Chapter 19: Normal Newborn Processes of Adaptation Flashcards
1
Q
Neonatal Resuscitation
A
- ABCs
- thermoregulation
- glucose metabolism
2
Q
development of fetal lungs
A
- during fetal life, the alveoli produce fetal lung fluid that expands the alveoli and is essential for lung development
- as fetus nears term, the amount of fluid produced decreases in preparation for birth when the fluid must be cleared for the infant to breathe
- average size baby makes 400 mL/day
3
Q
fetal lung fluid
A
- decreases in amount near end of the pregnancy
- during labor, the fluid begins to move into the interstitial spaces, where it is absorbed
- absorption is accelerated by secretion of fetal epinephrine and corticosteroids but may be delayed by C/S w/o labor
- removal of fluid helps reduce pulmonary resistance to blood flow that is present before birth and enhances the advent of air breathing
4
Q
pulmonary surfactant
A
- this is a combination of lipoproteins that is detectable by 24-25 weeks of gestation
- lines the inside of alveoli and reduces surface tension w/in alveoli which allows them to remain partially open when the infant breathes
- w/o surfactant, alveoli collapse when infant exhales and must re-expand w/ each breath which inc WOB
- by 34-36 weeks, sufficient surfactant is produced to prevent RDS
- surfactant secretion inc during labor and immediately after birth to enhance transition to neonatal life
5
Q
steroids and pulmonary surfactant
A
- steriods are given to a woman in preterm labor to help inc surfactant production and speed maturation of the lungs
6
Q
which conditions can cause accelerated lung maturation?
A
- intrauterine growth restrictions
- stress from conditions like maternal HTN, heroin addiction, pre-E, or infection
- placental insufficiency
- PROM greater than 48 hours
7
Q
which condition slows fetal lung maturity?
A
maternal GDM
8
Q
what happens at birth to allow the infant to breathe?
A
- at birth, the infant’s first breath must force remaining fetal lung fluid out of the alveoli and into the interstitial spaces around the alveoli to allow air to enter the lungs
9
Q
what are chemical factors that initiate breathing?
A
- chemoreceptors in the carotid arteries and aorta respond to hypoxia in the blood that occurs w/ birth
- a dec in O2 and pH and an inc in CO2 stimulates the respiratory center
- occlusion of vessels in the cord ends the flow of placental substances that inhibit respirations
- if prolonged hypoxia caused CNS depression, then stimulation of the respiratory center will not occur
10
Q
what are mechanical factors that initiate breathing?
A
- during a vaginal birth, the fetal chest is compressed by narrow birth canal
- 1/3 of lung fluid is forced out of lungs into upper airway passages and is suctioned out
- when pressure against chest is released at birth, recoil of chest draws a small amount of air into the lungs and helps remove some of the fluid
- complete absorption of fluid may take 24 hours
11
Q
what are thermal factors that initiate breathing?
A
- temp changes that occurs w/ birth stimulates respirations
- at birth, the infant moves from a warm, fluid filled uterus to a coller temp
- sensors in the skin respond to the change and send impulses to the medulla to stimulate breathing
- at birth, the infant moves from a warm, fluid filled uterus to a coller temp
12
Q
what are sensory factors that initiate respirations?
A
- tactile, visual, auditory, and olfactory stimuli occur
- nurses hold, dry, place infants skin to skin, and wrap them in blankets to provide more stimuli
13
Q
continuation of respirations
A
- as alveoli expand, surfactant allows them to remain partially open b/w breaths
- some air from first breaths remain in the lungs to become residual capacity, so then subsequent breaths require less effort
- as infant cries, pressure in lungs inc and push remaining fetal lung fluid into interstitial spaces where it is absorbed into circulatory and lymphatic systems
- why lungs may be moist sounding at first
14
Q
interference w/ lung expansion
A
- lack of thoracic squeeze
- occurs w/ small babies and C/S
- respiratory depression
- aspiration of amniotic fluid or meconium
15
Q
periodic/episodic breathing
A
- occurs in some full term, but more common in preterm
- count respiratory rate for 1 min to make up for this
- this is pauses of 5-15 sec w/o changes in skin color/HR followed by rapid respirations for 10-15 sec
16
Q
signs of respiratory distress
A
- tachypnea (RR > 60)
- see saw respirations/paradoxical respirations
- nasal flaring
- expiratory grunting or sighing
- intercostal/xiphoid retractions
- central cyanosis
17
Q
what are the goals for a nursing diagnosis of ineffective airway clearance?
what are the interventions?
A
- goals:
- maintain patent airway
- maintain RR of 30-60
- no signs of respiratory distress
- interventions:
- positioning
- suctioning
18
Q
assessment of newborn respiratory system
A
- rate:
- 30-60, easily altered by stimuli
- normal is an irregular respiratory rate
- may be up to 60-70 for 1st-2 hours
- 30-60, easily altered by stimuli
- characteristics: abdominal breathing and obligatory nose breathers
- breath sounds should be present in all lung fields
- assess for grunting, flaring, retractions
19
Q
what are 3 shunts in fetal circulation and what is there purpose?
A
- ductus venosus
- foramen ovale
- ductus arteriosus
- allows the most highly oxygenated blood to be sent to the brain and heart
20
Q
fetal circulatory circuit involving the 3 shunts
A
- oxygenated blood from placenta goes thru the umbilical V to the fetus–>about 2/3 go to the liver (by term) and the rest goes straight to the IVC by the ductus venosus
- blood enters RA and joins with deoxygenated blood from lower body/head–>blood goes thru the foramen ovale to the LA–>LV–>aorta–>body
- a small amt of blood from the RV is sent to the lungs to nourish that tissue, then the rest of the blood from the RV goes the ductus arteriosus to the aorta
21
Q
what are the changes in blood circulation of the baby after birth?
A
- as infant breathes and the lungs expand, blood flow to the lungs increases, pressure in the right side of the heart falls, and foramen ovale closes
- ductus arteriosus constricts as arterial O2 levels rise
- ductus venosus constricts when blood flow from the umbilical cord stops
- after birth, the ductus venosus and umbilical As and V become ligaments
22
Q
heart murmurs in infants
A
- common
- 90% are not associated with anomalies
23
Q
newborn characteristics that lead to heat loss
A
- skin is thin
- blood vessels are close to the surface
- little subcutaneous fat is present
- they also have 3x more body surface area which provides more area for heat loss
24
Q
how do full term infants reduce the amount of skin exposed to surrounding temps and dec heat loss?
A
- they remain in a position of flexion
- sick/preterm infants have decreased muscle tone and are unable to maintain a flexed position, so at inc risk for cold stress
25
Q
normal infant axillary temp
A
36.5-37.5 deg C (97.7-99.4 F)
26
Q
what are the 4 methods of heat loss?
A
- conduction: movement of heat away from body occurs when newborns have direct contact with objects that are cooler than skin
- convection: transfer of heat from infant to cooler surrounding air
- occurs when drafts come in
- radiation: transfer of heat to cooler objects that are not in direct contact with infant
- heat loss from infant’s body to sides of crib
- evaporation: conversion of liquid to vapor
- air drying of the skin that results in cooling
- reason we dry off infant ASAP, to prevent evaporation
27
Q
nonshivering thermogenesis (NST)
A
- this is the primary method of heat production in infants
- it is the metabolism of brown fat to produce heat
- begins when thermal receptors in the skin detect a skin temp of 35-36 deg C (95-96.8 deg F)–>thermal receptor stimulation is transmitted to hypothalamus–>norepinephrine is released is released in brown fat–>metabolism starts
- occurs even before core body temp drops
28
Q
brown fat
A
- contains an abundant supply of blood vessels
- located primarily around the back of the neck; in the axillae; around the heart, kidneys, and adrenals; b/c scapulae; along abdominal aorta
- blood passing through brown fat is warmed and carries heat to the rest of the body
- accumulated mainly in the 3rd trimester (starting at 26-30 wks), so preterm infants may not have adequate amounts
29
Q
which infants may have trouble raising their body temp with nonshivering thermogenesis?
A
- preterm infants, b/c brown fat is accumulated in 3ed trimester
- infants who had intrauterine growth restriction may have depleted fat stores before birth
- hypoxia, hypoglycemia, and acidosis may interfere w/ infant’s ability to use brown fat
30
Q
what are the effects of cold stress?
A
- inc oxygen need
- decreased surfactant production–>impedes lung expansion
- causes respiratory distress
- hypoglycemia
- metabolic acidosis
- jaundice (hyperbilirubinemia)
31
Q
neutral thermal environment
A
- this is one in which the infant can maintain a stable body temp w/ minimal oxygen need and w/o an inc in BMR
- the range of environmental temp that allows this stability is called the thermoneutral zone, which in a health, unclothed, full term newborn, it is 32-33.5 deg C (89.6-92.3 deg F)
- varies according to gestational age, size, and postnatal age
32
Q
if there is a nursing diagnosis of risk for altered body temp, what are the interventions?
A
- avoid heat loss
- recheck temp
- if low, warm infant:
- warm blankets
- triple wrap with hat
- skin to skin
- warmer
- recheck in 30 min
33
Q
hyperthermia
A
- when temperature of the infant rises–>this inc the metabolic rate–>causing an inc need for oxygen and glucose
- cause:
- poorly regulated equipment designed to keep them warm (environment)
- infection
34
Q
RBC in newborn
A
- has inc erythrocytes (4.8-7.1) and Hgb (15-24) than an adult due to the partial pressure in the fetal blood being lower than the adult
- adequate oxygenation of cells is possible b/c fetal Hgb carries more oxygen
- fetal RBC have a shortened life span
- hemolysis of RBC–>jaundice
35
Q
Hct in Newborn
A
- 44-70% for first month
- a level above 65% from a central site indicates polycythemia (high erythrocyte count) which inc the risk of jaundice
36
Q
WBC in newborn
A
- r/t the stress of birth, 10,000-30,000 is normal
- infection: inc number of immature leukocytes and decreased platelets
- normal platelets in newborn is 84-478
37
Q
risk of clotting deficiency
A
- newborns are at risk of clotting deficiency during 1st few days b/c of low levels of vit K which is necessary to activate several clotting factors
- at birth, intestines are sterile and therefore, there is no bacteria to synthesize vit K
- w/o vitamin K, liver can’t produce prothrombin
- to dec risk of hemorrhagic disease of the newborn, vitamin K is administed IM
- also called Aqua Mephyton
38
Q
GI adaptation
A
- newborn’s stomach capacity is 50-60 mL (6 mL/kg)
- gastric emptying may be delayed at first
- full stomach–>gastrocolic reflex–>causes inc peristalsis–>stool during or after feeding
- cardiac sphincter is immature and relaxed which causes frequent regurgitation
39
Q
stool cycle
A
- meconium:
- 1st stool w/in 24 hours
- thick, tarry black to greenish
- transitional stools:
- 3rd day
- combination of meconium and milk
- greenish brown and looser consistency
- depend on feeding:
- breast: seedy, mustard color, sweet-sour smell
- more frequent stools, possibly with each feeding
- at least 4 stools/day
- bottle: pale yellow to light brown, firmer, normal odor of stool
- several stools daily or only 1-2
- breast: seedy, mustard color, sweet-sour smell
40
Q
Blood Glucose Maintenance
A
- glucose is the primary source of energy
- normal in term infant: 40-60 on first day, 50-90 after that
- hypoglycemia is below 40-45
- normal in term infant: 40-60 on first day, 50-90 after that
- S/S of hypoglycemia: jittery, tremors, hypotonia, low temp
41
Q
infants who would have a problem with hypoglycemia
A
- infants that are preterm, late preterm, and SGA may have not accumulated glycogen and may be at risk for hypoglycemia
- LGA and those with diabetic mothers produce more insulin and use of glucose supplies, but after birth, b/c no longer getting glucose from mom but insulin still high, so rapid drop in glucose levels about 2 hours after birth
- postterm: would have to use up glucose stores before birth, b/c not getting enough nutrition from placenta
42
Q
how to do a heel stick
A
- put thumb up the center of the heel
- do a heel stick on either side
- do it this way so you miss the nerves
43
Q
conjugation of bilirubin
A
- principal source of bilirubin is hemolysis of erythrocytes
- bilirubin released in unconjugated form (indirect) into bloodstream–>attaches to binding site on albumin–>carried to the liver
- if enough binding sites on albumin, then bilirubin is conjugated–>excreted in bile–>stool
- if not enough sites, then unconjugated bilirubin is free, unbound, and moves into tissues and brains
- Total serum bilirubin measures unconjugated (indirect) and conjugated (direct)
44
Q
factors influencing hyperbilirubinemia
A
- excess production of bilirubin d/t accelerated destruction of RBCs, shorter RBC lifespan
- accelerated destruction also occurs from brusing from forceps, cephalohematoma
- impaired conjugation:
- liver immaturity: does not make enough enzyme to conjugate bili
- interference w/ binding of indirect bilirubin with albumin:
- meds like pitocin, sulfa, and aspirin
- cold stress
- dec albumin
- dec intestinal flora
- inc bilirubin reabsorption: b/c of dec intestinal motility so more time to deconjugate bili and take it back up & no bacteria to reduce conjugated bilirubin
45
Q
physiologic jaundice
A
- transient hyperbilirubinemia: excess bili in the blood
- considered normal
- appears on 2nd-3rd day of life
- noticeable when bili reaches 5-7 mg/dL
- usually peaks by 4th day then falls
- may not need treatment
46
Q
nonphysiologic jaundice
A
- abnormal
- may occur in first 24 hours
- rises more rapidly to higher levels and stays higher longer
- causes:
- differences in mother’s and infant’s blood type
- infection
- metabolic disorders
- tx: phototherapy
- preterm infants treated sooner
47
Q
Breastfeeding Jaundice (Early Onset)
A
- bili levels greater than 12 mg/dL
- most common causes: insufficient intake, less colostrum, less stooling
- tx: assist with better breastfeeding and pumping in order to help stimulate milk production and inc infant’s intake
- may need supplemental formula if infant is dehydrated or losing weight
48
Q
True Breast Milk Jaundice (late onset)
A
- occurs after first 3-5 days of life
- lasts 3 weeks-3 mos
- TSB b/w 5-10 and falls slowly
- tx: close monitoring of TSB and at least 8-12 feedings each 24 hours
- phototherapy if levels require it
- may switch to formula temporarily in order to cause a rapid drop in bili levels
49
Q
Assessment for Jaundice
A
- press skin, as blanching occurs look for icterus (yellow color)
- visible at 5-7
- progresses from the nose, face, trunk, extremities, hands/feet
50
Q
Kernicterus
A
- brain damage that occurs in a newborn with severe jaundice
- occurs when term babies have a bili level persistently higher than 20, and when preterm babies have a bili level persistently higher than 12
51
Q
nursing care with phototherapy
A
- eye patches
- monitor temp
- undress
- cover gonads
- monitor light intensity
- keep hydrated
- promote elimination
- support for parents
52
Q
kidney development and function
A
- by 34-36 wks gestation, fetal kidneys have as many nephrons as an adult
- blood flow to the kidneys inc after birth
- GFR is immature and inc to adult levels by 1-2 yrs of age, so dec ability to remove waste products as a newborn
- voiding occurs within 12-24 hours for most newborns
- failure to void may be a result of hypovolemia
- 1-2 voidings during first 2 days
- at least 6 voidings/day by 4th day
53
Q
fluid balance in newborns
A
- full term infants need 60-100 mL/kg daily during the first 3-5 days, then 150-175 mL/kg a day by 7 days
- 78% of newborn’s body is composed of water
- extracellular water is easily lost
- water lost from skin and respiratory tract contributes to insensible water loss–>inc in newborns b/c of a large surface area
- urine dilution and conc: only have half the ability to concentrate urine as adults, but same ability to dilute
- poor waste removal
- specific gravity: 1.001-1.005
54
Q
acid base balance and electrolytes in newborns
A
- b/c newborns tend to lose bicarb at lower levels, they have an inc risk for metabolic acidosis
- have limited excretion of sodium
55
Q
brick dust
A
- pinkish stains–crystals of uric acid
- innocuous
56
Q
pseudomenstruation
A
- result of withdrawal of maternal hormones
57
Q
immunologic adaptations
A
- immune system not fully activated at birth–>failure to recognize, localize, and destroy bacteria
- signs of infection:
- subtle and nonspecific
- hypothermia: reliable sign
- fever is not reliable r/t poor hypothalamic response
58
Q
IgG
A
- crosses placenta starting in 1st trimester
- provides passive immunity to bacteria and viruses if mom has developed immunity
- doesn’t start production in fetus until about 6 mos
59
Q
IgM
A
- 1st immunoglobulin produced by the body
- helps against gram negative bacteria
- begins production a few days after birth
- does not cross placenta
60
Q
IgA
A
- does not cross placenta
- must be produced by infant, but also present in colostrum and breast milk
- protects against GI and respiratory infections
61
Q
neurological and sensory adaptation
A
- purposeless, uncoordinated, bilateral movements of extremities
- able to fixate on faces and geometric objects or patterns–>prefer high contrast (black & white)
- hypertonic (flexed position)
- reflexes indicate neurologic integrity
62
Q
periods of reactivity
A
- First Period:
- 1st 30 min after birth
- awake, alert, strong suck
- RR and HR may be elevated
- period of inactivity to sleep phase
- infants quiet and fall into sleep
- difficult to awaken, no interest in eating
- few min to 2-4 hours
- infants quiet and fall into sleep
- 2nd Period:
- lasts 4-6 hous
- awake and alert
- production of respiratory and gastric mucous
- may gag and regurgitate
63
Q
deep or quiet sleep
A
- change in state is unlikely
- closed eyes with no eye movement
- regular even breathing
64
Q
active rapid eye movements of infant
A
- closed eyes with rapid eye movement
- minimal activity
- irregular respirations
- irregular sucking motions
65
Q
drowsy state in infant
A
- transitional period b/w sleep and wake
- fluttering eye lids
- semi dozing appearance
- state will change with sensory stimulus
66
Q
active alert state in infant
A
- restless, inc motor movements, fussy
- faster, more irregular respirations
- eyes are open
67
Q
quiet alert state
A
- good time to inc bonding
- focus on onjects and people
- respond to parents with intense gazing and seem bright and interested in surroundings
- respond to stimuli and interaction
68
Q
crying state in infant
A
- may follow active alert state if no intervention to comfort infant
- cries are continuous, lusty; active body movement
- infant does not respond positively to stimulation
- respirations are irregular and rapid
