MATERNITY NEWBORN NURSING CARE & COMPLICATIONS OF THE NEWBORN Reliable Study Guide 2021

Newborn Assessment Respiratory and circulatory systems are required to rapidly adjust to life outside of the uterus. The establishment of respiratory function w/the cutting of the cord is the most critical extrauterine adjustment as air inflates the lungs with the first breath. APGAR SCORE-0 Absent HR Absent RR Flaccid Muscle Tone No reflex irritability Blue, pale color APGAR SCORE-1 HR 100 bpm Slow, weak cry Some flexion of extremities Grimace Pink body, cyanotic hands and feet APGAR SCORE-2 HR 100 bpm Good cry Well flexed Cry Completely pink Meconium staining can indicate fetal hypoxia. AVA-umbilical cord-1 vein, 2 arteries Weight: g (5.5-8.8 b) Length: 45-55cm (18-22 in) Head circumference: 32-36.8 cm (12.6-14.5 in) Chest circumference: 30-33 cm (12-13 in) New Ballard Scale –rating system from –1 to 5 to determine maturity of gestational age. At term, the hand should touch the wrist resulting in a 0 degree angle. Knees and toes can reach the head straight w/a premie. Term newborns will have a bend in the knee. AGA– weight between 10th & 90th percentile Low birth weight=less than 2500 g Intrauterine growth restriction=growth rate does not meet expected norms Term: 37 –42 weeks Preterm: 37 weeks Postmature: Born after 42 wks w/ evidence of placental insufficiency RESPIRATORY Respiratory rate: 30-60/min with periods of apnea less than 15 seconds Crackles and wheezing: fluid or infection in lungs Grunting and nasal flaring: respiratory distress HEART RATE: 110—160/min. Apical HR for 1 full minute. Stethoscope placed over 4th/5th intercostal space at the left midclavicular line over the apex of the newborn’s heart. Murmurs are documented and reported. BLOOD PRESSURE: 60-80 mm Hg systolic, 40-50 mm Hg diastolic TEMPERATURE 97.7-99.5 axillary. 36.5-37.5 C If the child becomes chilled (cold stress), oxygen demands increase and acidosis can occur. SKIN Jaundice can appear on 3rd day. Desquamation = peeling that occurs a few days after birth Vernix caseosa = thick, cheesy covering Lanugo= fine, downy hair. Usually found on pinnae of ears, forehead and shoulders