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NR 327 Maternal-Child Health Nursing Newborn Assessment 2022/2022 STUDY GUIDE

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NR 327 Maternal-Child Health Nursing Newborn Assessment ASSESSMENT TEXTBOOK NORMS ALTERATIONS AND POSSIBLE CAUSE(S) NURSING IMPLICATIONS/RESPONSES TO DATA Posture Freely moving, flexed extremit... ies; resist extension; rapid return to flexed state; usually hands are clenched; movements symmetric; slight tremors on crying; responds by quieting when needs are met; “molds” body to caretakers body; breech extended and stiff legs Flaccid, floppy, limp, or rigid extremities (poss. cause preterm labor, hypoxia, meds, CNS injury). Jitteriness or tremors (poss. cause hypoglycemia or hypocalcemia) Opisthotones, stiff feeling when held, seizures (poss. cause CNS injury) Investigate causes and refer to abnormalities Vital Signs Blood pressure varies with weight, activity, and gestational age. Systolic Norm – 65-95 mmHg Diastolic Norm – 30-60 mmHg Axillary temp – 36.5-37.5C HR – 120-160 bpm RR – 30-60/min Hypotension (poss. cause hypovolemia, shock, sepsis) BP 20mmHg or greater than in arms than legs (poss. cause coarctation of the aorta) Prepare for intensive care if BP declines further; refer abnormal BP Head Sutures are palpable with small separation between each; anterior fontanel is diamond-shaped, 4-6cm, soft, and flat; possible bulge when crying; posterior fontanel is triangular, 0.5-1cm; hair will be silky and soft with Large head (poss cause hydrocephalus, increase ICP) Widely separated sutures (poss cause hydrocephalus) Hard/rigid areas at sutures (poss cause craniosynostrosis) Investigate causes of variations; monitor for s/s of dehydration (fontanel depression); monitor and assess for increased ICP with fontanel bulging and widened suture separation; refer for treatment; monitor for jaundice; monitor 1NR 327 [Show More]

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