NSG 300 Maternal Newborn 1 ATI – Our lady of Holy Cross College | NSG300 Maternal Newborn 1 ATI

NSG 300 Maternal Newborn 1 ATI – Our lady of Holy Cross College. Maternal-Newborn Care Quiz: 1. A nurse is caring for a term newborn who has just had a circumcision using the Gomco clamp technique. Which of the following instructions should the nurse include when teaching the parents to care for the site? (select all that apply.) a. Apply petroleum jelly to the penis for the first 24 hr. b. Cleanse the penis with warm water and mild soap c. Apply gentle pressure from a sterile gauze pad to control slight bleeding d. Gently wipe away any yellow exudate on the penis e. Apply the diaper loosely over the penis 2. A patient who is 1 day postpartum tells the nurse that she is concerned about her newborn receiving enough nourishment from breastfeeding. The nurse should explain that she should look for which of the following as a sign of adequate nutrition? a. The newborn feeds at least six times in 24 hr. b. The newborn has six wet diapers and three stools per day c. The milk supply is plentiful by the newborn’s second day d. The newborn has returned to his birth weight 6 to 8 days following delivery 3. A nurse is performing umbilical cord care for a term newborn. Which of the following findings requires further assessment and intervention? a. Blackening of the stump b. Redness at the base c. Clear gel at the tip d. Hardening of the stump 4. A nurse is performing a gestational age assessment using the New Ballard Score for newborn maturity rating. Which of the following findings indicates that the newborn is preterm? a. Flexion of the extremities at rest b. Creases over the entire plantar surface c. Leathery skin d. Flat areola 5. A nurse is caring for a patient who is in labor and has pain in her lower back because the fetal head is in a posterior position. Which of the following nonpharmacological pain management techniques is likely to be most effective in relieving this type of pain? a. Counterpressure b. Effleurage c. Therapeutic touch d. Breathing techniques 6. A nurse is teaching the parents of a term newborn how to bathe him. Which of the following instructions should the nurse include? a. Bathe him every day b. Give him a bath after he has had a feeding. c. Give him a sponge bath until his cord stump falls off d. Clean his ears and nose with cotton swabs 7. A newborn delivered vaginally at term 1 min ago cried loudly at delivery, has a heart rate of 140/min, has well flexed arms and legs, grimaces when the nurse rubs the soles of his feet, and is pink with mild acrocyanosis. What apgar score should the nurse assign to this newborn? a. 8 8. A nurse is assessing a patient at a routine antepartum visit. For a rough estimate of the number of gestational weeks the patient is at, the nurse should measure the number of cm between which two anatomical landmarks? a. The mons pubis and the xiphoid process b. The top of the fundus and the umbilicus c. The symphysis pubis and the top of the fundus d. The mons pubis and the umbilicus 9. A nurse is assessing a patient who is 1 day postpartum and is not breastfeeding. The nurse notes the patient’s breasts are engorged. Which of the following actions is appropriate for the patient to take? a. Applying ice packs b. Wearing a loose-fitting bra c. Pumping her breasts d. Taking a warm shower 10. A nurse is assessing a patient who is at 20 weeks of gestation. She instructs the patient to be sure to report headaches, blurred vision, and swelling of her hands because these are indications of which of the following complications of pregnancy? a. Gestational diabetes b. Preeclampsia c. Hyperemesis gravidarum d. Abruptio placentae Auscultating Fetal Heart Tones • Possible to hear fetal heart tones around the 10th or 11th week of gestation with an ultrasound fetoscope or stethoscope. o Regular fetoscope and stethoscope can transmit fetal heart tones at 18 to 20 weeks • To auscultate fetal heart tones: o Apply conductive gel to the patient’s skin o Position the device midline just above the symphysis pubis o Apply firm pressure o Move the device around slowly until you hear heart tones o Count the fetal rate for 1 minute  Assess the quality and rhythm • The fetal heart typically beats 120 to 160 times a minute Gestational Age Assessment • To determine the approximate age, you will assess six neuromuscular and six physical characteristics • The New Ballard Score o Appropriate for newborns from 20 to 44 weeks of gestation o Each parameter scores from a minus 2 to 5 with the cumulative score correlating with a gestational age between 26 and 44 weeks • For newborns younter than 26 gestational weeks, perform the assessment sooner than 12 hours after birth. • For newborns beyond 26 gestational weeks, perform the examination within 96 hours of birth. (best to perform the examination within 48 hours of birth) • The gestational assessment is important because it relates directly to the likelihood of complications during the newborn period o Lower scores correlate with prematurity o Higher scores correlate with postmaturity. • Neuromuscular assessment components o Posture  Assess posture for the degree of flexion of the extremitites  At term, they are moderately flexed at rest  Preterm show lesser degrees of flexion o Square window  Assess square window by grasping the newborn’s forearm and gently flexing the wrist toward the inner arm.  Do not allow rotation of the wrist  Measure the angle that forms where the hand meets the wrist • At term, the hand should touch the wrist  Preterm newborns show greater angles of flexion • Very preterm newborns have an angle of wrist flexion of 90 degrees or more o Arm recoil  Measure arm recoil by first flexing and holding both forearms for 5 seconds, then extending the arms and hands fully at the newborn’s side.  Release the hands and allow the arms to recoil (return to flexion)  Term newborns demonstrate full recoil to a position of flexion while preterm newborns show less flexion  Measure the arm at the elbow to determine the arm recoil score o Popliteal angle  Press the newborns thigh against his abdomen, measure the popliteal angle by moving the foot gently toward the head until you meet resistance.  Measure the angle behind the knee in the popliteal area  Term newborns are less flexible with about a 90-degree angle.  Very preterm newborns, the leg straightens to a 180-degree angle o Scarf sign  Assess the scarf sign by grasping the newborn’s hand and attempting to cross the arm over his body at the neck.  The arms of term newborns meet resistance before crossing midline, while preterm newborns cross the elbow past midline o Heal to ear  Assess heel to ear by raising the newborn’s heel toward his head in an attempt to bring the foot to the ear.  Do not raise the newborns buttocks off the examination surface.  Stop when you meet resistance and measure the degree of extension of the leg  With preterm newborns, you’ll come close to touching the heel to ear, while you’ll meet resistance almost immediately with term newborns o Perform all of these assessments with the newborn lying supine o Refer to the scoring sheet for specific scores based on your findings • Physical Maturity o Components of physical maturity:  Skin • Ranges from translucent and friable in preterm newborns • Leathery, cracked, and wrinkled in post-term newborns  Lanugo • Very fine body hair • Extremely premature newborns have none • During the third trimester, most fetuses have plentiful lanugo • Term newborns have very little, and it is nearly absent in post-term newborns  Plantar surface • Inspect for creases • Term newborns have creases over the entire plantar surface • Preterm newborn range from absent to faint red markings  Breast • Inspect the breast to assess the size of the breast bud in millimeters and the development of the areola. • Preterm newborns lack developed breast tissue • Term newborns have a raised to full areola with breast buds that are 3 to 10 millimeters in diameter  Eye/ear • Analysis of the ear cartilage and shape of the pinna • Pinna is less curved in preterm newborns • Term newborns have a well-curved pinna with firm cartilage • Ear recoil o Fold the pinna down and assess how quickly it returns to its previous position. • Very preterm newborns may have fused eyelids  Genitals • Observe the genitals for physical maturity - - - - - - - - - - - - - -- - - - - - - - - - - - - • The third trimester o During the third trimester, when women are preparing for the birth of their baby, they will want to know how they can tell the difference between “true” and “false” labor. o During true labor, your patient will have regular contractions that gradually become stronger and closer together. She will feel the pain of true labor in her lower back, and it will move forward across her lower abdomen. Her cervix will dilate and efface, and as the cervix dilates, she will pass what is called a bloody show vaginally and feel the baby moving down into the birth canal. o With false labor, contractions are usually irregular, although they can be regular for short periods. Walking and other activities will stop false labor, as will comfort measures and hydration. (These do not stop true labor.) And of course, with false labor, the cervix does not dilate and it does not efface. o The previous danger signs still apply, although after 37 weeks, ruptured membranes are likely to signal an imminent onset of term labor and not a danger sign of preterm labor. Apgar Scoring Apgar scoring is an assessment of five indications of a newborn’s physiologic state: heart rate, respiratory effort, muscle tone, reflex irritability, and color at 1 and at 5 min following birth. For heart rate, 0 means absent, 1 is slow (below 100/min), and 2 means above 100/min. This newborn scores 2 for a heart rate of 140/min. For respiratory effort, 0 means absent, 1 means slow or weak, and 2 reflects a good cry. This newborn scores 2 for crying loudly at delivery. For muscle tone, 0 is flaccid, 1 indicates some flexion of the extremities, and 2 is well flexed. This newborn scores 2 for well-flexed extremities. For reflex irritability, 0 means no response, 1 is a grimace, and 2 is a cry. This newborn scores 1 for grimacing when the nurse rubs the soles of his feet. For color, 0 is pale or blue, 1 reflects a pink body with blue extremities, and 2 means completely pink. This newborn scores 1 for being pink with mild acrocyanosis. Adding the newborn’s scores of 2, 2, 2, 1, and 1, this infant’s Apgar score at 1 min is 8. •