Exam 4 - Neonatal Assessment and Hospital Discharge (sync) Flashcards
Why do we give eye prophylaxis to newborns? Within how many hours are drops given?
Tetracycline or erythromycin drops given to prevent chlamydia or gonorrhea conjunctivitis that can be transmitted via birth canal
Given within first hour of life
Does vitamin K cross the placenta?
No, not readily available in breastmilk/formula
How long is one shot of vitamin K good for?
Single injection provides enough vitamin K to last until the newborn gets sufficient amounts from solid foods (around 6 months of age)
When should a newborn receive their first shot of hep B?
Within first 24 hours
What are the guidelines for hep B vaccine if the infant is born to a hep B NEG mother? What if the infant is <2000 g?
Administer to infants weighing >2000 g in first 24 hours
If <2000 g, administer at 1 month or at hospital discharge
What are the guidelines for hep B vaccine if the infant is born to a hep B POS mother?
Administer hep B vaccine within first 24 hours regardless of weight AND give hep B immunoglobulin
What five screenings should be done before the newborn can be discharged?
- Glucose screen
- Jaundice screen
- Hearing screen
- Newborn metabolic screen
- Congenital heart disease screen
How would the provider perform a newborn metabolic disorder screening?
Simple heel stick between 24-48 hours after birth
Air dry for 4 hours then sent to states lab
- Takes 10-14 days for results
What factors can influence newborn metabolic disorder results?
- Samples obtained too early
- On antibiotics
- Blood transfusion
- Stress or sick infant (CAH)
- Failure to wipe away first drop of blood
- Not enough feeding
- Inadequate sample
Under what conditions will the provider institute immediate treatment for based on newborn metabolid disorder screening results?
- Galactosemia
- Maple syrup urine disease (MSUD)
No treatment for any other positive results until further testing confirms diagnosis
Do glucose levels increase or decrease withint the first hour after birth? What are currently guidelines for intervention based on glucose levels?
Levels DROP within first hour
What maternal situations would cause the provider to monitor glucose levels closely?
- Gestational diabetes –> increased insulin levels at birth
- Preeclampsia/HTN
- Previous macrosomic infant
- Substance abuse
- Exposure to medications (tocolytics, glucose)
What neonate situations would cause the provider to monitor glucose levels closely?
- Prematurity/IUGR
- HIE event
- Sepsis
- Congenital cardiac, endocrine, inborn errors of metabolism disorders
Signs and symptoms of hypoglycemia in neonate
- Irritability
- Tremors
- Lethargy
- Changes in LOC
- Seizures
- Hypotonia
- Feeding difficulty
- Respiratory distress
- High pitched cry
At what point are newborns screened for hyperbilirubinemia?
Prior to hospital discharge
- If discharged sooner than 72 hours, done in primary care
Hearing screening: otoacoustic emission test (OAE)
Measures sound waves produced in inner ear
- Soft probe placed in ear canal
- Series of soft “clicking” sounds sent via computer and probe
- Measures echo of sound back
Hearing screening: automated auditory brainstem response (AABR)
Measures how the acoustic nerve and brain respond to sound
- Tones played through headphones
- Electrodes measure brains response to sound
What is the goal of a newborn hearing screening?
Screen by 1 month
Identify deficit by 3 months
Be receiving services and/or treatment by 6 months of age
What is the pattern of bloodflow in the fetus prior to birth?
- From the placenta, oxygenated blood travels through umbilical vein to IVC
- Bypasses the liver (ductus venosus)
- From IVC, oxygenated blood enters R atrium + mixes with deoxygenated blood
- Passes through foramen ovale to L atrium
- L atrium to L ventricle –> goes to aorta and upper body
- Upper body to SVC –> returns to R atrium + mixes with oxygenated blood
- R atrium to R ventricle
- Blood goes to lower body via ductus arteriosus
How does blood flow change at birth for the neonate?
First breath and air entering the alveoli triggers a drop in SVR –> rapid increase in perfusion of lungs d/t increased pressure of L ventricle
- At same time, cord clamping occurs –> vasoconstriction and rise in SVR
What three events must occur to cause increased systemic vascular resistance and decreased pulmonary vascular resistance?
- Increased pressure in L atrium
- Increased PO2
- Decreasing levels of prostaglandins
Although the three major fetal shunts close with the newborns first breath, what causes the ductus arteriosus to open?
Can remain open
- Most commonly in premature neonates or neonates with other cardiac anomalies
Can the foramen ovale reopen at any time?
Yes, until 6 months of age before cells seal shunt closed
Are murmurs common in newborns?
Yes, newborn is still transitioning while at hospital
However, some cardiac anomalies won’t become evident until transition is complete and the newborn is home
What five topics/assessments should be completed by the provider prior to newborn discharge?
- Stable vital signs
- Temp - 36.5-37.4 C
- RR <60
- No signs of distress
- HR 70-100 bpm
- Established feedings - 2+ feedings
- Established elimination pattern - at least 1 void and 1 stool
- Screening and therapies completed
- Parent education completed
What is the APGAR screen?
Tool used as a rapid and standardized method of assessing the clinical status of a newborn immediately after birth
At what time intervals is a APGAR screen completed?
Conducted at 1 and 5 minutes after birth
- Continue at 5 minute intervals for first 20 minutes if score is under 7
What does the acronym APGAR stand for (what does it test for)?
- A - appearance (color)
- P - pulse (HR)
- G - grimace (reflex irritability/response)
- A - activity (muscle tone)
- R - respiration (breathing ability)
What are the ranges of scores for APGAR?
- Critically low - 0-3
- Below normal - 4-6
- Normal - 7-10
What are limitations associated with APGAR scores?
- Influenced by maternal sedation/anesthesia, congenital conditions, gestational age, trauma
- Subjectivity of score by clinician
- Cannot be used to predict morbidity or mortality of neonate
Which vessel (umbilical vein or artery) carries oxygenated blood? Deoxygenated blood?
Umbilical vein = oxygenated blood (from placenta to fetus)
Umbilical artery = deoxygenated blood (from fetus to placenta)
Normal newborn vital signs
- Temperature - 97.7 - 99.0 F
- HR - 80-180 bpm
- RR - 30-60
- BP - not routinely done in primary care unless there is concern
- Pain - FLACC
When should the WHO growth chart be used versus the CDC growth chart (at what ages)?
WHO growth chart - birth to 2 years old
- Correct for prematurity through 2 years of age
CDC growth chart - 2-18 years old
What is the average head circumference of a newborn?
12-15 inches (32-38 cm)
What is the average weight and length of a newborn?
Weight (full term): 5 lb 8 oz - 8 lb 13 oz
Length: 18-22 inches (45-54 cm)
What are the four components of a newborn cardiac exam?
- Auscultate all five areas: aortic, pulmonic, Erb’s, tricuspid, mitral + axilla, right sternal border, and back
- Listen for normal S1, S2
- Rule out murmurs or prescence of S3, S4
- Palpate for heaves/lifts/thrills
- Assess perfusion - skin color, temperature
- Pulses - symmetry, quality, presence
What is the most common innocent heart murmur in neworns?
Still’s murmur - vibratory, musical in nature
- Heard along left sternal border
- Louder when supine
What would be signs of a pathologic murmur (red flags)?
- Holocystolic
- Diastolic
- Grade 3+
- Harsh
What would a PDA murmur sound like?
Continuous, machine-like murmur
- Heard at upper left sternal border
What would a ASD murmur sound like?
Grade 2 or 3 systolic ejection murmur
- Heard at upper left sternal border
- Split S2
What would a VSD murmur sound like?
Harsh holosystolic
- Heard at lower left sternal border
- Can sometimes palpate a thrill
What should be assessed during a newborn respiratory assessment?
- Observe rise/fall of chest
- Inspect AP ratio - should be 1:1
- Count respirations for full minute
- Observe for signs of distress
- Nasal flaring
- Retractions or use of accessory muscles
- Grunting/noisy breathing
- Auscultate lung sounds
When observing the newborns skin, what conditions would be considered normal findings?
- Acrocyanosis vs mottling
- Erythema toxicum
- Milia
- Neonatal acne
- “Birth marks” - nevus simplex, mongolian spots, port wine stain
What two common skin findings would require further investigation depending on size, location, and overall number?
- Hemangioma
- Cafe au lait spots
What two skin conditions would raise concern and require immediate referral for workup?
- Petechiae
- Vesicular rash
If petechiae are present, where would it normally present? When does it resolve? What is it associated with?
- Normal on presenting parts –> won’t develop new sites
- Resolves within 24-48 hours
- Can be associated with infections
- Rule out sepsis and TORCH infections
How do vesicular rashes present on a newborn? What would treatment be? What organisms cause this?
- HSV and varicella can present with clustered vesicles a few days after birth
- Treatment: IV acyclovir
- Causative organisms: staph, strep
What can cause microcephaly?
- CNS malformation
- Infection
- Genetic syndrome
What can cause macrocephaly?
- CNS disorder
- Brain tumor
- Hydrocephalus
- Hereditary
What are characteristics of caput succedaneum (scalp edema)?
- Crosses suture lines
- Usually pitting
- Resolves in 48 hours
What are characteristics of cephalohematoma (subperiosteal hemorrhage)?
- Due to injury of blood vessels during delivery (e.g. forceps, vacuum)
- Does NOT cross suture lines
- Can get worse before it gets better
- Takes about 3-4 months to reabsorb
What two conditions would having a cephalohematoma put the newborn at risk for?
- Jaundice
- Sepsis
What is the most important finding that should be noted during the newborn eye exam?
Red reflex - light should project on both eyes simultaneously
- Symmetry without opacities or light/dark spots
- Rule out corneal lesions/cataracts
-
Having a light spot can indicate retinoblastoma
- Refer out
Are infants obligate mouth or nose breathers?
Nose breathers - assess for any blockage because that would put the infant in respiratory distress (e.g. choanal atresia)
When does the infants umbilical cord normally fall off?
Falls off in 7-10 days
Do inguinal hernias require treatment if present in the newborn?
Requires surgical repair
Do hydroceles require treatment if present on exam?
Due to fluid in inguinal canal - transilluminates
- Resolves within first 1-2 years
What should the provider do if they palpate bilateral undescended testes, micropenis, or bifid scrotum in the newborn?
Requires prompt evaluation for ambiguous genitalia
What is cryptorchidism? What does this put the newborn at risk for? Does it resolve on its own?
Failure of tests to descend
- Associated with increased risk of testicular cancers and reduced fertility
- Should descend by 3-6 months
- Consider orchiopexy if not descended by 1 year old
What are the anatomical differences in female genitalia between term and preterm infants?
Term infants - prominent labia majora
Preterm infants - prominent labia minora and clitoris
Is discharge or blood normal in the newborn?
Small amounts of white discharge or blood within the first 3-4 days is normal
- Due to maternal estrogen withdrawal
While assessing for the patecy of the hymen in infants, would anatomical conditions would cause the provider to refer out for prompt evaluation?
Fused labia or clitoromegaly
- Needs prompt evaluation for ambiguous genitalia
When considering the neck of a newborn, what condition is a common musculoskeletal finding? What are potential complications with this condition?
Torticollis
- Due to birth trauma of sternocleidomastoid
- Requires referral to PT - can lead to plagiocephaly and ear misalignment
What test could the provider use to detect clavicle fractures?
Moro reflex - reaction will be non symmetric
What is the difference between the barlow and ortolani test?
Barlow - “dislocate”
- ADDuction and forward motion towards the bed
Ortolani - “relocate”
- Move hips outward to ABduction
When the provider is observing a baby crying, what cranial nerves are being assessed?
- CN VII (facial)
- CN IX (glossopharyngeal)
- CN X (vagus)
When the provider is observing a baby feeding, what cranial nerves are being assessed?
- CN V (trigeminal)
- CN VII (facial)
- CN IX (glossopharyngeal)
- CN X (vagus)
When the provider is observing a babies eye movements, what cranial nerves are being assessed?
- CN III (oculomotor)
- CN IV (trochlear)
- CN VI (abducens)
Assessed by vestibulo-ocular reflex (doll’s eyes maneuver) - when the head is turned, there is conjugate eye movement in the opposite direction
When the provider is observing a babies response to light AND sound, what cranial nerves are being assessed?
- Response to light - CN II (optic)
- Sound - CN VIII (vestibulocochlear)
When is the moro reflex present?
2-4 months
When is the sucking reflex present?
2-3 months
When is the rooting reflex present?
By 4 months
When is the stepping reflex present?
4 months
When is the tonic neck reflex present?
By 6 months
When is the grasping reflex present?
5-6 months
How does the babinski reflex differ between adults and infants?
The babinski reflex occurs after the sole of the foot has been firmly stroked –> big toe will move upward or toward the top surface of the foot
What is the normal schedule of well child visits?
- 3-5 days
- 1 month
- 2 months
- 4 months
- 6 months
- 9 months
- 12 months
- 15 months
- 18 months
- 24 months
- 30 months
- 3 years
- 4 yeasrs
- Once every year thereafter
