care of the premature, postmature, and sick infant · care of the premature, postmature, and sick...
TRANSCRIPT
Care of the Premature,
Postmature, and Sick
Infant
Terminology
Assessment
Nursing Interventions
Neonatal Resuscitation
Objectives
� Define premature, postmature, SGA,
LGA, low birth weight infants.
� Assess the premature and postmature
infant.infant.
� Examine the steps of the Neonatal
Resuscitation Program
� Review nursing interventions for delivery
care, hypothermia, respiratory distress,
and hypoglycemia
Terminology
� Premature infant: < 38 weeks gestation
� Low birth weight: < 2500 Gm regardless of gestational age
Moderately low birth weight: 1501-2500 � Moderately low birth weight: 1501-2500 Gm
� Very low birth weight: < 1500 Gm
� Extremely low birth weight: < 1000 Gm
Terminology
� Postmature infant: 42 weeks gestation
or greater
� Small for gestation age: < 10% on
growth chart
� Large for gestation age: above 90% on
growth chart
Premature Infant
� Infant born < 38 weeks gestation
� Factors contributing to premature birth are:
� Incompetent cervix
Multiple gestation� Multiple gestation
� Premature rupture of membranes
� Adolescent pregnancy
� Maternal hypertension (preeclampsia)
� Maternal infection or disease
� History of premature deliveries
Premature Infant
� Problems of premature infant:
� Hypoglycemia
� Hypothermia
� Respiratory distress syndrome
� Infection
� Neurological problems (intraventricular hemorrhage)
� Necrotizing enterocolitis
� Problems related to immaturity of every body system
Premature Infant
� Assessment:
� Thin, gelatinous skin< 26 weeks, bright pink in color
� Presence or absence of lanugo, plantar creases, breast tissue, ear cartilage
� Eyes fused < 24 weeks
� Soft cranium, hair is fine
� Lack subcutaneous fat
� Head large in proportion to body
� Female – prominent clitoris and labia
� Male – nondescended testes, few rugae
� Immature reflexes
Premature Infant
�� Pictures courtesy Pictures courtesy
of Yahoo!of Yahoo!
FIGURE 30–6 A 6-day-old, 28-
week gestational age, 960-g preterm
infant.
Postmature Infant� Infant born > 42 weeks gestation
� Placenta has lost ability to provide sufficient nutrients and oxygen and to eliminate waste products.
� Problems of postmature infant are:� Meconium aspiration
� Malnutrition, hypoglycemia
� Hypothermia
� Asphyxia, Death
Postmature Infant
� Assessment:
� Dry, cracking skin
� Absence of vernix and lanugo
� Extremities may be long and thin
� Long fingernails� Long fingernails
� Skin may be deep yellow or green from meconium
� Abundant scalp hair
� Thin appearance due to loss of subcutaneous fat
Postterm Infant
FIGURE 30–5 Postterm
infant demonstrates deep
cracking and peeling of skin.
Nursing Interventions
with the Preterm,
Postterm, and Sick
InfantInfant
Delivery NRP Admission to
Nursery/NICU
Nursing Interventions at Delivery
and Admission to Nursery/NICU
� Place under radiant warmer at 36.5C
� Dry and stimulate with warm blankets
� Obtain vital signs� Obtain vital signs
� Apply O2 – bag & mask, ventilate
� Suction as needed
� Obtain 1 minute, 5 minute, 10 minute
APGAR scores
� Assess umbilical cord – 3 vessels
Nursing Interventions at Delivery
and Admission to Nursery/NICU
� Place ID bands on
� Obtain footprint
� Allow mother to see newborn� Allow mother to see newborn
� Transport to Nursery or NICU
� Obtain weight & length
� Complete physical and gestational
age assessments
� Administer erythromycin ointment and
vitamin K
Neonatal Resuscitation
Program (NRP)
� At delivery, ask 4
questions:
� Term gestation?
� Clear amniotic
� Routine care
� Provide warmth
� Clear airway
� Dry
Yes
� Clear amniotic
fluid?
� Breathing or
crying?
� Good muscle
tone?
� Dry
� Assess color
� Provide warmth
� Position, clear airway
� Dry, stimulate,
reposition
� Evaluate respirations,
heart rate, color
No
Neonatal Resuscitation
Program (NRP)
� Evaluate
respirations, heart
rate, color
� Breathing
� HR > 100 Observe
� Pink
Yes
� Cyanotic – give
supplemental oxygen
� Apneic or PPV
� HR < 100
� HR < 60 – Chest
compressions,
epinephrine
Bag/Mask Ventilation
�� Use a cushioned, anatomically Use a cushioned, anatomically shaped maskshaped mask
�� Mask must cover Mask must cover nose and mouth nose and mouth nose and mouth nose and mouth completelycompletely
�� Bottom rim should Bottom rim should cover the edge cover the edge of the chinof the chin
� Place thumb over the nose portion of the mask
� Watch for chest rise while squeezing the bag
� If chest does not rise
1.1. Recheck sealRecheck seal
2.2. Reposition headReposition head
3.3. Increase inflating Increase inflating pressurepressure
Assisting with Intubation
�� Hold the suction catheter Hold the suction catheter close to the operatorclose to the operator
�� Provide oxygenProvide oxygen�� Provide oxygenProvide oxygen
�� Check tube cm markingCheck tube cm marking
at lipat lip
�� Place a gastric tube Place a gastric tube to decompress the to decompress the stomachstomach
ET Tube Location on CXR
Optimal ET Optimal ET tube locationtube locationOptimal ET Optimal ET tube locationtube location
CarinaCarinaCarinaCarina
tube locationtube locationtube locationtube location
© S.T.A.B.L.E.®
© S.T.A.B.L.E.®
ET tube in ET tube in acceptable acceptable
positionposition
ET tube in ET tube in acceptable acceptable
positionposition
© S.T.A.B.L.E.®
© S.T.A.B.L.E.®
ET tube ET tube in right in right mainstem mainstem bronchusbronchus
ET tube ET tube in right in right mainstem mainstem bronchusbronchus
Total left Total left lung lung atelectasisatelectasis
Total left Total left lung lung atelectasisatelectasis
© S.T.A.B.L.E.®
© S.T.A.B.L.E.®
Chest Compressions/Ventilation
� 3:1 ratio of compressions to ventilations
� 90 compressions and 30 breaths = 120 events per minute120 events per minute
� Reassess every 30 seconds
� Discontinue resuscitation after 10 minutes of no heart beat and no respirations
TTemperature RegulationTTemperature Regulation
� Hypothermic infants
� How body heat is lost
� Detrimental effects of cold stress � Detrimental effects of cold stress
� Warming hypothermic and severely
hypothermic infants
Hypothermia
� Extremely vulnerable infants
include:
� Low birth weight
� Those requiring� Those requiring
prolonged
resuscitation
� Preventing cold
stress is a
challenge.© S.T.A.B.L.E.®
© S.T.A.B.L.E.®
Contact with cold or wet objectsContact with cold or wet objects
XX--rayray
Heat Loss by ConductionConductionConductionConduction
ScalesScales
XX--rayrayplatesplates
PrePre--warm scales warm scales and xand x--ray platesray plates
CautiouslyCautiously use use radiant heatradiant heat
Cover scale with Cover scale with warm blanketwarm blanket
© S.T.A.B.L.E.®
© S.T.A.B.L.E.®
Drafts and cold airDrafts and cold air
Heat Loss by ConvectionConvectionConvectionConvectionConvectionConvectionConvectionConvection
60 70 80 90
Move away from draftsMove away from drafts
Raise sides on warmerRaise sides on warmer
Close port holesClose port holes
Raise room temperatureRaise room temperature
© S.T.A.B.L.E.®
© S.T.A.B.L.E.®
Delivery, bathing, damp linensDelivery, bathing, damp linens
Dry thoroughlyDry thoroughly
Replace Replace wet linenswet linens
Heat Loss by EvaporationEvaporationEvaporationEvaporationEvaporationEvaporationEvaporationEvaporation
wet linenswet linens
CautiouslyCautiously use use radiant heatradiant heat
Do not bathe Do not bathe infant if infant if
showing signs showing signs of compromise of compromise
© S.T.A.B.L.E.®
© S.T.A.B.L.E.®
Cold windows and wallsCold windows and walls Use double walled Use double walled incubatorincubator
Use ISC Use ISC temperature probe temperature probe on radiant warmer on radiant warmer
(not manual)(not manual)
Heat Loss by RadiationRadiationRadiationRadiationRadiationRadiationRadiationRadiation
Move away from Move away from outside walls and outside walls and
windows windows
(not manual)(not manual)
© S.T.A.B.L.E.®
© S.T.A.B.L.E.®
Detrimental Effects of Cold
Stress
� Development of Metabolic Acidosis
caused by:
1. Brown fat metabolism causing
vasoconstrictionvasoconstriction
2. Decreased surfactant production
3. Increased anaerobic metabolism
4. Increased metabolic rate
FIGURE 31–6 Cold stress chain of events. The hypothermic, or cold-stressed,
newborn attempts to compensate by conserving heat and increasing heat production.
These physiologic compensatory mechanisms initiate a series of metabolic events
that result in hypoxemia and altered surfactant production, metabolic acidosis,
hypoglycemia, and hyperbilirubinemia.
Nursing Interventions to
Prevent Cold Stress
� Dry quickly — remove wet linens
� Use warm blankets
� Provide radiant warmer heat
� Place infant on ISC/servo control � Place infant on ISC/servo control
� Use heated, humidified O2 as soon as possible
� Remember: cold gas (O2) in, warm exhaled gases out
Guidelines for Re-warming
� Severely hypothermic infants —temperature < 35ºC (95ºF)
� Incubator
� Radiant warmer� Radiant warmer
� Core temperature goal — 37ºC (98.6ºF)
� While re-warming:
� Monitor vital signs constantly
� At risk for apnea, hypotension, RDS, metabolic acidosis, shock, death
© S.T.A.B.L.E.®
© S.T.A.B.L.E.®
AArtificial/Assisted BreathingAArtificial/Assisted Breathing
� Evaluating respiratory distress
� Indications for endotracheal intubation and
positive pressure ventilation
� Evaluating for pneumothorax, airway
obstruction
Respiratory distress is the most common Respiratory distress is the most common
reason for referral to an intensive care nurseryreason for referral to an intensive care nursery
Assessment & Monitoring
�� TemperatureTemperature
�� Heart rate and rhythm Heart rate and rhythm
�� Respiratory rate and effort Respiratory rate and effort
�� Blood pressureBlood pressure
�� OO22 saturationsaturation
�� OO2 2 concentrationconcentration
�� Skin perfusionSkin perfusion
�� Strength of pulses in arms and legsStrength of pulses in arms and legs© S.T.A.B.L.E.
®© S.T.A.B.L.E.
®
Diagnostic Tests to Perform
� Chest x-ray � If respiratory distress
� Abdominal x-ray
� If abdominal problem� If abdominal problem
� Blood gas
� Arterial or capillary
� CBC with differential
� Hematocrit
Respiratory Rate
� High rate: greater than 60 breaths per minute
� Low rate: less than 40 breaths per minute Low rate: less than 40 breaths per minute
� Shallow vs. labored
� Apnea
� Gasping
� Ominous pre-cardiac arrest sign!
Evaluate Respiratory Distress
� Retractions
� Mild, moderate, severe
� Intercostal, subcostal, substernal
� Nasal flaring present?
� Grunting
� Audible without a stethoscope?
Areas to Assess for Retractions
�� Substernal Substernal �� Substernal Substernal
�� SubcostalSubcostal�� SubcostalSubcostal
�� IntercostalIntercostal�� IntercostalIntercostal
�� SuprasternalSuprasternal�� SuprasternalSuprasternal
© S.T.A.B.L.E.®
© S.T.A.B.L.E.®
Evaluate Perfusion
� Capillary filling time — trunk and legs
� Strength of pulses
� Heart rate and rhythm
� Temperature of extremities
� Cyanosis and/or skin mottling
� Report color differences — upper versus lower body - Harlequin
Color and Oxygen Requirement
� Degree of cyanosis
� Peripheral versus central
� Amount of O2 to keep saturation > 88%2
� Rapidly increasing O2 concentration
� Arterial PO2 < 50 in more than 50% oxygen?
HCOHCO33 pHpH PCOPCO22
10
15
20
25
30
35
40
8.0
7.9
7.8
7.7
7.6
7.5
7.4
7.3
7.2
7.1
60
50
40
35
30
25
20
1540
50
60
70
80
90100110120130140150
7.1
7.0
6.9
6.8
6.7
6.6
10
9
8
7
6
4
3
© S.T.A.B.L.E.®
© S.T.A.B.L.E.®
HCOHCO33 pHpH PCOPCO22
10
15
20
25
30
35
40
8.0
7.9
7.8
7.7
7.6
7.5
7.4
7.3
7.2
7.1
60
50
40
35
30
25
20
15
MM
EE
TT
AA
BB
OO
L L
RR
EE
SS
P P
I I
RR
A A
TT
pH 7.4pH 7.4
PCOPCO22 3535
HCOHCO33 2222
POPO2 2 7575
© S.T.A.B.L.E.®
© S.T.A.B.L.E.®
40
50
60
70
80
90100110120130140150
7.1
7.0
6.9
6.8
6.7
6.6
10
9
8
7
6
4
3
L L
I I
CC
TT
OO
RR
YY
Is the pH normal? Is the pH normal?
Is the PCOIs the PCO22 normal? normal?
Is the HCOIs the HCO33 normal? normal?
Acidosis
� pH < 7.30 is abnormal
�� pH pH < 7.25< 7.25 is is concerningconcerning ——especially if in combination with poor especially if in combination with poor perfusion, tachycardia and/or low BPperfusion, tachycardia and/or low BPperfusion, tachycardia and/or low BPperfusion, tachycardia and/or low BP
�� pH pH < 7.20< 7.20 indicates indicates severe illnesssevere illnessand need for immediate interventionand need for immediate intervention
�� pH pH < 7.15< 7.15 indicates the infant is in indicates the infant is in severe crisissevere crisis
Causes of Respiratory Acidosis
Inadequate ventilation Inadequate ventilation →→→→→→→→ ↑↑↑↑↑↑↑↑ in in COCO22
� Lung disease
� Pneumonia, aspiration, RDS
� Pneumothorax� Pneumothorax
� Airway obstruction, Diaphragmatic Hernia
� Decreased respiratory drive
� Prematurity, apnea
� Neurologic impairment, asphyxia
Causes of Metabolic Acidosis
� Shock
� Poor perfusion
� Inadequate tissue oxygenation
↑↑↑↑↑↑↑↑ Lactic acid production Lactic acid production →→→→→→→→ ↓↓↓↓↓↓↓↓ in Hin HCOCO33
� Inadequate tissue oxygenation
� Cardiac disease - congenital heart defects
� Brain disorders – hemorrhage, meningitis
� Inborn errors of metabolism
Pneumothorax
� Sudden deterioration
�Bradycardia
�Cyanosis
�Signs of respiratory distress�Signs of respiratory distress
�� Evaluate forEvaluate for
�� Chest asymmetryChest asymmetry
�� Shift in point of maximum impulseShift in point of maximum impulse (PMI) (PMI)
�� Hypotension Hypotension
�� Poor peripheral pulsesPoor peripheral pulses
Note:Note:
ET tube in right ET tube in right mainstem mainstem bronchusbronchus
Note:Note:
ET tube in right ET tube in right mainstem mainstem bronchusbronchus
Pneumothorax Pneumothorax
bronchusbronchusbronchusbronchus
Right Right pneumothoraxpneumothoraxRight Right pneumothoraxpneumothorax
© S.T.A.B.L.E.®
2001
© S.T.A.B.L.E.®
2001
Right Right pneumothorax pneumothorax with left lung with left lung atelectasisatelectasis
Right Right pneumothorax pneumothorax with left lung with left lung atelectasisatelectasis
Pneumothorax Pneumothorax
�� UAC tip T6UAC tip T6--T7T7�� UAC tip T6UAC tip T6--T7T7
�� UVC tip T8UVC tip T8--T9T9�� UVC tip T8UVC tip T8--T9T9
�� ET tube T1ET tube T1�� ET tube T1ET tube T1
© S.T.A.B.L.E.®
© S.T.A.B.L.E.®
�� ET tube in ET tube in good positiongood position
�� ET tube in ET tube in good positiongood position
Pneumothorax Pneumothorax Pneumothorax Pneumothorax Pneumothorax Pneumothorax Pneumothorax Pneumothorax ���� SubpulmonicSubpulmonicSubpulmonicSubpulmonic���� SubpulmonicSubpulmonicSubpulmonicSubpulmonic
�� UAC tip T8UAC tip T8�� UAC tip T8UAC tip T8
�� UVC tip UVC tip right atriumright atrium
�� UVC tip UVC tip right atriumright atrium
© S.T.A.B.L.E.®
© S.T.A.B.L.E.®
Pneumothorax Pneumothorax Pneumothorax Pneumothorax Pneumothorax Pneumothorax Pneumothorax Pneumothorax ���� BilateralBilateralBilateralBilateral���� BilateralBilateralBilateralBilateral
© S.T.A.B.L.E.®
© S.T.A.B.L.E.®
Pneumothorax Pneumothorax Pneumothorax Pneumothorax Pneumothorax Pneumothorax Pneumothorax Pneumothorax ����Massive TensionMassive TensionMassive TensionMassive Tension����Massive TensionMassive TensionMassive TensionMassive Tension
Note:Note:
Mediastinal Mediastinal shiftshift
Note:Note:
Mediastinal Mediastinal shiftshift
© S.T.A.B.L.E.®
© S.T.A.B.L.E.®
shiftshiftshiftshift
Complete Complete right lung right lung collapsecollapse
Complete Complete right lung right lung collapsecollapse
Pneumopericardium
© S.T.A.B.L.E.®
© S.T.A.B.L.E.®
Airway Obstruction
� Main symptoms
� Stridor
� Retractions
� Airway obstruction may � Airway obstruction may occur at:
��NoseNose
��Mouth and jawMouth and jaw
��Larynx or trachea Larynx or trachea
��Bronchi Bronchi
Airway Obstruction
Choanal Atresia
�� Nasal obstructionNasal obstruction
�� Baby is cyanotic at restBaby is cyanotic at rest
�� “Pinks up” with crying “Pinks up” with crying
ChallengesChallengesChallengesChallengesChallengesChallengesChallengesChallenges
�� “Pinks up” with crying “Pinks up” with crying
�� If bilateral, may need oral airway or If bilateral, may need oral airway or endotracheal intubationendotracheal intubation
�� Oral airway sizes: Oral airway sizes:
�� 00 for small infants00 for small infants
�� 0 for term or large infants0 for term or large infants
Airway Obstruction Airway Obstruction Challenges Challenges -- PierrePierre--Robin SequenceRobin Sequence
Note small jawNote small jawNote small jawNote small jaw
Note cleft palateNote cleft palateNote cleft palateNote cleft palate
© S.T.A.B.L.E.®
© S.T.A.B.L.E.®
Intubation and PPV
Strongly consider intubation if:
�� Unable to or prolonged ventilation Unable to or prolonged ventilation and/or oxygenation with bag/mask and/or oxygenation with bag/mask ventilationventilation
�� Is cyanotic or marginally oxygenated in Is cyanotic or marginally oxygenated in 80% oxygen (O2 saturation < 88%)80% oxygen (O2 saturation < 88%)
�� PCOPCO22 is > 55, especially if pH < 7.25is > 55, especially if pH < 7.25
�� Diaphragmatic hernia, choanal atresia Diaphragmatic hernia, choanal atresia presentpresent
�� Apnea or gaspingApnea or gasping
© S.T.A.B.L.E.®
© S.T.A.B.L.E.®
Infants at Risk for Hypoglycemia
� SGA Small for gestational age
� LGA Large for gestational age
↓↓↓↓↓↓↓↓ Glycogen storesGlycogen stores↓↓↓↓↓↓↓↓ Glycogen storesGlycogen stores
HyperinsulinismHyperinsulinismHyperinsulinismHyperinsulinism
� IDM Infant of the diabetic mother
� Premature
� Stressed or sick
HyperinsulinismHyperinsulinismHyperinsulinismHyperinsulinism
↑↑↑↑↑↑↑↑ Glucose utilizationGlucose utilization↑↑↑↑↑↑↑↑ Glucose utilizationGlucose utilization
↓↓↓↓↓↓↓↓ Glycogen storesGlycogen stores↓↓↓↓↓↓↓↓ Glycogen storesGlycogen stores
© S.T.A.B.L.E.®
© S.T.A.B.L.E.®
Symptoms of Hypoglycemia
� Hypothermia
� Temperature instability
� Poor suck or refusal to eat
� Vomiting
� Cyanosis
�� JitterinessJitteriness
instability
� Lethargy, hypotonia
� Apnea, irregular respirations
� Cyanosis
� High-pitched or weak cry
� Seizures
Blood Glucose � Guidelines
� Avoid enteral feedings (PO or NG)
� Increased risk of aspiration w/ respiratory rate > 60 breaths per minute
• Gastroesophageal reflux
� Impaired bowel blood flow� Impaired bowel blood flow
• Necrotizing enterocolitis
� Establish IV access quickly to
� Normalize the blood sugar
� Provide emergency IV access
Blood Sugar Screening
� q 15-30 minutes until > 50 mg/dl (2.8mmol/L) on two consecutive tests
�� Perform frequently!Perform frequently!
�� If > 150 mg/dl (8.3 mmol/L) on two If > 150 mg/dl (8.3 mmol/L) on two consecutive tests consecutive tests —— seek consultationseek consultation
�� If (very) low obtain a serum blood sugar If (very) low obtain a serum blood sugar ��But don’t delay treatmentBut don’t delay treatment
Treatment
Initial blood sugar
< 50 (2.8 mmol/L)
�� Begin IV of Begin IV of DD W at 80 ml/kg/dayW at 80 ml/kg/day�� Begin IV of Begin IV of DD1010W at 80 ml/kg/dayW at 80 ml/kg/day
�� Repeat blood sugar within 30 minutes Repeat blood sugar within 30 minutes of first testof first test
�� Check blood sugar everyCheck blood sugar every 30 minutes 30 minutes until > 50 (2.8 mmol/L) on two until > 50 (2.8 mmol/L) on two consecutive testsconsecutive tests
Initial IV Fluid and Rate
� D10W without electrolytes
� 80 ml/kg/day
� Weight in kg multiplied by 80
� Then divide by 24 (hours)� Then divide by 24 (hours)
� Equals ml per hour to run the IV (via an infusion pump)
== ml/hrml/hrkg x 80
24
Treatment
Repeat blood sugar
< 50 (2.8 mmol/L)
after 1 hour of IV therapy
�� IncreaseIncrease the IV rate to the IV rate to 100 ml/kg/day100 ml/kg/day
�� Once > 50 (2.8 mmol/L) screen every Once > 50 (2.8 mmol/L) screen every 1 to 2 hours until transported or as 1 to 2 hours until transported or as needed based on patient’s conditionneeded based on patient’s condition
UAC low UAC low UAC low UAC low
UVC tip UVC tip in good in good
position at position at
UVC tip UVC tip in good in good
position at position at UAC low UAC low line line –– tip tip in good in good position position at L3at L3
UAC low UAC low line line –– tip tip in good in good position position at L3at L3
T12L1
2
3
4
L5
IVC/RA IVC/RA junctionjunctionIVC/RA IVC/RA junctionjunction
© S.T.A.B.L.E.®
© S.T.A.B.L.E.®
Umbilical Catheter Safety
� Use sterile technique
� Maintain an air-tight system
� Risk of significant blood loss with disconnection →disconnection →especially with UAC
� Tape securely
� Avoid thrombus
by adding heparin© S.T.A.B.L.E.
®© S.T.A.B.L.E.
®
FIGURE 30–4 Macrosomic infant of diabetic mother.
ScenarioS
29 week gestation infant precipitously delivers in
the birthing room
Assessment:
� Mottled skin — axillary temp 34°C (93.2°F)
Respiratory rate 80, grunting and retracting� Respiratory rate 80, grunting and retracting
� 80% O2 by hood oxygen
� Blood gas — PCO2 = 72
� Blood sugar 24 mg/dl (1.1 mmol/L)
� What is newborn’s problem(s)?
6 hours after delivery, term infant found to be 6 hours after delivery, term infant found to be dusky and tachypneic in mother’s roomdusky and tachypneic in mother’s room
ScenarioS
Assessment:
�Room air O2 saturation — 75%
Ashen skin color — axillary temp 35°C (95°F) �Ashen skin color — axillary temp 35°C (95°F)
�Respiratory rate — 70
�Capillary refill = 5 seconds — BP 40/20
� Initial blood gas pH 7.06 — consistent with severe metabolic acidosis
�What is newborn’s problem(s)?
NCLEX Question
� The nurse notes that at 5 minute after
birth, a neonate is pink with
acrocyanosis, has his knees flexed and
fists clenched, has a whimpering cry, has
a heart rate of 128 beats/minute, and a heart rate of 128 beats/minute, and
withdraws his foot to a slap on the sole.
What 5-minute Apgar score should the
nurse record for this neonate?
NCLEX Question� In the nursery, the nurse is performing a neurological
assessment on a 1-day-old neonate. Which findings would indicate possible asphyxia in utero? Select all that apply.
1. The neonate grasps the nurse’s finger when she puts it in the palm of his hand.the palm of his hand.
2. The neonate does stepping movements when held upright with his sole touching a surface.
3. The neonate’s toes don’t curl downward when the soles are stroked.
4. The neonate doesn’t respond when the nurse claps her hands above the baby.
5. The neonate turns toward an object when the nurse touches the cheek with it.
6. The neonate displays weak, ineffective sucking.
Thank you !Thank you !Thank you !Thank you !Thank you !Thank you !Thank you !Thank you !© S.T.A.B.L.E.
®© S.T.A.B.L.E.
®