MATERNAL - PEDIATRIC NEWBORN ASSESSMENT

45問 • 6ヶ月前

問題一覧

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

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

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

EFFECTS OF COLD STRESS _______ - due to the use of glucose as glycogen

HYPOGLYCEMIA

EFFECTS OF COLD STRESS •_________ – due to catabolism ( breakdown) of brown fats( best insulator of newborn) leading to formation of ketone bodies

METABOLIC ACIDOSIS

EFFECTS OF COLD STRESS _____ center is underdeveloped

THERMOREGULATORY

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

HEAT LOSS IN NEWBORN _______ – loss of heat through conversion of a liquid to a vapor Ex. __ of amniotic fluid from skin surface

EVAPORATION

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

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

HEAT LOSS IN NEWBORN ______ – flow of heat from body surface to cooler surroundings Ex. Electric fan or air conditioner

CONVECTION

APGAR SCORING SYSTEM standard tool to evaluate the condition of the neonate Done twice: - ___ minute: to determine general condition (NEURO/RESPI/CIRCULATORY CHECK)

FIRST

?? standard tool to evaluate neonate

APGAR SCORING SYSTEM

?? RESPIRATORY DISTRESS

SILVERMANN ANDERSON SCORING

?? GESTATIONAL ASSESSMENT

DUBOWITZ

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

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

born before the 38th week

PRETERM

born after 42 weeks

POST TERM

born at 38 to 42 weeks

FULL TERM

BW is < 10th percentile

SMALL GESTATIONAL AGE

BW > 90th percentile

LARGE GESTATIONAL AGE

BW within 10-90th percentile

APPROPRIATE GESTATIONAL AGE

BW < 2,500 grams

LOW BIRTHWEIGHT

BW 1000 – 1500g

VERY LOW BIRTHWEIGHT

BW 500 – 1000g

EXTREMELY VERY LOW BIRTHWEIGHT

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

Full bath is safely given is safely given once the cord has fallen ( ___ days)

7-10

Physical Examination Nursing Considerations in Pediatric Assessment: • If the client is a ______, cover area that is not being examined to prevent hypothermia

NEWBORN

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

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

Physical Examination •Nursing Considerations in Pediatric Assessment: • if the client is ______ & ______, explain the procedure

SCHOOL AGE, ADOLESCENT

Take Anthropometric Measurements (Vital Statistics) • BW: ______ kgs

2.5-3.4

Take Anthropometric Measurements (Vital Statistics) BL: Average: _____ cm / ___ in

50.8,20

Take Anthropometric Measurements (Vital Statistics) Normal BL : ____ – ____ cm (19 – 21 ½ in)

47.5-53.5

Take Anthropometric Measurements (Vital Statistics) HC: _____ cm

33-35

Take Anthropometric Measurements (Vital Statistics) CC: ______ cm

31-33

Take Anthropometric Measurements (Vital Statistics) AC: _____ cm

31-33

heart rate: _______ bpm

120-140

respiration: ______ breaths per min

30-60

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

sticky greenish black stool

MECONIUM

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

_______ Opthalmic Ointment

ERYTHROMYCIN

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

HCI

JHAYS · 5問 · 1年前

HCI