Maternal Child Nursing Care

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created 9 years ago by SOCO
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Maternal nursing
updated 9 years ago by SOCO
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1

Denver II screening test

For children birth to 6 years.

2

Denver II test assesses:

Personal-social,
fine motor-adaptive,
gross motor and language skills

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When clarifying the chief complaint for the child's history, the nurse may use the mnemonic:

OLD CAT
O-Onset, L-Location, D-Duration, C-Character, A-Aggravating/Alleviating, T-Timing

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Mnemonic for OLD CAT:

O(Onset)When did the child become ill? L (Location) Where is the Pain? D(Duration)How long does the pain last C (Character) Pain scale 1-10. A(Aggravating/Alleviating)What makes the pain better or worse? T(Timing) When does the pain start/stop?

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Erickson's developmental task: Infant

Trust vs Mistrust

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Erickson's developmental task: Toddler

Autonomy vs Shame and doubt

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Erickson's developmental task: Preschool

Initiative vs guilt

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Erickson's developmental task: School Age

Industry vs Inferiority

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Erickson's developmental task: Adolescent

Identity vs role confusion

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Newborn vital signs:
Temperature

Normal range: 97.7-99.4 F (36.5-37.0 C)
Axillary: 97.5-99.99 F (36.5-37.2)

11

Newborn vital signs:
Pulse

120-160 BPM (Count pulse rate 1full minute)
During sleep pulse can be as low as 80 Beats per minute.
During crying the pulse can be as low as 180 BPM

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Newborn vital signs:
Respirations

30-60 RPM (Count respirations for 1 full minute)
Abnormal breathing is normal.

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Periodic breathing

is considered normal and is classified as short pauses in the breathing of the newborn that last only approx. 3 sec.

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Apneic episodes

Are significant if they last more than 15 to 20 seconds; they may be accompainied by abrupt pallor, hypotonia, cyanosis, and bradycardia.

15

Caution: withhold oral feeding if the respiratory rate ______ per minute

>60 respirations per minute

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Newborn vital signs:
Blood pressure

Systolic 60-80mm Hg; Diastolic 40-50mm HG
Systolic 95-100mm HG; Diastolic slight increase @ 10days of age

17

During the neonatal assessment, the nurse is alert to the following signs and symtoms that are indicative of respiratory distess. Physician notified immediately, if any symtpoms are present

Generalized cyanosis, Tachycardia (HR >160BPM)
Tachypnea (RR >70BPM), Rib retractions, Expiratory grunting, Flaring nostrils