NUR 426 NEWBORN Exam Study Guide
I. Assessment
a. APGAR scoring
i. What is it: brief physical exam done immediately following postpartum to rule
... [Show More] out abnormalities that is performed at 1 and 5 min of life
ii. 0-3= Severe Distress
iii. 4-6= Moderate Distress
iv. 7-10= Minimal Difficulty Adjusting to Extrauterine Life
SCORE: 0 1 2
Heart Rate Absent <100/min >100/min
Respiration
Rate Absent Slow/weak cry Good cry
Muscle Tone Flaccid Some flexion Well-flexed
Reflex
Irritability None Grimace Cry
Color Blue/pale Acrocyanosis (pink
body, cyanotic hands/feet) Completely pink
b. New Ballard Scale
i. What is it: gestational age assessment performed in newborns w/in first 48hrs following birth. New Ballard assessment provides an estimation of gestational age and a baseline to assess growth and development that assesses neuromuscular and physical maturity
1. Each individual parameter displays at least 6 ranges of development; w/ each range of development being assigned a number from -1 to 5, where the totals are added to give a maturity rating in weeks of gestation
a. Ex: score of 35 indicates 38 weeks of gestation
ii. Posture: extended=premature. Fully flexed=mature
iii. Square window: Measures wrist flexibility. >90-degree angle=premature. 0- degree angle=mature
iv. Arm recoil: no recoil=premature. Full recoil mature
v. Classification:
1. Appropriate gestational age weight: between 10th & 90th percentile
a. Small <10th percentile; Large >90th percentile
2. Low birth weight: <2,500g @ birth
c. Vital Signs
i. Fun facts:
1. Only use axillary thermometer; BP cuff that is 2.5 cm wide
2. Checked in the following sequence
a. Respirations, HR, BP, temperature
ii. Respiratory rate: 30-60 breaths/minute w/ short periods of apnea (<15 seconds). No crackles, wheezing, grunting, nasal flaring, or substernal retractions. Infants are obligatory nose breathers
1. Investigate apnea >15secs
iii. Heart rate: 110-160 beats/min w/ brief fluctuations above/below this range (w/ certain activities)
1. Place stethoscope at 4th or 5th left midclavicular intercostal space
iv. Blood pressure: 60-80 SBP / 40-50 DBP
v. Temperature: 36.5-37.5 ℃ (axillary)
1. Newborn is @ risk for hypothermia; chilled newborn=cold stress(increase O2 demand & acidosis)
vi. Length 45-55cm (18-22 inches) vii. Weight: 2500-4000g (5.5-8.8 lb)
d. Assessment by each body system
i. Posture
1. Lying in curled position/ arms & legs in moderate flexion
ii. Skin
1. Color: pink or acrocyanotic, no jaundice
2. Vernix casesosa (thick, cheesy covering): amounts will vary
3. Lanugo (fine, downy hair): amount will vary
4. Normal variations
a. Milia: small, white raised spots on face
b. Mongolian spots: blue/purple pigmented skin on back or buttocks. Common w/ babies of African American, Asian, or Native American origin
c. Telangiectatic nevi (stork bites): blanchable red marks on face
d. Nevus flammeus (port wine stain): capillary angioma below the surface of the skin
iii. Head
1. Expected findings
a. 2-3cm larger than chest circumference
i. if >4cm=hydrocephalus; circumference <32cm= microcephaly
b. Anterior fontanel: diamond shaped, soft/flat, 5cm
c. Posterior fontanel: triangular shaped, soft-flat, smaller
d. Sutures: palpable, may be overlapping from head compression during birth
2. Caput succedaneum: Swelling of soft tissues of the scalp which
crosses the suture line. Usually resolves in 3-4 days
3. Cephalohematoma: Collection of blood between the skull and periosteum. Does NOT cross suture line. Usually resolves in 2-3 weeks
iv. Eyes, Ears, Mouth
1. Eyes: blue or gray at birth-permanent eye color established at 3-12 months
2. Ears: eyes should be at the same level as the upper tip of the pinna (low-set ears indicative of chromosome abnormality such as Down syndrome)
a. Ears & Kidneys grow at the same time
3. Mouth: Epstein’s pearls (small white cysts on gums and soft/hard palates) are expected. Gums and tongue should be pink (gray-white patches indicate thrush, a fungal infection)
v. Neck
1. Absence of head control can indicate prematurity or down syndrome
vi. Abdomen
1. Umbilical cord should be odorless & show no intestinal structures
2. Bowel sounds should be present 1-2hrs postpartum
vii. Anogenital
1. Meconium should be passed w/in 24-48hrs postpartum
2. Vaginal blood-tinged discharge can happen in female newborns due to maternal hormones THIS IS NORMAL
3. Hymenal tag present
4. Urine should be passed and will appear rusty (caused by uric acid crystals)
viii. Reflexes
1. Sucking/rooting reflex: elicit by stroking cheek. Infant turns toward that side and starts to suck
a. Expected age: birth to 4 months
2. Palmar grasp: elicit by placing object in baby’s palm. Infant grasps object
a. Expected age: birth to 4 months
3. Plantar grasp: elicit by touching sole of foot. Infant curls toes
a. Expected age: birth to 8 months
4. Moro reflex: infant’s response to lack of support (falling). Arms and legs extend, and fingers form a “C”
a. Expected age: birth to 6 months; if still there indicative of cerebral palsy
5. Tonic neck reflex: when head is turned to one side, arm and leg extend.
Arm and leg on other side flex
a. Expected age: birth to 3-4 months
6. Babinski’s reflex: elicit by stroking outer edge of the sole of the foot.
Toes fan up and out
a. Expected age: birth-1 year
7. Stepping: elicit by touching infant’s feet to a flat surface. Infant responds w/ stepping movements
a. Expected age: birth to 4 weeks
ix. Vision
1. Newborn should be able to focus on objects 8-12 inches away from face
e. Cord blood collection
i. Collected at birth to determine fetal ABO blood type and Rh status
f. Airway obstruction
i. Nursing considerations
1. Mouth and nose are suctioned w/ bulb syringe. Gentle percussion over the chest can help loosen secretions
g. Hypothermia
i. Monitor axillary temperature (97.7 ℉ - 98.6 ℉ )
ii. If temp is unstable place infant in radiant warmer to maintain 97.7 body temp
iii. Other methods: skin-to-skin contact w/ mom
II. Nursing Care of Newborns:
a. Periods of reactivity
i. First period of reactivity
1. Newborn is alert; makes sucking sounds; has rapid HR and RR but will have a stable HR of 60-100
2. Lasts 30mins postpartum
ii. Period of relative inactivity
1. Newborn will become quiet and begin to rest & sleep; HR and RR will decrease
2. Lasts 60-100min postpartum
iii. Second period of reactivity
1. Newborn reawakens and becomes responsive again
2. Occurs 2-8hr postpartum and can last 10min to several hours
b. Laboratory tests
i. RBC: 4.8 x 106-7.1 X 106
ii. Hgb: 14-24 g/dL
iii. Hct: 44-64%
iv. Platelets: 150,000-300,000/mm3
v. Glucose: 40-60 mg/dL
vi. Leukocytes: 9,000-30,000/mm3
vii. Bilirubin: 24hrs (2-6mg/dL); 48hrs (6-7mg/dL); 3-5days (4-6mg/dL)
c. Diagnostic screening
i. Metabolic screening: capillary heel stick should be done w/in 24hr postpartum; PKU testing (defect in protein metabolism that can result in retardation)
ii. Collecting blood samples
1. Warm newborn’s heel to increase blood circulation
2. Cleanse w/ antiseptic and allow to dry
3. Use spring-activated lancet on outer aspect of heel
4. Apply pressure w/ dry gauze, cover w/ bandage
5. Comfort newborn
d. Respiratory complications
i. Bradypnea: respirations <30/min
ii. Tachypnea: respirations >60/min
iii. Abnormal: expiratory grunting, crackles, and wheezes
iv. Respiratory distress: nasal flaring, retractions, grunting, gasping, and labored breathing
v. Interventions:
1. Suction mouth first then nasal passages w/ bulb syringe
2. If bulb syringe is unsuccessful proceed w/ mechanical suction
3. Bulb suction only on side of mouth not stimulating gag reflex
e. Identification
i. Utilizes 2 identifiers
1. The newborn, mom, and mom’s partner is identified by plastic ID bands
2. ID bands should include newborn’s name, sex, date, time of birth, mother’s health record number
f. Thermoregulation
i. Newborns keep warm by metabolizing brown fat; becoming chilled will cause hypothermia (temp lower than 97.7, cyanosis, increased RR)
ii. Interventions to maintain body temp
1. Conduction: heat loss from direct contact with cooler surface (stethoscope, scale)
2. Convection: heat loss from cooler environmental air (fan, AC vent)
3. Evaporation: heat loss when surface liquid is converted to vapor (bathing). Immediately after delivery-dry and cover infant w/ warm sterile blanket
4. Radiation: heat loss from close proximity to cooler surface (windows)
iii. Temp stabilizes at 98.6 ℉ after 4 hours birth if chilling is prevented
g. Bathing
i. Bathing can be completed once the newborn’s temp is stabilized to 97.7 ℉
ii. Complete sponge bath should be complete w/in 1 to 2 hr after birth under radiant heat source
h. Feeding
i. Can be started immediately after birth (breastfeed ASAP!) if formula feeding, don’t start until 2-4hr postpartum
ii. Sips of water can be used to assess sucking and swallowing reflexes
iii. Newborn is fed on demand (every 3-4hr for bottle fed), and every 2 hr for breastfeeding
i. Sleep
i. Newborns sleep 16-19 hr/day and sleep supine “safe sleep” to prevent SIDS
ii. No toys, loose linens should be in bassinet
j. Elimination
i. Newborns void once w/in 24hrs (should void 6-8 times per 24hr period)
ii. Meconium should be passed w/in first 24-48hrs
iii. They should have at least 3 stools per day for first month
k. Infection control
i. Provide individual bassinets; all individuals should srub w/ antimicrobial soap from elbows to fingers [Show Less]