NSG 3500 -- Exam 4 Boxes
Normal Newborn Vital Signs HR: 110 - 160 bpm (120 - 160 pm book) RR: 30-60 per min/irregular/shallow/diaphragmatic Temperature: 97.5 - 99.5 F > (97.7 -- 99.3 F book) BP: systolic: 60-80 mmHg; diastolic 40-50 mmHg Apgar Do it @ 1 min (should be > 7), then again @ 5 min Highest is 10 Infant stabilization needed if: Nasal flaring, grunting, rib retractions, HR < 120 or > 160 Neural tube defects Infant of a diabetic mother Infant who appears SGA (small for gestational age)
Unstable
Tachycardic: > 160 bpm Tachypneic: > 60 RR
Reflexes
Sucking and Rooting Stroke infant's cheek and watch them turn toward the finger, open their mouth, and suck on an object placed in their mouth Palmar The infant curls their fingers around and object Moro Observe the infant's head as it is lifted while the nurse mimics a release and watches for extension of both arms along with flexion of the legs Plantar The infant curls their toes around an object that has been placed at the sole of the foot Babinski Lightly stroke the plantar surface of the foot from heel toward the toes. The infant responds by incurving the toes and then uncurling and stretching them out (fanning) Eye prophylaxis Done after delivery within 1st day CDC recommends to be done ASAP after birth Prevents ophthalmia neonatorum: eye inflammation from gonorrhea > erythromycin drops/ointment Apply by starting at inner canthus and move to the outer canthus NAS Neonatal abstinence syndrome: occur in newborns exposed to certain substances, including opioids, during pregnancy S/S: Irritability, tremors, wakefulness, uncoordinated feeding patterns, loose stools, yawning, hiccups, poor weight gain, hypertonia, seizures, exaggerated rooting reflex, vomiting,
Vitamin K (AquaMEPHYTON)
All infants are at risk for hemorrhagic disease; vitamin K deficiency produced by bacteria gut (around 8 days of life) Risk for intracranial hemorrhage from vaginal birth Where is it given? Vastus lateralus Dose? 0.5 or a 1.0 mL - DO NOT MASSAGE
Umbilical cord
Clamped umbilical cord should not show active bleeding or oozing Vein = 1 & Arteries = 2 Cord Care Discharge from umbilical cord indicates infection Keep clean and dry -- prevent stool/urine into contact Inspect for redness, foul odor = infection Fold and position diaper below stump Sponge bath until cord falls off -> immersed in water
Provide a quiet environment with minimal stimuli to promote sleep Naloxone -> AVOID since it increases withdrawal in infant
Feet Creases Preterm finding -> smooth foot = NO creases Postdate findings In postmature infant, the skin is tough and leather, with cracking and peeling No lanugo and vernix caseosa Desquamation and peeling Dry wrinkly feet = HAVE creases
Normal findings
Milia: small white, papules or sebaceous cysts on the infant's face that resemble pimples. It is benign and will resolve spontaneously within 1 month of life Vernix caseosa: a protective thick whitish substance that covers the infant intrauterine; may be present in folds and creases (axillary and genital areas; may indic