Chapter 18: Nursing Management of the Newborn Flashcards
Newborn assessment
Is completed immediately, and then again within 2 to 4 hours when the baby is admitted to nursery. The third assessment is completed before discharge. During the initial assessment look for signs that indicate a problem such as nasal flaring, chest retractions, Grunting on exhalation, labored breathing, generalized cyanosis, abnormal breath sounds, tachypnea greater than 60 or bradypnea less than 25, flaccid body posture, tachycardia over 160, bradycardia less than 100, abnormal size
Apgar scoring
< 3 hours
Can result in fetal hypoxia,,asphyxia, or intracranial hemorrhage
Length and weight
Length 44-55cm, 17-22 inches
Weight 2500-4000g, 5lbs8oz - 8lbs14oz
10% lost by 3-4 days, back by 10 days.
LBW less than 2500g
VLBW less than 1500g
Extremely LBW less than 1000g
Head 32-38 cm (13-15 inches) about 1/4 length
Small: rubella, toxoplasmosis, or SGA.
Enlarged: hydrocephalus, increased pressures
Chest 30-36cm (12-14 inches) equal or 1 inch less than head
Vital signs
Temp 97.7-99.5 (axillary)
Heart rate 120-160 up to 180 when crying (apical for 1 min)
Respirations 30-60 at rest, increase with crying
BP 50-75/30-45
HR, T, and R every 30 min for 2 hrs or stable, then every 8 hours
BP not usually assessed
Gestational age assessment
Uses physical signs and neurologic characteristics.
Physical maturity is done within two hours after birth and uses the Ballard examination tool. Includes skin texture, lanugo, plantar creases, breast tissue, eyes and ears, genitals
Neuromuscular is completed within 24 hours. It includes posture, square window of the wrist, arm recoil, popliteal angle (of the knee), scarf sign, heel to ear.
Add 2 scores together. Preterm is before 37 weeks Term between 38 and 42, postterm after 42, postmature is after 42 and signs of placental aging
Maintaining airway patency
Suction mouth first and then the nose. Always keep the bulb syringe near newborn.
Administering medications
Vitamin K promotes blood clotting. It is not produce because the newborn bowel is sterile. Usually takes about a week. IM dose of 0.5 to 1 mg
Erythromycin in the eye. Prophylactic and given ASAP and within two hours. It is state mandated to prevent ophthalmia neonatorum. It comes from infected vaginal discharge
Acrocyanosis
Persistent cyanosis of the fingers, hands, toes, and feet with mottled blue or red discoloration and coldness. It is normal and intermittent. Usually during the first few weeks of life.
Vernix caseosa
A thick white substance that protets the skin of the fetus. It is formed by secretion from the fetuses oil glands and is found during the first two or three days after birth and in body creases and the hair. It does not need to be removed.
Stork bites
Usually on the nape of the neck, eyelids, between the eyes, and upper lip. They are from immature blood vessels. They usually fade during the first year
Milia
Unopen sebaceous gland found on the nose chin and forehead. They will disappear into two to four weeks. In the mouth they are called Epstein pearls.
Mongolian spot
Blue or purple splotches that appear on the lower back and butt. Usually in Africans, Asians, and Indians, or dark skinned newborns. They are caused by a concentration of pigmented cells and disappear within the first four years of life.
Erythema toxicum
Newborn rash that is benign, idiopathic, generalized, and transient. Currently 70% of all Newborns during the first week of life. Small papules are pustules look like flea bites. No pattern is seen. Caused from eosinophils reacting to environment.
Harlequin sign
Dilation of blood vessels on one side of the body. Have a distinct midnight line demarcation. Pale on the nondependent side and red on the opposite. Usually seen in low birth weight. This transient and no intervention is needed
Nevus flammeus
Port wine stain that commonly appears on the newborn face or other areas. It is a capillary angioma, flat with sharp demarcations, purple/red. It is permanent and will not fade. It should be monitored and may need treatment.
Nevus Vasculosus
Strawberries hemangioma, benign capillary hemangioma in the dermal and subdermal layers. Raised, rough, dark red, sharply demarcated. Usually on the head within a few weeks after birth. It may increase in size and number. Usually seen in premature infants less than 1500 g. Usually go away within three years
Fontanelles
Interior fontanelle is diamond shape and closes at 18-24 months. The posterior is triangular and closes around 6 to 12 weeks.
Caput succedaneum
Edema on the scalp from the pressure of the birth process. Soft tissue swelling that crosses suture line. Pitting edema and petechiae may be are noted. Usually goes away in three days.
Cephalhematoma
Localized effusion of blood beneath the periosteum of the skull. Due to the disruption of vessels during birth. The swelling does not cross suture line and his firm to the touch. Hyperbilirubinemia may follow it. usually appears on the second or third day and disappears in weeks to month.
Microcephaly
A head circumference less than 10% of normal parameters for the gestational age. caused by failure of brain development. It often occurs along with epilepsy, cerebral palsy, intellectual disability, ophthalmologic and hearing disorders. It can be inherited, from infections, rubella, toxoplasmosis, trisomy syndromes, and fetal alcohol syndrome.
Macrocephaly
Head circumference of more than 90% of normal. Usually related to hydrocephalus. It is often inherited from autosomal dominant and can be isolated or manifestation of other anomalies. It can be a manifestation of achondroplasia
Large fontanels
More than 6 cm in the anterior diameter, or more than 1 cm in the Postier fontanel. Possibly from malnutrition, hydrocephaly, congenital hypothyroidism, trisomy 13 18 and 21, and bone disorders such as osteogenesis imperfecta.
Small or closed fontanels
Smaller than normal anterior and posterior diameters were closed. Craniosynostosis and abnormal brain development are associated with them.
Abnormalities of the ears
Low-set years or abnormally shaped ears are characteristic of many syndromes and genetic abnormalities such as trisomy 13 or 18. Internal organ abnormalities involving the renal system can also be the cause. Findings of sinuses or preauriular skin tag should prompt further evaluation for renal abnormalities. Both systems develop at the same time.
Heart sounds
Listen when the newborn is quiet or sleeping. The point of maximum impulse is lateral to midclavicular line located at the fourth intercostal space. The displaced point of maximal impulse indicates a tension pneumothorax, or cardiomegaly. Murmersi are often heard that usually benign, but should be evaluated if still present after 12 hours.
Genitals
Penis: hypospadius if urinary meatus is on ventral portion
epispadius if is is on the dorsal portion
Avoid circumcision if either above conditions.
criptorchidism: undescended testes
Female: pseudomenstruation is a bloody discharge due to mothers hormones, it is normal and no treatment.
Labial bulge: indicates a inguinal hernia, ambiguous genitalia, rectovaginal fistula, or imperforate hymen.
Abnormalities of the hand
Polydactyly is having too many digits. Syndactyly is having fused digits. Most newborns have three palmar creases. A single, crease, call simian line, is associated with down syndrome
Brachial plexus injury
Erbs palsy or klumpke palsie. They may be from a large birth weight: breech delivery, and shoulder dystocia. Paralysis can be from lateral traction on the head. The arms lay limp alongside the body, no moro reflex. May take 6 months to recover
Ortolani and Barlow Maneuvers
To detect congenital dysplasia of the hip
Ortoani: Newborn in supine, flex hips and knees to 90° at the hip. Grasp the inner aspect of the thighs and abduct the hips while applying pressure upward. Listen for any sounds or clicks during the maneuver.
Barlow: Supine position, grasps the inner aspect of the thighs, adduct the thighs while applying outport and downward pressure to the thighs. Feel for femoral head slipping and clicking
Review reflexes
Chapter 25 and pg 589-590
Bathing the newborn
Start at the eyes and end with the diaper area. Use plain warm water on the face and eyes. add a mild soap for the remainder of the body. Wash, rinse, dry each area before going onto the next. Wash the hair using running water so the scalp can be thoroughly rinsed. It is not necessary to avoid the fontanelles. Cleanse all creases, especially the neck folds to remove any milk that may have dripped into these areas. Continue downward washing the trunk and extremities ending up with the diaper area last.
Circumcision
Risks include infection, hemorrhage, skin dehiscense, adhesions, urethral fistula, in pain.
Benefits include decreased urinary tract infections, decrease STD infections, lower penile cancer rate
Assess bleeding every 30 minutes for two hours. Document the first voiding, squeeze soapy water over the area and rinse. Keep petroleum jelly on the tip every diaper change. Fasten the diaper loosely and do not place baby on stomach.
PKU
Autosomal recessive inherited deficiency. Manifestations include irritability, vomiting protein feedings, the musty odor to the skin or body secretions, mental and motor retardation, seizures, microcephaly, poor growth and development. Treatment includes a life time diet foods low in phenylalanine. Monitor blood levels. Testing is done 24 to 48 hours after protein feeding. Should not be done prior to 24 hours.
Congenital hypothyroidism
Deficiency of the thyroid hormone necessary for normal brain growth, metabolism, development. Increased risk with newborns under 2000 g or over 4500 g, Hispanics and Asians. Feeding problems, growth and breathing problems, and irreversible brain damage and intellectual disability. Testing is done between four and six days and would include thyroid replacement therapy.
Galactosemia
Absence of the enzyme needed to convert galactose to glucose. Manifestations include poor weight gain, vomiting, jaundice, mood changes, loss of eyesight, seizures, intellectual disability. If untreated galactose buildup causes permanent damage to the brain, eyes, liver, and even death. Treatment includes eliminating milk and replacing with soy. 1st test done on discharge and again within 1 month
Sickle cell anemia
Recessively inherited commonly found in African. Manifestations include anemia shortly after birth, it increases the risk for infection, growth restriction, and vaso-occlusive crisis. Treatment includes maintenance of hydration and hemodilution, rest, electrolyte replacement, pain management, blood replacement, and antibiotics. Testing is done at the newborn screening or prior to three months
Transient tachypnea
Accompanied by retractions, expiratory grunting, or cyanosis and is relieved by low-dose oxygen therapy. It occurs when fetal liquid in the lungs is remove slowly or incompletely. Nursing care includes giving oxygen, ensuring warmth, respiratory status frequently, allowing time for the remaining fluid to be removed. Usually benign and resolves in 24 to 72 hours.
Jaundice
Imbalance between the production and elimination of bilirubin.
Prevention and management includes promoting breast-feeding and making sure the newborn is well hydrated and stooling frequently, advise mothers to nurse 8 to 12 times per day, avoid supplementation with water and dextrose. Ensure all infants are monitored for jaundice, treat with phototherapy when indicated.
Side effects of phototherapy include frequent loose stools, insensible water loss, rash, potential retinal damage.
Phototherapy is used nurses must closely monitor body temperature and fluid electrolyte balance, document stools, monitor hydration, turning frequently, observe skin integrity, provided eye protection, encourage parents to participate.
Hypoglycemia
At risk include diabetic mothers, preterm, newborns with intrauterine growth restriction, in adequate calorie intake, sepsis, asphyxia, hypothermia, polycythemia, glycogen storage disorders, and endocrine deficiencies.
Symptoms include jitteriness, lethargy, cyanosis, apnea, seizures, a high-pitched or weak cry, hypothermia, poor feeding. It can cause learning and intellectual disabilities.
Treatment includes administration of rapid acting glucose or early formula feeding. If severe IV administration may be required. glucose screening should only be performed on at risk infants. Preevent it by initiating early feedings
Nutrition
110-120 cal/kg/day
Breast milk and formula contains 20 cal/oz
Iron supplements for formula fed babies
400 iU of Viatmin D to prevent rickets
Flouride if not in water at 6 months age
LATCH
5 componets for breast feeding L:latch A:audible swallowing T:type of nipple C:comfort of nipple H: hold-positioning
Breast milk storage
Fridge is only good for 24 hours. Frozen milk must be used within three months. Never refreeze.
Check up schedule
2-4 days after discharge, 2-4 weeks 2,4,6, checkup and vaccines 9 checkup 12 checkup and TB test 15, 18 checkups and vaccines 2 yrs checkup
Signs of illness
Temperature above 101. Forceful persistent vomiting. Refusal to feed. Two or more green diarrhea stools. Infrequent wet diapers and change in bowel. Lethargic or sleepiness. Inconsolable crying and fussiness, abdominal distention. Difficult for labored breathing.
