問題一覧
1
SUNCTIONING
Suction gently and quickly ( _____ seconds). Prolonged and deep suctioning of the nasopharynx during the first 5 to 10 minutes of life will stimulate the VAGUS NERVE (located in the esophagus) and cause bradycardia.
5-10
2
Suction the _____ first before the nose. If the
nose is suctioned first, the stimulation of the
nasal mucosa will cause reflex inhalation of
pharyngeal material into the trachea and bronchi, causing ASPIRATION.
MOUTH
3
POSITIONING OF THE NEWBORN
The position when suctioning should be one that promotes drainage of secretions – _____ LOWER THAN THE REST OF THE BODY BUT head should be higher than the rest of the body if there are signs of increased ICP:
•Vomiting
•Bulging, tense fontanels
•Dilated scalp veins
•Abnormally large head
•Increased BP
•Decreased PR and RR
•Widening pulse pressure
•Shrill, high-pitched cry
HEAD
4
EFFECTS OF COLD STRESS
_______ - due to the use of glucose as glycogen
HYPOGLYCEMIA
5
EFFECTS OF COLD STRESS
•_________ – due to catabolism ( breakdown) of brown fats( best insulator of newborn) leading to formation of ketone bodies
METABOLIC ACIDOSIS
6
EFFECTS OF COLD STRESS
_____ center is underdeveloped
THERMOREGULATORY
7
Prevention of Cold Stress
1. Immediately after birth dry & wrap newborns . Ensure head is well covered.
2. Mechanical measures
*Pre-heated radiant warmers, isolette/
incubator
*Temperature should not fall below ____ C
3. Prevent unnecessary exposure – cover the areas not being examined
4. Embrace the baby – human blanket / kangaroo care
36.5
8
HEAT LOSS IN NEWBORN
_______ – loss of heat through conversion of a liquid to a vapor
Ex. __ of amniotic fluid from skin surface
EVAPORATION
9
HEAT LOSS IN NEWBORN
_______ – transfer of body heat to a cooler solid object not in contact with the body
Ex. do not place crib beside the wall to prevent heat loss
RADIATION
10
HEAT LOSS IN NEWBORN
_______ – transfer of body heat to a cooler solid object in contact with the body
Ex. metal stet; cold weighing scale, cold metal in DR
CONDUCTION
11
HEAT LOSS IN NEWBORN
______ – flow of heat from body surface to cooler surroundings
Ex. Electric fan or air conditioner
CONVECTION
12
APGAR SCORING SYSTEM
standard tool to evaluate the condition of the neonate
Done twice:
- ___ minute: to determine general condition (NEURO/RESPI/CIRCULATORY CHECK)
FIRST
13
??
standard tool to evaluate neonate
APGAR SCORING SYSTEM
14
??
RESPIRATORY DISTRESS
SILVERMANN ANDERSON SCORING
15
??
GESTATIONAL ASSESSMENT
DUBOWITZ
16
1. Appearance (color) – _____ IMPORTANT CRITERIA
2. Pulse rate (apical pulse) - _________ IMPORTANT CRITERIA
3. Grimace (reflex activity)- irritability
4. Activity (muscle tone)
5. Respiration
LEAST, MOST
17
APGAR SCORING SYSTEM
standard tool to evaluate the condition of the neonate
Done twice:
- ___ minute: to determine if neonate can adjust to extrauterine life
FIFTH
18
born before the 38th week
PRETERM
19
born after 42 weeks
POST TERM
20
born at 38 to 42 weeks
FULL TERM
21
BW is < 10th percentile
SMALL GESTATIONAL AGE
22
BW > 90th percentile
LARGE GESTATIONAL AGE
23
BW within 10-90th percentile
APPROPRIATE GESTATIONAL AGE
24
BW < 2,500 grams
LOW BIRTHWEIGHT
25
BW 1000 – 1500g
VERY LOW BIRTHWEIGHT
26
BW 500 – 1000g
EXTREMELY VERY LOW BIRTHWEIGHT
27
II. Care of the Newborn
• Check the ID bands of mother and baby
• THERMOREGULATION
• BATH – done if infant’s skin temperature stabilizes at 36.5ºC (98.6ºF); temperature stabilizes ___ hours after birth
•+ Initial bath : oil bath to cleanse the baby & spread the vernix caseosa ( bacteriostatic & insulator)
6-8
28
Full bath is safely given is safely given once the cord has fallen ( ___ days)
7-10
29
Physical Examination
Nursing Considerations in Pediatric Assessment:
• If the client is a ______, cover area that is not being examined to prevent hypothermia
NEWBORN
30
Physical Examination
•Nursing Considerations in Pediatric Assessment:
• If the client is an _____, the first VS to take is RR to follow assessment from least intrusive to the most intrusive method
INFANT
31
Physical Examination
•Nursing Considerations in Pediatric Assessment:
• If the client is a ______ & _____, let them handle an instrument such as a toy syringe or stet
TODDLER, PRESCHOOL
32
Physical Examination
•Nursing Considerations in Pediatric Assessment:
• if the client is ______ & ______, explain the procedure
SCHOOL AGE, ADOLESCENT
33
Take Anthropometric Measurements (Vital Statistics)
• BW: ______ kgs
2.5-3.4
34
Take Anthropometric Measurements (Vital Statistics)
BL: Average: _____ cm / ___ in
50.8,20
35
Take Anthropometric Measurements (Vital Statistics)
Normal BL : ____ – ____ cm (19 – 21 ½ in)
47.5-53.5
36
Take Anthropometric Measurements (Vital Statistics)
HC: _____ cm
33-35
37
Take Anthropometric Measurements (Vital Statistics)
CC: ______ cm
31-33
38
Take Anthropometric Measurements (Vital Statistics)
AC: _____ cm
31-33
39
heart rate: _______ bpm
120-140
40
respiration: ______ breaths per min
30-60
41
Taking Temperature
• Maintain at _____ºC- _____ºC to prevent hypoglycemia and acidosis due to hypothermia (cold stress).
•**Rectal route is preferred in order to check patency of the anus
•**Passage of meconium should be within 24 to 36 hrs afterbirth.
35.5-36.5
42
sticky greenish black stool
MECONIUM
43
CREDE’S PROPHYLAXIS
• to prevent __________ or Gonorrheal Conjunctivitis (Neisseria gonorrhea) which causes blindness if not treated.
• Infection can be acquired during delivery from a mother with untreated gonorrhea
OPTHALMIA NEONATORUM
44
_______ Opthalmic Ointment
ERYTHROMYCIN
45
Vitamin K Injection
Vitamin K facilitates production of the clotting factor (Prothrombin) ; thus, prevents bleeding, should be given within one hour after birth.
Preterm ___ ml; term ____ ml
Aquamephyton (generic: phytonadione)
Route: IM into the lateral anterior thigh (Vastus lateralis). In children below 12 months of age who have not yet learned how to walk, this is the preferred site of injection because the gluteal muscles are not yet fully developed.
0.5,1
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28問 • 10ヶ月前問題一覧
1
SUNCTIONING
Suction gently and quickly ( _____ seconds). Prolonged and deep suctioning of the nasopharynx during the first 5 to 10 minutes of life will stimulate the VAGUS NERVE (located in the esophagus) and cause bradycardia.
5-10
2
Suction the _____ first before the nose. If the
nose is suctioned first, the stimulation of the
nasal mucosa will cause reflex inhalation of
pharyngeal material into the trachea and bronchi, causing ASPIRATION.
MOUTH
3
POSITIONING OF THE NEWBORN
The position when suctioning should be one that promotes drainage of secretions – _____ LOWER THAN THE REST OF THE BODY BUT head should be higher than the rest of the body if there are signs of increased ICP:
•Vomiting
•Bulging, tense fontanels
•Dilated scalp veins
•Abnormally large head
•Increased BP
•Decreased PR and RR
•Widening pulse pressure
•Shrill, high-pitched cry
HEAD
4
EFFECTS OF COLD STRESS
_______ - due to the use of glucose as glycogen
HYPOGLYCEMIA
5
EFFECTS OF COLD STRESS
•_________ – due to catabolism ( breakdown) of brown fats( best insulator of newborn) leading to formation of ketone bodies
METABOLIC ACIDOSIS
6
EFFECTS OF COLD STRESS
_____ center is underdeveloped
THERMOREGULATORY
7
Prevention of Cold Stress
1. Immediately after birth dry & wrap newborns . Ensure head is well covered.
2. Mechanical measures
*Pre-heated radiant warmers, isolette/
incubator
*Temperature should not fall below ____ C
3. Prevent unnecessary exposure – cover the areas not being examined
4. Embrace the baby – human blanket / kangaroo care
36.5
8
HEAT LOSS IN NEWBORN
_______ – loss of heat through conversion of a liquid to a vapor
Ex. __ of amniotic fluid from skin surface
EVAPORATION
9
HEAT LOSS IN NEWBORN
_______ – transfer of body heat to a cooler solid object not in contact with the body
Ex. do not place crib beside the wall to prevent heat loss
RADIATION
10
HEAT LOSS IN NEWBORN
_______ – transfer of body heat to a cooler solid object in contact with the body
Ex. metal stet; cold weighing scale, cold metal in DR
CONDUCTION
11
HEAT LOSS IN NEWBORN
______ – flow of heat from body surface to cooler surroundings
Ex. Electric fan or air conditioner
CONVECTION
12
APGAR SCORING SYSTEM
standard tool to evaluate the condition of the neonate
Done twice:
- ___ minute: to determine general condition (NEURO/RESPI/CIRCULATORY CHECK)
FIRST
13
??
standard tool to evaluate neonate
APGAR SCORING SYSTEM
14
??
RESPIRATORY DISTRESS
SILVERMANN ANDERSON SCORING
15
??
GESTATIONAL ASSESSMENT
DUBOWITZ
16
1. Appearance (color) – _____ IMPORTANT CRITERIA
2. Pulse rate (apical pulse) - _________ IMPORTANT CRITERIA
3. Grimace (reflex activity)- irritability
4. Activity (muscle tone)
5. Respiration
LEAST, MOST
17
APGAR SCORING SYSTEM
standard tool to evaluate the condition of the neonate
Done twice:
- ___ minute: to determine if neonate can adjust to extrauterine life
FIFTH
18
born before the 38th week
PRETERM
19
born after 42 weeks
POST TERM
20
born at 38 to 42 weeks
FULL TERM
21
BW is < 10th percentile
SMALL GESTATIONAL AGE
22
BW > 90th percentile
LARGE GESTATIONAL AGE
23
BW within 10-90th percentile
APPROPRIATE GESTATIONAL AGE
24
BW < 2,500 grams
LOW BIRTHWEIGHT
25
BW 1000 – 1500g
VERY LOW BIRTHWEIGHT
26
BW 500 – 1000g
EXTREMELY VERY LOW BIRTHWEIGHT
27
II. Care of the Newborn
• Check the ID bands of mother and baby
• THERMOREGULATION
• BATH – done if infant’s skin temperature stabilizes at 36.5ºC (98.6ºF); temperature stabilizes ___ hours after birth
•+ Initial bath : oil bath to cleanse the baby & spread the vernix caseosa ( bacteriostatic & insulator)
6-8
28
Full bath is safely given is safely given once the cord has fallen ( ___ days)
7-10
29
Physical Examination
Nursing Considerations in Pediatric Assessment:
• If the client is a ______, cover area that is not being examined to prevent hypothermia
NEWBORN
30
Physical Examination
•Nursing Considerations in Pediatric Assessment:
• If the client is an _____, the first VS to take is RR to follow assessment from least intrusive to the most intrusive method
INFANT
31
Physical Examination
•Nursing Considerations in Pediatric Assessment:
• If the client is a ______ & _____, let them handle an instrument such as a toy syringe or stet
TODDLER, PRESCHOOL
32
Physical Examination
•Nursing Considerations in Pediatric Assessment:
• if the client is ______ & ______, explain the procedure
SCHOOL AGE, ADOLESCENT
33
Take Anthropometric Measurements (Vital Statistics)
• BW: ______ kgs
2.5-3.4
34
Take Anthropometric Measurements (Vital Statistics)
BL: Average: _____ cm / ___ in
50.8,20
35
Take Anthropometric Measurements (Vital Statistics)
Normal BL : ____ – ____ cm (19 – 21 ½ in)
47.5-53.5
36
Take Anthropometric Measurements (Vital Statistics)
HC: _____ cm
33-35
37
Take Anthropometric Measurements (Vital Statistics)
CC: ______ cm
31-33
38
Take Anthropometric Measurements (Vital Statistics)
AC: _____ cm
31-33
39
heart rate: _______ bpm
120-140
40
respiration: ______ breaths per min
30-60
41
Taking Temperature
• Maintain at _____ºC- _____ºC to prevent hypoglycemia and acidosis due to hypothermia (cold stress).
•**Rectal route is preferred in order to check patency of the anus
•**Passage of meconium should be within 24 to 36 hrs afterbirth.
35.5-36.5
42
sticky greenish black stool
MECONIUM
43
CREDE’S PROPHYLAXIS
• to prevent __________ or Gonorrheal Conjunctivitis (Neisseria gonorrhea) which causes blindness if not treated.
• Infection can be acquired during delivery from a mother with untreated gonorrhea
OPTHALMIA NEONATORUM
44
_______ Opthalmic Ointment
ERYTHROMYCIN
45
Vitamin K Injection
Vitamin K facilitates production of the clotting factor (Prothrombin) ; thus, prevents bleeding, should be given within one hour after birth.
Preterm ___ ml; term ____ ml
Aquamephyton (generic: phytonadione)
Route: IM into the lateral anterior thigh (Vastus lateralis). In children below 12 months of age who have not yet learned how to walk, this is the preferred site of injection because the gluteal muscles are not yet fully developed.
0.5,1