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New Born Lecture
 

New Born Lecture

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    New Born Lecture New Born Lecture Presentation Transcript

    • ASSESMENT OF THE NEWBORN
      • NEWBORN
      • IMMEDIATE CARE OF THE NEWBORN
      • Care of the Newborn at Delivery Room
      • A. Establishing and maintain respirations
      • Suctioning – duration :5-10 seconds or <5 seconds in preterm.
      • -Mouth before nose
      • Positioning – head lower than body (10-15 degrees)
      • slight trendelenburg
      • side lying
      • Purposes:
      • promotes drainage of secretion
      • prevents increase ICP
      • Promotes gastric emptying thereby prevent reflux of gastric contents and aspirations
      • supine(recommended for infants above 3 months)
      • prone ( maybe a cause in SIDS)
      • B. Maintain Neutral Thermal Environment – prevent hypothermia
      • How? – drying newborn body at once
        • wrap/cover the newborn
        • expose newborn body, either with floor lamp, overhead radiant warmer
      • Reasons:
      • Loss of Body heat:
      • A. Evaporation - heat loss as water evaporates from skin and from lungs; occurs when infant's body is wet with amniotic fluid at birth.
      • B. Convection - movement of body heat to flow of cool air; infant loses heat to the cool air in the delivery room.
      • C. Conduction- direct transfer of heat to a surface on which the infant is lying; infant loses heat to a cool sheet or blanket.
      • D. Radiation - Heat is lost from the infant's warm body as it travels through the air to cooler objects in the room; heat loss often occurs during the days after birth, especially when an unclothed infant is placed in an incubator.
    • Shivering Mechanism is rarely functioning A. Heat is generated immediately by shivering ; infant shivering is characterized by increased muscular activity, restlessness, and crying. B. Infant shivering activity is not apparent as adult shivering activity. C. Metabolism of brown fat (brown adipose tissue). Functions to produce heat under the stress of cooling. Brown fat is located in the intrascapular region, in the posterior triangle on the neck, in the axillae, and behind the sternum. Brown fat is metabolized and utilized within several weeks after birth.  
      • Thermo regulatory Center is underdeveloped
        • Flexed position helps guard newborn against heat loss
      • – less skin surface exposed to environment
      • Less subcutaneous /adipose tissue
      •  
      • Conversion:
      • 1. F = C x 9/5 + 32
      • 2. C = F – 32 x 5/9
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      • Levels of Maturity
            • LGA- Large for Gestational Age
            • SGA – small for Gestational Age
            • AGA- Appropriate x Gestational Age
            • Prematurity
            • Full term
            • Post term
      •  
      • D. Assessment of the Condition of the Newborn
      • Apgar Scoring – provides an indication of the infants stability
      • - done at 1 minute – suggest the degree of acidosis
      • done at 5 minutes – predicts mortality and morbidity
      • done at 10 minutes – if Apgar Score after 5 minutes
      • E. Proper Identification
      • – done before NB is brought to Nursery
      • – ID band placed either on feet or hand.
        • Footprints /fingertips of baby
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      • CARE OF THE NEWBORN AT NURSERY
      • - Note of ID bands of mother and baby is matched
      • -Special care
      •  
      • Initial Bath
      • – done infant skin temp. stabilize at 36.5 C (97.6F) or core temp. 37 C (98.6F)
        • bathing with warm water – 1 st week
        • Use of mild soap, oils, powder under study
      •  
      • Initial Cord Dressing
      • – prevent tetanus NB
        • used of Providone 12/triple dye70% Ethyl/Isopropyl alcohol
        • Practice strict aseptic technique
        • -Note for umbilical blood vessel 2 arteries and 1 vein – absence of 1 to 2 arteries indicates Congenital Anomaly
      • Crede’s Prophylaxis – done to prevent Opthalmia Neonatorum or Gonorrheal Conjunctivitis
        • legal requirement for all NB
        • Infection can be acquired during delivery from a mother with untreated Gonorrhea
        • Medications – Ag NO31% -1-2gtts
      • Site: lower conjunctival sac; inner to outer cantus.
      • Vitamin K injection – prevent bleeding
      • Cause: Physiologic hypoprothrombinemia
      • Lack of adequate supplies of Vitamin K since NB bowel is sterile.
      • Med. Aquamephyton (Phytonadion/Phytomenadione)
      • 1 mg. – IM at vastus lateralis
      • Note: Gluteal muscles not use until baby can walk
    • OPTHALMIA NEONATORUM
    • Take Anthropometric Measurements Weight – 2, 500g – 4, 000g (2.5 kg. – 8 lbs. & 13 oz) Length – 45-55 cm (18-22in) HC – 33-55 cm (13-14in) 2-3 cm larger than chest CC – 30-33cm (12-13in) AC-29-33 cm   Note: A reduction of newborn weight of about 5-10% or less known as physiologic weight loss occurs 1 st 5 days   Causes: Infant is no longer under the influence of maternal hormones Voids and defecates Relatively low nutritional intake
      • Initial Feeding – given 1 - 6 hours after birth
        • giving of sterile H2O around 1 oz
        • glucose H2O predispose NB – aspirations Pneumonia
        • Observe for reflexes: rooting, sucking, swallowing
        • Purpose of 1 st feeding; evaluate NB ability to swallow without developing aspirations
        • Breastfeeding: recommended method of feedings; initially as soon as fetus is delivered
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      • Purpose of Breastfeeding:
      • Primarily to promote bonding
      • Facilitates uterine contraction thru sucking- because of release of oxytocin
      • Facilitate release of colostrums (contains CHON globulin and Iga Antibody)
      • Physical Assessment
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      • I. Vital Signs:
            • CR – using Apical Pulse
              • ( located lateral to the nipple line at 4 th ICS)
              • 160-180 beats / minute at birth stable at 120-160 beats/ minute
              • characterized as irregular and rapid
              • Radial pulse: normally not prominent, if prominent indicates Congenital Anomaly
              • Femoral and Brachial Pulse: if weak/absent indicates: thrombophlebitis, coarctation of the aorta and hip dislocation
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      • RR. Normally
      • – rapid, irregular, shallow and quiet abdominal, diaphragmatic
      • -60-80 breaths/min. at birth; stable at 30-60 breaths/min
      • -with physiologic apnea of less 15 than seconds.
      • -Usually observe during REM
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      • c. BP – 75/42 approximately at birth - 60-80 mmHg systolic 40-50 mmHg diastolic at 10 days – 95-100 mmHg – systolic slightly elevated - diastolic
      • B. Common Marks
      • Desquamation- peeling of the skin, observed on baby palm and soles; if present at birth, indicates post maturity
      • Mongolian spots – bluish-black areas of pigmentation and more commonly noted at the back, buttocks upper arm and shoulder; common among dark skinned individuals (Asians, Latin Americans, Mediterranean shores) Disappear at pre-school period.
      • Vernix Caseosa – cheese – like substance; a product of sebaceous glands; serves as insulator after birth
      • Milia – clogged sebaceous glands; commonly described as small white pimples found at the tip of nose and chin of the baby. Disappears at 2-4 weeks
    • Nevi – known as stork bites pink or red flat areas of capillary dilatation commonly seen at upper eyelids, nose upper lip, lower occiput bone, nape and the neck. Disappears at 1 st and 2 nd year Erythema Toxicum – also known as Erythema Neonatorum, Newborn Rash transient rash: Characteristics as pink papules with vesicles seen at nape, back and buttocks. Appears at 2 nd day and disappears without treatment. Strawberry Mark – Nevus Vascularis – second most common type of capillary hemangioma. Lesion is elevated, sharply demarcated and bright or dark red, rough surface swelling. Remain until school age or even longer. Portwine Stain or Nevus Flammeus – observed at birth, red to purple color: do not blanch on pressure and do not disappear; commonly found on the face Lanugo – fine downy hair seen at shoulder and upper arm and back; disappears within 2 weeks  
    • Mouth – take note of symmetry of lip movements: if assymetrical – cranial nerve VII paralysis   *Oral thrush Moniliasis – white cheesy –like substance on cheeks and tongue that bleeds when touched (acquired during passage) caused by Candida ;application of Nystatin If with tooth – possibly due to hypervitaminosis – it is extracted to prevent aspirations Epstein pearl – glistening cystals commonly seen at the palate and gums: due to extra load of maternal calcium. Chest – symmetrically expand retraction indicates respiratory distress. Breast – normally are swollen with appearance of a transparent fluid known as witch milk-these condition are due to effect of maternal hormones
      • Back – flat when or prone position: curve begins to form by time baby learns to sit
        • -note for mass, hairy nebule and a dimple along axis
      • Abdomen – normally dome shaped if scaphoid (sunken) with bowel sounds heard in the chest
      • -signs of respiratory distress indicates Diaphragmatic hernia
      • Liver, Spleen ad Kidneys are normally palpable.
      • Extremities – should be symmetric and of equal length
      • -fingers and toes in equal count, extra digits (polydactyl) and fused digits (Syndactyl- webbed fingers or toes) should be noted.
      • -Simian line: a single palmar crease often found in Down’s syndrome.
    • Anogenital – note for passage of stool and urine   Genitals – externally are edematous or swollen and may pass a mucoid slightly bloody vaginal discharge known as Pseudomenstruation. -Note for Cryptorchidism or undescended testes Phimosis; adhesion of the foreskin usually manage by circumcision -Hydrocele; accumulation of fluid around the testes and is considered normal finding -Note for Epispadia: urinary meatus at the dorsal portion and hypospadias at ventral portion of penis                            
      • General Characteristics
      • ALERT: Assess a newborn; monitor a newborn for complications.
      • Length.
      • Average length of term neonate: 48 to 53 cm (I8- 21 inches).
      • 2. Infant is measured by being placed flat on the back paper and determining the distance from head to heels a pencil is used to mark the locations of head - heels, and the distance between locations is measure when the infant is removed.
    • B. Weight. 1. Average birth weight for a term neonate: 3400 gm (' 8oz). 2. Low birth weight: <2500 gm (5 Ib 8 oz). 3. Excessive weight: >4080 gm (9 Ib). 4. Weight loss: between 5% and 10% of birth weight within the first few days of life; infant usually regains weight within 10 to 14 days. C. Head. 1. Molding. a. Head may appear elongated at birth; molding usually disappears within 24 to 48 hours, b. Occurs as a result of abnormal fetal posture in utero and pressure during passage through the birth canal.
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      • 2. Caput succedaneum
      • Edema of the scalp caused by the pressure occurring at the time of delivery. b. Disappears within 1 to 2 days, c. Edema goes across the cranial suture lines.
      • 3. Cephalhematoma
      • a. A collection of blood between the periosteum and the skull,
      • b. Usually results from trauma during labor and delivery.
      • c. Absorbed in a few weeks.
      • d. Does not cross cranial suture lines.
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    • 4. Head measurement a. Average head circumference of the term neonate: 34.2cm; usual variation ranges from 33-35cm b. Head circumference is approximately 2-3 cm greater than the chest circumference; extremes in size may indicate microcephaly, hydrocephaly or increased intracranial pressure.
    • 5. Fontanels a. Anterior: diamond shape about 5 cm, will increase as molding resolves. b. Posterior: smaller than anterior. c. Palpate for size and tension. d. Increase in tension may indicate tumor, hemorrhage, infection, or congenital anomaly. e. Decrease in tension (sunken fontanel) may indicate dehydration. f. Anterior will close in about 12 to 18 months; pos­terior will close in 2 to 3 months.
    • D. Umbilical cord. 1. Determine number of blood vessels; there should be two arteries and one vein surrounded by Wharton's jelly. 2. Cord atrophies and sloughs off by day 10 to 14. 3. Should be no bleeding or oozing.
      • Behavioral Characteristics
      • A. Sleep and awake states.
      • Newborn sleeps an average of 16 to 20 hours a day during the first 2 weeks of life, with an average of 4 hours at a time.
      • 2. May vary from a drowsy or semi-dozing state to an alert state to a crying state.
      • B. Infants vary a great deal in how they respond to stimuli.
      • Infants move easily from one state of sleep to another state of consciousness.
      • 2. As the infant develops, he or she will reduce the total amount of sleeping time; wakeful periods will lengthen; sleeping will shift from daytime to nighttime.
    • Specific Body System Clinical Findings: A. Nervous system. 1. Nervous system is relatively immature and characterized by me following: a. Poor nervous control; easily startled. b. Quivering chin. c. Tremors of the lower extremities of short duration. 2. Reflex activity: The presence or absence of certain reflexes is indicative of ongoing normal development. 3. Presence of positive Babinski sign. a. Normal finding until the age of 1 year. b. Dorsiflexion of big toe and fanning of the other toes. 4. Neonatal reflexes
    •  
    • NURSING PRIORITY: Monitor the passage of the first meconium stool a. Meconium: sticky, black, odorless, sterile stool that is passed within the first 24 to 48 hours after birth; if no stool is passed, further assessment is needed. b. Stools change according to type and amount of feedings. (1) Transitional stools: occurs during period between second and fourth day; consist of meconium and milk; greenish brown or greenish yellow; loose and often contain mucus. (2) Milk stools: usually occur by the fourth day; stools of formula-fed infant are drier, more formed, and paler. (3) Stools of breast-fed infants are golden yellow, have a pasty consistency, and occur more frequently than stools of formula-fed infants.
    • D. Genitourinary system. NURSING PRIORITY: Most newborns void within the first 24 to 48 hours after birth. 1. Urinary. a. Urinary output is low during the first few days of life or until fluid intake increases. b. Thirty to 60 milliliters is voided per day during the first 2 days of life; followed by 200 ml per day by the end of the first week. c. Frequency of voiding: average of two to six times per day, increasing up to 10 to 15 times per day. 2. Genitalia. a. Female: Labia majora are underdeveloped; small amount of bloody discharge from the vagina may be seen as a result of the presence of maternal hormones. b. Male: Scrotum may be edematous; testes should have descended; assess the urethral opening.
      • G. Sensory system.
      • Vision : visual acuity of 20/100 to 20/400; retinal development is advanced,
      • a. Eyes appear large, and pupils appear small,
      • b. All infants' eyes are blue or slate blue at birth;become their permanent color at age 3 months,
      • c. Tears do not develop until 2 to 4 weeks of age.
      • d. Eyes close in response to bright light; red reflex is present; pupils react to light,
      • e. Visual preferences: yellow, green, red, and black and white patterns.
      • 2. Hearing .
      • a. Sudden loud noises may elicit startle response,
      • b. Usually able to locate the general direction of sounds.
    • 3. Sense of smell is present at birth; infants react to strong odors. 4. Taste. a. Differentiates between pleasant and unpleasant tastes, b. Rejects especially salty, sour, or bitter tastes by grimacing; also stops sucking. 5. Tactile senses . a. Most sensitive area is around the mouth. b. Searches for food when cheek is touched or begins sucking movement when lips are touched.
    • H. Musculoskeletal system. 1. Assumes the position of comfort, which is usually the position assumed in utero. 2. Normal palmar crease is present (simian crease is indicative of Down syndrome). 3. Spine is straight and flat when in prone position. 4. Creases and fat pads are present on the soles of the feet 5. All digits are present on hands and feet; fingernails are present.
    • Nursing Intervention ALERT: Provide physical care for a newborn. Goal: To establish and maintain a patent airway and promote oxygenation.
    • Goal: To establish and maintain a patent airway and promote oxygenation. A. Position infant with head slightly lower than chest; may use postural drainage or side-lying position. B. Suction nostrils and oropharynx with bulb syringe. C. Observe for apnea, cyanosis, and mucus collection and be ready to use oropharyngeal suctioning, stimulation, oxygen administration, or resuscitative procedures, if necessary.
    • NURSING PRIORITY: During first 4 hours after birth, the priority nursing goals are to maintain a clear airway, maintain a neutral thermal environment, and prevent hemorrhage and infection. Bathing will be initiated when infant's temperature is stabilized; feeding may begin immediately if infant is interested. Goal: To protect against heat loss A. Immediately after birth, wrap infant in warm blanket and dry off amniotic fluid. B. Replace wet blanket with warm dry blanket. C. Cover wet hair and head with a blanket or cap. D. Give infant to mother to cuddle; place baby on a warm padded surface, preferably under a radiant heater or in an incubator; or provide for skin-to-skin contact with the mother. E. Avoid any unnecessary procedures until body temperature is stable.
      • Goal: To collect data and assess physical condition and behavior.
      • Determine Apgar score at 1 minute and again at 5 minutes
      • 1. The 1 -minute Apgar score is a rapid evaluation of the status of the neonate's intrauterine oxygenation.
      • 2. The 5-minute Apgar score is an evaluation of the neonate's response to cardiorespiratory adaptation after birth.
    • B. Obtain an axillary temperature (rectal thermometer may perforate mucosa). C. Monitor vital signs every 15 minutes to 1 hour until infant's temperature stabilizes (usually in about 4 hours). D. Weigh and measure infant. E. Assess for gestational age and intrauterine growth. F. Determine special needs and whether any significant risk factors are present. G. Perform glucose checks for hypoglycemia on infant of diabetic mother or newborn with complications.
    •  
    • Goal: To assess periods of reactivity. A. First period of reactivity. 1. Lasts approximately 30 minutes. 2. Newborn is alert, awake, and usually hungry. B. Sleep phase. 1 . First sleep usually occurs an average of 3 to 4 hours after birth and may last from a few minutes to several hours. 2. Newborn is difficult to awaken during this phase. C. Second period of reactivity. 1. Infant is alert and awake. 2. Lasts approximately 4 to 6 hours. NURSING PRIORITY: Periods of reactivity are excellent opportunities for promoting attachment response.
    • Goal: To protect against infection. A. Follow guidelines for proper hand washing before handling infant. B. Prevent ophthalmia neonatorum. 1. Administer prophylactic treatment to eyes soon after birth. 2. Place ophthalmic ointment or solution in the conjunctiva! sac and massage eyelid. C. Avoid exposure to people with possible upper respiratory tract, skin, or GI infections.
    • Goal: To prevent hypofibrinogenemia. A. Administer 0.5 to 1.0 mg of vitamin K, intramuscularly into the upper third of the lateral aspect of the thigh Goal: To properly identify infant. A. Secure identification bands to wrist or ankle of infant and wrist of mother in the delivery room. B. Prints of infant's foot, palms, or fingers may be obtained according to hospital policy; mother's palm prints or fingerprints may also be obtained. C. Advise parents not to release the infant to anyone who does not have proper unit identification.
    • ALERT: Promote newborn and family bonding. Goal: To promote parental attachment to infant immediately after birth. A. Wrap infant snugly in warm blanket and encourage parents to hold infant. Do not allow chilling to occur. B. Encourage touching and holding during periods of reactivity.
      • Goal: To initiate feeding and to evaluate parents' ability to feed infant and provide nutrition.
      • Encourage breast feeding, if desired, immediately after delivery or in recovery area.
      • B. Assess infant's ability to feed; assess for active bowel sounds, absence of abdominal distention; rooting, sucking, swallowing reflexes and alertness.
      • C. First feeding or test feeding: Administer 10 to 15 ml of sterile water, followed by a 5% or 10% glucose solution.
      • Goal: To provide daily general care.
      • Ongoing assessment and observation of vital signs, activity, appearance, color, and bowel and bladder function.
      • B. Care of the umbilical cord stump.
      • 1. A drying solution of alcohol and triple dye is applied to the cord.
      • 2. Clean the umbilical cord stump several times a day, especially after infant voids (for a male infant).
      • 3. To encourage drying of the cord, expose umbilical area to air frequently and position diaper below umbilicus.
      • 4. Observe for bleeding, oozing, or foul odor.
    • C. Circumcision care. 1. Keep area clean; change diaper frequently. 2. Observe for bleeding. 3. A sterile gauze dressing with petroleum jelly may be applied to the area during the first 2 to 3 days. 4. If a plastic bell was used, keep area clean; application of petroleum jelly is not necessary; plastic bell will dislodge when area has healed. a whitish-yellow exudate around the glans is granulation tissue and is normal and not indicative of infection. It may be observed for 2 to 3 days and should not be removed.
    • D. Neonate's bath. 1. Bath is delayed until vital signs and temperature stabilize. 2. Warm water is used for the first 4 days; do not immerse infant in water until umbilical cord stump has been released. 3. When bathing neonate, apply principles of clean-to-dirty areas; wash areas in the following order: eyes, face, ears, head, body, genitals, buttocks. 4. Head is an area of significant heat loss; keep it covered.
    • E. Determine weight loss over first 24 hours after birth. F. Assess stools. 1. Meconium stools. 2. Transitional stools. 2. Infant will require more frequent feedings initially; will generally establish a routine of feeding every 3 to 4 hours. B. Breast-feeding . 1. First feeding should occur immediately or within a few hours after birth. 2. Stimulates release of prolactin to initiate milk production. 3. Assess the mother's knowledge of breast-feeding during the first feeding.
    • 4. Assist the mother to hold the infant at the breast with the infant's ear, shoulder, and hips in a straight line. 5. Have the mother touch the infant's lower lip with the nipple to stimulate the latch-on reflex. 6. Most of the areola should be in the infant's mouth 7. Frequent feedings are important initially to establish milk production, often every VA to 2 hours. 8. One of the primary reasons mothers stop breastfeeding is the perception that their milk supply is not sufficient. 9. Encourage mother to not offer the infant a bottle until lactation is well established, generally after about 4 weeks. 10. Engorgement and nipple soreness are the most common problems the mother experiences.
    • C. Bottle-feeding . 1 . It is not necessary to sterilize the water used to reconstitute infant's formula. 2. The infant should be placed in a semi-upright position for feeding. 3. Never prop the bottle, and always hold the infant. 4. Mother should not coax infant to finish all of the bon every time; any unused formula should be discarded 5. Bottles warmed in the microwave should be gem rotated to achieve an even temperature, and temperature of milk should be checked carefully before it :-given to the infant. This warming method is not recommended.
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      • POST TEST
      • Once upon a time in the delivery room……….
      • SEPT. 6,2008 EXACTLY 10:01 AM, ALIVE BABY BOY WAS BORN VIA NSVD WITH RMLE. THE BABY’S APPEARANCE IS COLOR PINK WITH SLIGHTLY BLUISH PALM AND SOLE, HIS PR IS 135 BPM AND CRIES LUSTILY UPON STIMULATION, MAINTAINS A WELL FLEXED EXTREMITIES BUT THE RR IS SHALLOW AND IRREGULAR. WHAT IS YOUR APGAR SCORE?*(1)
      • THE PEDIATRICIAN NOTICED THE BABY’S BREATHING AND STARTED SUCTIONING. WHICH GOES FIRST? MOUTH-NOSE OR NOSE-MOUTH?*(2) SUCTIONING IS INITIATED FOR HOW MANY SECONDS?*(3) THEN THE BABY’S APGAR SCORE IS 9 AFTER 5 MINUTES. NEWBORN CARE THEN STARTED AND OPTHALMIC OINTMENT APPLIED TO BOTH EYES FROM INNER TO OUTER CANTUS,THIS PROCEDURE IS TERMED AS?*(4) THIS IS A LEGAL REQUIREMENT FOR ALL NB TO PREVENT WHAT COMPLICATIONS?*(5) WHAT VITAMIN IS INJECTED TO PREVENT BLEEDING?*(6) ROUTE OF ADMINISTRATION?*(7)
      • SOON THE BABY’S NAME IS STRONG, THE HC MEASURED & IT REVEALS 36 CM, WHAT IS THE EXPECTED CC?*(8) ASSESSMENT OF THE HEAD NOTED TO HAVE A DIAMOND SHAPED FONTANELL THAT CLOSES AT WHAT MONTH?*(9) STRONG’S TOES HAS AN EXTRA DIGIT AT R BIGTOE, THIS IS TERMED AS?*(10) STRONG WAS THEN BROUGHT TO NURSERY, THE NICU NURSE OBSERVED A SMALL WHITE PIMPLES FOUND AT THE TIP OF THE NOSE & CHIN. WHAT MARK IS THAT?*(11) WHEN THE NURSE LIGHTLY STROKE STRONG’S CHEEK & HEAD TURNS TO SIDES IS WHAT KIND OF REFLEX?*(12) WHAT REFLEX IS DESCRIBE WHEN THE NURSE LIGHTLY STROKE THE LATERAL SIDE OF THE FOOT FROM HEEL TO TOE AND THE BIG TOE DORSIFLEXED & TOES FANNED?*(13)
      • WHAT STOOL THAT IS STICKY, BLACK, ODORLESS THAT IS PASSED OUT WITHIN THE FIRST 24-48 HOURS?*(14) STRONG NORMALLY SLEEPS FOR 16-20 HOURS AND WHEN THE NURSING STUDENT MADE A LOUD NOISE CAUSING HIM TO STIFFEN, ABDUCTS AND EXTEND ARMS WITH THE HANDS OPEN AND EXTENDED TO A C SHAPE IS WHAT KIND OF REFLEX?*(15)
      • SOON…. Strong TRAVELS THE MILESTONES OF GROWING UP….
      • And……More Post test for strong…