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NCLEX-RN考试学习笔记:Normal Newborn

发表日期:2016-02-01 | 来源 :国际护士网 | 作者 :www.the-nurses.com |点击数: 次 收听:
 
Normal newborn assessment:
 
Weight:  6-9lbs. Will loose 5%-10% in first few days. Will regin in 1-2 weeks
 
Length:19-21inches (48-53cm)
 
Head circumference 13-14 inches (33-35cm)
 
Chest: 1inch less than head circumference ( 12-13inchs)
 
T: 97.7-99.7 ax
 
P: 100bpm ( sleep),120-140 (awake), up to 180 (crying)
 
R: 30-60b/min , short period of apnea (<15s)
 
Bp: 65/40 in arm and calf
 
APGAR Score
 
At 1 and 5 min after birth 
(1st score is the transitional score and 2nd is planning care of newborn) 
8-10 = ok 
2 1 0 
Appearance [All pink, pink&blue, blue/pale]
 
Pulse [> 100, < 100, No Response]
Grimace [cough, grimace, no response]
Activity [flexed, flaccid, limp]
Resp [strong cry, weak cry, no cry]
 
HESI Hint: Physical assessment: A detailed physical assessment is performed by the nurse or physician. Regardles of who performs the physical assessment, the nurse must know normal versus abnormal variations in the new born, Observations must be recorded zne the physician notified regarding abnormalities.
 
Normal Newborn reflexes:
 
Rooting and sucking: disappears by 4-7 months
 
Palmar grasp: fades by 3-4 months
 
Planter grasp: lessens by 8 months
 
Tonic neck: disappears by 3-4 months
 
Moro: disappears by 3-4 months
 
Stepping: fades 4-5 months
 
Babinski: reverts to adult response by 12 months
 
HESI Hint: These neurologic reflexes are transient and, as such,disappear usually within the first year of life. In thepediatric client, prolonged presence of these reflexes can indicate CNS defects, Anticipate NCLEX_RN questions regarding normal newborn reflexes. Physician assessment questions focus on normal charateristics of the newborn and the differentiation of conditions such as caput succedaneum ( edema under the scalp 胎头水肿,又名先锋头)and cephalhematoma (blood under the periosteum 头血肿)
 
HESI Hint:The caput crosses suture lines and is usually present at birth, whereas the cephalhematoma does not cross suture lines and manifests a few hours after birth. The danger of cephalhematoma is icreased hyperbilirubinemia due to excess RBC breakdown.
 
HESI Hint: The umbilical cord should always be chacked at birth. It should contain three vessels: one vein, Which carries oxygenated blood to the fetus, and two arteries, which carry unoxygenated blood back to the placenta. This is the opposite of normal circulation in the sdult. Cord abnormalities usually indicate cardiovascular or renal anomalies.

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标签: NCLEX-RN考试  NCLEX-RN学习笔记  
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