APGAR/NIPS/NAS
The APGAR scoring tool uses what criteria to assess an infant?
Appearance
Pulse
Grimace (reflex, irritability)
Activity (muscle tone)
Respirations
Localized soft tissue edema that crosses the suture line
Caput Succedaneum
The newborn who fails a hearing screen should be retested when
in 1 month
The proper position for the front strap on a car seat
Across the breastbone
Interventions for hypothermia in an infant
skin-to-skin
Place cap on baby's head
Reassess temp
Remove the source of heat loss
The Finnegan NAS tool is used to assess what in an infant?
Signs of withdrawal
Normal findings on a newborn breathing assessment
shallow, irregular
abdominal breathing
RR 30-60 breaths/min
Pauses up to 15 seconds
During a CCHD Screen, where are the oxygen saturation monitors applied on the newborn?
Right wrist and one of the feet.
Which one is preductal and which one is post ductal?
Teaching parents how to know that the infant is feeding adequately.
8-12 wet diapers/day
Breastfeeding-may stool with each feed
Formula- daily stool
A blood glucose below this is considered hypoglycemia
<45mg/dl
This scale is used to measure pain in an infant.
the Neonatal Infant Pain Scale (NIPS)
Nursing actions for an infant that is shivering
head-to-toe assessment
BG check
Assess for seizure activity
Possible drug screen
Which infant requires a Ballard score?
An infant born at 34 weeks.
An infant born to a mother with no prenatal care.
An infant who is SGA with premature features.
All of the above.
Teaching for circumcision care
report if red, warm, swollen, bleeding, or drainage
Nursing interventions for abdominal wall defects
Cover with moist sterile gauze
Place infant on their back
Maintain NPO status
Keep the bowel above the infant
Appearance: Pink
Pulse: 102
Grimace: little response with back rub
Activity: Arms and legs are flexed
Respirations: irregular, RR 26
7
Normal VS ranges for newborns
Temp 97.7-98.6
RR 30-60 breaths/min
HR 110-160
How do you position the infant to illicit the tonic neck reflex.
Turn head to the right or left, whichever direction the head is turned, the infant should extend that arm and flex the opposite arm.
What does the nurse teach to prevent omphalitis?
Cord care
A bulging anterior fontanel could be a sign of this complication
Intraventricular hemorrhage
What symptoms would you assess for and document on the Finnegan NAS tool?
Signs of withdrawal
diarrhea, high pitched cry, hyperreflexia, sneezing, tremors, tachypnea, yawning
Assessments for an LGA infant
Arm movement and pain
Hypoglycemia
The CCHD is an assessment to detect what infant complication(s)?
Congenital Heart Defects
The nurse is scheduling the first follow-up visit after discharge. What is the time frame?
3-5 days after discharge
This disorder requires a phenylalanine-free diet.
phenlketonuria (PKU)
An infant scores 3 on the Neonatal Infant Pain Scale (NIPS). What is the most appropriate nursing intervention.
Non-pharmacological intervention and reassessment in 30 minutes.
These should be worn during a newborn assessment
Gloves
This can affect the hearing screening.
Fluid
The nurse is teaching parents how to feed their infant diagnosed with GERD. What should she tell them?
small/frequent feedings
feed slowly in an upright position
Keep upright 30 min after feeding
HOB at 30 degree angle for sleeping
Nursing responsibilities for preparing an infant for phototherapy for hyperbilirubinemia
Check temp
Turn Q 2 hours
Cover eyes and genitals
Feeding