OB-Contemporary Maternity Nursing-EXAM 1

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Pre-Assessment
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A nurse who uses current research, statistical data, and quality measurements as a guide for nursing care is providing care that is: 1. Based on personal opinion. 2. Derived from memory. 3. Evidence-based. 4. Directed by habit.
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A nurse gathers data on the number of families with small children that reside in housing units in a community with lead-based paint, which can cause serious health problems for exposed children. The nurse is using statistics in order to:
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1. Evaluate the success of specific nursing interventions. 2. Assess the relationship between specific factors. 3. Determine populations at risk. 4. Help establish databases for specific client populations.
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When the nurse asks a child’s parents what they feel caused their newborn’s illness, she is recognizing the importance of the family’s: 4 things
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Communication patterns. Religion. Education. Cultural values and beliefs
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Contemporary Childbirth
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1. The healthcare environment 2 Culturally competent care 3 Professional options in maternal-newborn nursing practice 4 Legal and ethical considerations 5 Evidence-based practice in maternal-child nursing
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Contemporary Childbirth Emphasis
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On family, family centered birth
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Shortened Hospital Stays
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Newborns’ and Mothers’ Health Protection Act of 1996 48 hours after a vaginal delivery 96 hours after delivery by cesarean Nurses have responsibility for teaching (home health visit would be ideal)
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Ethnocentrism
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Avoid imposing cultural values
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What is a family?
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-A group of individuals related by blood, marriage, or mutual goals. -Bound by strong emotional ties, a sense of belonging.
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extended kin network family
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two nuclear families live in close proximity to each other and share responsibilities and resources
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Use what to assess? assess, prioritize, plan, sequence and evaluate nursing interventions
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Maslow’s Hierarchy of Human Needs
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A newborn is born at 38 weeks’ gestation weighing 2250 grams. Which is the most appropriate nursing diagnosis? a.Ineffective Airway Clearance b. Risk for Altered Body Temperature c Acute Pain d Altered Nutrition: More Than Body Requirements
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b Risk for Altered Body Temperature This newborn is small for gestational age, and would be at risk for experiencing heat loss due to low birth weight. It is a priority of the nurse to ensure a neutral thermal environment. No information is given to indicate that the other nursing diagnoses would be priorities
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Before giving a newborn his first sponge bath, the nurse must first do which of the following? 1 Check the temperature. 2 Decrease room lighting. 3 Weigh the baby. 4 Check capillary refill.
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1 Check the temperature. The nurse must make sure the newborn can maintain an adequate body temperature before exposing the newborn to different water temperatures. Decreasing room lighting, weighing the baby, and checking capillary refill are not related to ensuring a newborn’s readiness for a bath.
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Broad Nursing Goals
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– Promote physical well-being of newborn Provide comprehensive care to newborn -Support establishment of well-functioning family Provide education Support family efforts
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Nursing assessment and diagnosis Admission and First 4 hours of life
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– Review prenatal record for possible risk factors – Review birth record – Preliminary physical examination – Notify physician/nurse practitioner of deviations from normal
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Nursing Care During Admission and First Four Hours of Life Nursing diagnoses include
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– Ineffective Airway Clearance – Risk for Imbalanced Body Temperature – Ineffective Peripheral Tissue Perfusion – Acute Pain
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Nursing Plan and Implementation Initiate newborn admission procedures
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Maternal and birth history Airway clearance Vital signs, body temperature Neurologic status Ability to feed Evidence of complications and/or illness
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Essential Data to Be Recorded with newborn
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Condition of newborn Labor and birth record Antepartal history Parent-newborn interaction information Weigh newborn in grams and pounds Length Circumference of head, chest Rapidly assess color, tone, alertness, general state Vital signs Blood glucose evaluations if done
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Vitamin K
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Prevent Vitamin K deficiency bleeding Prophylactic injection of vitamin K1 given Prevents hemorrhage Low prothrombin levels Absence of gut bacteria Given intramuscularly
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Procedure for vitamin K injection
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Cleanse area thoroughly with alcohol swab, and allow skin to dry. Bunch the tissue of the midanterior lateral aspect of the thigh (vastus lateralis muscle) and quickly insert a 25-gauge 5/8-inch needle at a 90-degree angle to the thigh. Aspirate, then slowly inject the solution to distribute the medication evenly and minimize the baby’s discomfort. Remove the needle and massage the site with an alcohol swab
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Eye Infection Prevention
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Neisseria gonorrhoeae eye treatment Prophylactic Legally required Topical agents 0.5% erythromycin ophthalmic ointment 1% tetracycline
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Signs of Neonatal Distress
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Increased RR more than 60/min, difficult Respirations Sternal, substernal, intercostal retractions Nasal flaring grunting excessive mucous facial grimacing cyanosis abdominal distention vomiting of bile Absence of meconium, urine within 24 hours birth Jaundice of skin within 24 hours birth Temp instability Bitterness or glucose less than 40mg %
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Nursing Management of the Newborn Following Transition
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Nursing diagnoses – Risk for Ineffective Breathing Pattern – Imbalanced Nutrition: Less Than Body Requirements – Impaired Urinary Elimination – Risk for Infection – Readiness for Enhanced Knowledge – Readiness for Enhanced Family Relationship – Risk for Injury
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Maintenance of cardiopulmonary function
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– Assess vital signs every 6 to 8 hours or more – Place on back for sleeping – Bulb syringe within reach
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Maintain Neutral Thermal Environment
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Maintain within normal range Dried completely Dressed, head covering Increased respiratory rate Increased insensible fluid loss
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Promotion of Adequate Hydration and Nutrition
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– Record caloric and fluid intake (# of feedings) – Early and frequent feedings – Record voiding and stooling patterns – Birthweight should be regained by 2 weeks – Excessive handling can increase metabolic rate Cues of fatigue – Decrease in muscle tension and activity – Loss of eye contact -Assess woman’s comfort, latching-on techniques
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Umbilical cord assessed
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Clamp removed within 24 to 48 hours of birth Keep clean and dry Fold diaper down
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Prevention of Complications Newborns at continued risk for complications
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– Hemorrhage – Late-onset cardiac symptoms – Jaundice – Infection
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Circumcision
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Remove diaper, place newborn on padded circumcision board Assess newborn’s response Anesthesia Comfort procedures Assess for signs of hemorrhage, infection Every 30 minutes for at least 2 hours Observe for first void Petroleum applied to site immediately Teach family members Care of circumcision or Plastibell
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Safety topics Teach for going home
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Back to sleep, bulb syringe Alone only in crib Demonstrating bath, cord care, temperature assessment When to call healthcare provider
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Newborn Screening and Immunization Program Newborn screening tests
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Cystic fibrosis Galactosemia Congenital adrenal hyperplasia Maple syrup urine disease Sickle cell trait Phenylketonuria Hypothyroidism Hearing screenings Immunize for hepatitis B Critical cardiac disorders screening
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Normal progression of stool changes
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(1) Meconium (thick, tarry, dark green) (2) Transitional stools (thin, brown to green) (3a) Breastfed infant (yellow gold, soft, mushy) (3b) Formula-fed infant (pale yellow, formed, pasty)
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Circumcision Care
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Squeeze water over circumcision site once daily Rinse area off with warm water, pat dry Each diaper change, apply small amount of petroleum jelly Check daily Foul-smelling drainage, bleeding Let Plastibell fall off by itself About 8 days after circumcision Do not pull off Plastibell Light, sticky, yellow drainage Part of healing process May form over head of penis
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How and when to reach care providers Temperatures
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Temperature above 38°C (100.4°F) axillary Below 36.6°C (97.8°F) axillary Continual rise in temperature
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When To Reach Care Providers
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Discharge, bleeding Umbilical cord, circumcision, any opening Two consecutive green watery or black stools Increased frequency of stools No wet diapers for 18 to 24 hours Fewer than six to eight wet diapers per day after 4 days of age Eye drainage More than one episode of forceful vomiting Frequent vomiting over 6-hour period Refusal of two feedings in a row Lethargy, difficulty in awakening baby Cyanosis with or without feeding Absence of breathing >20 seconds Inconsolable infant, continuous high-pitched cry
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Respiratory Adaptations Intrauterine factors
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Fetal lung development (last organ to develop) Fetal breathing movements
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Respiratory Adaptations Initiation of breathing
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Mechanical events (with delivery)
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RR newborn
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30-60/min
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Characteristics of newborn respirations
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Periodic breathing Nose breathers Cyanosis, acrocyanosis Use of intercostal muscles May indicate distress
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Cardiovascular Adaptations Fetal-newborn transitional physiology
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Fetal life Increased aortic pressure, decreased venous pressure Increased systemic pressure, decreased pulmonary pressure Closure of foramen ovale, ductus arteriosus, ductus venosus
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Characteristics of Cardiac Function heart rate
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120-160 in first week of life
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Characteristics of Cardiac Function BP
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Average mean BP 5-55mm Hg
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Characteristics of Cardiac Function Sounds
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Heart murmurs
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Temperature Regulation
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Maintenance of thermal balance Less adipose tissue (insulating fat) Preterm Small for gestational age (SGA) Large body surface in relation to mass
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Hepatic Adaptations Liver palpable
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Frequently palpable, 40% of abdominal cavity
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Hepatic Adaptations Liver
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Iron storage, red blood cell (RBC) production Iron supplement after 6 months Mother’s iron intake sufficient store for 5 months
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Carbohydrate Metabolism
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Carbohydrate reserves low Glucose main source of energy 4-6 h after birth Fuel source consumed quickly Assess glucose level of newborn
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Physiologic Jaundice Facts
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Accelerated destruction of fetal RBCs Normal 50% term, 80% preterm newborns Daylight assists in early recognition Prevention – fluids Nursing care for jaundice
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Physiologic Jaundice
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occurs after first 24 hours of life During first week of life, bilirubin should not exceed 13mg/dl Bilirubin peaks at 3-5 days in term infants
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Breast milk jaundice
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Bilirubin levels begin to rise about the fourth day after mature breast milk comes in Peaks of 5-10mg/dl is reached at 2-3 weeks of age May be necessary to interrupt breastfeeding for a short period when bilirubin reaches 20 mg
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Coagulation
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Coagulation factors II, VII, IX, X Absence of normal intestinal flora Vitamin K prophylactically
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Integumentary system Neonatal Skin Condition Score (NSCS)
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Dryness Erythema Breakdown/excoriation
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Gastrointestinal Adaptations
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Proteins require more digestion Absorbs and digests fats less efficiently Experienced swallowing, gastric emptying in utero Air enters stomach immediately after birth 50-60 ml capacity by day 10 Cardiac sphincter immature Monitor regurgitation Requires 120 kcal/kg/day
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Elimination
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Meconium within 8 to 24 hours Transitional stools Breastfed Formula Frequency varies
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Urinary Adaptations
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Glomerular filtration rate low Limited capacity to concentrate urine Voids within 48 hours Urine may be cloudy Pseudomenstruation
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Immunologic Adaptations
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Not fully activated Fever not reliable indicator of infection IgG crosses placenta Passive acquired immunity Transferred primarily in third trimester No IgA until 4-6 months unless the newborn is breastfed
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Neurologic and Sensory/Perceptual Functioning
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Brain one-quarter size of adult brain Myelination of nerve fibers incomplete Usually partially flexed extremities Organization and intensity of motor activity Influenced by several factors Eye movements Cry
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Specific Symmetric Deep Tendon Reflexes
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Knee jerk brisk Normal ankle clonus 3 to 4 beats Plantar flexion Moro reflex Grasping Rooting Sucking reflexes Babinski
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Babinski
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occurs after the sole of the foot has been firmly stroked. The big toe then moves upward or toward the top surface of the foot. The other toes fan out.
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Moro reflex
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normally present in all infants/newborns up to 4 or 5 months of age as a response to a sudden loss of support, when the infant feels as if it is falling. It involves three distinct components: spreading out the arms (abduction) unspreading the arms (adduction) crying (usually)
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First period of reactivity
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Birth to about 30 minutes after birth Bonding, initiate breastfeeding Respirations and heart rate rapid
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Period of inactivity to sleep Periods of reactivity
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Heart rate, respirations decrease Sleep phase from minutes to 2-4 hours
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Second period of reactivity
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Awake and alert 4 to 6 hours Physiologic responses vary Close observations GI tract more active
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Behavioral States of the Newborn
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-Sleep states Deep or quiet sleep Light sleep -Rapid eye movement (REM) active sleep -Quiet sleep -Alert states
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Behavioral and Sensory Capacities Self-quieting ability
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Hand to mouth movement Sucking on fist or tongue Attending to external stimuli Neurologically impaired Swaddling
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Behavioral and Sensory Capacities Visual
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Orientation Prefers human face, high contrast
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Behavioral and Sensory Capacities Auditory
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Definite organized behavior repertoire
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Behavioral and Sensory Capacities Olfactory
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Can differentiate mother by smell
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Behavioral and Sensory Capacities Taste and sucking
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Sweet and sour Sucking patterns, rooting reflex
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Behavioral and Sensory Capacities Tactile
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May be most important, very sensitive
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A routine hematocrit level is drawn on a newborn immediately after delivery, and is found to be above normal. What might have contributed to this abnormally high hematocrit level? a. Congenital heart defect b. Leukocytosis c. Delayed cord clamping d. Hypovolemia
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c. Blood volume increases by approximately 61% with delayed cord clamping; this increase is reflected by a rise in hemoglobin level and an increase in hematocrit. Congenital heart defects, leukocytosis, and hypovolemia are not related at all to high hematocrit levels.
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Which of the following interventions results in convection heat loss in the newborn? a. Removal from an incubator for procedures b. Placing the newborn on a cold surface, such as a scale c. Giving a bath d. Placing the isolette near a cold surface such as a window or outside wall
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d. Convection is defined as loss of heat from the warm body surface to the cooler air currents. The other options are examples of radiation, evaporation, and conduction.
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Which of the following physical assessment findings indicates a need for further evaluation? a. Absence of the rooting reflex b. Flexion of extremities c. Brisk knee jerk d. Plantar flexion
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a. Absence or delayed disappearance of reflexes will always be a concern and a reason to refer for developmental screening. Flexion is expected. Hypotonia would be a definite need for a referral. Brisk knee jerk and plantar flexion should be found upon exam of the newborn.
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What is the most appropriate nursing intervention for a newborn experiencing acrocyanosis? a. Administer IV fluids. b. Suction vigorously. c. Place in the Trendelenburg position. d. Assess temperature.
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d. Assess temperature Acrocyanosis is caused by poor peripheral circulation. Administering IV fluids will not help peripherally; suction is not indicated in this scenario; and the Trendelenburg position will not assist with better perfusion. Decreased temperature can decrease peripheral perfusion and worsen acrocyanosis. If the temperature is decreased, measures can be instituted to warm the infant and improve perfusion.
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According to gestational dates of the mother, it is estimated that the newborn is slightly over 42 weeks’ gestation. What is the highest-priority nursing diagnosis for the newborn during delivery? a. Altered Health Maintenance b. At Risk for Injury c. Altered Tissue Perfusion d. Altered Nutrition: More Than Body Requirements
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b. At Risk for Injury An infant estimated to be at 42 weeks’ gestation will be obviously larger in size, making At Risk for Injury the highest-priority nursing diagnosis listed. The other nursing diagnoses may be considered, but more information would be needed to make these a priority nursing diagnosis.
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A newborn appears large for its gestational age, while a lower score for neurological maturation is noted on the gestational exam. The nurse knows that which cause can best explain this outcome? a. Maternal pre-eclampsia b. Maternal analgesia and anesthesia c. Maternal hypertension d. Maternal diabetes
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d. maternal diabetes Maternal diabetes accelerates fetal growth, but retards maturation. Maternal hypertension retards physical growth and speeds maturation. Maternal analgesia causes respiratory depression. Maternal pre-eclampsia causes active muscle tone and edema.
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Timing of Newborn Assessments
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1. First assessment in birthing area Need for resuscitation Placed with parents if stable 2. Second assessment on admission to mom/baby unit Progress of adaptation to extrauterine life Ongoing assessment for high-risk problems 3. Before discharge Complete physical examination Nutritional status and ability to feed Formula or breastfeed Behavioral state organization abilities
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Estimation of Gestational Age Establish in first 4 hours after birth Gestational age tools
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External physical characteristics Neurologic development Nervous system unstable during first 24 hours of life Second assessment in 24 hours
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Estimation of Gestational Age Ballard Tool
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Each finding given a point value Physical characteristic, neurologic characteristics New Ballard Score Maternal conditions may affect certain components

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