newborn assessment Flashcards

Terms Definitions
normal temperature
normal length
18-22 in
head circumference is above the
nails should
Extend beyond nail bed
Use mechonium aspirator suction if mechonium is present at birth and newborn is not ____ at time of birth
small head related to body size
skin texture should be
soft without scales
caused by increase in vascular pressure. disappears in 1-2 days
yellowish tint related to excessive billirubin. Normal after 24 hour. check sclera
turgor is best done
over the sternum
lack of cartilage in ear indicates
____ reflex is the fencer position
Tonic neck
Chest expansion and ____ are not normal
___ is the presence of extra digits
may be a sign of cardiovascular disease
body is pink and extremities are blue
subcutaneous fat
insulates newborn from temperature extremes
mongolian spot
bruised appearance. most common on buttocks. usually in dark skinned individuals, only 9% in caucasions. Fades over months or years
caput succedaneum
edematous swelling beneath the scalp. caused by prolonged pressure of head against cervix. COVERS SUTURE LINE Most common over occiput, disappears in 3-4 days
Mongoloid slant of the eyes indicates
Down Syndrome
milk white spots, contraced when baby passes through birth canal
____ reflex is stimulated by a flash of light
If femoral pulses are not palpaable but brachial pulses are this is caused from
aortic coartion
place the newborn on their back unless they have ____
Heel to ear extention - with advancing gestational age, the newborn demonstrates increasing ____
Assessment color
should be pink. Acrocyanosis is bluish discoloration of hands and feet and mottling is a lacy pattern of dilated blood vessles under the skin, jaundice
____ is an opening at juncture of cranial bones
vernix caseosa
white cheesy substance found on the skin after birth. Consider this a body fluid.
epstein's pearls
pin size white or yellow elevated epithelial cysta, normal variant
nevus vasculosus
(strawberry mark) bright or dark red raised areas caused by dilated, newly formed capillaries. 75% found on head. Can remain till school age or longer.
anterior fontanel
diamond shaped, closes at 18 months, 1-6 cm sagital and coronal sutures
____ palsy is paralysis of portions of the arm results from trauma to the brachial plexus during birth
Brachial palsy
If risk factors are present, how soon should blood sugars be done
1 hr
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?
T/F the chest is 1:1 ratio anterior:lateral
True - cylindrical
____ reflex is a response to sudden movement or loud noise and should be one symmetric extension and abduction of arms with fingers extended
Moro response
____ reflex is when toes curl downard when sole of foot is stimulated
Plantar grasp
A preterm newborn's pea size testes are not within the ____, and the scrotal surface has few ____
scrotum, few rugae
harlequin color change
unknown in origin, is a color discrepency between light and dark.
if head circumference is > or equal to 4 cm more than the chest than what is suspected
Nursing diagnosis for heat loss
Risk for altered body temperature related to evaporation, radiant, conductive and convective heat losses
care of circumcision
squeeze 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
If the penis meatus is not on the tip, but on top, it is refered to as
flaring of the nose after 1st 15 mins indicates
respiratory distress
____ is a single palmer crease
simian line (frequently present in children with Down syndrome)
In the APGAR rating of reflex irriability what does 0,1,&2 mean
0=no response to stimulation, 1=grimace/feeble cry when stimulated, 2=sneeze/cough/pulls away when stimulated
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
____ is white, cheeselike substance often present between the labia
smegma, removing it may traumatize tender tissue
____ 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 base
Erythema toxicum (newborn rash) peak 24-48 hrs
Name the 5 things APGAR scores
Skin color, Heart rate, Reflex irriability, muscle tone, & breathing
Normal color of Iris
grey or blue in caucasion, blue to brown in other races
Crying should be strong, lusty and ____
consolable. Cocaine babies have high pitch cat cry
Newborn range of blood pressure
80-60 / 45-40 (about half of adult normal)
How large is the anterior and posterior fontanelle's
anterior fontanelle 3-4cm x 2-3cm diamond shaped. posterior fontanelle 1-2 cm triangular shaped
respond immediately to signs of respiratory problems by doing what
nasal & oral suctioning and position with vigorous fingertip stroking of spine
In the AA=PGAR rating of muscle tone what does 0,1,&2 mean
0=none 1=some flexion, 2=active movement
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
Average weight of newborn
2400-4000g or 5 lb 8 oz -13lbs with 8 lb average
Neck - check for webbing, fracture to ____, moro reflex and symmetrical shoulders
clavicals fracture that can occure with a difficult birth
The newborn's nose should be ____
patent - they are nose breathers for the first few months.
red light reflex if abnormal indicates
if white could be tumor or congenital cataracts
____ of the hip is asymmetry of gluteal and thigh fat folds
developmental dysplasia of the hip - best seen if newborn is in prone position
How often are the APGAR scoring done
First minute after birth and again in five minutes if resuscitated.
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)
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
The square window sign is the angle of flexation of the wrist, the amount of flexation increases or decreases with gestational age
increases (90 degrees 28-30 wks, 30 degrees 39-40 weeks, and 0 degrees 40-42 weeks)
Not normal in the first 24 hours, after first 24 hourse due to immature liver breakdown of billirubin
jaundice - from head to toe, blach over cartaliage (nose) & turn yellow.
Ears - check for drainage of ___. Lowset (below outter canthus) could indicate ___
CSF - low set could indicate kidney problems or chromosomal abnormalities
____ sign - place the arm around the neck, the elbow is past the midline in a premie
Scarf sign (at midline 30-4- wks, will not reach midline after 40 wks)
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