RNSG 2504 – Care of the Patient with Common Health Care Needs
Unit I – Care of the Patient Experiencing Perinatal Cycle
Part D - Newborn
1.
Behavioral Objectives
Define the terms in the content
column as related to the newborn in
the neonatal period.
Content Outline
I. Definition of terms
A.
Acrocyanosis
B.
Apgar score
C.
Bilirubin
D.
Caput Succedaneum
E.
Cephalhematoma
F.
Circumoral Cyanosis
G.
Conduction
H.
Convection
I.
Ductus Arteriosus
J.
Ductus Venosis
K.
Ecchymosis
L.
Epispadius
M.
Epstein’s Pearls
N.
Erythema Toxicum
O.
Evaporation
P.
Fontanelles
Q.
Foramen Ovale
R.
Hydrocele
S.
Jaundice
T.
Lanugo
U.
Meconium
V.
Milia
W.
Molding
X.
Mongolian Spots
Y.
Moro Reflex
Z.
Mottling
AA. Hypospadius
BB. Nevus Flammeus
CC. Nevus Vasculosus
DD. Periods of Reactivity
EE.
Petechia
FF.
PKU (Phenylketonuria)
GG. Plethora
HH. Radiation
II.
Strabismus
Clinical Objectives
25
Learning Opportunities
RNSG 2504 – Care of the Patient with Common Health Care Needs
Unit I – Care of the Patient Experiencing Perinatal Cycle
Part D - Newborn
Behavioral Objectives
Content Outline
JJ.
Subconjunctival Hemorrhage
KK. Surfactant
LL.
Sutures
MM. Talipes Equinovarus
NN. Telangiectic Nevi
OO.
Vernix Caseosa
Clinical Objectives
2.
Compare and contrast the changes
that occur to the newborn during the
physical/psychological adaptation to
extrauterine life.
II. Adaptation to extrauterine life
A. Physiological
1. Respiratory
2. Cardiovascular
3. Hematological
4. Temperature regulation
5. Hepatic changes
6. Gastrointestinal
7. Genitourinary
8. Immunological
9. Neurological & sensory perceptual
10. Behavioral
3.
Identify factors influencing the
assessment of the newborn.
III. Newborn assessment
A. Maternal prenatal/intrapartal history
B. Initial assessment (at time of birth)
1. Vital signs
a. Respiratory rate
b. Heart rate
c. Temperature
2. Apgar score
a. Respiratory effort
b. Muscle tone
c. Reflex irritability
d. Color
3. General appearance
a. Posture
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Learning Opportunities
RNSG 2504 – Care of the Patient with Common Health Care Needs
Unit I – Care of the Patient Experiencing Perinatal Cycle
Part D - Newborn
Behavioral Objectives
Content Outline
C. Head to toe assessment
1. Vital signs
a. Temperature
b. Pulse
c. Respirations
d. Blood pressure
2. Measurements
a. Weight
b. Length
c. Head circumference (FOC)
d. Chest circumference
e. Abdominal circumference
3. Posture
4. Skin characteristics
a. Color
b. Texture
c. Turgor
d. Pigmentation/birthmarks
5. Head
a. General appearance, movement
b. Molding
c. Sutures
d. Fontanelles
e. Hair
6. Face, eyes, ears, nose, mouth
7. Neck
8. Chest, heart
9. Abdomen/umbilicus
10. Genitals
11. Buttocks & anus
12. Extremities & trunk
13. Neuromuscular
14. Reflexes
15. Gestational Age Assessment
a. Neuromuscular maturity
b. Physical maturity
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Clinical Objectives
Learning Opportunities
RNSG 2504 – Care of the Patient with Common Health Care Needs
Unit I – Care of the Patient Experiencing Perinatal Cycle
Part D - Newborn
Behavioral Objectives
Content Outline
D. Behavioral assessment
E. Cultural Considerations
F. Diagnostic studies
1. Newborn screening test (PKU)
2. Coombs/blood type
3. Hgb/hct
4. Blood glucose
4.
Discuss, analysis, planning,
implementation, and
evaluation of nursing
management of the newborn.
IV. Selected nursing diagnoses / implementation/
evaluation
A. Initial care (delivery)
1. Ineffective airway clearance
a. Independent interventions
b. Assess ABC’s (airway, breathing,
circulation)
c. Suction
1. Bulb
2. Deep
d. Assess respiratory rate
e. Position
f. Apgar score
g. Stimulate
h. Reassess respiratory status frequently
i. Collaborative interventions
(1) Consult with respiratory
therapist
(2) Consult with pediatrician
j. Evaluation of outcomes: The
newborn will have improved airway
clearance as exhibited by:
(1) Maintaining respiratory rate 3060 per minute within 15 minutes
of delivery.
(2) Absence of retractions, nasal
flaring, or use of accessory
muscles within 1-2 hours of
delivery
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Clinical Objectives
Learning Opportunities
RNSG 2504 – Care of the Patient with Common Health Care Needs
Unit I – Care of the Patient Experiencing Perinatal Cycle
Part D - Newborn
Behavioral Objectives
Content Outline
Clinical Objectives
(3) Clear breath sounds within 1-2
hours of delivery
2. Risk for altered body temperature
a. Independent interventions
(1) Dry the baby
(2) Place in controlled environment
(radiant warmer)
(3) Monitor temperature.
b. Evaluation of outcomes: The
newborn will have a decreased risk
for altered body temperature as
exhibited by:
(1) Use of radiant warmer the first
hours after delivery.
(2) Obtaining temperature of 9798.8F
B. Nursery Care
1. Altered peripheral tissue perfusion
a. Independent interventions
(1) Assess cardiopulmonary status
(2) Maintain patent airway
(3) Maintain thermal neutral
environment
(4) Promote adequate hydration
b. Collaborative interventions
(1) Administer medications and
monitor for desired
effects/adverse effects/side
effects
(a) Vitamin K
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Learning Opportunities
RNSG 2504 – Care of the Patient with Common Health Care Needs
Unit I – Care of the Patient Experiencing Perinatal Cycle
Part D - Newborn
Behavioral Objectives
c.
2.
Content Outline
Evaluation of outcomes: The
newborn will have adequate tissue
profusion as exhibited by
(1) Stable vital signs within 1-3
hours after delivery
(2) Maintenance of temperature 9798.6 degrees
Altered nutritional/elimination status
a. Independent interventions
(1) Monitor feeding behavior
patterns (formula vs breast
feeding)
(2) Position after feeding
(3) Keep bulb suction available
(4) Observe for regurgitation after
feeding
(5) Measure and document type of
feeding, how much taken, and
retained
(6) Monitor and record output –
stool, urine
b. Collaborative interventions
(1) Glucose monitoring on
admission to the nursery
(2) Refer to WIC, La Leche League
c. Evaluation of outcomes: The
newborn will have adequate
nutrition/elimination status as
exhibited by:
(1) Breast feeding every 2-3 hours
or bottle feeding 1-2 ounces of
formula with minimal
regurgitation every 3-4 hours
(2) Voiding every 2 hours after first
24 hours of life
(3) Passage of stool
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Clinical Objectives
Learning Opportunities
RNSG 2504 – Care of the Patient with Common Health Care Needs
Unit I – Care of the Patient Experiencing Perinatal Cycle
Part D - Newborn
Behavioral Objectives
Content Outline
3. Risk for infection
a. Independent interventions
(1) Eye care
(2) Cord care
(3) Circumcision care
(4) Skin care/bathing/clothing
b. Collaborative interventions
(1) Refer to urologist or pediatrician
for circumcision
c. Evaluation of outcomes: The
newborn will have a decreased risk
for infection as exhibited by:
(1) No evidence of eye, cord, or
circumcision infection by
discharge
(2) No evidence of infection at first
newborn checkup
4. Risk for injury
a. Independent interventions
(1) Maintain bacteriologic,
mechanical, & thermal safety
(2) Position on side or back
(3) Accurate identification
(4) Abduction precautions
b. Collaborative interventions
(1) Administer medications and
monitor for desired
effects/adverse effects/side
effects
(a) Antibiotics
- Eye
- Cord
c. Evaluation of outcomes: The
newborn will have a decreased risk
or injury as exhibited by:
(1) Verbalization by parents of
methods of maintaining
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Clinical Objectives
Learning Opportunities
RNSG 2504 – Care of the Patient with Common Health Care Needs
Unit I – Care of the Patient Experiencing Perinatal Cycle
Part D - Newborn
Behavioral Objectives
5.
6.
Content Outline
bacteriologic, mechanical, and
thermal safety.
(2) Verbalization by parents of
rationale for maintaining side
lying or back lying position
(3) Armbands, footprints and
maternal fingerprints
(4) Verbalization by parents of
abduction precautions
Risk for altered parenting
a. Independent interventions
(1) Facilitate early bonding
(2) Identify – armbands, prints
(3) Monitor infant response to
nurturing activities
(4) Monitor sleep/activity patterns
(5) Provide tactile/sensory
stimulation
b. Evaluation of outcome: The
newborn will have a decreased risk
for altered parenting as exhibited by:
(1) Enface interaction between
parent and infant
(2) No evidence of attachment
difficulties
Knowledge deficit of newborn care skills
a. Independent
(1) Bathing
(2) Dressing
(3) Nutritional needs
(4) Follow up care
(5) Safety needs
(6) Expected behavior patterns
(7) Sleep patterns
(8) Sensory stimulation
(9) Family adjustments
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Clinical Objectives
Learning Opportunities
RNSG 2504 – Care of the Patient with Common Health Care Needs
Unit I – Care of the Patient Experiencing Perinatal Cycle
Part D - Newborn
Behavioral Objectives
b.
c.
Content Outline
Collaborative interventions
(1) Refer to available resources
(a) Family planning clinic
(b) Well baby clinics
(c) La Leche League
Evaluation of outcomes: The parents
will have a decreased knowledge
deficit of newborn care skills as
evidenced by:
(1) Demonstrating bathing &
dressing the newborn
(2) Demonstrating feeding and
holding techniques
(3) Verbalization of follow up
schedule for well baby check ups
and PKU testing
(4) Verbalization of safety measures
N/ADN Spring 10/Unit I Care of the Patient Experiencing Perinatal Cycle
Clinical Objectives
Learning Opportunities
Reviewed 10/09
Reviewed 11/11
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