Increased risk for brain damage. Congenital anomalies involve
cleft lip/palate and tracheoesophageal fistula, excessive mucous
secretions and drooling, periodic cyanotic episodes and choking,
distended abdomen. PKU can result in cognitive impairment if
untreated, not evident at birth and it’s found in newborn screening.
Hypothyroidism: hypothermia, poor feeding, lethargy, jaundice,
cretinism. Spina bifida is a protrusion of meninges and/or spinal cord,
tufts of hair on the spine. Patent ductus arteriosus is another neonate
complication that includes murmurs, abnormal heart rate or rhythm,
breathlessness, and fatigue while feeding.
• Tetralogy of Fallot is a combination of four congenital abnormalities that
has respiratory difficulties, cyanosis, tachycardia, tachypnea, and
diaphoresis. Down syndrome, also known as trisomy 21, exhibits oblique
palpebral fissures or upward slant of the eyes, epicanthal folds, flat facial
profile with a depressed nasal bridge and small nose, protruding tongue,
short broad hands with a fifth finger that has one flexion crease instead
of two, a deep crease across the center of the palm, hyperflexibility,
hypotonic muscles.
ii. Medical Conditions: Priority Finding That Requires Further Assessment (Chp 9)
• Cervical insufficiency is a painless opening of the cervix that results in delivery of the baby in the 2nd trimester of pregnancy. Some expected findings are pink stained vaginal discharge or bleeding, possible gush of fluid, and uterine contractions w/ expulsion of fetus. The nurse needs to evaluate the client’s support system and if assistance is available for them if they are prescribed activity restrictions or bed rest. Assess the [Show Less]