NUR 106 Mat/Child6-13-09

NEWBORN NURSERYCLINICAL ROTATION QUIZ

1. Give the normal ranges of temperature, pulse, respiration, weight and length in the newborn. How are each of these assessed?The normal range of temperature, pulse, respirations, weight and length in the newborn are as follows: Temp: 97.7-99.5F (taken in the axilla); Pulse: 120-160bpm (pulse assessed at the 3rd to 4th intercostal space slightly left of the midclavicular line; brachial, femoral, and pedal pulses are felt for equality bilaterally); Respirations: 30-60 per min apnea may be present, but respirations should be irregular, shallow and unlabored, chest should be symmetric. Breath sounds should be present and clear bilaterally; Weight: 2500g-4000g or 5lb, 8oz-8lb, 13oz. Weight loss in the newborn 0-3days should be no less than 10% of birth weight; Length: 48-53cm or 19-21in, measured from the crown of the head to the heel of the foot.

2. Describe the normal appearance of the umbilical cord. Discuss how it is cared for andwhat you would teach the mother about its care after discharge?The normal appearance of the umbilical cord following birth is important to assess. It should have 2 arteries and 1 vein surrounded by a sufficient amount of Wharton's jelly, the cord is usually grey in appearance immediately following birth and may have the two arteries standing up on the end it was cut. Teaching cord care to the parents includes instructing them on when and how to clean the cord and the signs of infections to watch for.Parents are usually told to clean the cord stump three times a day with alcohol and to fold the diaper under the cord to avoid any pulling or irritation from occurring. The signs of infection to look for are redness at the base of the cord, discharge. It is normal for some bleeding to occur as well as possible odors of the cord but the signs of infection should be brought to the physician's attention as well as any other concerns the parent(s) may have.

3. List the 4 mechanisms of heat loss in the newborn and describe ways to prevent it.Newborn's lose heat by evaporation, conduction, convection and radiation. Evaporation occurs when wet surfaces are exposed to air, such as immediately following birth when the infant is covered in amniotic fluids or baths. The most effective way to prevent heat loss by evaporation is by keeping the infant dry, especially the head since heat is lost quickly there. The parent(s) should be taught to keep the infant in a swaddled blanket and a knit cap on the infants head, diapers should be checked often and changed when needed. Conduction occurs when the newborn is in direct contact with a surface that is cooler than their skin, placing the infant of surfaces with a higher temperature than their skin will increase their temperature. To prevent heat loss by conduction ,surfaces the infant is going to be in contact with should be warmed, immediately following birth the newborn is usually put directly on the mothers skin to help keep the child warm. Heat lost by convection occurs when heat is transferred to the air surrounding the child, such as from air conditioners or people moving around creating air currents. Prevention of heat lost through convection should include keeping the infant out of drafts, maintaining a warm environment, keeping the child swaddled, warming any oxygen prior to prolonged administration. Incubators circulate warm air around the infant to help keep them warm by convection. Radiation is the transfer of heat to cooler objects that are not in direct contact with the infant, such as placing the infant near a cold window. Newborns can also gain heat by radiation. Preventing heat loss by radiation includes keeping the infant's crib and/or incubator away from cold windows or walls.

4. Describe 2 methods of circumcision and the risks and benefits of each. Discuss the careof the circumcised and non-circumcised penis.Circumcisions are done to remove the foreskin from the penis. The two most common devices of circumcision are the Gomco clamp and the Plastibell, in both methods the prepuce is separated from the glans of the penis with a probe and incised to expose the glans. Circumcisions that are done by the Gomco method remove the prepuce 3-5 minutes following the compression of the blood vessels in the foreskin. Compression is done by pulling the prepuce over a cone and then tightening a clamp placed around the cone, this is done to prevent excessive bleeding. Circumcisions performed using the plastibell include the doctor placing a plastic ring over the glans then drawing the foreskin over it and then a suture is tied around the prepuce and the Plastibell. The Plastibell usually falls off in 5-8 days. The Plastibell is the most common method of circumcision in Alabama. Care for the uncircumcised penis includes keeping the infant's penis clean and dry, to remove soiled diapers and to wash the penis every change, the foreskin should never be forced back because the prepuce does not usually separate from the glans until the age of 2 or 3. Care of the circumcised penis includes inspecting the circumcision site for any signs of infection at every diaper change, petroleum jelly should be applied to the site for the first 24 hours following the procedure unless circumcision was done using a Platibell. Keeping the circumcision site clean is the most important action to help in preventing infection or any other possible complications.

5. Define the scoring system for the newborn and what five areas are assessed. Discuss the scoring system and what should be done for the newborn if the score is high, medium or low.The Apgar test scores the infant on five areas at one minute after birth and then again at five minutes following birth. This test is a rapid way to evaluate the cardiorespiratory adaptation of the infant following birth. The five areas assessed are the heart rate, respiratory effort, muscle tone, reflex response and skin color. The infant is given a score of 0-2 depending on the activity noted during the scoring, total amount of points from all areas are the Apgar score. A score of 0-3 required resuscitation of the infant; 4-7 score stimulation of the infants back and O2 are given and if mother was given narcotic's, Narcan may need to be administered as an antidote. A score of 8-10 requires no support, just further observation.

6. Describe the Ballard or Dubowitz rating system and name the items it assesses underneuromuscular and physical maturity. Why is this scoring done?The Ballard and Dubowitz systems are used to assess gestational age by examining the infant's physical and neurological characteristics. The Dubowitz scoring system is an in-depth and detailed assessment that includes the examination of physical, neurological and behavioral characteristics. The New Ballard Score is a revised and simplified version of the Dubowitz and it assess physical and neuromuscular characteristics, this system is also adapted to include very preterm infants. Neuromuscular characteristics assessed are as follows: posture; square window sign(wrist angle); arm recoil, popliteal angle; scarf sign; and heel to ear. The physical characteristics assessed are as follows: skin; lanugo; plantar surface; breasts; eyes and ears; and the genitals. The total score of all assessed characteristics determines the gestational age. A difference of 2.5 points in two different examiners scores allow the gestational age to be changed by a week.

7. Vitamin K, Hepatitis Vaccine and Silver Nitrate or Erythromycin ointment are uses routinely for the newborn. Why are each of these used and what is the route, site andamount for each?Vitamin K is given to the newborn with in the first few hours after birth as a prophylaxis

against hemorrhagic disease of the newborn. Vitamin K is needed because the newborn does not have enough bacterial flora in the intestines to synthesize Vitamin K. The vitamin is given intramuscularly within the first hour after birth. The dose is 0.5-1mg , although the dose may be lower or for an infant weighing less than 2500g or more for an infant whose mother took anticoagulants during pregnancy. Hepatitis B Vaccine is given to newborns that are exposed to the virus as well as those who were not exposed as a prevention method. The dose is 5mcg to an exposed infant and 2.5mcg to an unexposed infant, it is given as an intramuscular injection in the anterolateral thigh. Silver Nitrate or Erythromycin is given to inhibit protein synthesis of the bacteria Neisseria gonorrhoeae and Chlamydia trachomatis. It is by law that all infant are to be given a prophylaxis for gonorrhea regardless of the mothers infection status.

8. What is physiological jaundice and what is the most common treatment? What nursing care is given while the newborn is being treated?Physiological jaundice also called developmental jaundice occurs on the second to third day after birth and is considered a normal occurrence. The bilirubin level of physiological jaundice peaks at 5-6mg/dl at the 2nd to 4th day and then begins to fall to 1mg/dl by 10-14 days of age. Preterm infants usually have a slightly longer period of jaundice. No treatment is necessary unless bilirubin levels are higher than those expected for physiological jaundice. Care includes monitoring bilirubin levels, infants color and activity levels.

9. What is meconium and how soon is it usually observed in the newborn? What condition might be present if meconium is not observed? Meconium is the first stool produced by a newborn. Meconium is a greenish-black with a tar-like consistency it is made up of amniotic fluid particles such as skin cells, vernix, hair, bile, intestinal secretions and accumulates in the fetus's intestinal tract prior to birth. The first stool should pass with in 48 hours following birth and is usually passes with in the first 12 hours after birth. Failure to pass meconium with in this time may be a sign of intestinal obstruction, or abnormality.

10. Define PKU and state when, how, and why the test is performed.PKU or Phenylketonuria is a genetic condition that inhibits the infants ability to metabolize the amino acid phenylalanine that is common in protein rich foods. The accumulation of phenylalanine can cause severe metal retardation. The screening test is usually done the first week after birth. The test requires for a small blood sample usually taken from the heel of the foot by puncturing the heel with a needle and gently squeezing the heel to collect the blood.

11. List 4 things that are different in the preterm infant than the full term. How do these affect the preterm and what should the nurse do to prevent complications?Preterm infants are at risk for developing RDS or respiratory distress syndrome, due to the inadequate amount of surfactant and lung immaturity. They also have a underdeveloped cough reflex which may allow for secretions to accumulate in the air passages. Treatment often occurs prior to birth when the mother is given steroid shots to accelerate the maturation of the fetal lungs, however the labor must be delayed for at least 48 hours for the effects of the steroids to work. If steroids were not given or not given time to work the child would need frequent position changes to help clear air ways, although the prone position is not recommended due to the increased risk of SIDS. Infants that are preterm may also need oxygen therapy, suctioning of airways, and also require adequate hydration. Preterm infants also have more problems with thermoregulation, because little subcutaneous fat accumulated beneath the surface of the skin. The veins of a preterm infant are usually clearly visible than the veins of a full term infant, this allows internal heat to be lost because little insulation is present to preserve heat. The head is also larger in proportion to the body than a full term infant and allows for more heat to be lost from the head. Prevention of heat loss includes

incubation if necessary, swaddling the infant, knit cap on head. Over heating is also a problem to watch for when treating thermoregulation. Kangaroo care is also a good treatment for thermoregulation problems and helps promote bonding with the parents. Premature infants also have an increased risk for infections due to possible maternal infections or the lack of immunoglobulin G that may not have been received during the third trimester of pregnancy. The most important preventive measure is hand washing. Maintaining the infants skin integrity and assessment of any signs or symptoms of possible infection are also important. Dehydration is always a risk for preterm infants due to the decrease in subcutaneous fat and increased permeability of the skin, insensible loss is also a way the infant can become dehydrated. Treatments include careful regulation of IV fluids, and assessing intake and output, weight changes and laboratory values.

12. What are major things that the preterm infant is a risk for developing? How can these be prevented?Jaundice is one condition the preterm infant is at risk for developing. The percentage of jaundice occurring in full term infants is 60% while the percentage rate for preterm infants is 80%. Jaundice is the accumulation of excess bilirubin in the body. Preventing jaundice includes the use of phototherapy, which is the use of UV light to help break down the bilirubin in the body. Lab values are also closely monitored to assess the bilirubin levels in the blood. Retinopathy caused by damage to blood vessels often associated with oxygen use can cause loss of vision and even blindness. Prevention of this condition includes careful monitoring of the oxygen levels in the arterial blood, or pulse oximetry or transcutaneous monitoring may also be used to measure O2 levels. Weaning the preterm infant from O2 as early as possible is also indicated. Increased pain is another major problem preterm infants may have due to the needed invasive interventions to help keep them alive. Pain can cause other problems such as increased intracranial pressure which then increases the risk for intraventricular hemorrhage. The release of cortisol and catecholamines due to pain can cause increases or decreases in heart rate and respirations, may elevate blood glucose levels, increase the metabolic rate, and even cause a greater need for oxygen which then could lead to other problems. Pain should be assessed as the 5th vital sign, nurses should assess the level of pain and the infants response to painful stimuli, comfort measures such as pacifiers should be used but are not alone enough for moderate to severe pain. In cases of moderate to severe pain non-narcotic analgesics should be used such as acetaminophen.

13. What are the symptoms of hypoglycemia in the newborn and how is it treated? What newborns are at risk for this condition?Hypoglycemia is low blood glucose levels. Infants at risk for hypoglycemia are premature infants, postmature infants, intrauterine growth restrictions, smaller or larger size for gestational age, maternal diabetes, asphyxia, cold stress, maternal intake of terbutaline or ritodrine. Treatment includes prevention, such as normal blood glucose monitoring, feeding if glucose reading is 40-45mg/dl to prevent further decrease in levels. Hypoglycemia can be a serious problem if not treated, it can cause severe brain damage. Signs and symptoms to look for include: poor sucking, respiratory distress, tachycardia, tachypnea, poor muscle tone, jitteriness, irritability, seizures, and even coma; however many infants show little or no signs of hypoglycemia.

14. Define the following terms:

Milia-

White cysts, 1-2 mm in size, resulting from distended sebaceous glands.Molding-The shaping of the fetal head during movement through the birth canal.Fontanel-Space at the intersection of sutures connecting fetal or infant skull bones.Lanugo-Fine, soft hair covering the fetus.Phimosis-Foreskin that cannot be retracted from the glans of the penis.Vernix-Thick, white substance that protects the skin of the fetus.Caput-Area of edema over the presenting part of the fetus or newborn resulting from pressure against the cervix.Acrocyanosis-Bluish discoloration of the hands and feet due to reduced peripheral circulation. Ortalani's Maneuver-A method of testing for hip instability. Ortolani's manuever requires the legs to be extended while in the prone position to assess leg length, and bending of the infants knees while feet are on a flat surface to look at knee height. Cephalohematoma-Bleeding between the peiosteum and skull from pressure during birth, does not cross suture lines.Erythema Toxicum-Benign rash of unknown cause in newborns, with blotchy red areas that may have white or yellow papules or vesicles in the center. Mongolian Spots-Bruise like marks that primarily occur in newborns with dark skin tones. Pseudomenstruation-Vaginal bleeding in the newborn, resulting from withdrawal of placental hormones.