Maternity Exam 4
Respiratory
o Always is the priority!!
o Irregular periods of apnea (over 20 seconds)
o Rate 30-60
o Distress, grunting, flaring, and retractions are not normal
S/S of Respiratory Distress:
Use of accessory muscles, nasal flaring, expiratory grunting,
cyanosis, rapid breathing, labored breathing, decreased
breath sounds, periods of apnea, etc
Cardiovascular
o The Foramen Ovale closes
o Ductus Arteriosus + Ducks venous
o Rate 110-160
Can range from 80-170
o Blood pressure can range from 60-85/40-55
APGAR Score (Respiration is our 1st priority)
o 5 areas:
Appearance
A score of 2 indicates the infant's skin is completely pink, but
A score of 1 means the extremities are blue.
A score of 0, baby is blue all over
Acrocyanosis: seen in most newborns
Pulse
A score of 2 is more than 100 BPM
A score of 1 is less than 100 BPM
A score of 0 is an absent pulse
Grimace
A score of 2 is a strong cry to stimuli
A score of 1 is a grimace weak response to stimuli
A score of 0 is a no response to stimuli
Activity
A score of 2 is well-flexed arms and legs, with active motion
A score of 1 is some flexion of the arms and legs
A score of 0 is absent/ flaccid
Respiration
A score of 2 is a vigorous cry
A score of 1 is a weak/ irregular cry
A score of 0 is absent
o APGAR above 7 is considered normal, and under 3 is considered critical
o If the APGARs are above 7, you will stimulate, dry, warm, position, and
suction
, o If the APGARs are between 4 and 6, you will give oxygen via a blow-by
mask and possibly intubate
o If the APGARS are below 3, start with the blow-by mask, then you will
begin chest compressions and administer medications
Ballard Score
Done within the first 12 hours of the line
Measures gestational age
*Know preterm, term, and post-term characteristics*
Normal Vital Signs and Weight/Length
HR: 120-160
BP: 60-80/40-50
RR: 30-60
Temp: Rectal (98.6-100) and axillary (97.7-99.3)
Weight
o Should be measured in grams
Length
o Measured in CM
o Measured from crown of the head to the heel
Head circumference
o Place the tape measure above eyebrows and the ear and wrap it
around the heel. Measure 3 times and take the largest
measurement.
o Head circumference: 13-15 IN (33-38 cm)
Chest circumference: Tape measure on nipple line, head should be 2cm
bigger than the chest (12-13 inches) (30-33 cm)
Behavioral States:
Active alert
Respiratory
o Always is the priority!!
o Irregular periods of apnea (over 20 seconds)
o Rate 30-60
o Distress, grunting, flaring, and retractions are not normal
S/S of Respiratory Distress:
Use of accessory muscles, nasal flaring, expiratory grunting,
cyanosis, rapid breathing, labored breathing, decreased
breath sounds, periods of apnea, etc
Cardiovascular
o The Foramen Ovale closes
o Ductus Arteriosus + Ducks venous
o Rate 110-160
Can range from 80-170
o Blood pressure can range from 60-85/40-55
APGAR Score (Respiration is our 1st priority)
o 5 areas:
Appearance
A score of 2 indicates the infant's skin is completely pink, but
A score of 1 means the extremities are blue.
A score of 0, baby is blue all over
Acrocyanosis: seen in most newborns
Pulse
A score of 2 is more than 100 BPM
A score of 1 is less than 100 BPM
A score of 0 is an absent pulse
Grimace
A score of 2 is a strong cry to stimuli
A score of 1 is a grimace weak response to stimuli
A score of 0 is a no response to stimuli
Activity
A score of 2 is well-flexed arms and legs, with active motion
A score of 1 is some flexion of the arms and legs
A score of 0 is absent/ flaccid
Respiration
A score of 2 is a vigorous cry
A score of 1 is a weak/ irregular cry
A score of 0 is absent
o APGAR above 7 is considered normal, and under 3 is considered critical
o If the APGARs are above 7, you will stimulate, dry, warm, position, and
suction
, o If the APGARs are between 4 and 6, you will give oxygen via a blow-by
mask and possibly intubate
o If the APGARS are below 3, start with the blow-by mask, then you will
begin chest compressions and administer medications
Ballard Score
Done within the first 12 hours of the line
Measures gestational age
*Know preterm, term, and post-term characteristics*
Normal Vital Signs and Weight/Length
HR: 120-160
BP: 60-80/40-50
RR: 30-60
Temp: Rectal (98.6-100) and axillary (97.7-99.3)
Weight
o Should be measured in grams
Length
o Measured in CM
o Measured from crown of the head to the heel
Head circumference
o Place the tape measure above eyebrows and the ear and wrap it
around the heel. Measure 3 times and take the largest
measurement.
o Head circumference: 13-15 IN (33-38 cm)
Chest circumference: Tape measure on nipple line, head should be 2cm
bigger than the chest (12-13 inches) (30-33 cm)
Behavioral States:
Active alert
