Maternal Newborn Nursing exam study guide

Newborn Data Collection: Prioritizing CAre Check respirations, heart rate, temperature, and blood pressure, but blood pressure is not routinely measured unless there is a risk of cardiac issues. Observe respirations rate before the newborn becomes active or agitated by stethoscope, thermometer, blood pressure cuff Respirations rate, 30-60 bpm with short periods of apnea (less than 15 sec) report if longer. Crackles and wheezing can mean fluid retention or infection in the lung. Grunting or nasal flaring can mean respiratory distress. Expected Heart Rate, 110-160/min with brief changing above and below this range depending on activity level (crying, sleeping). Count apical pulse for a full 1 min (its better when the baby is sleeping). You check heart beat at 4th or 5th intercostal space at left midclavicular line over. Document anything abnormal like a murmur. Blood pressure, 60-80 mm Hg systolic and 40-50 mm Hg is diastolic Expected temperature range, 36.5 C to 37.5 C (97.7 F to 99.5 F) . Newborns are at risk for hypo/hyperthermia until thermoregulation (which is when baby can produce body heat and they can maintain it). If newborn becomes chilled oxygen demands and can increase and acidosis can occur. Sucking and rooting reflexes, you stroke the cheek or edge of mouth. Newborn turns the head toward the side that is touched and starts to suck. Usually disappears after 3-4 months but can extend until 1 yr. Palmar grasp reflexes, place finger in palm of newborns hand. The newborn’s fingers curl around your finger. Lessens (becomes less) 3-4 months Plantar grasp reflexes, place finger at the base of the newborns toes and see if the toes curl downward, that happens from birth to 8 months Moro reflex, allowing the head and the trunk of the newborn in a semi sitting position to fall backward to a angle of at least 30 degrees. The newborn will symmetrically extend and then abduct the arms at the elbows and fingers spread to form a “c”. This happens from birth to 6 months. Tonic neck reflex (fencing), newborn in supine position and in neutral position, examiner turns newborns head quickly one side. The newborns leg and arm on that extend and opposing arm and leg flex. Babinski reflex (plantar), stroke outer edge of sole foot,moving up toward toes, toes will fan upward and out Stepping (walking), holding the newborn upright with feet touching a flat surface. The newborn responds by taking step movements. That lasts from birth to 4 weeks. Identifying a finding to re