Chapter 20: Assessment Of The Normal Newborn Flashcards
Labor and birth history includes:
- Type of delivery (vacuum assist, c-section, vaginal?)
- Infections during delivery
- Conditions at delivery (HTN, diabetes, amniotic fluid, PROM, etc.)
- Length and course of labor
- Any medications given during labor
- EDB
- Prenatal lab results (prenatal care/no prenatal care, folic acid deficiency, drug use, etc.)
What is a normal respiratory rate of a newborn?
30-60 breaths per minute
Frequency of respiration assessments
- The nurse assesses respiration’s at least once every 30 minutes until infant has been stable for 2 hours after birth.
- If abnormalities are noted, respiration’s are assessed more often.
In what case may infants breathe faster?
- Immediately after birth
- During crying
- During the first and second periods of reactivity
In order to attain an accurate respiratory rate, what should you do?
Count for a full minute.
Normal qualities of respiration in a newborn
Nonlabored
Symmetric chest movements
Periodic breathing
- Pauses in breathing lasting 5-10 seconds without other changes followed by rapid respiration’s for 10-15 seconds.
- Occurs in some full-term infants but is more common in preterm infants.
Newborns first gasp of air is
Exaggerated
Crackles in Newborns
Crackles during the first hour or two after birth is normal
What breath sounds should be reported?
-Wheezes
-Crackles
-Rhonchi
-Stridor
-Diminished
That persists should be reported.
Bowel sounds in chest may be a sign of
Diaphragmatic hernia
Signs of Respiratory Distress includes:
- Tachypnea
- Retractions
- Seesaw or paradoxical respiration’s
- Cyanosis
- Grunting/Flaring
- Asymmetry
When is tachypnea in a newborn normal?
- During first hour after birth.
- During periods of reactivity.
Retractions include
- Xiphoid
- Intercostal
- Supraclavicular
Seesaw or Paradoxical Respiration’s
- Chest falls when the abdomen rises (vise versa)
- Normal chest should rise and fall together
Cyanosis
Purplish blue discoloration indicating the infant is not getting enough oxygen.
Central cyanosis involves the
- lips
- tongue
- mucous membranes
- trunk
Central cyanosis indicates
- True hypoxia.
- This means inadequate oxygenation to the vital organs and requires immediate attention.
Bruising of the face
May occur from a tight unchallenged cord or pressure during birth and may look like central cyanosis.
How can you differentiate bruising from cyanosis?
- By applying pressure to the area.
- Cyanosis area will blanch, but a bruised area remains blue.
How can cyanosis in infants with dark skin tones be checked?
- Looking at the color of the mucous membranes
- Pulse oximeter may be used to determine oxygen saturation in infants with cyanosis
Peripheral cyanosis (acrocyanosis)
- Cyanosis only involving the extremities.
- Results from poor perfusion of blood to the periphery of the body.
Cyanosis at birth
It is normal to see a cyanosis infant at birth whose color quickly turns pink as the infant begins to breathe.
Cyanosis can occur whenever the
Occurs when the infant’s breathing is impaired such as during feedings d/t difficulty in coordinating sucking, swallowing and breathing.
Infants who become cyanosis on exertion or when crying may have
A congenital heart defect
Pallor in an infant
Can indicate the infant is slightly hypoxic or anemic
A ruddy color in some infants may indicate
Polycythemia (an excessive number of RBC’s)
What hematocrit levels indicates polycythemia?
> 65%**
Increased hematocrit levels can increase the risk for what?
Jaundice
Nasal Flaring
A reflex widening of the nostrils that occurs when the infant is receiving insufficient oxygen.
How does nasal flaring help the infant breathe?
Helps decrease airway resistance and increase the amount of air entering the lungs.
Intermittent nasal flaring may occur
In the first hour after birth
Continued nasal flaring can indicate
A more serious respiratory problem
Grunting
Noise made on expiration when air crosses partially closed vocal cords.
How can grunting help an infant with respirations?
Increases the pressure within the alveoli, which keeps the alveoli open and enhances exchange of gases in the lungs.
Grunting that is loud enough to be heard unaided in an infant can indicate
An infant having severe respiratory difficulty
Persistent grunting in an infant is a common sign of
Respiratory distress syndrome and necessitates expanded assessment and referral for treatment.
Choanal Stresia
- Blockage/narrowing of one or both nasal passages by bone or tissue.
- Requires surgery.
- Infant becomes cyanosis when quiet and pink when crying (draws air in mouth)
What method of breathing do newborns use for 4-6 weeks of life?
Newborns are nose breathers for 4-6 weeks of life (except when crying)
What is a normal temperature in a newborn?
97.7 F to 99.5 F
Lecture: 97.8 - 99.8 F
What is the normal axillary temperature in a newborn?
97.7 F to 99.8 F
How do you assess for respiratory distress?
- First, pulse ox (see if above or below 90%)
- Check warmth (cold stress will cause exacerbations)
Interventions for respiratory distress
- Free flow of oxygen is available to assist in the infant’s transition
- Warm them up
Interventions for fluid in the lungs of an infant
- Stimulate their back (rub-makes them cry and get the fluid out or resolves RR distress issues)
- Suction secretions with bulb or suction catheter
Assessment of cardiorespiratory status includes
- Assess and maintain airway
- Heart rate and rhythm: evaluate murmur (location, timing, duration)
- Examine appearance of size of chest
- Note if there is a funnel chest, barrel chest, or unequal chest expansion
- Assess breath sounds and respiratory efforts
- Evaluate color for pallor or cyanosis
The apical pulse should be counted for
One full minute
How often should the infant heart rate be assessed?
- Once every 30 minutes until the infant is stable for 2 hours after birth.
- Once stable: once every 8 hours according to hospital policy unless a reason for more frequent assessment develops.
Where is the point of maximum impulse found in an infant?
3-4 intercostal space, midclavicular line
What are conditions that affect the position of the heart?
Pneumothorax
Dextrocardia (right to left reversal from normal heart position)
Heart rhythm in infants
- Rhythm should be regular and first and second heart sounds heard clearly.
- Abnormalities should be noted.
Murmurs in infants
- May indicate openings in the septum of the heart or problems with blood flow through the valves.
- Most murmurs are temporary.
A murmur is common until what happens?
The ductus arteriosus is functionally close.
Brachial and femoral pulses in infants
Should be present and equal bilaterally and rates should be the same.
Femoral pulses that are weaker than brachial pulses may result from
-Impaired blood flow in coarctation of the aorta. (A narrowed area of the aorta impedes blood flow to the lower part of the body and causes weaker pulses in the lower extremities)
What systolic BP may indicate a coarction of the aorta?
A systolic BP >20 mm hg higher than lower extremities may indicate a coarction of the aorta.
Blood Pressure in a newborn
Not a necessary part of a routine assessment of the newborn.
An average blood pressure for full term newborns is
65 to 95 mm Hg systolic
30 to 60 mm Hg diastolic
When is blood pressure taken in a newborn?
BP is taken on all extremities if the infant has unequal pulse rates, murmurs or other signs of cardiac complications
What should be done to obtain an accurate blood pressure measurement in an infant?
- Use of Doppler ultrasonography or other electronic measurement techniques
- Infant should be quiet when BP is taken (crying elevates BP)
- Width of BP cuff should cover the upper arm and leg without encroaching on the joints.
How much does BP in an infant rise in the first 3-8 days?
1 to 3 mm Hg daily
How much does BP in an infant rise in the first 5-7 weeks?
1 mg Hg weekly
When does an infants blood pressure reach a value that will remain stable for the first year?
2 months
Blood pressure of the lower extremities should be what in relation to the upper extremities?
Should the same of slightly higher than that of the upper extremities.
Capillary Refill in infants
- Should be less than 2-3 seconds. (Book says 3-4 seconds)
- Checked by depressing the skin over the chest, abdomen or extremity until the area blanches.
What route is used for the first temperature measurement in an infant?
Rectal route. (Axillary is preferred afterward)
Temperature instability in an infant often indicates what?
Infection
When is the neonates temperature taken?
-Soon after birth while infant is being held by mother or is in a radiant warmer with a skin probe attached to the abdomen.
Skin Probe
- Should not be attached over bony prominences.
- Allows the warmer to measure and sip lay infants skin temperature continuously.
How often should an infants temperature be taken?
- Should be assessed at least once every 30 minutes until the infant is stable for 2 hours after birth.
- Often checked again at 4 hours and then once every 8 hours or according to facility policy as long as it remains stable.
Why should a thermometer never be forced into the rectum?
Because of the possible presence of an imperforate anus (closed anus)
The normal rectal temperature in a newborn is
36.5 C - 37.7 C (97.7 to 99.8 F)
Asymmetry of the head of a newborn can be caused by
- Molding
- Type of birth
- Cephalhematoma
Molding
Changes in the shape of the head to allow it to pass through the birth canal.
What causes molding?
- It is caused by overriding of the cranial bones at the sutures. (The parietal bones often override the occipital and frontal bones and a ridge can be felt at those areas)
- Is common, especially after a long second stage of labor.
How long does it take for molding to resolve?
- Resolves within a few days to 1 week after birth **
- Often, dramatic improvement is seen by the end of the first day of life.
What is the usual shape of the head of an infant born via c-section?
Round
What is the usual shape of the head of an infant born via vaginal birth?
Molding
What is the usual shape of the head of an infant born via breech position?
Flat head
Newborn Head Assessment: Hair
- Hair should be fine with a consistent pattern.
- Abnormal hair growth patterns may indicate genetic abnormalities.
A newborn head assessment includes:
- Shape
- Hair
- Fontanels
- Sutures
What would indicate that a fetal monitor electrode was inserted into the skin of the scalp?
- A small, red mark.
- Later,a small scab forms (this area occasionally becomes infected and topical antibiotic is applied)
Newborn Head Assessment: Sutures
All sutures should be palpated.
What can cause a separation of the sutures in a newborn?
- May be a temporary result of molding.
- If it persists or widens, may indicate increased intracranial pressure.
What can cause no space to be found between suture lines in a newborn?
-May be a result of molding and overriding bones.
Craniosynostosis
Define + it may impair brain growth and the shape of the head and requires surgery
A hard, ridged area not resulting from molding may indicate
Premature closure of sutures called craniosynostosis.
Fontanels
Areas of the head where sutures between the bones meet.
Fontanels in a newborn
- Areas are not calcified but are covered by membrane.
- This allows space for the brain to grow
Newborn Assessment of the Head: Fontanels
Palpate and note the position in relation to other bones in the skull
Palpation of the Fontanel Procedure
- Infants head is elevated during palpation for accurate assessment
- Infant may be placed in a semi sitting position or held in an upright position
- Fontanel should be palpated when the infant is quiet, because crying may cause it to protrude.
The anterior fontanel
Is a diamond-shaped area where the frontal and parietal bones meet*
Assessment of the eyes
- Examined for abnormalities and signs of inflammation.
- Eyes should be symmetric and same size.
- Sclera
- Conjuctiva
- Eye color
- Pupils
- Tearing
- Visual acuity
- Response to visual stimuli
Slanting of epicanthal folds in a non-Asian infant may be a sign of what?
Down syndrome or other abnormal conditions
How can pressure on the head during birth affect the eyes?
- Causes capillary rupture in the sclera -> edema of the eyelids and subconjunctival hemorrhage’s (reddened areas of the sclera)
- Edema usually resolves in a few days; hemorrhage resolves in a week.
What color should the sclera be in a newborn?
White or bluish white