Maternal exam 3 final

what is the normal newborn heart rate

110-160bpm

what is the normal respiratory rate

30-60 breaths/min

A newborn has temperature bellow 97.7. what does this indicate?

hypothermia intervention needed

what is acrocyanosis and is it normal

Blue hands/feet only; normal for 0–48 hours

What is central cyanosis and what should the nurse do?

Blue lips/tongue/trunk; ALWAYS abnormal — notify provider

What does TGNR stand for?

Tachypnea, Grunting, Nasal flaring, Retractions.

What is the LATE sign of respiratory distress?

Bradycardia

What is a normal Babinski reflex in a newborn?

Toes fan out (positive)

How do you elicit the rooting reflex?

stroke the cheek → head turns toward stimulus

What does a bulging fontanelle indicate?

Increased intracranial pressure.

What does a sunken fontanelle indicate?

Dehydration

Which crosses sutures: caput or cephalohematoma?

Caput succedaneum crosses sutures

Which resolves faster: caput or cephalohematoma?

Caput (hours)

What are signs of newborn hypoglycemia?

Jitteriness, lethargy, weak cry

What is the FIRST action for suspected hypoglycemia

Check blood glucose

what is NAS

Neonatal Abstinence Syndrome is a condition in which a newborn experiences withdrawal symptoms after birth due to in‑utero exposure to opioids

What causes NAS?

Opioid withdrawal after birth

What are signs of NAS?

High‑pitched cry, tremors, poor feeding, loose stools, sneezing, yawning

When is jaundice considered pathologic?

Within the first 24 hours

What must be covered during phototherapy?

Eyes and genitalia

Should infants with epispadias or hypospadias be circumcised?

NO — foreskin may be needed for repair

what is RDS?

Respiratory distress syndrome is a lung condition seen primarily in preterm infants caused by insufficient surfactant, which leads to alveolar collapse, poor gas exchange, and increased work of breathing

What causes RDS in preterm infants?

Insufficient surfactant

What is NEC

Necrotizing Enterocolitis (NEC) is a life‑threatening inflammatory disease of the newborn intestines, where part of the bowel becomes inflamed, begins to die, and can perforate — leading to sepsis and shock

What are signs of NEC?

Abdominal distention, bloody stools, apnea

what is the sac in spina bifida?

The “sac” refers to the protruding fluid‑filled membrane on the newborn’s back in spina bifida cystica (specifically meningocele or myelomeningocele)

What is the priority position for an infant with a sac?

Prone

what is PKU

Phenylketonuria (PKU) is a genetic metabolic disorder where the newborn cannot break down phenylalanine, an amino acid found in protein

Why does PKU happen

Because the infant is missing the enzyme phenylalanine hydroxylase, which normally converts phenylalanine into tyrosine

What diet is required for PKU?

Low phenylalanine; avoid regular milk

Why is vitamin K given at birth?

Newborns lack clotting factors

What two injections must be given within 12 hours?

HBV vaccine + HBIG (separate sites)

What type of bath until cord falls off?

Sponge bath only

How many vessels are in a normal umbilical cord?

two arteries and one vein

What do the umbilical arteries do?

Carry deoxygenated blood from the fetus to the placenta

What does the umbilical vein do?

Carries oxygenated, nutrient‑rich blood from the placenta to the fetus

What should be applied to the penis after circumcision?

Petroleum jelly

What antibody is found in colostrum?

IgA

Should breastfeeding continue with mastitis?

YES — continue on both sides + antibiotics

What color is lochia rubra and when does it occur?

Bright red; days 1–3.

What color is lochia serosa and when does it occur?

Pinkish‑brown; days 4–10

What color is lochia alba and when does it occur?

White or yellow‑white; day 10 and beyond

What does foul‑smelling lochia indicate?

Infections

What are signs of endometritis?

Fever, uterine tenderness, foul lochia

What is the FIRST action for a boggy uterus?

Massage the fundus

Firm uterus + continued bleeding indicates what?

Laceration/trauma

Which PPH medication is contraindicated in hypertension?

Methergine

Which PPH medication is contraindicated in asthma?

Hemabate

What should you NEVER do if DVT is suspected?

Do NOT massage the leg

What characterizes the Taking‑In phase?

Mom focuses on herself; passive

What characterizes the Taking‑Hold phase?

Mom becomes more independent; actively learns newborn care

What characterizes the Letting‑Go phase?

Mom adjusts to new role; integrates baby into family; releases old expectations

Jittery newborn — first action?

Check blood glucose

Baby under phototherapy — what must be covered?

Eyes + genitalia; no lotion

Spina bifida sac — first action?

Prone position + moist sterile dressing

What is the transition to extrauterine life?

The newborn’s shift from placental dependence to independent functioning

What happens during the first period of reactivity?

Infant is alert, has strong reflexes, ↑ HR, irregular respirations; ideal time for feeding

What happens during the sleep phase?

Infant becomes less active and rests

What happens during the second period of reactivity?

Infant becomes alert again, ↑ mucus, may pass meconium

What closes after birth: foramen ovale, ductus arteriosus, or ductus venosus?

All three fetal shunts close

What does surfactant do?

Keeps alveoli open and prevents collapse

What are signs of respiratory distress?

Grunting, nasal flaring, retractions

Why do newborns lose heat easily?

Large surface area, thin skin, little fat.

What is brown adipose tissue (BAT) used for?

Non‑shivering thermogenesis

What does cold stress cause?

↑ oxygen use and ↑ glucose use

What are the four ways newborns lose heat?

Evaporation, convection, conduction, radiation

When should newborns pass meconium?

Within the first 24 hour

When should newborns void?

Within 24 hours

What antibody protects newborns initially?

Maternal IgG

What is vernix caseosa?

Creamy protective skin coating

What is lanugo?

Fine hair on shoulders, back, face

Which does NOT cross sutures?

Cephalohematoma

When do fontanelles close?

• Anterior: 12–18 months

• Posterior: 2–3 months

What is the Moro reflex

Startle → arms extend then flex

How is hearing screened?

Hearing is screened using otoacoustic emissions (OAE) or auditory brainstem response (ABR)

How is CCHD screened

Critical congenital heart defects are screened using pulse oximetry on the right hand and one foot

What does erythromycin ointment prevent?

Ophthalmia neonatorum

What must be given before circumcision?

Vitamin K

What should nurses monitor after circumcision?

Bleeding, swelling, infection

What is safe sleep?

Back to sleep, firm surface, no loose bedding

What are the two priority nursing diagnoses related to newborn nutrition?

Knowledge deficit and alteration in comfort

What causes knowledge deficit in newborn feeding?

Lack of experience with breastfeeding, milk expression, or formula preparation

Why is breastfeeding considered the gold standard?

Provides ideal nutrients, antibodies, enzymes, and hormones

What are newborn benefits of breastfeeding?

↓ infections, ↓ SIDS, ↓ allergies, ↑ cognitive development, ↓ obesity risk

What are maternal benefits of breastfeeding?

Uterine involution, ↓ bleeding, ↓ breast/ovarian cancer, ↓ type 2 diabetes, bonding

Name major contraindications to breastfeeding

Active TB, HIV (U.S.), breast HSV lesions, infant galactosemia, chemo/radiation, illicit drugs

What are the three stages of human milk?

Colostrum, transitional milk, mature milk.

What is colostrum?

Thick, yellow, antibody‑rich milk produced in the first days postpartum

When does transitional milk occur?

Days 3–8 postpartum

When does mature milk develop?

After the first week

What is mammogenesis?

Breast development during pregnancy.

What is Lactogenesis I?

Colostrum production during pregnancy.

What is Lactogenesis II?

Milk volume increases around days 3–8

What is galactopoiesis?

Ongoing milk production regulated by supply and demand.

What does skin‑to‑skin contact do for the infant?

Stabilizes temperature, HR, and respirations

How does skin‑to‑skin support breastfeeding?

Stimulates oxytocin and prolactin → supports milk production

What are early feeding cues?

Rooting, hand‑to‑mouth, quiet alert state

Is crying an early or late feeding cue?

Late

What does a good latch look like?

Wide mouth, flanged lips, audible swallowing, minimal pain

What does LATCH stand for?

Latch, Audible swallowing, Type of nipple, Comfort, Help needed