Chapter 21: Care Of The Normal Newborn Flashcards
APGAR Score
Method for rapid evaluation of the infant’s cardiorepsiratory adaptation after birth
What does APGAR stand for?
A - Appearance (color) P - Pulse (HR) G - Grimace (reflex response) A - Activity (muscle tone) R - Respirations (respiratory effort)
What is a normal APGAR score?
8-10
An APGAR score of < 7 indicates
Need to watch out for neurological damage.
Watch baby closely.
How is an APGAR score obtained?
- Nurse scores an infant at 1 minute and 5 minutes in each of the five areas.
- Assessments are arranged from most important to least
- Infants are assigned a score of 0-2 in each of the five areas and the scores are totaled.
Resuscitation should NOT be delayed until
The 1 minute score is obtained.
General guidelines for infant’s care is based on 3 ranges of 1 minute scores:
- 0-2
- 3-6
- 7-10
Vitamin K (Phytonadione): Indication
Given to neonates because they receive only small amounts of the vitamin from the mother and cannot synthesize vitamin K in the intestines without bacteria.
What is the action of vitamin K?
Promotes the formation of clotting factors by the liver (II, VII, IX, X)
What is the usual dose of vitamin K?
0.5 to 1 mg
IM, usually within 1 hour after birth.
What are adverse effects of Vitamin K?
- Erythema, pain and edema at injection site.
- Anaphylaxis, hemolysis and hyperbilirubinemia
Nursing Considerations for Vitamin K:
- Protect the drug from light until just before administration
- Observe all infants for signs of Vitamin K deficiency (ecchymoses or bleeding from any site)
- Check that the infant had Vitamin K before a circumcision is performed.
Erythromycin Opthalmic Ointment: Indications
Prophylaxis against organisms Neisseria gonorrhoeae and clamydia trachomatis.
Erythromycin Ophthalmic Ointment helps prevent:
- ophthalmia neonatorum in infants of mothers infected with gonorrhea
- conjunctivitis in infants of mothers infected with chlamydia
Prophylaxis against gonorrhea
Is required by law for all infants, even if the mother is not known to be infected.
Normal Dosage and Route of Erythromycin Ophthalmic Ointment
- A ribbon of ointment (~1 cm long)
- Applied to lower conjuctival sac of each eye within 1 hour after birth.
What are adverse reaction of Erythromycin Ophthalmic Ointment?
- Burning, itching
- Irritation may result in chemical conjunctivitis lasting 24-48 hours
- May cause temporary blurred vision.
Nursing Considerations for application of Erythromycin Ophthalmic Ointment
- Cleanse infant’s eyes as need before application.
- Hold tube horizontal rather than vertical to prevent injury to eye from sudden movement
- Administer from inner to outer canthus
- Do not touch tip of tube to any part of the eye (may spread infectious material from one eye to another)
- Do not rinse. Ointment may be wiped from outer eye after 1 minute.
If any discharge from the eyes, especially purulent, is noted, this should alert the nurse to
A possibility of infection. (Culture may be ordered and drainage should be removed with sterile saline and cotton ball)
Erythromycin Ophthalmic Ointment can be delay until
The end of the first hour after birth without adverse effects.
Hepatitis B Vaccine: Indications
- Prevents hep B in exposed and unexposed infants
- Provides immunization against hep B infection
Hep B Vaccine: Dosage and Route
-5mcg (recombivax HB)
-10 mcg (energix-B):
1st dose: before discharge
2nd dose: age 1-2 months
3rd dose: 6-18 months
What are contraindications to Hep B vaccinations?
Hypersensitivity to yeast
What are adverse reactions to Hep B?
Pain or redness at site
Fever
Fatigue
Headache
Nursing Considerations for administration of Hep B Vaccine
- If used vial, shake well before preparing.
- Give vaccine within 12 hours of birth to infants of infected moms
- Parenteral administration NOT IV or intradermally (need to obtain parental consent)
Administration of Injections in Newborn: Preparation
- Wash infants thigh if the bath has not been given yet.
- Use a 1 mL syringe and a 5/8 inch, 25 gauge needle.
- Use filter if drawing medication from glass ampule.
Administration of Medication in Newborns: Injection
- Cleanse area with alcohol wipe.
- Stabilize leg firmly while grasping thigh between the thumb and fingers.
- Insert needle at 90 degree angle
- Withdraw the needle and apply gentle pressure to the site with an alcohol wipe.
Where is the best site for injection in newborns?
- Vastus lateralis muscle.
- Divide area between the greater trochanter of the femur and the knee into thirds.
- Give the injection in the middle third of the muscle, lateral to the midline of the anterior thigh.
Monitoring Safe Glucose Levels
Assess all newborns for risk factors associated with decrease blood glucose levels.
A newborns temperature should be assessed PRIOR to **
Accucheck
Blood glucose levels should be noted it they are at what levels?
< 40-45 mg/dL
Interventions for Hypoglycemia
- Feed the newborn if glucose screening shows a level of <40-45 mg/dl to prevent further depletion of glucose.
- Infants with severe hypoglycemia may need IV feedings to provide glucose rapidly. (For most infants, breastfeeding or giving formula is sufficient)
For hypoglycemia, agency protocols usually allow the nurse to
Intervene for hypoglycemia and then notify the physician of the infant’s response.
Planning for hypoglycemia revolves around the nurses role including:
- ) assess for signs of hypoglycemia
- ) Notify physician about signs of hypoglycemia or follow hospital protocol for infant’s with signs of hypoglycemia and then notify physician
- ) Intervening to minimize hypoglycemia.
Why is glucose-water alone not recommended for newborns?
Increases glucose level = increases insulin production = decrease glucose level.
What can provide a longer-lasting supply of glucose?
Milk
If infants do not have enough glucose, what can happen?
They may experience a drop in temperature -> respiratory distress as oxygen is needed for NST
Hearing Screening
- Is done on every baby.
- Auditory screening is performed within the first month.
- Most common congenital abnormality.
Infants who don’t pass the screening should be
-Re-screened.
If they still don’t pass -> audiologic and medical evaluation no later than 3 months of age
What is the goal of healthy people 2020 for hearing screenings?
- Newborns screened for hearing impairment: by age 1 month
- Audiologic evaluation by 3 months of age
- Enrolled in appropriate intervention services by 6 months of age
Types of Hearing Tests include:
- Otoacoustic emissions test
- Acoustic brainstem response test (can be done during sleep)
Screening Tests
- Easy and inexpensive
- Requires a blood sample taken from infant’s heel (only one is needed for all tests)
When are screening tests performed on infants?
24-48 hours after birth.
Further testing is done to confirm any abnormal results.
What is the difference between tests done within the first 24 hours of life than those performed after 24 hours of life?
Tests done within first 24 hrs of life are less sensitive than those performed after 24 hrs of life.
Infants tested before age 12-24 hours should have repeat tests at what ages?
1-2 weeks
PKU
Genetic condition in which the infant cannot metabolize amino acid phenylalanine (common protein foods such as milk).
Accumulation of amino acid phenylalanine can lead to
Severe intellectual disability
Treatment for PKU should be started when?
by the third week of life.
What is used to treat PKU?
Special low-phenylalanine diet
How often are complete assessments of newborns done?
Q8hrs or according to hospital policy
How often are infants weighed?
Once daily.
Gain or loss is documented.
Assessment of the skin of an infant
- Assess for new marks or changes in old ones
- Marks on scalp may not be obvious if covered by abundant hair
- Assess skin turgor
What is used to determine when to bathe the infant?
A temperature of 98 degrees F (36.7 C) or higher is often used to determine when to bathe the infant.
What is the benefit of early bathing of an infant?
Early bathing decreases exposure to maternal blood and possible blood borne organisms on the infant’s skin. (i.e hepatitis B or HIV)
The bath should be given before
The performance of any invasive procedures such as injections or heel sticks that might draw organisms on the skin into the infant’s SQ tissue or bloodstream.
What is the benefit of tub bathing versus sponge bathing?
Infants maintain their temperatures better during tub bathing than during sponge bathing.
Tub Bathing
- In order to keep the infant warm, they should be immersed in water that covers their shoulders.
- Water temperature should be approximately 38 degrees C (100.4 F)
Sponge Bath
- Can be done with infant under the radiant warmer to help maintain infant’s temperature.
- Should be performed quickly and the infant thoroughly dried to prevent heat loss by evaporation.
After bath procedures
- Combing infant hair during bath to remove blood and after bath to hasten drying of the hair.
- Infant is dried thoroughly.
- Infant remains under radiant warmer until hair is dry and temperature returns to previous level.
- Infant is dressed and wrapped in two warm blankets and a cap is placed on head before he or she is removed from radiant warmer.
- The temperature is rechecked within 1 hour to ensure the infant is maintaining thermoregulation adequately**
Diaper Rash can be caused by
Frequent stools
Infrequent changing of diaper
Prolonged exposure to diarrhea/urine
What is used for cleaning the diaper area?
Plain water or mild soap solutions may be used for cleaning the diaper area.
If commercial diaper wipes are used, they should be
Detergent free and alcohol free
Breast feeding needs to occur how often?
2-3 hours
How often does a baby need to be fed if they are drinking formula?
3-4 hours
Characteristics of the anterior fontanel
- 4-5 cm from bone to bone (although this varies d/t molding and individual differences)
- should be flat (level with surrounding bones) or only slightly sunken
- should feel soft
When does the anterior fontanel close?
By 18 months of age.
Abnormal findings of anterior fontanel
- bulging at rest
- depressed
What can cause bulging of the anterior fontanel in newborns?
May indicate increased intracranial pressure
What can cause a depressed fontanel in a newborn?
- Molding
- After molding resolves, can be a sign of dehydration.
The posterior fontanel
A triangular area where the occipital and parietal bones meet.
Characteristics of the posterior fontanel
- Smaller than anterior fontanel, measuring 0.5-1 cm
- Feels like a dimple at the juncture of occipital and parietal bones
When does the posterior fontanel close in a newborn?
2-4 months of age
What may complicate identification of the posterior fontanel?
Molding because it causes overlapping bones to impinge on that space
Caput Succedaneum
Is a collection of fluid, edematous swelling of the scalp.
What causes caput succedaneum?
- Often appears over the vertex of the newborn’s head as a result of pressure against the mother’s cervix during labor.
- This pressure interferes with blood flow from the area, causing localized edema at birth.
- May also occur when a vacuum extractor is used to hasten second-stage labor.
Characteristics of Caput Succedaneum
- Edematous area crosses suture lines
- Is soft
- Varies in size
- Present at birth or shortly thereafter
When does caput succedaneum resolve?
Resolves quickly and generally disappears within 12-48 hours**
Cephalhematoma
Bleeding between the periosteum and the skull as a result of pressure during birth.
Characteristics of Cephalhematomas
- Occurs on one or both sides of the head over the parietal bones or occasionally over the occipital bones.
- Swelling may not be present at birth but may develop within the first 24-48 hours.
- Does not cross suture lines
- Does not increase in size with crying
How long does it take for a cephalhematoma to resolve?
Reabsorbs slowly and may take 2-3 months to completely resolve.
Cephalhematoma increases the risk for
Jaundice d/t breakdown of RBCs within the hematoma and bruising.
Both caput succedaneum and cephalhematoma may be frightening to parents. Therefore, the nurse should
Reassure parents that the conditions are not harmful to the infant.
Newborn Assessment: Face
Should be examined for:
- Symmetry
- Facial features
- Movement
- Expression
Transient Asymmetry of the face
Can be a used by intrauterine pressure.
Lasts a few weeks or months.
Drooping of the mouth in an newborn
- Appears as a one-sided cry.
- May be caused by facial nerve trauma.
Infections in a newborn can be indicated by what signs?
Instead of a fever, the infant’s temperature may decrease.
The infant may feed poorly, be lethargic, or have periods of apnea without obvious cause.
Average number of stools in bottle fed neonates
@ least 1 stool/day
Average number of stools in breast fed neonates
@ least 4 stools per day
What temperatures should baths be for newborns?
100-104 degrees F
When does the umbilical cord fall off?
With in 10-14 days
The umbilical cord turns black within
2-3 days
Yellow scab or crust after circumcision
Expect a yellow crust or scab to form over the circumcision site.
This is a normal part of healing and should not be removed.
The scab will fall off within 7 to 10 days
Signs of complications of circumcision include the following:
- Bleeding more than a few drops with first diaper changes
- Failure to urinate
- Signs of infection: fever or low temperature, purulent or foul-smelling drainage
- Displacement of the PlastiBell ring
Parents of uncircumcised infants should be taught
not to retract the foreskin until it becomes separated from the glans later in childhood.
Risks of circumcision include
- hemorrhage
- infection
- unsatisfactory cosmetic effect
- urinary retention
- urethral stenosis or fistulas
- adhesions
- necrosis
- injury to the glans
- pain during and after surgery.
Nonpharmacologic pain relief methods during and after the circumcision include
pacifiers, oral sucrose, soothing music, recordings of intrauterine sounds, decreased lights, and talking softly to the infant.
The nurse is preparing a newborn for a circumcision. Which pharmacological interventions should the nurse implement to alleviate pain?
Acetaminophen may be given throughout the first day for postprocedure pain. EMLA cream (eutectic mixture of local anesthetics) may be applied to anesthetize the skin before the procedure.
