Final Study Flashcards
What are the 2 broad goals of nursing care when providing care for the newborn?
To promote the physical well-being of the newborn (assessing and stabilizing)
To support the establishment of a well-functioning family unit
What does essential newborn care include according to the WHO?
Immediate care at birth
- delayed cord clamping
- thorough drying
- assessment of breathing
- skin-to-skin contact
- early initiation of breastfeeding
Thermal care
Resuscitation when needed
Generally, how long after birth is the cord cut?
Approximately 30 seconds after birth
In the delivery room, where is the umbilical cord clamped and cut?
Clamped twice about 8 inches from the abdomen and then cut in between
In the nursery room, where is the umbilical cord clamped and cut?
1/2 to 1 inch from the abdomen and the cord is cut between them
How many times is the cord cut?
Twice
First is within 30 seconds after birth about 8 inches from the abdomen
Second is in the nursery a while later about 1/2-1 inch from the abdomen
How is the cord cleaned with the initial cleaning?
With antiseptic solution however the manner of cord care depends on hospital protocol
When is the cord clamp usually removed from the newborn?
After 48 hours when the cord has dried
About how long after birth does the cord stump usually dry and fall off?
What is the healing process?
In 2-3 days, the cord begins to shrivel and blacken
Within 7 to 10 days the stump falls off; although another part said average time is 10-14 days; apparently it can take up to 3 weeks for it to occur
Some dried blood may be seen in the umbilicus at separation
Leaves a granulating area that heals over the next 7 to 10 days
What instructions should the mother receive about providing cord care for her newborn?
MEMORY - new babies are spicy like WASABI
W - wet should be avoided
Avoid wetting the cord. Fold diaper below so that it does not cover the cord and does not get wet when the diaper soaks with urine. See to it that cord does not get wet by water or urine.
A - Apply nothing
Do notapplyanything on the cord such as baby powder or antibiotic, except the prescribed antiseptic solution which is 70% alcohol. It can be cleaned with just plain water and a q-tip. This varies depending on hospital policy
S - Sponge baths and tub baths
Just remember to completely dry the cord after and maintain their body temperature during the bathing process
A - Air exposure
Leave cord exposed to air. Do notapplydressing or abdominal binder over it but you can place loose clothing over it. The cord dries and separates more rapidly if it is exposed to air.
B - Bleeding
If you notice the cord to be bleeding,applyfirm pressure and check cord clamp if loose and fasten.
I - Infection
Report any unusual signs and symptoms which indicates infection
What can the mother put on the cord to keep it clean?
Nothing except the prescribed antiseptic solution
When can mom give the baby a tub bath?
Optimal timing for the first bath is individual according to the newborns ability to maintain a stable body temperature, which can often take 8 hours or more
Some hospitals may delay it for 24 hours, meaning the baby may be discharged before this time
Why should the mom fold the diaper under the cord?
It prevents the diaper from overing the cord risking it from getting wet when the diaper is soaked in urine
How can mom encourage the cord to fall off?
Leave it exposed to air, do not apply any dressing or abdominal binder over it. The cored dries and separates more rapidly if it is exposed to air.
What should the mother do if she notices bleeding from the cord?
Apply firm pressure and check the cord clamp to see if its loose and fasten it.
What signs of infection should the parents be evaluating the umbilical stump for?
MEMORY: we HOPED for no infection
H - hyperthermia
O - odour that is foul in the cord
P - presence of discharge
E - erythema
D - Does not fall off within 7-10 and remains wet
Why do we dry the newborn infant with vigorous rubbing?
removes moisture to prevent evaporative heat loss and provides tactile stimulation to stimulate respiratory effort
What is the primary goal in the first moments of life?
Establish effective respirations
What are the initial steps to care for a newborn infant?
Dry the infant
Wipe mouth and nose of secretions
Suction secretions from mouth and nose
Stimulate the baby to cry
How do you suction the secretions from the mouth and nose of a newborn?
- Bulb syringe, squeeze before inserting
- Suction mouth first, then, the nose
- Insert bulb syringe in one side of the mouth
How do we stimulate the newborn baby to cry?
After secretions are removed from the airway, vigorously rub the baby.
Do not slap the buttocks, but you can rub the soles of the feet.
What is a normal cry for a newborn infant?
Loud and husky
What are abnormal cries for a newborn infant and what do each mean?
High pitched - hypoglycemia or increased ICP
Weak - prematurity
Hoarse - laryngeal stridor
What cry may indicate hypoglycemia?
High pitched
What cry is an abnormal but expected finding in premature babies?
weak cry
Describe skin to skin care of the newborn?
Place the baby in an upright position on the mother or partner’s chest with no clothing or blankets placed between the infant and the parent.
Skin to skin care is facilitated immediately after birth and should be uninterrupted for the first 1-2 hours, unless mom or baby needs special medical attention.
Frequent skin to skin care is encouraged in the early days of baby’s life.
What should be facilitated immediately after birth unless there are medical necessities that preclude it?
Skin to skin care
What are the benefits of skin to skin care?
MEMORY: skin to skin helps babies be hungry as VAMPIRES
V - vital signs in the newborn stabilize
A - Allows mom and baby to learn each other through senses
M - Milk supply is stronger
P - promotes bonding and breastfeeding
I - Immune and digestive systems are stronger
R - reduces bleeding in postpartum moms
E - encourages the baby to spend more time in deep sleep and quiet alert states
S - stress reduction for baby and parents
What vital signs in the newborn can be stabilized with skin to skin care?
body temperature, heartbeat, breathing and blood oxygen levels
What does the APGAR score measure?
A - Activity (muscle tone)
P - Pulse
G - Grimace (reflex irritability)
A - Appearance (skin colour)
R - Respiration
When is the APGAR performed?
1 minute and 5 minutes after birth
Repeat scoring every 5 minutes as needed for depressed infants
The ______ APGAR score indicates the necessity for resuscitation
1 minute
The ______ APGAR score is more reliable in predicting mortality and neurologic deficits
5 minutes
What is the order of importance for the APGAR score?
MEMORY: Persistent Repetition Always Gains Confidence
Pulse
Respiration
Activity (muscle tone)
Grimace (reflex irritability)
Colour (appearance)
What is the term the instructor uses for activity in the APGAR score?
Muscle tone
What is the term the instructor uses for grimace in the APGAR score?
reflex irritability
What are the points awarded for activity (muscle tone) in the APGAR score?
0 - absent, limp, flaccid
1 - some flexion, limited resistance to extension
2 - active movement, tight flexion
What are the points awarded for pulse in the APGAR score?
0 - absent
1 - < 100 bpm
2 - > 100 bpm
What are the points awarded for grimace (reflex irritability) in the APGAR score?
0 - floppy, no response
1 - minimal response to stimulation (grimace)
2 - prompt response to stimulation, vigorous crying
What are the points awarded for appearance (skin colour) in the APGAR score?
0 - blue/pale
1 - pink body, blue extremities
2 - pink
What are the points awarded for respiration in the APGAR score?
0 - absent
1 - slow and irregular; weak cry
2 - vigorous cry
What is the term the instructor uses for appearance in the APGAR score?
skin colour
What does a heart rate in a newborn < 100 indicate?
Possibly asphyxiated baby, but should not be used alone as evidence of asphyxia as outcomes studies show that while widely reported, it is often inappropriate
What does a heart rate > 160 in a newborn indicate?
Distress
What APGAR score is considered normal?
7 to 10
What APGAR score indicates the baby needs some rescue breathing measures and careful monitoring?
4 to 6
What APGAR score indicates a need of rescue breathing and lifesaving techniques?
0 to 3
What may cause variation within APGAR score measurements?
MEMORY: Baby SCAM
B - birth weight
S - subjectivity of HCP
C - congenital anomalies
A - age (gestational)
M - maternal medications, drug use, and anesthesia
Why is the APGAR score prone to inter-rater variability?
Several components of the score are subjective so the Apgar score is limited in that it provides somewhat subjective information about an infant’s physiology at a point in time.
What should always take precedence over calculating an APGAR score?
Resuscitation
While the APGAR score should not be used to extrapolate outcome, what is it useful in gauging?
The response to resuscitation
What is the normal newborn heart rate?
110-160 bpm
What is the normal newborn respiration rate?
30-60/min
What is the normal newborn temperature?
36.5-37.5
What can diminished breath sounds in the newborn signify?
What should be done in this case?
Pneumothorax
Pleural effusion
Diaphragmatic hernia
You’re gonna need a chest ultrasound
Describe TTN.
Definition, phatho, tx, etc.
Transient tachypnea of the newborn (TTN)
Occurs when fluid is retained in the lungs resulting in tachypnea and increased work of breathing
TTN may require supplemental oxygen therapy
Usually resolves within 48 hours.
What are signs of respiratory distress in the newborn?
Tachypnea
Nasal flaring
Grunting
Retractions
Cyanosis
What heart sounds are normal when auscultating a newborn?
Single first sound and a split second sound
What is common on the first day of life but is often transient in the newborn?
Heart murmurs
When assessing a newborn, you notice they have a heart murmur. What should be done next?
Why? What are we looking for?
Take the blood pressure in all 4 extremities
Abnormal findings:
-upper and lower pressure gradient difference > 20 mmHg
-abnormal femoral pulses
Looking for coarctation of the aorta, will need to do a transthoracic echocardiography
You check the blood pressure in all 4 limbs of a newborn and you notice a pressure difference of 25 mmHg.
What might this be an indication of?
What should we do next?
Coarctation (narrowing) of the aorta may be noted if the upper and lower pressure gradient difference > 20 mmHg
Will need to do a transthoracic echocardiography
When should the nurse identify the newborn?
- on admission
-prior to transfer of newborn from birthing area or operating room - prior to separation of birth person and newborn
-upon transport to another facility/unit - following shift handover
- prior to medication administration
- prior to undergoing procedures
- prior to discharge
Who will need identification bands after giving birth?
The birth parent and the newborn.
Support person may also get a matching band
How is the length of the newborn measured?
From the top of the head to the heel
How is the head circumference measured?
The greatest diameter of the head, so occipitofrontal line
What is the average birth weight for babies? What is considered normal?
Average: 3.5 kg (7.5 lbs)
Normal: 2.5 - 4.5 kg (5.5 - 10 lbs)
Compare boy birth weights to girls
Boys are usually a little heavier than girls
Compare first baby birth weights to those of their later siblings
First babies are usually lighter than than later siblings
Large parents generally have ______ babies while small parents generally have ______ babies
Large
Small
Newborns often lose around ______ in the first _______ days after birth but they regain it by about _______ days of age.
230 g (8 oz)
4 to 5
10 to 12
In the first month, the typical newborn gains about _____ a day, or about _____ to ______ a week.
20 g (0.70 oz)
110 g (4 oz) to 230 g (8 oz)
What is the average length of full term babies? What is considered the normal range?
50 cm (20 inches)
46 cm (18 inches) to 60 cm (22 inches)
How much do babies grow in length during their first month?
4 - 5 cm (1.5-2 inches)
Why does the baby’s head grow at its fastest rate during the first 4 months after birth than at any other time?
To accommodate for the rapid brain growth
What is the average head circumference in the newborn?
What is the average size by the end of the first month?
34.5 cm (13.5 inches)
37.6 cm (15 inches)
What might a growth chart show measurements for?
What do they represent?
Weight, height, and head circumference
Represents the average of one of the above measurements of an aggregate of a baseline for children
What are the lines on a growth chart called? Which lines are usually included?
Percentile lines
5%, 10%, 25%, 50%, 75%, 90%, 95% and 97%.
What does it mean if a child’s weight is at the 50th percentile line?
out of 100 normal children her age, 50 will be bigger than she is and 50 smaller
What does it mean if a child’s weight is in the 75th percentile?
she is bigger than 75 children and smaller than only 25, compared with 100 children her age
What matters when looking at growth percentiles?
The rate of growth over time rather than any one measurement at a single point in time
What is a normal rate of growth for a child when looking at a growth chart?
The child’s growth closely follows a percentile line on the chart.
When do we begin to worry about insufficient or excessive growth of a child?
When they have crossed at least 2 percentile lines (i.e. from above the 90th percentile to below the 50th)
You are measuring a child and realize that they are below the 5th percentile. What should we do? Is more investigation required?
Look to see if her growth points have always paralleled the 5th percentile line.
If yes, than her growth rate is normal.
If she is suddenly falling farther behind, this is more concerning and more investigation might be done.
What is the gestational age of the preterm newborn?
Also called premature
born before 37 completed weeks, regardless of birth weight
What is the gestational age of the late preterm newborn?
born between 34 0/7 and 36 6/7 weeks
What is the gestational age of the early term newborn?
born between 37 and 38+6 weeks gestation
What is the gestational age of the full term newborn?
born between the beginning of 39 and the end of week 40+6
What is the gestational age of the late term newborn?
born in the 41st week
What is the gestational age of the post-term newborn?
Also called postdate
born after 42 weeks + 0 days
What is the gestational age of the post-mature newborn?
born after completion of week 42 and showing signs of placental aging (insufficiency)
What score is based on the neonate’s physical and neuromuscular maturity and can be used up to 4 days after birth (in practice, it is usually used in the first 24 hours)?
Ballard score
Describe the Ballard Score.
The Ballard score is based on the neonate’s physical and neuromuscular maturity and can be used up to 4 days after birth (in practice, the Ballard score is usually used in the first 24 hours).
The Ballard score is commonly used to determine gestational age. Here’s how it works:
Scores are given for 6 physical and 6 nerve and muscle development (neuromuscular) signs of maturity. The scores for each may range from -1 to 5.
The scores are added together to determine the baby’s gestational age. The total score may range from -10 to 50.
Premature babies have low scores. Babies born late have high scores.
Newborn physical examination findingsare used by clinicians to estimate gestational age, using thenew Ballard score. The Ballard score is accurate only within plus or minus 2 weeks. Newborn clinical assessments of gestational age have been found to overestimate gestational age in preterm infants and underestimate gestational age in small-for-gestational-age infants
What is the accuracy of the Ballard score when estimating gestational age?
Which gestational ages are the most difficult to accurately assess?
+/- 2 weeks gestation
Newborn clinical assessments of gestational age have been found to overestimate gestational age in preterm infants and underestimate gestational age in small-for-gestational-age infants
What does the Ballard score determine?
Gestational age
What is the total score that may be given with a Ballard score?
-10 to 50
Premature babies have ______ Ballard scores. Babies born late have ______ Ballard scores.
Low
High
What are the 6 physical maturity signs assessed by the Ballard score?
MEMORY: Scrupulously Examine Gestation of Little Premature Babies
Skin
Eye/Ear
Genitals
Lanugo
Plantar surface
Breast
What are the 6 neuromuscular activity signs assessed by the Ballard score?
MEMORY: Precise Healthcare Staff Assess Prematurity Signs
Posture
Heal to ear
Square window (wrist)
Arm recoil
Popliteal angle
Scarf sign
What muscle is the vitamin K shot given to the newborn?
IM injection in the vastus lateralis
What is the dose of vitamin K given to the newborn?
1.0 mg if birth weight ≥ 1500 g
0.5 mg if birth weight < 1500 g
1500 g is 3.3 lbs
Why is the vitamin K shot given to newborns?
What is the risk if it is not given?
Prophylactic measure to prevent hemorrhagic disease of the newborn (HDN)
Without the vitamin K injection, babies are about 80 times more likely to have vitamin K deficiency bleeding. This bleeding can lead to death or serious long-term disability.
Parent says “I don’t need vitamin K shots, so why does my baby need it?”
What should you tell this parent about how the baby makes their own vitamin K?
Vitamin K is synthesized by intestinal flora which are not present at birth.
The introduction of bacteria begins with the first feeding
Healthy newborns are able to produce their own Vitamin K by day 7
If even after teaching, the parent refuses to allow a vitamin K shot for their newborn, what is an alternative treatment that can be offered? What is the dose used?
Why is it not recommended over the vitamin K shot?
An oral dose of 2 mg can be given at the first feeding, with follow-up doses given at 2 to 4 weeks of age and 6 to 8 weeks of age.
This treatment is not recommended because it is less effective in preventing late hemorrhagic disease of the newborn. Parents should be advised of the importance of the baby receiving the follow-up doses and be cautioned that their infants remain at increased risk of late hemorrhagic disease
When does the first period of reactivity in the newborn occur? What is this characterized by?
What should be encouraged during this time?
Occurs in the first 30-60 minutes of life
Described by an alert, exploratory and active newborn
Suck is strongest at this time therefore this is the best time to breastfeed
Bowel sounds are audible and meconium may be passed
Fine crackles may be heard in the lungs as well as some retractions and nasal flaring but this should all resolve by the end of this period
Early skin to-skin contact (SSC) begins ideally at birth and involves placing the naked baby, covered across the back with a warm blanket, prone on the mother’s bare chest. This time may represent a psychophysiologically ‘sensitive period’ for programming future behavior, and may benefit breastfeeding outcomes, early mother-infant attachment, infant crying and cardiorespiratory stability.”
When does the period of decreased responsivity in the newborn occur? What is this characterized by?
Can breastfeeding be done during this time?
What happens to the newborns vital signs during this time?
Takes place 2 -3 hours after birth
The newborn becomes less interested in external stimuli and falls asleep for a few minutes to several hours
During deep sleeps, the baby is difficult to arouse
Feeding may be difficult
Heart rate should stabilize at 100 - 140 bpm and the respiratory rate decrease to 40 to 60 breaths per minute. The newborn should be centrally pink with clear breath sounds and show no signs of respiratory distress.
Bowel sounds are audible and peristaltic weaves over the rounded abdomen may be noted
When does the second period of reactivity in the newborn occur? What is this characterized by?
What happens to the newborns vital signs during this time?
Occurs between 4 - 6 hours after birth and lasts from 10 minutes to several hours
Described by an alert, exploratory and active newborn
Heart and respiratory rates may increase but should remain within normal limits although brief periods of tachycardia and tachypnea may occur, associated with increased muscle tone, skin colour changes, and mucus production.
Meconium is commonly passed during this phase.
Most healthy newborns experience this transition regardless of type of birth. Physiological immaturity prevents this in very preterm newborns.
Breastfeeding rates have been _______ in Canada from < 25% in 1965 to between _____ and ______ in 2019.
Increasing
57% and 96%
______ of Canadian mothers continue to breastfeed somewhat for 6 months or longer, although close to 25% of the mothers who initiate breastfeeding stop breastfeeding before their newborn is _________ old
Over half
1 month
Mothers most often choose to breastfeed because they are aware of the ______ to the infant, reinforcing the need for _________.
Breastfeeding is a natural extension of pregnancy and childbirth; it is much more than simply a means of supplying nutrition for infants.
Many people seek the unique ___________ between mother and infant that is characteristic of breastfeeding.
Benefits
Prenatal education about the importance of breastfeeding.
Bonding experience
____________ is a major factor in a person’s decision to breastfeed and in their ability to do so successfully.
The support of the partner and family
Patients are more likely to breastfeed successfully when partners and family members have a _________ view of breastfeeding and support the mother’s decision.
positive
Ideally, prenatal preparation includes the partner and family, who need information about what?
the benefits of breastfeeding and how they can participate in infant care and nurturing
Experiences such as birth and breastfeeding are shaped by the context in which they occur. As such, beliefs and perceived community norms are significant influences on infant feeding. What are some of these traditions that affect breastfeeding rates in Canada?
Current feeding practices in Canada are affected by a long tradition of bottle-feeding and aggressive formula marketing.
Beliefs about infant feeding are also deeply embedded in beliefs and practices about child-rearing.
Other North American beliefs may include, for example, that children are “spoiled” by being held or carried too much, or that breastfed babies need to learn how to bottle-feed, and feedings need to be scheduled or timed; these beliefs may all affect breastfeeding duration and success.
What are some guidelines to support breastfeeding?
- immediate skin-to-skin contact after birth
- teach responsive feeding to recognize early feeding cues
- encourage breastfeeding early and often
- teach cues that baby is feeding well
- ensure community follow up
How many times per day should a new mother attempt to breastfeed her baby?
At least 8-12 times per day
How many months should a mother be encouraged to breastfeed for?
Exclusive breastfeeding for the first 6 months
Introduce complementary foods at 6 months and continue to breastfeed to 2 years and beyond
Describe the breast anatomy of the breastfeeding mother
Each female breast is composed of approximately 15 to 25 segments (lobes) embedded in fat and connective tissues and well supplied with blood vessels, lymphatic vessels, and nerves.
Within each lobe is glandular tissue consisting of alveoli, the milk-producing cells, surrounded by myoepithelial cells that contract to send the milk forward to the nipple during milk ejection.
Each nipple has multiple pores that transfer milk to the suckling infant.
The ratio of glandular to adipose tissue in the lactating breast is approximately 2:1, compared with a 1:1 ratio in the nonlactating breast.
Within each breast is a complex, intertwining network of milk ducts that transport milk from the alveoli to the nipple. The milk ducts dilate and expand at milk ejection.
The nipple and areola are very elastic so that they can be drawn fully into the infant’s mouth for deep latch-on.
Each female breast is composed of approximately ____to ____ segments, called ______, embedded in fat and connective tissues and well supplied with _____, _______, and ______.
15 to 25
lobes
blood vessels, lymphatic vessels, and nerves
Within each lobe of the breast is ________ tissue consisting of ______, the milk-producing cells, surrounded by myoepithelial cells that contract to send the milk forward to the nipple during milk ejection.
glandular
alveoli
Each nipple has __________ that transfer milk to the suckling infant.
multiple pores
The ratio of glandular to adipose tissue in the lactating breast is approximately __:__ compared with a __:__ ratio in the nonlactating breast.
2:1
1:1
Within each breast is a complex, intertwining network of _______ that transport milk from the alveoli to the nipple. These ______ and ______ at milk ejection.
milk ducts
dilate
expand
Why are the nipple and areola very elastic?
so that they can be drawn fully into the infant’s mouth for deep latch-on
What is the purpose of the alveoli in the breast?
They are milk-producing cells
What cells contract to send the milk forward to the nipple during milk ejection?
Myoepithelial cells
After the mother gives birth, a precipitous fall in ________ triggers the release of _______ from the anterior pituitary to prepare the breast for breastfeeding.
Progesterone
Prolactin
What is the process of developing the ability to secrete milk?
Lactogenesis
What is the role of prolactin during pregnancy?
prepares the breasts to secrete milk
What is the role of prolactin during lactation?
Synthesize and secrete milk
Where is prolactin released from?
The anterior pituitary
Describe the levels of prolactin after the birth of the baby?
highest during the first 10 days after birth, gradually declining over time but remaining above baseline levels for the duration of lactation
While the fall in progesterone after birth initially triggers the release of prolactin from the anterior pituitary, what continues to trigger its production after birth?
In response to newborn suckling and emptying the breasts
When the baby is done feeding, are the breasts empty of milk?
No, milk is constantly being produced by the alveoli as the infant feeds
What type of system is milk production?
supply-meets-demand system (i.e., as milk is removed from the breast, more is produced)
What can incomplete removal of milk from the breasts lead to?
Decreased milk production
What hormone is responsible for the milk ejection reflex?
Oxytocin hormone
What triggers oxytocin release during breastfeeding?
The suckling infant stimulates the nipple prompting oxytocin production
Where is oxytocin released from?
Posterior pituitary
What is the function of oxytocin in breastfeeding?
The milk ejection reflex (MER)
Stimulates the cells around the alveoli to contract, squeezing milk into the ducts and towards the nipple
Describe the prolactin hormone during breastfeeding
After the mother gives birth, a precipitous fall in progesterone triggers the release of prolactin from the anterior pituitary.
During pregnancy, prolactin prepares the breasts to secrete milk and during lactation to synthesize and secrete milk.
Prolactin levels are highest during the first 10 days after birth, gradually declining over time but remaining above baseline levels for the duration of lactation.
Prolactin is produced in response to newborn suckling and emptying the breasts (lactating breasts are never completely empty; milk is constantly being produced by the alveoli as the infant feeds). Milk production is a supply-meets-demand system (i.e., as milk is removed from the breast, more is produced). Incomplete removal of milk from the breasts can lead to decreased milk production.
Describe the oxytocin hormone during breastfeeding
Oxytocin a hormone essential to lactation.
As the nipple is stimulated by the suckling infant, the posterior pituitary is prompted by the hypothalamus to produce oxytocin.
This hormone is responsible for the milk ejection reflex (MER), or let-down reflex.
Oxytocin stimulates the cells around the alveoli to contract, squeezing milk into the ducts and towards the nipple
What pains can be caused by the oxytocin release during breastfeeding?
Why does this happen?
How long does this happen for?
Who is most likely to experience these pains?
“After pains” of the uterus that occur during and after breastfeeding
Oxytocin is the same hormone that causes uterine contractions during labour
3-5 days after birth, and should resolve completely within a week after birth
More common in multiparas and patients who gave birth to multiples
What are benefits of breastfeeding for the mother?
MEMORY: once the CORD is cut you have to PUMP
PUMP
- Postpartum bleeding decreased and more rapid uterine involution
- Unique bonding experience
- Mental health protection when breastfeeding difficulties are appropriately dressed
- Post partum weight loss is faster
CORD
- Chronic disease risk reduction (ovarian cancer, breast cancer, rheumatoid arthritis, hypertension, hypercholesterolemia, cardiovascular disease, and type 2 diabetes)
- Osteoporosis protection
- Return of menses delayed
- Development of maternal role increased
What are benefits of breastfeeding to the infant/child?
*Reduced infant and child mortality
*Enhanced maturation of the gastrointestinal tract and immune factors
*↓ risk for gastroenteritis, celiac disease, Crohn disease, necrotizing enterocolitis in preterm infants; obesity in childhood, adolescence, and adulthood
*helps protect against otitis media, respiratory illnesses such as respiratory syncytial virus and pneumonia, urinary tract infections, bacteremia, and bacterial meningitis
*Lower incidence of certain allergies among breastfed infants, particularly for families at high risk
*Less likely to die from SIDS
*May have a protective effect against childhood lymphoma and type 1 and type 2 diabetes mellitus
*Decreased risk of dental malocclusions
*May enhance cognitive developmental for term and preterm infants
*Pain relief for newborns undergoing painful procedures
What is included in the breastfeeding assessment?
L - latch is effective
A - audible swallowing
T - type of nipple
C - comfort level of mom
H - holding skills
What are indications of a good latch?
MEMORY: don’t take a good latch for GRANTeD
G - glide of jaw is smooth
R - Rounded cheeks when sucking
A - audible swallowing “ca” sounds
N - not easily removed from breast
T - tugging sensation
D - distortion of nipple not noted after feeding
What are examples of holds that can be used when breastfeeding?
Cradle hold
Cross-cradle hold
Football hold
side lying
Laid back
What are some infant feeding cues?
- hand to mouth or hand to hand movements; sucking on fingers/hands
- sucking motions
- rooting reflex
- mouthing
- flexed arms and legs
Describe the hunger posture of the newborn?
Flexed arms and legs with clenched fists held over chest and tummy
When assessing the mother during breastfeeding, what things would we look for?
- comfort in handling the infant
- level of confidence
- signs of discomfort or pain
- recognition of infant hunger cues and signs of satiety
What should we be looking for when assessing the condition of a breastfeeding mothers breasts?
Soft, filling, firmness
What should we be looking for when assessing the condition of a breastfeeding mothers nipples?
Intact, bleeding, blistering
What are the stages of lactogenesis?
Stage I - secretory differentiation
Stage II - secretory activation
Stage III - galactopoiesis
Stage IV - involution
What is the first stage of lactogenesis called?
When does this occur?
What happens during this stage?
Secretory differentiation
Begins mid-pregnancy to day 2 or 3 postpartum
the breasts develop the capacity to secrete breast milk, including the secretion of colostrum
What is the second stage of lactogenesis called?
When does this occur?
What happens during this stage?
Secretory activation
Begins on day 2-3 postpartum until day 8
breast milk volume increases rapidly and then abruptly levels off
What is the third stage of lactogenesis called?
When does this occur?
What happens during this stage?
Galactopoiesis (means to make milk)
From approximately day 9 postpartum and onward
The volume of breast milk produced is maintained through a supply and demand mechanism.
What is the fourth stage of lactogenesis called?
When does this occur?
What happens during this stage?
Involution
occurs, on average, 40 days after the last breastfeed
Breast milk secretion ceases
Which stage of lactogenesis produces colostrum?
Stage I - secretory differentiation
Which stage of lactogenesis does the milk volume rapidly increase before it abruptly levels off?
Stage II - secretory activation
What stage of lactogenesis is the general milk production using the supply and demand mechanism?
Stage III - Galactopoiesis
What stage of lactogenesis sees milk production cease?
Stage IV - involution
Newborns consume small amounts of ________ with frequent feedings during the first 3 days of life.
colostrum
As the breastfeeding babies milk intake increases and the digestive tract is cleared of _________, the newborn’s fluid intake gradually increases.
meconium
What factors might influence the frequency of breastfeeding of a newborn?
Infant
- age
- weight
- stomach capacity
- gastric emptying time
Mother
- storage capacity of the breast
Describe cluster feedings
A pattern of breastfeeding in which the baby breastfeeds every hour or so for three to five feedings and then sleeping for 3 to 4 hours between clusters
How can we encourage new mothers to look for opportunities to feed their newborn?
Rooming-in and skin-to-skin care will help parents recognize and quickly respond to newborn feeding cues
“watch the baby, not the clock”
If the newborn is stirring, parents should be encouraged to pick the baby up and offer the breast
After 24 hours of life, if newborns are not consistently beginning to wake on their own to feed at least eight times in 24 hours, what should be done?
What can the nurse do?
Parents should be encouraged to wake the baby up to feed
Careful assessment of the newborn on how well they are feeding should be done
How is feeding frequency determined?
counting from the beginning of one feeding to the beginning of the next
What is the vitamin D recommendation for infants?
400 IU per day
May be in the formula already, double check your specific type
What is the iron recommendation for breastfed babies?
They actually draw on their iron reserves for the first 6 months and then it will need to be added to the diet (which is when you’re introducing solid foods)
What is the iron recommendation for formula-fed babies?
Iron-fortified formula is required until 1 year old
What is the water recommendation for infants?
None required (there is enough fluids in the milk/formula to meet the needs)
A C-section mother is still a surgical patient and will require pain control. What is the effects of the narcotics on the baby?
Can make them sleepy as it is transmitted through the breastmilk
A C-section mother is still a surgical patient and will require pain control which can make her drowsy. What should be done in this instance?
Remember that she needs someone to be with her when drowsy and trying to breastfeed for safety
C-section moms will need __________ with breastfeeding
assistance
What positions are best for breastfeeding after a c-section?
side-lying or football hold
A pillow can help support the newborn
After a C-section, milk supply may ________, so we need to ensure early breastfeeding as this helps _________.
come in late
stimulate milk production
It is speculated that the infant’s ______ development may be affected by maternal alcohol use.
psychomotor
Frequent or heavy drinking can impair the parent’s _______ and _______.
The mother’s _____ and ______ can also be adversely be affected by her alcohol intake.
Judgement and functioning
MER (milk ejection reflex) and milk production
Alcohol passes freely from the parent’s blood into_________, with peak levels occurring in __ to __ minutes on an empty stomach and __ to __ minutes when consumed with food.
breast milk
30-60
60-90
Because alcohol passes into the breast milk, how might some mothers attempt to minimize alcohol exposure to their infant?
Some mothers attempt to time their consumption to minimize exposure to their infant (e.g., consume alcohol immediately after a feeding rather than before)
Because nicotine is transferred to the breastmilk, lactating parents who continue to smoke should be advised not to smoke within ______ before breastfeeding, and they, along with other family members who smoke, should __________.
2 hours
go outside to smoke
For mothers who consume large amounts of caffeine while breastfeeding, what might they notice about their infant?
Unusually active and wakeful
________ amounts of caffeine pass through to the infant in the breast milk and moderate intake of caffeine by lactating parents appears to pose
______. However, how can caffeine affect breast milk and what can this lead to?
Minimal
no risk to healthy full-term infants
Reduced iron concentration in the breast milk leading to anemia in the infant
What are some breastfeeding complications?
MEMORY: body has been MINED of breastmilk
M - mastitis
I - infection (yeast)
N - nipples that are sore
E - engorgement
D - ducts that are plugged
While breast fullness around the third day postpartum is a reassuring sign of normal lactation, what signs/symptoms may indicate engorgement?
MEMORY: Problematically DENSER breasts
P - painful
D - difficulty latching/decreased milk flow
E - enlarged
N - nipples effaced (flattened)
S - shiny
E - edematous
R - reddened
What are some factors that may contribute to engorgement?
Any situation causing milk stasis including
- delayed initiation of breastfeeding
- infrequent or time-restricted feedings
- feeding supplementation
- inefficient infant latch
-breast surgery
What might unrelieved engorgement cause?
Decreased milk production and possible involution (shrinkage) of the breast tissue
What are some ways to minimize the more severe symptoms of engorgement?
Frequent, effective feeding
Milk removal via hand expressing or pumping
Breast massage
What are some of the predisposing factors of mastitis?
Inadequate emptying of the breasts
- engorgement
- plugged ducts
- sudden decrease in the number of feedings/abrupt weaning
- underwire bras
Other factors- TIPS
- trauma of the breast
- ill family members
- poor parental nutrition
- stress/fatigue
What might provide a portal of entry for a causative organism to cause mastitis?
Sore, cracked nipples
What are the most common causative organisms for mastitis?
staphylococci, streptococci, and E. coli
What are some complications of mastitis?
MEMORY: FAC! this is bad
F - fungal infections
A - abscess of the breast
C - chronic mastitis
What is the term used to refer to an infection of the breast?
Mastitis
What is the term used for breasts that are painfully overfull of milk?
Engorgement
What causes a milk duct to become clogged and stops allowing breast milk flowing to the nipple?
Plugged milk ducts
What are the symptoms of a plugged milk duct?
Swollen and tender area of the breast that does not empty or soften with feeding/pumping
Mother is afebrile with no generalized symptoms
What can plugged milk ducts make a mother susceptible for?
Breast infection
If a breastfeeding parent is having milk ducts that are repeatedly becoming blocked, what can they do to help?
Take lecithin, a fat emulsifier
While mild nipple discomfort at the beginning of feedings is common, severe soreness and abraded, cracked, or bleeding nipples are not normal and most often result from _______, _______, or _______.
poor latch, improper suck, or infection
What can the mother do if the first few sucks of breastfeeding their infant is uncomfortable?
Express a few drops of milk to moisten the nipple and areola before latch
Break the seal of the infants mouth with a finger and readjust to see if the pain resolves
Attempt to reposition the infant
If it continues, see a nurse/lactation consultant to ensure a good latch and position
What are the contraindications to breastfeeding?
ANSWER: these cause the need for a CHIASM from breastfeeding
C - cancer therapy in the mother
H - HIV in the mother
I - Infant galactosemia (rare hereditary disorder where they cant process milk)
A - Active TB infection not under treatment in mother
S - substance use/some medications
M - Maternal HTLV (virus)
What are some indications that a newborn is ready for their first formula feeding?
Generally occurs within the first hour
Ideally after initial transition to extrauterine life
- stability of vital signs
- bowel sounds
- active sucking reflex
- effective breathing pattern
These will become more obvious to parents who are frequently holding the baby skin to skin
What is a late hunger cue in a newborn?
crying
What is the best type of bottle and nipple?
Most baby feed well with any of them, it’s really parental preference
How should bottles be cleaned?
Use hot, soapy water using a bottle and nipple brush to facilitate thorough cleansing
Most household dishwashers use hot water and are safe for cleaning bottles and nipples.
Boiling of bottles and nipples is not always needed. It is best to check with the local Public Health Department regarding recommendations.
Recommendations for preterm or vulnerable babies may be more stringent.
After 6 months, what supplement should the formula-fed infant be given?
fluoride supplementation of 0.25 mg/day is required if the local water supply is not fluoridated.
How should the baby be positioned when preparing to formula feed them?
Parent sitting comfortably, holding the infant closely in a semi-upright position
How should the bottle nipple be presented to the infant when bottle feeding?
Gently invite the infant to take the nipple without forcing the infant to finish the bottle
If the infant shows signs of distress when bottle feeding, what should the parent do?
Lower the bottle to slow the flow of milk
(I also learned some nipples have larger/smaller flow, so you may want to change up the nipple if this is a consistent issue)
How can parents avoid the risk of choking when feeding their infant with a bottle?
Avoid propping the bottle or letting small children feed the infant unsupervised
How can parents avoid overfeeding when feeding the infant?
Watch for signs of satiation such as the infant
- stops sucking
- falls asleep
- moves their mouth away from the nipple
What can happen with overfeeding in formula fed infants?
Can contribute to obesity
Why should the bottle be removed from the infant’s mouth before they fall asleep when formula feeding?
It can contribute to nursing-bottle caries, which is decay of the first teeth, resulting from continuous bathing of the teeth with carbohydrate-containing fluid as the infant sporadically sucks the nipple while sleeping
In the first 24 to 48 hours of life, how much formula does a newborn typically consume per feeding?
How much by the end of the first week?
How does the parent know when and how much to feed them?
10 to 30 mL for first 48 ish hours
60 to 90 mL by the end of week 1
Use hunger and satiation cues and feed them at least 8 times in 24 hours, even if you have to wake them up, but rigid schedules are not recommended
How do parents know when they can stop waking the baby to formula feed them?
when they show an adequate weight gain they can be allowed to sleep at night and be fed when they wake up
While scheduling formula feedings is not recommended, usually after how long does an infant develop their own relatively predictable feeding pattern?
3-4 weeks
During growth spurts, an infants appetite will increase. When do these growth spurts occur?
While breastfeeding will automatically adapt to this increase in demand through the supply and demand mechanism, how much should parents formula feeding their babies increase each feed by?
7-10 days
3 weeks
6 weeks
3 months
6 months
Increase each feed by about 30 mL
How much formula should be given to a baby during the following periods:
neonate
1-3 months
3-6 months
6-9 months
9-12 months
0 - 1 month: 2-3 oz every 3-4 hours
1 - 3 months: 4-5 oz every 4-6 hours
3 - 6 months: 4-8 oz every 4-6 hours and 2 tbsp of solid food
6 - 9 months: 6-8 oz every 3-4 hours and increase the solid food
9-12 months: 7-8 oz every 6-8 hours and continue to increase the solid food intake
How should the bottle be held when formula feeding an infant?
Upright to fill the nipple and decrease the air in the bottle; this prevents the air from going into the infants stomach; this increases the need for burping, and they may need it several times during a feeding
Paced bottle-feeding may be a more physiological approach. Describe this method.
The bottle is held at more of a horizontal angle, when the baby pauses between bursts of sucking, the parent lowers the bottle to slow the flow of milk, until the infant is ready to resume sucking.
Describe the treatment of water used to mix with formula.
Water that is used to make formula needs to be boiled for 2 minutes and the water cooled to no less than 70°C, and then the powder is added (Government of Canada, 2021).
Bottled water that is labelled as “sterile” is safe for mixing formula. However, nonsterile bottled water should be boiled for 2 minutes and cooled
What should a parent try if their bottle fed infant is spitting up formula?
- decrease amount of feeding or small amounts more frequently
- burp several times when feeding
- hold baby upright for 30 minutes after feeding
- avoid bouncing or placing on the abdomen soon after feeding
While spitting can be a normal occurrence when formula feeding, what else might it indicate?
Overfeeding
Gastroesophageal reflux
When should a parent report an infants spitting up/vomiting to their health care provider?
- vomiting 1/3 or more of the feeding at most feeding sessions
- projectile vomiting
What should parents who are formula feeding do prior to changing the infants formula?
Consult their health care provider
What are the 4 main categories of commercially prepared infant formulas?
- cow’s milk-based
- soy-based (primarily for babies who cannot consume dairy or cultural/religious reasons)
- casein or whey-hydrolysate (primarily used for babies who cannot tolerate the cow or soy based)
- amino acid (used for infants with multiple food-protein intolerances)
What formula type should a baby with galactosemia have?
Soy-based formula
(this is a rare hereditary disorder of carbohydrate metabolism that affects the body’s ability to convert galactose to glucose)
What should infants with documented IgE allergies caused by cow’s milk be fed when using formula?
casein or whey-hydrolysate
an extensively hydrolyzed protein formula, because about 10 to 14% of infants with cow’s milk–based formula intolerance will also have a soy protein allergy
Have soy-based formulas been proven effective in preventing colic or allergy in health or high risk infants?
no
What allows alveoli to remain open instead of collapsing completely during exhalation and provide the lungs stability needed for gas exchange in the newborn?
Surfactant
How can fetal lung maturity be determined?
amniocentesis after the 35th week
analysis of amniotic fluid; lecithin-to-sphingomyelin ratio
After birth, what is the most critical and immediate adjustment?
Establishment of respirations
Most newborns spontaneously breathe and are able to maintain adequate oxygenation
In utero, fetal blood was shunted away from the lungs, but when birth occurs the ___________ must be fully perfused for this purpose.
What causes a rise in blood pressure (BP), which increases circulation and lung perfusion immediately after birth?
pulmonary vasculature
Clamping the umbilical cord
What is the trigger for newborn respiratory function?
There is no single trigger, rather it’s the result of a combination of chemical, mechanical, thermal, and sensory factors.
What is surfactant in the newborns? What does it do? Where is it produced?
a group of phospholipids that reduce the alveolar surface tension
It reduces the pressure required to keep the alveoli in the lungs open with inspiration, preventing total alveolar collapse on exhalation, thus maintaining alveolar stability. The decreased surface tension results in increased lung compliance, helping to establish the functional residual capacity of the lungs
Produced in the Type II alveolar cells that make up about 5% of the alveolar surface
What happens in an infant when they have absent or decreased lung surfactant?
more pressure must be generated for inspiration, which can soon tire or exhaust preterm or sick term newborns
What is neonatal respiratory distress syndrome (RDS)?
Common cause of respiratory distress in a newborn, presenting within hours after birth, often immediately after delivery.
Occurs from a deficiency of surfactant, due to either inadequate surfactant production, or surfactant inactivation in the context of immature lungs. Prematurity affects both these factors, thereby directly contributing to RDS.
What chemical factors help trigger respirations in the newborn?
Chemoreceptors in carotid and aorta activated due to hypoxia associated with labour
Medulla’s respiratory center stimulated by increased CO2 and decreased O2 levels
Clamping the cord may cause a drop in prostaglandin (this hormone inhibits respirations prior to birth)
What mechanical factors help trigger respirations in the newborn?
Changes in intrathoracic pressure - Increases from compression as they pass through the vaginal canal and then drops immediately after they are born drawing air into the lungs
Crying increases the distribution of air in the lungs and promotes expansion of the alveoli
Positive pressure created by crying helps to keep the alveoli open
What thermal factors help trigger respirations in the newborn?
The suddenly cold environment as they are born stimulates receptors in the skin resulting in stimulation of the respiratory center in the medulla.
Prolonged cold exposure should be avoided though
What sensory factors help trigger respirations in the newborn?
Stimulated by handling and drying
The lights, sounds, and smells of the new environment can also be involved
Pain from birth might be involved too
What occurs before the onset of labour that appears to promote fluid clearance from the lungs in the newborn?
Catecholamine surge
The Newborns First Breaths
____________ and _________ must be strong enough to move fluids that fill the fetal airway from the trachea to the terminal air sacs
The movement of lung fluid from the air spaces takes place through active transport into the interstitium and then drained through ______ and __________
The liquid in the lungs must be replaced with an equal volume of ______
Lung expansion and first breaths
pulmonary circulation and lymphatic system
air
With the newborns first breaths, ______ must be retained in the alveoli so subsequent breaths are easier
some air
The newborn must establish _______, which is the air remaining in the lungs at the end of the expiration
Functional residual capacity
What can retention of lung fluid interfere with in the newborn?
What conditions may compound this issue?
Maintaining adequate oxygenation
Factors include:
- meconium aspiration
- congenital diaphragmatic hernia
- esophageal atresia with fistula (esophagus and trachea have abnormal connections)
- choanal atresia (nasal cavity connection to nasopharynx is occluded by soft tissue and/or bone)
- congenital cardiac defect
- immature alveoli
How is lung clearance affected in newborns born via C-section that did not experience the normal birthing process?
What are these babies most likely to develop?
can experience some lung fluid retention, although it typically clears without deleterious effects on the newborn
transient tachypnea of the newborn (TTNB) caused by the lower levels of catecholamines . TTNB usually resolves in 24 to 48 hours.
Describe normal newborn respirations
Shallow and irregular
30-60 breaths/min
Respiratory rate increases with activity
Periodic breathing includes pauses lasting less than 20 seconds
Clear breath sounds equal bilaterally
Abdominal breathing is characteristic because their rib cage cannot expand with inspiration like adults
Chest and abdomen rise simultaneously with inspiration
What are signs of respiratory distress in the newborn?
- nasal flaring
- intercostal or subcostal retractions
- grunting with respirations
- paradoxical respirations
- < 30 resps/min or > 60 resps/min
- changes in colour
What signs can indicate an upper airway obstruction in a newborn?
Suprasternal or subclavicular retractions with stridor or gasping
What can a slowed, depressed, or absent breathing rate in the newborn be caused by?
Analgesics or anesthetics administered to the mother during birth
What can apneic episodes in the newborn be related to?
- rapid increase in body temperature
- hypothermia
- hypoglycemia
- sepsis
What can cause tachypnea in the newborn?
Inadequate clearance of lung fluid, or it can be an indication of newborn respiratory distress syndrome (RDS).
Tachypnea can be the first sign of respiratory, cardiac, metabolic, or infectious illnesses.
What is acrocyanosis?
the bluish discoloration of hands and feet, is a normal finding in the first 7 to 10 days after birth
What is the bluish discoloration of hands and feet, a normal finding in the first 7 to 10 days after birth?
Acrocyanosis
While transient periods of duskiness in the newborn while crying are not uncommon immediately after birth, what colouring is considered abnormal?
central cyanosis
It’s a late sign and there is usually significant hypoxia when this appears
What does central cyanosis in the newborn look like?
lips and mucous membranes are bluish
What can result in central cyanosis in the newborn?
- inadequate deliver of oxygen to the alveoli
- poor perfusion of the lungs that inhibits gas exchange
- cardiac dysfunction
What is a late sign of respiratory distress in the newborn?
Central cyanosis, newborns usually have significant hypoxemia when cyanosis appears.
What is the umbilical cord composed of and what is it covered by?
two umbilical arteries and one umbilical vein surrounding by a gelatin-like extracellular matrix known as Wharton’s jelly.
Describe the umbilical vein?
Babies have 1, and it carries oxygenated blood and nutrients from the placenta to the ductus venosus and the liver
Describe the umbilical arteries?
Babies have 2, it carries deoxygenated blood and waste from the hypogastric arteries of the infant to the placenta
What does the ductus venosus connect?
What happens to it after birth?
connects the umbilical vein to the inferior vena cava
Post delivery, closed; becoming ligamentum venosum after obliteration, due to loss of blood flow from umbilical vein.
What does the ductus arteriosus connect?
What happens to it after birth?
Connects the main pulmonary artery to the descending aorta
Post delivery functionally closed almost immediately after birth
Anatomical obliteration of lumen by fibrous proliferation requiring 1 to 3 months, becoming ligamentum arteriosum due to increased oxygen content of blood in ductus arteriosus creating vasospasm of its muscular wall.
Decreased blood flow through the ductus after birth is due to the change from the low systemic resistance and high pulmonary resistance in the fetus to the high systemic resistance and low pulmonary resistance of the newborn.
Describe the foramen ovale.
What happens to it after birth?
A valve opening that allows blood to flow from the right atrium to the left atrium
Post delivery it is functionally closed at birth
The higher pressure in the left atrium and lower pressure in the right atrium after birth cause the valve to close and the constant apposition (positioned together) gradually leads to fusion and permanent closure within a few months or years
The fetal system has high/low pulmonary vascular resistance (PVR) and high/low aortic systemic vascular resistance (SVR).
high pulmonary
low systemic
What is the average systolic and diastolic pressure of the newborn?
Values for newborn BP vary with gestational age and weight.
The term newborn’s
- average systolic BP is 60 to 80mm Hg
- average diastolic BP is 40 to 50mm Hg.
When is blood pressure taken in a newborn?
Not routinely measured in a newborn
Only done if there are cardiovascular symptoms such as
- tachycardia
- abnormal pulses
- murmur
- poor perfusion
- abnormal precordial activity (movement over the chest wall)
MEMORY: cardiac TAMPAnade
If there are cardiovascular symptoms in the newborn, how should the BP be taken?
What is a sign that warrants further investigation?
BP should be taken in all 4 extremities
If the systolic pressure is more than 10mm Hg higher in the upper extremities than in the lower extremities, further diagnostic testing may be needed.
If there are cardiovascular symptoms in the newborn, how should the O2 sats be taken?
What does this tell us?
What is a sign that warrants further investigation?
Preductal - SPO2 site in the right hand
Postductal - SPO2 site on either foot
Represents the degree of right to left shunting across a patent ductus arteriosus
They should all be above 95% and not different by more than 3%
89% of less needs a stat echocardiography
What is thermoregulation?
maintenance of balance between heat loss and heat production
What thermoregulation issue is common and dangerous for newborns?
Hypothermia
What anatomical/physiological characteristics of newborns put them at risk of hypothermia?
- thin layer of subcutaneous fat
- blood vessels close to the skin surface
- cooler environments influence the temperature regulation centers in the hypothalamus
- larger body surface area to body weight ratios are larger than adults
What are the 4 ways that newborns lose heat to the environment?
-convection
-conduction
-radiation
-evaporation
What is convection? How do we prevent this heat loss in newborns?
The flow of heat from the body surface to cooler ambient air.
Ambient temperature in the newborn care area should range between 22° and 26°C a
Newborns in open bassinets are wrapped to protect them from the cold
A cap may be worn to decrease heat loss from the newborn’s head.
What is radiation? How do we prevent this heat loss in newborns?
The loss of heat from the body surface to a cooler solid surface not in direct contact but in relative proximity.
Place cribs and examining tables away from outside windows
Care providers need to avoid exposing the newborn to direct air drafts
What is evaporation? How do we prevent this heat loss in newborns?
The loss of heat that occurs when a liquid is converted to a vapour (i.e. the moisture from the newborns skin vaporized)
Completely dry the newborn directly after birth or with bathing
The less mature the newborn, the more severe the evaporative heat loss. Evaporative heat loss, as a component of insensible water loss, is the most significant cause of heat loss in the first few days of life.
What is conduction? How do we prevent this heat loss in newborns?
The loss of heat from the body surface to cooler surfaces in direct contact.
The scales used for weighing the newborn should have a protective cover to minimize conductive heat loss.
What mode of heat loss is the most significant cause of heat loss in the first few days of a newborns life?
Evaporation
_____________ of the gut is established within the first week of birth
Bacterial colonization
What is the stomach capacity in the day old new born?
30 mL (size of a cherry)
What can failure to pass meconium indicate?
A bowel obstruction related to conditions such as
- malrotation
- small or large bowel atresia (absence or closure of bowels)
- inborn error of metabolism (i.e. cystic fibrosis)
- congenital disorder (i.e. Hirschsprung disease or an imperforate anus)
What does meconium consist of?
- amniotic fluid
- intestinal secretions
- shed mucosal cells
- possibly blood
Describe the appearance of meconium and when it is passed
Greenish black, tarry consistency
Usually passed within 12 to 24 hours of birth; almost all do so by 48 hours
The first meconium passed is usually _______, but within hours all meconium passed contains _______.
sterile
bacteria
What do progressive changes in the stool pattern of a newborn during the first week indicate?
A properly functioning GI tract
Describe transitional stools
Appear by third day after initiation of feeding
Greenish brown to yellowish brown
Thin and less sticky than meconium
May contain some milk curds
Describe milk stools
Usually appears by day 4
Breastfed: yellow to golden, pasty, odour similar to sour milk
Formula fed: pale yellow to light brown, firmer consistency, odour more characteristic of a normal stool
How many urine voids are expected on the first 5 days of life?
Minimum of 1 void per day
Frequency of voids increases with age
How many urine voids are expected at 1 week of age?
6-8 voids per day
Frequency of voids increases with age
About how much does the renal system secrete in the first few days of life?
About 15-60 mL/kg
What is molding in the newborn?
Elongated shape of the skull as a result of overlapping of cranial bones during birth
When babies are born vaginally, they have a bit of a conehead, what is this called?
Molding
What is the localized edema on the scalp often after a prolonged labour or use of vacuum extraction called?
Capput succedaneum
What is capput succedaneum. What casuses it? How long does it take to resolve?
Easily identifiable edematous area of the scalp, most commonly found on the occiput. Swelling CROSSES SUTURE LINES
The sustained pressure of the presenting vertex against the cervix results in compression of local vessels, thereby slowing venous return. The slower venous return causes an increase in tissue fluids within the skin of the scalp, and an edematous swelling develops.
May also be caused by vacuum extrication
Dissipates in about 3-4 days
What is a collection of blood beneath the periosteum of the skull called?
Cephalohematoma
Describe a cephalohematoma. When does it appear? How long does it take to resolve? What can it result in?
A collection of blood beneath the periosteum of the skull.
Swelling does NOT cross suture lines.
Appears on day 2 or 3 and disappears in weeks or months.
Jaundice may result.
What can be the result of a cephalohematoma?
Jaundice
What might cause bleeding resulting in a cephalohematoma in the newborn?
Bleeding may occur with spontaneous birth from pressure against the maternal bony pelvis. Low forceps birth and difficult forceps rotation and extraction may also cause bleeding.
What is the anterior fontanelle? When does it close?
Diamond-shaped “soft spot”.
Remains open up to 18 months to allow the brain to grow.
What is torticollis? What does this result in?
Tightness of the sternocleidomastoid muscle,
Results in the newborn’s head tilting to one side
Why might a newborns head be tilted to the side when you do your assessment?
Torticollis, which is a tightness of the sternocleidomastoid muscle
What is milia?
Distended, small white sebaceous glands on the nose, chin, and forehead of the newborn
They disappear on their own
When assessing the newborn, you notice distended, small white sebaceous glands on the nose, chin, and forehead. What are these called?
Milia, they disappear on their own
What is telangiectatic nevi? How long do they last?
Also called stork bites
Superficial vascular areas (flat, pink, capillary hemangiomas) on nape of neck, eyelids, nose, upper lip, and lower occiput.
More visible when crying.
Fades in first and second years of life
When assessing the newborn, you notice flat, pink, capillary hemangiomas on the back of the infants neck and their nose. What are these?
telangiectatic nevi
Also called stork bites
Superficial vascular areas (flat, pink, capillary hemangiomas) on nape of neck, eyelids, nose, upper lip, and lower occiput.
More visible when crying.
Fades in first and second years of life
What is cutis marmorata in the newborn? Is this a cause for concern? Why does this occur?
Also called mottling
Lacy patterns of blood vessels under the skin
Normal physiological response to cold temperature.
Results from NB undeveloped nerve and blood vessel systems.
When the skin cools, the blood vessels near the surface contract and dilate alternately. The red color is produced when the vessels expand and the pale part is produced when the vessels shrink.
When assessing the newborn, you notice mottled pale and red areas of the body. What is this?
cutis marmorata
Also called mottling
Lacy patterns of blood vessels under the skin
Normal physiological response to cold temperature.
Results from NB undeveloped nerve and blood vessel systems.
When the skin cools, the blood vessels near the surface contract and dilate alternately. The red color is produced when the vessels expand and the pale part is produced when the vessels shrink.
What is erytheum toxicum? What treatment is needed for this newborn?
Also called a newborn rash and is very common in the first week.
Small white or yellow papules or vesicles on the skin.
No clinical significance. No treatment
When assessing the newborn, you notice small white papules on the skin that sort of looks like acne, what is this?
erytheum toxicum
Also called a newborn rash and is very common in the first week.
Small white or yellow papules or vesicles on the skin.
No clinical significance. No treatment
True/False
The likelihood to breastfeed exclusively is greater if the decision to do so occurs during pregnancy, rather than during the first stage of labour
True
True/False
A major barrier to breastfeeding is the belief that formula-feeding is more convenient
False
A major barrier for many patients is the influence of family and friends
True/False
Transgender men may give birth and provide human milk through breast feeding (also called chest feeding)
True
True/False
Except for Vitamin D, human milk contains all vitamins required for infant nutrition (with individual variations based on maternal diet and genetic differences).
True
True/False
Breastfed and formula-fed newborns require water, especially those living in very hot climates.
False
Breast milk contains 87% water, which easily meets the newborn’s fluid requirements. Feeding water to newborns can decrease caloric consumption at a time when they are growing rapidly.
True/False
The whey/casein ratio in human milk makes it harder to digest and produces hard stools in breastfed infants
False
Human milk contains the two proteins whey and casein in a ratio of approximately 70:30, compared with the ratio of 20:80 in most cow’s milk–based formula (Blackburn, 2018). This whey/casein ratio in human milk makes it more easily digestible and produces the soft stools seen in breastfed infants.
True/False
The size and shape of the breast are not accurate indicators of its ability to produce milk
True
True/False
Few breast changes during puberty or early pregnancy are associated with insufficient glandular development in the breast and inability to breastfeed exclusively
True
True/False
Mothers who breastfeed are at a decreased risk for postpartum hemorrhage
True
True/False
Afterpains, uterine contractions that occur during and after breast feedings for the first 3-5 days postpartum, are the most common in primiparas
False
These “after-pains” are more common in multiparas and patients who give birth to multiples and tend to resolve completely within 1 week after birth.
True/False
Milk produced by mothers of preterm newborns differs in composition from that of mothers who gave birth at term
True
Breast milk is specific to the needs of each infant. Wild
True/False
Patients with flat or inverted nipples are not able to breastfeed
False
The nipple-erection reflex is an integral part of lactation. Some people have flat or inverted nipples that do not become erect with stimulation; these patients may need assistance to help their newborns achieve an effective latch. Their newborns should not be offered bottles or pacifiers until breastfeeding is well established.
True/False
Breast fullness at around the 3rd day post partum is a reassuring sign of normal lactation
True
True/False
A normal bathing routine is all that is required to keep the breast clean; soap can have a drying effect on the nipples
True
True/False
Newborns should be fed based on cues, without time restrictions, and on average at least 6 times per 24 hours
False
8 times in 24 hours
True/False
Crying is a late sign of hunger
True
True/False
Usually, when latching onto the breast, the infant’s mouth should cover the nipple and areola with more of the areola visible below the baby’s upper lip than above the lower lip.
False
The amount of the areola in the newborn’s mouth with latch depends on the size of the newborn’s mouth and the size of the areola and nipple. In general, the infant’s mouth should cover the nipple and areola, with more of the areola visible above the baby’s upper lip than below the lower lip
True/False
The newborn has a “good” latch when swallowing is audible and sounds like a series of “ca” sounds.
True
True/False
At 2-3 days of age, newborns should have more than 4-6 voids
False
2-3 wet diapers and 1 or more meconium or greenish brown transition stools
What is complementary feeding?
The introduction of solid foods given to the infant in addition to human milk or formula. It’s recommended they be introduced at 6 months of age.
What is vernix caseosa?
What is the treatment for it?
The thick, white substance that protects the skin of the fetus.
Common in body creases.
Don’t wash it off – it has positive benefits for neonatal skin moisture and integrity.
You are assessing a newborn who is covered in a thick, white substance. What is this?
Vernix caseosa
The thick, white substance that protects the skin of the fetus.
Common in body creases.
Don’t wash it off – it has positive benefits for neonatal skin moisture and integrity.
What is lanugo? When does it disappear?
Soft, downy hair on the body, particularly on the face, shoulders and back.
Disappears over the first few weeks of life.
You are assessing a newborn and you note soft, downy hair all down the shoulders and back of the infant. What is this?
Lanugo
What are Mongolian spots?
Who is more likely to have this?
When do they appear/disappear?
Bluish black areas of pigmentation commonly noted on the back and buttocks.
Occurs more frequently in ethnicities from Asia, Africa, Indigenous North America
Appear at birth or within first few weeks
Fade gradually over months or years
You are assessing a newborn and you note a bluish black region on the lower back of the infant. What is this?
Mongolian spots
What is jaundice? What is it caused by?
Yellowish discolouration of the skin.
Caused by excess bilirubin in infants blood
What does the treatment of jaundice in the newborn depend upon?
Bilirubin levels
At what bilirubin levels are we going to notice the yellowing of the skin and sclera of the newborn?
85-102 mcmol/L
mcmol/L is micromoles per liter
The level of bilirubin at which jaundice is evident varies considerably
Where is jaundice most likely to be noticed first on the newborn?
How does the jaundice progress?
First seen in head, especially sclera and mucous membranes
Gradually progresses to the thorax, abdomen, and extremities
What variables can affect the total serum bilirubin levels of the newborn?
MEMORY: your liver is a NEWB at the GAME
N - Nutritional status
E - Extravasated blood (e.g., cephalohematoma or severe bruising).
W - Weight
B - Blood group
G - Gestational age (premature most at risk)
A - Age
M - Mode of feeding (breastfeeding at higher risk)
E - Ethnic background (Asians and Indigenous backgrounds have higher bilirubin levels)
True/False
Traditionally, newborn jaundice has been categorized as either physiological or pathological, depending on the time it appears and serum bilirubin levels
True
But there is controversy around the definitions of normal or physiological ranges of total serum bilirubin
What factor is the most likely to increase the risk of hyperbilirubinemia in the newborn?
Why is this?
Prematurity
Prematurity affects liver and brain metabolism and albumin binding sites, placing preterm and late preterm newborns at greater risk for hyperbilirubinemia.
What should the nurse know about ethnic backgrounds when assessing the newborn for risk factors of hyperbilirubinemia?
Newborns of Asian and Indigenous backgrounds have higher bilirubin levels.
What should the nurse know about mode of feeding when assessing the newborn for risk factors of hyperbilirubinemia?
Breastfeeding newborns are at greater risk of hyperbilirubinemia.
Although there is no consistent definition for neonatal hyperbilirubinemia, the Canadian Paediatric Society suggests that an unconjugated bilirubin greater than __________ in the first 28 days of life constitutes hyperbilirubinemia.
340 mcmol/L
Physiological or _________ jaundice occurs in approximately 60% of newborns born at term and ______ of preterm infants. It appears after ________ of age and usually resolves with___________
nonpathological
80%
24 hours
No treatment
Jaundice is usually considered pathological or __________ if it appears within ________ of birth, if total serum bilirubin levels increase by more than _________ in 24 hours, and if the serum bilirubin level exceeds __________ at any time
nonphysiological
24 hours
100 mcmcol/L
256 mcmol/L
You are assessing a newborns ears. How should they be aligned? What is a common alteration and what causes this?
Should be aligned with outer canthi of the eyes
Lower set eyes are characteristic of many syndromes and internal organ abnormalities involving the renal system.
What is ankyloglossia?
What is the treatment?
Who is more likely to experience it?
Tongue tie
A ridge of frenulum tissue attached to the underside of the tongue, causing a heart-shape at the tip of the tongue
Can be surgically incised if causing feeding issues
More common in boys, genetic component
What is a ridge of frenulum tissue attached to the underside of the tongue that may cause feeding issues in newborns?
A tongue tie or ankyloglossia
If when attempting to breastfeed and the mother experiences pain, how does she remove the baby from the breast in order to readjust them?
Break the suction by inserting their finger into the side of the infants mouth between the gums and keep it there until the nipple is completely out of the newborns mouth
You are assessing a new infant in the community clinic and you notice white patches on the mucous membranes of the mouth and cheeks. What is this?
Thrush
Candida albicans infection
What is thrush?
How is it treated?
Candida albicans infection
White fungal patches that adhere to mucous membranes of the mouth (cheeks, lips) caused by exposure to Candida albicans
Treated with anti-fungal drops
Should treat mother too (nipples)
You are assessing a newborn boy and you notice that his breasts are enlarged and they actually secrete a little milk. Is this normal? What is it caused by? What is the treatment?
It is normal for both boys and girls
Caused by high exposure to maternal estrogen in utero
No treatment needed, it usually dissipates in a few weeks
What is talipes equinovarus?
What can it be caused by?
How is it treated?
Also called club foot
A painless malposition of the feet – can be turned in.
May be due to intrauterine positioning, environmental or genetic factors
Can be linked to other conditions such as spina bifida
Treated with casting, splinting or surgery; and physiotherapy
You are assessing the newborn and you notice that she has malpositioned feet that are turned in. What is this called? What else should we carefully evaluate for?
Talipes equinovarus (aka club foot)
Look for spina bifida
You are assessing the newborn boy. What conditions are you assessing the penis for?
Hypospadias - urethral opening on the underside of the penis
Epispadias - urinary meatus on the dorsal (top) surface of the glans
What is hypospadias?
What are the risk factors?
What is the treatment?
The urethral opening is on the underside (ventral aspect) of the penis at any place along the shaft
Risk factors: Mothers >35, obesity, fertility or hormone treatments
Tx: Surgery – baby should not be circumcised as foreskin might be needed for repair
What is epispadias?
What is the treatment?
The urinary meatus is on the dorsal surface (top side) of the glans
Rare birth defect
Tx: surgery
Can also happen in girls where urethral opening is located elsewhere and there are other abnormalities of the genitalia
You are assessing a newborn boy and you notice that there is a collection of blood around the testes. What is this?
Hydrocele
What is hydrocele?
What causes this?
What is the treatment?
A collection of fluid surrounding the testes in the scrotum
During development, each testicle has a naturally occurring sac around it that contains fluid. Normally, this sac closes itself and the body absorbs the fluid inside during the baby’s first year. However, this doesn’t happen for babies with a hydrocele.
Usually resolves by age 1 without intervention
When does a child’s testicles descend into the scrotum?
Towards the end of pregnancy
You are seeing a mother of a new baby girl at the clinic and she reports to you that she has seen some blood and mucous in her daughters diapers and she is concerned. What is this?
What treatment is required?
Pseudomenstruation
Can present in girls in the first few weeks of life.
It is caused by the drop in estrogen experienced when the baby is no longer receiving this hormone from her mother
No treatment needed
What is pseudomenstruation?
a vaginal discharge composed of mucus mixed with blood
may be present during the first few weeks of life
requires no treatment.
What is leukorrhea in the newborn?
whitish discharge from vagina – caused by mother’s estrogen in newborn
What is a whitish discharge noticed from the vagina of the newborn girl?
Leukorrhea
What is developmental dysplasia of the hip (DDH)?
Who is it more common in?
Condition where socket of hip joint does not form properly – too shallow so that ball of hip is loose and can come out
More common in females, left hip and firstborns
How is developmental dysplasia of the hip (DDH) treated?
Treated with Pavlik harness
May need surgery
What are the signs and symptoms of developmental dysplasia of the hip (DDH)?
MEMORY: the hips move ABOUT too much
A - asymmetrical gluteal folds
B - Barlow test is positive (hip can be popped out of place)
O - Ortolani test positive (hip can be popped back in)
U - uneven knee levels
T - thigh folds uneven
You are assessing a newborn and as you assess the back, you notice that their gluteal folds are asymmetrical. What should you further assess this child for?
Developmental Dysplasia of the Hip (DDH)
What does the Barlow test determine?
How is it performed?
Determines if the hip can pop out of place to assess for Developmental Dysplasia of the Hip (DDH)
Examiner places the middle finger over the greater trochanter and the thumb along the midthigh.
The hip is flexed to 90 degrees and adducted, followed by gentle downward pushing of the femoral head.
If the hip can be dislocated with this manoeuvre, the femoral head moves out of the acetabulum, and the examiner feels a “clunk.”
What does the Ortolani test determine?
How is it performed?
Determines if the dislocated hip can pop in to place to assess for Developmental Dysplasia of the Hip (DDH)
As the hip is abducted and upward leverage is applied, a dislocated hip returns to the acetabulum with a clunk that is felt by the examiner.
Describe the rooting reflex
When does it disappear?
Elicited when the side of the newborn’s mouth or cheek is touched.
The newborn turns toward that side and opens the lips
Disappears 3-4 months
Describe the sucking reflex
When does it disappear?
An object placed in the newborn’s mouth or anything touches the lips will elicit this reflex.
Disappears after 3 months
Describe the Moro reflex
When does it disappear?
Elicited when the newborn is startled or lifted slightly above the crib and then suddenly lowered.
The newborn’s arms straighten, hands move outward (fingers fan out), thumb and forefinger form a “C” and knees flex. Slowly the arms return to the chest
Disappears 5-6 months
Describe the tonic neck reflex
When does it disappear?
When infant is in a supine position, with head turned to one side, the arm and leg extend on the side to which the head is turned; the opposite arm and leg flex (“fencing” position).
Disappears 6-7 months
Describe the palmar grasp reflex
When does it disappear?
Place a finger in the newborn’s palm. The newborn’s fingers curl around the examiner’s finger
Disappears 2-3 months
Describe the plantar grasp reflex
When does it disappear?
Place finger under toes, toes will curl
Disappears at 9-10 months
Describe the Babinski reflex
When does it disappear?
Fanning and hyperextension of all the toes and dorsiflexion of the big toe, occurs when the lateral aspect of the sole is stroked from the heel upwards and across the ball of the foot.
Disappears 2 years of age
Describe the Galant reflex
When does it disappear?
This reflex is observed when the infant, while prone and stroked along the spine, causes the pelvis to turn to the stimulated side
Disappears at 1 month
Describe the Stepping reflex
When does it disappear?
When held upright with one foot touching a flat surface, the newborn puts one foot in front of the other and “walks”
Disappears at 2 months
Describe the levels of behavioural adaptations of the newborn
First - autonomic regulation
Second - motor organization
Third - State regulation (sleep/wake cycles)
Fourth - Attention and social interaction
What is the optimal state of arousal for the newborn?
Quiet alert state
During what state do newborns smile, vocalize, move in synchrony with speech, watch their parents’ faces, and respond to people talking to them?
Quiet alert state
What is the ability to make smooth transitions between sleep and wake states called?
State modulation
The ability to regulate sleep–wake states is essential in the newborn’s _______________ development.
Term newborns are better able than ________ infants to cope with external or internal factors that affect the sleep–wake patterns.
neurobehavioural
preterm
What is one thing the newborn should be able to do prior to getting their first bath?
How long after birth does this happen
Regulate their body temperature
Can take 8 hours or more
How can we ensure the newborns temperature stays stable during their first bath?
Wash hair separate from the body
Wash hair, dry it and then apply cap prior to bathing infant body
OR
Dry infant, wrap in towel or receiving blanket, and then wash infants hair, drying well after with a towel and applying a cap
What are some safety topics that should be taught to parents about bathing their infant?
Test water before baby goes in on inner part of the arm
DO NOT put water in after baby
Do not leave them alone
Bathing a newborn
Move from ______ areas to the most ______ area.
Wipe each eye from the _______ to _______ canthus
Use ________ of the washcloth to wash ears
Use __________ for the face, and can use __________ for rest of bath
cleanest, soiled
inner, outer
corner
plain, warm water
a mild non scented soap
What should be done at the end of each feeding?
Wipe the gums with a soft cloth
What should be done with the residual vernix on the newborn?
Leave it on the skin allowing it to wear off with normal care and handling
What type of bathing results in less heat loss and crying?
Immersing the infant (keeping the shoulders covered)
Why should harsh or antibacterial soaps not be used when bathing a newborn?
An important consideration in skin cleansing is preservation of the skin’s acid mantle, which is formed from the uppermost horny layer of the epidermis, sweat, superficial fat, metabolic products, and external substances such as amniotic fluid and microorganisms.
To protect the newborn’s skin, it is best to use a cleanser with a neutral pH and preferably without preservatives or with preservatives recognized as safe and well tolerated in newborns.
Do not use ______ water to wash the newborns hair as the temperature can change suddenly
Running
Can the area over a babies fontanels be washed?
Yes
How can we best wash the babies head and hair to prevent heat loss?
Do it before or after washing the rest of the body and then dry off completely; this way the body and the head are not wet at the same time
What type of soap/shampoo should be used?
Brands don’t matter, but it should be a mild soap/shampoo and unscented
What is seborrheic dermatitis?
What does it look like?
A chronic, recurrent, inflammatory reaction on the skin occurring most commonly on the scalp (cradle cap)
The lesions are characteristically thick, adherent, yellowish, scaly, oily patches that may or may not be mildly pruritic. Diagnosis is made primarily on the basis of the appearance and the location of the crusts or scales.
How is seborrheic dermatitis be prevented?
Scalp desquamation is what causes the cradle cap, this can be prevented with adequate scalp hygiene.
Frequently, parents omit shampooing the infant’s hair for fear of damaging the “soft spots,” or fontanels.
The nurse should discuss how to shampoo the infant’s hair and emphasize that the fontanel is like skin anywhere else on the body—it does not puncture or tear with mild pressure.
Remove any scales that present with a find toothed comb or brush after washing to prevent it from becoming full blown cradle cap
How is seborrheic dermatitis treated?
When cradle cap lesions are present, the treatment is directed at removing the crusts.
Parents should be taught the appropriate procedure to clean the scalp. Education may need to include a demonstration.
Shampooing should be done daily with a mild soap or commercial baby shampoo; medicated shampoos are not necessary, but an anti-seborrheic shampoo containing sulfur and salicylic acid may be used. Shampoo is applied to the scalp and allowed to remain on the scalp until the crusts soften. Then the scalp is thoroughly rinsed.
A fine-tooth comb or a soft facial brush helps remove the loosened crusts from the strands of hair after shampooing.
How does the umbilical cord stump deteriorate?
If there is only odour but no other indications of an infection, what does this indicate?
What other signs of infection should we be looking for?
Process of dry gangrene
Odour alone is not a positive indicator of omphalitis (infection of the umbilical stump)
Signs include redness, swelling, exudate, pain in the area
What is the term for an infection of the umbilical stump?
Omphallitis
What is a small, red, raw-appearing polyp where the umbilical cord separates?
Granuloma
When can the cord clamp be removed?
Once the cord is dry, usually 24-36 hours after birth but it is not routine practice in all hospitals; some send the newborn home with the clamp in place and it will fall off when the cord falls off
It is important to ensure that if a cord clamp remover is used, it is _______ between uses.
disinfected
If the parents are goin to cloth diaper, what should they be washed with?
Fragrance-free detergents
In baby girls, it is important to wipe _____________.
Front to back
What should be applied to the baby after cleaning their bottom with a mild soap and water?
Barrier cream
Are uric acid crystals in the diaper area normal?
Yes and will go away within the first week
What should we do to prevent diaper rash in newborns/babies?
- change diaper as soon as wet/soiled
- after using wipes, allow the area to air dry
- use zinc based barrier cream after cleaning the baby up
- expose the infants bottom to air several times a day (i.e. during tummy time)
What does a rash on an infants bottom that persists for more than 3 days mean?
It might be fungal and will need to be treated
What does diaper rash look like?
This dermatitis or skin inflammation appears as redness, scaling, blisters, or papules.
What factors contribute to the development of diaper rash?
Various factors contribute to diaper rash, including infrequent diaper changes, diarrhea, use of plastic pants to cover the diaper, or a change in the infant’s diet, such as when solid foods are added.
How should the babies bottom be cleaned during each diaper change?
Plain water with mild soap is used to cleanse the diaper area
If baby wipes are used, they should be unscented and contain no alcohol.
The baby’s skin should be allowed to dry completely before applying another diaper.
Diapers should be checked _______ and changed as soon as ___________.
often
the baby voids or stools
If the parents have been using baby wipes during diaper changes and the baby develops diaper rash, what should they do?
Change to washing with plain water rather than the wipes
What might be helpful in restoring the skin integrity when diaper rash occurs in the infant to provide some protection from the irritants of urine and stool?
Emollients, creams, or other protectants such as zinc oxide
Although diaper rash can be alarming to parents and annoying to babies, most cases resolve within _________ with simple home treatments.
a few days
What can contribute to a fungal diaper rash?
The usual source of infection is from handling by persons who do not practice adequate hand hygiene.
It may also appear 2 to 3 days after an oral infection (thrush).
What is the most common fungus to cause diaper rash?
Candida albicans
What does a fungal diaper rash look like?
dermatitis appears in the perianal area, inguinal folds, and lower abdomen. The affected area is intensely erythematous with a sharply demarcated, scalloped edge, often with numerous satellite lesions that extend beyond the larger lesion.
What is the treatment for a fungal diaper rash?
Anticandidal ointment, such as clotrimazole or miconazole, with each diaper change.
Sometimes the infant also is given an oral antifungal preparation such as nystatin or fluconazole to eliminate any gastrointestinal source of infection.
What is a circumcision?
a surgical procedure in which the prepuce, an epithelial layer covering the penis, is separated from the glans penis and excised which permits exposure of the glans
About how many man worldwide are circumcised? How do Alberta’s rates compare?
1/3
A little higher at 44%
Most parents’ decisions regarding circumcision are based on ______ rather than _______ reasons
social
medical
Does the Canadian Pediatric Society suggest circumcisions anymore?
“The overall evidence of the benefits and harms of circumcision is so evenly balanced that it does not support recommending circumcision as a routine procedure for newborns”
A reason the Canadian Pediatric Society would suggest a circumcision is phimosis. What is this?
the inability to retract the skin (foreskin or prepuce) covering the head (glans) of the penis
There is a strong association between _____ infection and penile cancer regardless of circumcision status, with 80% of tumour specimens being positive.
HPV
Observational studies performed in Africa and in developed countries since the emergence of HIV/AIDS have suggested that uncircumcised men are at _______ risk for HIV infection.
higher
This may suggest circumcision’s could reduce the risk but unsure if this can be applied to populations in developed countries
What is the strongest risk factor for penile cancer?
phimosis (the inability to retract the skin (foreskin or prepuce) covering the head (glans) of the penis)
Female partners of circumcised men have a ______ cervical cancer risk but it is expected that routine ____ vaccination for girls will dramatically decrease the incidence rate of cervical cancer.
reduced
HPV
What are the most common minor complications associated with circumcision?
Bleeding and infection
What should parents be taught about circumcision care?
Takes 7-10 days to heal
Gently wash penis with warm water after each diaper change
Put petroleum jelly on incised area as directed by physician
Fasten diaper loosely
A thin yellow film will form over incision area – this is normal – leave it.
What types of anesthetics might be used for a newborn undergoing circumcision?
ring block
dorsal penile nerve block (DPNB)
topical anesthetic such as eutectic mixture of lidocaine and prilocaine
What nonpharmacological methods may help with pain management for a newborn undergoing circumcision?
concentrated oral sucrose
non-nutritive sucking
swaddling
Pain during circumcision is most effectively managed using a combination of ___________ and ____________ measures.
pharmacological
nonpharmacological
What can be done to help a newborn baby after circumcision for the pain?
Immediately return to parents
Encourage breastfeeding and/or skin to skin contact
Fussy, disruption of sleep/wake cycles and feeding behaviours
Oral acetaminophen can be given before procedure and every 4 hours after
What is the maximum dose of acetaminophen in newborns?
maximum of five doses in 24 hours or a maximum of 75mg/kg/day.
In what situations would a parent need to contact their care provider after their newborn has a circumcision?
-baby running fever
-signs of an infection (swelling, redness, thick yellow discharge, red streak on the shaft of the penis)
-bleeding or bloodstained area larger than a quarter
-very fussy, high-pitched cry, or refusing to eat
-baby has not passed urine for 12 hours after the procedure
What is the purpose of the Universal Metabolic Newborn Screening?
to facilitate early recognition and treatment of several disorders before the onset of symptoms.
What is the recommended time frame for collecting a blood sample for the Universal Metabolic Newborn Screening?
Between 24-48 hours
Although there is no national policy for the extent of Universal Metabolic Newborn Screening, what diseases are tested for by most provinces?
- phenylketonuria (PKU)
- galactosemia
- congenital hypothyroidism (CH)
- Hb defects like sickle cell disease
What screening test is recommended to be done at the same time as the Universal Metabolic Newborn Screening, even though this practice isn’t routine in all provinces/territories in Canada?
Congenital hearing impairment
What is an an umbrella term applied to a large group of inherited diseases caused by the absence or deficiency of a substance essential to cellular metabolism, usually an enzyme?
Inborn errors of metabolism (IEM)
What is IEM?
What is the end result of it?
Inborn errors of metabolism
An umbrella term applied to a large group of inherited diseases caused by the absence or deficiency of a substance essential to cellular metabolism, usually an enzyme.
When the normal metabolic process is interrupted as a result of a missing enzyme, an accumulation of substances precedes the interruption, the end product of the process is absent, or the process takes an alternate metabolic pathway.
The consequence is manifested as an illness. Most IEMs are characterized by abnormal protein, carbohydrate, or fat metabolism.
While assessing a 2-hour-old neonate, a nurse observes acrocyanosis. Which nursing action should be performed initially?
a) Activate the code blue or emergency system
b) Do nothing because acrocyanosis is normal in the neonate
c) Immediately take the neonate’s temperature
d) Notify the physician of the need for a cardiac consult
b) Do nothing because acrocyanosis is normal in the neonate
At 1 minute of age, a neonate is pink with acrocyanosis; has flexed knees, clenched fists, a whimpering cry and a heart rate of 128 beats per minutes. The newborn withdraws the foot when slapped on the sole. What Apgar score would the nurse record for the newborn?
a) Apgar is 5
b) Apgar is 7
c) Apgar is 8
d) Apgar is 10
b) Apgar is 7
Activity (muscle tone) - flexed limbs - 1
Pulse - > 100 - 2 points
Grimace - prompt response to stimulation - 2
Appearance - pink body, blue extremities - 1
Respirations - weak cry -1
A neonate has been diagnosed with caput succedaneum (i.e., caput). Which information should the nurse include while teaching the parents about caput?
a) It usually resolves in 3 to 6 weeks
b) It doesn’t cross the cranial suture line
c) It’s a collection of blood between the skull and periosteum
d) It involves swelling of the tissue over the presenting part of the fetal head
d) It involves swelling of the tissue over the presenting part of the fetal head
A neonate has just been delivered without incident. Which symptom would indicate successful adaptation to extrauterine life?
a) Nasal flaring
b) Light audible grunting
c) Respiratory rate 40-60 breaths/minute
d) Apgar score of 5
c) Respiratory rate 40-60 breaths/minute
By what age does the posterior fontanel usually close?
a) 6 to 8 weeks
b) 10 to 12 weeks
c) 4 to 6 months
d) 8 to 10 months
a) 6 to 8 weeks
What information would the nurse include when teaching post-circumcision care to the parents of a newborn? Select all that apply.
a) The parent must note that the newborn has voided
b) Petroleum jelly should be used
c) The newborn can have tubs baths while the circumcision heals
d) The circumcision will require care for 2 to 4 days after discharge
e) A large amount of blood should be reported
a) The parent must note that the newborn has voided
b) Petroleum jelly should be used
d) The circumcision will require care for 2 to 4 days after discharge
e) A large amount of blood should be reported
A nurse is evaluating the return demonstration of cord
care by the mother of a newborn. Which actions would
the nurse encourage the mother to perform? Select all
that apply.
a) Placing the diaper below the cord
b) Tugging gently on the cord as it begins to dry
c) Applying antibiotic ointment to the cord twice daily
d) Cleaning the cord with alcohol several times a day
e) Using plain water and a Q-tip to cleanse the cord
a) Placing the diaper below the cord
e) Using plain water and a Q-tip to cleanse the cord
Which findings are normal in a neonate born at 42 weeks gestation? Select all that apply.
a) A three-vessel umbilical cord
b) Peeling skin on the feet
c) Absence of sole creases
d) Absence of vernix caseosa
e) Cyanosis of the hands and feet
a) A three-vessel umbilical cord
b) Peeling skin on the feet
d) Absence of vernix caseosa
e) Cyanosis of the hands and feet
In the classification of newborns by gestational age and birth weight, which is the appropriate-for-gestational-age (AGA) weight?
a) It falls between the 25th and 75th percentile for the infant’s age
b) It depends on the infant’s length and size of the head
c) The plot point falls between the 10th and 90th percentile
d) It should be modified to consider intrauterine growth restriction (IUGR)
c) The plot point falls between the 10th and 90th percentile
What would the nurse be aware of with regard to functioning of the renal system in the newborn?
a) The physician should be notified if the infant has not voided in 24 hours
b) Newborns should have 6 to 10 wet diapers during the first days of birth
c) “Brick dust” (uric acid crystals) on a diaper is always cause to notify the physician
d) Weight loss from fluid loss and other normal factors should be made up in 4 to 7 days
a) The physician should be notified if the infant has not voided in 24 hours
What percentage of postpartum clients experience postpartum blues?
a) 20% to 25%
b) 30% to 45%
c) 50% to 80%
d) 100%
c) 50% to 80%
A primipara who is Rh negative has just given birth to an Rh positive baby. Which priority nursing intervention should be included in the plan of care?
a) Administer RhoGam to the neonate within 3 days
b) Administer RhoGam to the client within 3 days
c) Administer RhoGam to the client at her first postpartum visit at 6 weeks
d) Administer RhoGam to the baby at the first well baby visit.
b) Administer RhoGam to the client within 3 days
Which condition should the nurse look for in a client’s history that may explain an increase in the severity of afterpains?
a) Bottle-feeding
b) Diabetes
c) Multiple gestation
d) Primiparity
c) Multiple gestation
Multiple gestation, breastfeeding, multiparity and conditions that cause over-distension of the uterus with increase the intensity of afterpains.
The nurse is assessing a postpartum client who has lochia serosa. When the client asks the nurse how long to expect this type of bleeding, the nurse’s response should be:
a) Days 3 and 4 postpartum
b) Days 3 to 10 postpartum
c) Days 10 to 14 postpartum
d) Days 14 to 42 postpartum
b) Days 3 to 10 postpartum
The nurse is assessing a client who is 4 hours postpartum. Based on the findings documented by the nurse, which action is most appropriate at this time?
Progress notes:
06/02/17 @1830: Client’s vital signs stable. Perineal pad changed for moderate amount of red drainage. Uterus palpated at the level of the umbilicus and the left side of the abdomen.
a) Ask the client to empty her bladder
b) Raise the head of the bed
c) Straight catheterize the client immediately
d) Call the client’s primary health care provider for direction
a) Ask the client to empty her bladder
A nurse observes several interactions between a client and her newborn son. Which behaviours by the mother would the nurse identify as evidence of mother-infant attachment? Select all that apply.
a) Talks to and coos at her son
b) Cuddles her son close to her
c) Does not make eye contact with her son
d) Encourages the father to hold the baby
e) Takes a nap while the baby is sleeping
a) Talks to and coos at her son
b) Cuddles her son close to her
A nurse is caring for a 1-day old postpartum client. The progress note below informs the nurse that the client is in which phase of the postpartum period (according to Rubin)?
Progress notes:
02/04/17v@ 1715: Mother verbalizing labour and delivery experience. Doesn’t appear confident about holding baby or changing diapers. Asking appropriate questions.
a) Letting go
b) Taking in
c) Holding out
d) Taking hold
b) Taking in
A client is two days postpartum. She states that she hasn’t had a bowel movement since before delivery and is experiencing slight discomfort. She has a second degree laceration. The nurse knows that the best remedy is:
a) A suppository
b) An enema to alleviate gas pains quickly
c) Stool softeners and fluids
d) Pain medication for the discomfort
c) Stool softeners and fluids
A multigravida 30-year-old woman has given Cesarean birth to a healthy term female infant due to abnormal fetal heart rate tracings. At 2 hours postpartum, the nurse assesses the client’s catheter and observes that the client’s urine is slightly red-
tinged. What should the nurse do next?
a) Continue to monitor the client’s input and output
b) Palpate the client’s fundus gently every 15 minutes
c) Assess the placement of the catheter
d) Contact the client’s physician for further instructions
d) Contact the client’s physician for further instructions
The nurse is preparing to perform a fundal massage on a
client who is 2 hours postpartum. Order the sequence of events for performing this procedure. All options must be
used:
a) Rotate the upper hand to massage the uterus until firm
b) Place the client in the supine position
c) Gently press the fundus between the hands using slight downward pressure
d) Place one hand around the top of the fundus
e) Ask the client to void
f) Place one hand on the abdomen just above the symphysis pubis
e) Ask the client to void
b) Place the client in the supine position
f) Place one hand on the abdomen just above the symphysis pubis
d) Place one hand around the top of the fundus
a) Rotate the upper hand to massage the uterus until firm
c) Gently press the fundus between the hands using slight downward pressure
When completing the morning postpartum assessment,
a nurse notices a client’s perineal pad is completely
saturated with lochia rubra. No clots. Which action should
be the nurse’s first response?
a) Vigorously massage the fundus
b) Immediately call the physician
c) Have another nurse review the assessment
d) Ask the client when she last changed her perineal pad
d) Ask the client when she last changed her perineal pad
Which finding is normal for a postpartum breastfeeding
client who has experienced a vaginal birth?
a) Redness or swelling in the calves
b) A palpable uterine fundus beyond 10 days postpartum
c) Vaginal dryness after the lochial flow has ended
d) Dark red lochia for approximately 6 weeks after the birth
c) Vaginal dryness after the lochial flow has ended
Which complication may be indicated by continuous
seepage of blood from the vagina of a postpartum client,
when palpation of the uterus reveals a firm fundus, 1 cm
below the umbilicus.
a) Retained placental fragments
b) Urinary tract infection
c) Cervical lacerations
d) Uterine atony
c) Cervical lacerations
Four clients each gave birth 12 hours ago. Which one
would most likely suffer complications after birth?
a) Cesarean birth, incisional site intact, hemoglobin level 9.8 g/dl
b) Cesarean birth, incisional site intact, pulse 84 beats/minute
c) Vaginal delivery, midline episiotomy, temperature 37.4° C
d) Vaginal delivery, ruptured membranes 10 hours before delivery
a) Cesarean birth, incisional site intact, hemoglobin level 9.8 g/dl
normal is 120–160 mmol/L (12–16g/dL)
A graduate nurse is explaining to the nurse mentor how to assess jaundice and the effects of phototherapy in a neonate. Which statement made by the graduate nurse would need clarification? Select all that apply.
a) “It is best to observe for jaundice on the sternum.”
b) “The unconjugated bilirubin is the dangerous one.”
c) “I will carefully record the newborn’s output, as limiting fluids is helpful.”
d) “Phototherapy treatment can cause frequent stools.”
e) After the TcB meter is used on the newborn, I will need to know the value displayed on the meter and the newborn’s gestational age in order to determine level of risk according to the nomogram
a) “It is best to observe for jaundice on the sternum.”
c) “I will carefully record the newborn’s output, as limiting fluids is helpful.”
e) After the TcB meter is used on the newborn, I will need to know the value displayed on the meter and the newborn’s gestational age in order to determine level of risk according to the nomogram
A client with gestational diabetes has just delivered a 4520-gram neonate at 39 weeks gestation. Which priority nursing intervention should be included in the care plan?
a) Teach the mother about the nutritional needs of the neonate
b) Obtain a serum neonatal glucose level
c) Obtain a neonatal bilirubin level
d) Prepare to administer insulin to the neonate
b) Obtain a serum neonatal glucose level
Priority is to monitor the neonate’s serum glucose level due to increased risk of hypoglycemia.
During pregnancy, the fetus secretes high levels of insulin to counteract the high maternal glucose levels.
This elevated insulin secretion in the neonate can lead to severe hypoglycemia after birth.
Because the neonate is at risk for hypoglycemia, insulin wouldn’t be appropriate.
Which of the following actions places a neonate at an increased risk for losing heat during the transition period?
a) Placing a cap on the neonate’s head immediately after delivery
b) Preheating the radiant warmer prior to delivery
c) Placing the neonate skin-to-skin
d) Wrapping the neonate in the same blanket used for drying
d) Wrapping the neonate in the same blanket used for drying
A nurse is explaining physiologic jaundice to parents of a neonate. Which statement made by the parents would indicate a correct understanding of the concept?
a) “The neonate usually also has a medical problem.”
b) “In term neonates, it usually appears after 24 hours.”
c) “It’s caused by elevated conjugated bilirubin levels.”
d) “It’s usually progressive from the neonate’s feet to his head.”
b) “In term neonates, it usually appears after 24 hours.”
When caring for an infant of a mother with gestational diabetes, which physiological finding is most indicative of a hypoglycemic episode?
a) Hyperalert state
b) Jitteriness
c) Excessive crying
d) Mottling
b) Jitteriness
A nurse is caring for a client with gestational diabetes. Which complication is the neonate most at risk for developing?
a) Anemia
b) Hypoglycemia
c) Jaundice
d) Cold Stress
b) Hypoglycemia
What statement is true about jaundice?
a) Neonatal jaundice is not common, but kernicterus is
b) The appearance of jaundice during the first 24 hours indicates a pathological process
c) Jaundice will most likely appear before discharge from hospital
d) Breastfed babies have a lower incidence of jaundice
b) The appearance of jaundice during the first 24 hours indicates a pathological process
What infant response to cool environmental conditions is protective?
a) Dilation of peripheral vessels
b) Shivering
c) Decreased respirations
d) Flexed position
d) Flexed position
A nurse enters the room to assess the mother
and newborn. She finds the newborn unwrapped
in his bassinet with a fan blowing over him. The
nurse instructs the mother that the fan should not be directed toward the newborn. What is the basis of the nurse’s response?
a) The baby will lose heat by convection, which means he will lose heat from his body to the cooler, ambient air
b) The baby may lose heat by conduction, which means that he will lose heat from his body to the cooler, ambient air
c) The baby may lose heat by evaporation
d) The baby will get cold stressed easily and needs to be bundled with several blankets at all times
a) The baby will lose heat by convection, which means he will lose heat from his body to the cooler, ambient air
The nurse is assigned to the postpartum unit caring for a breastfeeding client who gave birth by cesarean section. The client asks advice on breastfeeding. Which instruction on breastfeeding is most helpful at this time?
a) Delay breastfeeding until 24 hours after childbirth
b) Breastfeed frequently during the day and every 4-6 hours at night
c) Use the cradle-hold position to avoid incisional discomfort
d) Use the football-hold to avoid incisional discomfort
d) Use the football-hold to avoid incisional discomfort
A nurse is caring for a client with a history of a warm, reddened, painful area in the breast diagnosed as mastitis as well as cracked and fissured nipples. The client expresses the desire to continue breastfeeding throughout treatment. Which instructions would the nurse include to prevent recurrence of this condition? Select all that apply.
a) Wash the nipples with soap & water
b) Change the breast pads frequently
c) Expose the nipples to air for part of the day
d) Wash hands before handling the breast and breastfeeding
e) Make sure the baby grasps the nipple only
f) Release the baby’s grasp on the nipple before removing the baby from the breast
b) Change the breast pads frequently
c) Expose the nipples to air for part of the day
d) Wash hands before handling the breast and breastfeeding
f) Release the baby’s grasp on the nipple before removing the baby from the breast
Which statement by a client shows she understands how to prevent breast engorgement while breastfeeding?
a) “I will apply moist heat to my breasts three times a day.”
b) “I will breastfeed about every 2 hours.”
c) “I will use a breast pump to obtain milk for feedings.”
d) “I will wear a tight bra continually.”
b) “I will breastfeed about every 2 hours.”
A mother is preparing to breastfeed her baby. Which of the following actions would encourage the baby to open the mouth wide for the feeding?
a) Holding the baby in the en face position
b) Pushing down on the baby’s lower jaw
c) Tickling the baby’s lips with the nipple
d) Giving the baby a trial bottle of formula
c) Tickling the baby’s lips with the nipple
A nurse who is caring for a mother/newborn dyad 72 hours after a cesarean birth has identified the following nursing diagnosis: Effective breastfeeding. Which of the following would warrant this diagnosis?
a) Baby’s lips are flanged when latched
b) Baby feeds every four hours
c) Baby lost 12% of weight since birth
d) Baby has wet one diaper in the last 24 hours
a) Baby’s lips are flanged when latched
A mother tells the nurse that she is discontinuing breastfeeding her 5-month-old infant. What should the nurse recommend that the infant be given?
a) Skim milk
b) Whole cow’s milk
c) Commercial iron-fortified formula
d) Commercial formula without iron
c) Commercial iron-fortified formula
When is the best age for solid food to be introduced into the infant’s diet?
a) 3 months
b) 6 months
c) When birth weight has tripled
d) When tooth eruption has started
b) 6 months
For a breastfeeding client on the fourth postpartum day, which breast examination findings are normal?
a) Soft, non-tender breasts; colostrum present
b) Engorged breasts with inflamed, radiating areas that are sore to touch
c) Slightly tender, cracked nipples; slightly firm, non tender breasts; transitional milk
d) Intact nipples, firm, tender breasts; transitional milk
d) Intact nipples, firm, tender breasts; transitional milk
A nurse is discussing signs and symptoms of mastitis with a mother who is breastfeeding. Which sign should the nurse teach the mother about?
a) Increased heart rate
b) Numbness in the breast
c) A hot, reddened area on the breast
d) A small, white blister on the tip of the nipple
c) A hot, reddened area on the breast
Which signs would the nurse teach the breastfeeding
mother that indicate the infant has latched on correctly to
the breast. Select all that apply.
a) She feels a firm tugging sensation on her nipples
b) The baby sucks with cheeks rounded, not dimpled
c) The baby’s jaw glides smoothly with sucking
d) She hears a clicking or smacking sound
e) The baby’s nose is depressing the breast
a) She feels a firm tugging sensation on her nipples
b) The baby sucks with cheeks rounded, not dimpled
c) The baby’s jaw glides smoothly with sucking
What should the nurse keep in mind when helping the breastfeeding woman position the baby for nursing?
a) The cradle position is usually preferred by mothers who had a caesarean birth
b) Women with perineal pain and swelling prefer the modified cradle position
c) Whatever the position used, the infant’s body should be aligned (ear, shoulder, hip)
d) While supporting the head, the mother should push gently on the occiput
c) Whatever the position used, the infant’s body should be aligned (ear, shoulder, hip)
What should the nurse be aware of with regard to questions of human breast milk?
a) Frequent feedings during predictable growth spurts stimulate increased milk production
b) The milk of preterm mothers is the same as the milk of mothers who gave birth at term
c) The milk at the beginning of the feeding is the same as the milk at the end of the feeding
d) Colostrum is an early, less concentrated, less rich version of breast milk
a) Frequent feedings during predictable growth spurts stimulate increased milk production
Which is correct regarding recommendations about
infant nutrition according to the Canadian Pediatric Society?
a) Infants should be given only human milk for the first 6 months of life
b) Infants fed on formula should be started on solid foods sooner than breastfed infants
c) If infants are weaned from breast milk before 12 months they should receive cow’s milk, not formula
d) After 6 months, mothers should shift from breast milk to cow’s milk
a) Infants should be given only human milk for the first 6 months of life
A nurse is teaching the parents of a 6-month-old infant about normal growth and development. Which statements regarding infant development are true? Select all that apply.
a) A 6-month-old has difficulty holding objects
b) A 6-month-old can usually roll from prone to supine and supine to prone positions
c) A 6-month-old may be experiencing teething
d) Stranger anxiety usually peaks at 12 to 18 months
e) Head lag is commonly noted in infants at 6 months
b) A 6-month-old can usually roll from prone to supine and supine to prone positions
c) A 6-month-old may be experiencing teething
A nurse is assessing a 10-month-old infant during a check-up. Which developmental milestone would the nurse expect the infant to display? Select all that apply.
a) Holding the head erect
b) Demonstrating good bowel and bladder control
c) Sitting on a firm surface without support
d) Bearing the majority of weight on legs
e) Walking backward
a) Holding the head erect
c) Sitting on a firm surface without support
d) Bearing the majority of weight on legs
A nurse is teaching parents about the developmental milestones of an infant. Place the following developmental activities for an infant in order of occurrence by age from earliest to latest. All options must be used.
a) Crawling on hands and knees
b) Sitting alone
c) Turning self from supine to prone
d) Turning self from prone to supine
e) Effectively using pincer grasp
d) Turning self from prone to supine
c) Turning self from supine to prone
b) Sitting alone
a) Crawling on hands and knees
e) Effectively using pincer grasp
What behaviour indicates that an infant has developed object permanence?
a) Recognizes familiar face, such as mother
b) Recognizes familiar objects, such as a bottle
c) Actively searches for a hidden object
d) Secures objects by pulling on a string
c) Actively searches for a hidden object
The nurse is interviewing the father of a 12-month-old. The child is playing on the floor when she notices an electrical outlet and reaches up to touch it. Her father says “No” firmly and moves her away from the outlet. What should the nurse say to the father about the child’s
developmental level?
a) She is old enough to understand the word “No”
b) She is too young to understand the word “No”
c) She should already know the electrical outlets are dangerous
d) She will learn safety issues better if she is spanked
a) She is old enough to understand the word “No”
At what age should the nurse expect an infant
to begin smiling in response to pleasurable stimuli?
a) 1 month
b) 2 months
c) 3 months
d) 4 months
b) 2 months
The clinic is lending a federally approved car seat to an infant’s family. Where is the safest place to put the car seat?
a) Front-facing in the back seat
b) Rear-facing in the back seat
c) Front-facing in the front seat with airbag on the passenger side
d) Rear-facing in the front seat with airbag on the passenger seat
b) Rear-facing in the back seat
A mother tells a nurse that her 22-month-old child says “no” to everything. When scolded, the toddler becomes angry and starts crying loudly, but then immediately wants to be held. What is the best interpretation of this behavior?
a) The toddler isn’t effectively coping with the stress
b) The toddler’s need for affection isn’t being met
c) This is normal behaviour for a 2-year-old child
d) This behavior suggests the need for counseling
c) This is normal behaviour for a 2-year-old child
Two toddlers are playing in a sandbox, when one child suddenly grabs a toy from another. What is the best interpretation of this behaviour?
a) This is typical behaviour because toddlers are aggressive
b) This is typical behaviour because toddlers are egocentric
c) Toddlers should know that sharing toys is expected of them
d) Toddlers should have the cognitive ability to know right from wrong
b) This is typical behaviour because toddlers are egocentric
A toddler’s parent asks the nurse for suggestions on dealing with temper tantrums. Which is the most appropriate recommendation?
a) Punish child
b) Leave the child alone until the tantrum is over
c) Ignore the behaviour, provided it is not injurious
d) Explain to the child that this is wrong
c) Ignore the behaviour, provided it is not injurious
A parent asks the nurse about how to deal with negativism in toddlers. What is the most
appropriate recommendation?
a) Punish the child
b) Provide more attention
c) Ask the child to not always say “no”
d) Reduce the opportunities for a “no” answer
d) Reduce the opportunities for a “no” answer
Which nursing interventions are important when caring for a hospitalized toddler. Select all that apply.
a) Provide thorough explanations to the toddler prior to the procedure
b) Instruct parent that regression commonly occurs
c) Encourage use of a security object from home
d) Allow client autonomy by offering select choices
e) Maintain the toddler’s routine when able
f) Discourage parents’ participation in the child’s care
b) Instruct parent that regression commonly occurs
c) Encourage use of a security object from home
d) Allow client autonomy by offering select choices
e) Maintain the toddler’s routine when able
Which type of play is most typical of the
preschool period?
a) Solitary
b) Parallel
c) Associative
d) Team
c) Associative
When introducing hospital equipment to a preschooler who seems afraid, which principle
should the nurse keep in mind?
a) The child may think the equipment is alive
b) The child is too young to understand what the equipment does
c) Explaining the equipment will only increase the child’s fear
d) One brief explanation is enough to reduce the child’s fear
a) The child may think the equipment is alive
What is the term for head-to-tail direction of growth?
a) Cephalocaudal
b) Proximodistal
c) Mass to specific
d) Sequential
a) Cephalocaudal
By the time children reach their 12th birthday,
which should they have developed a sense of
according to Erickson?
a) Identity
b) Industry
c) Integrity
d) Intimacy
b) Industry
By what age should the nurse be concerned about pubertal delay in girls?
a) If breast development has not occurred by age 12
b) If breast development has not occurred by age 13
c) If menarche has not occurred within 2 years of the onset of breast development
d) If menarche has not occurred within 3 years of the onset of breast development
b) If breast development has not occurred by age 13
The school nurse tells adolescents in the clinic that confidentiality and privacy will be maintained unless a life-threatening situation arises. Which statement is true regarding this practice?
a) It is not appropriate for a school setting
b) It is never appropriate because adolescents are minors
c) It is important in establishing trusting relationships
d) It is suggestive that the nurse is meeting his or her own needs
c) It is important in establishing trusting relationships
A mother tells the nurse that she doesn’t want her infant immunized because of the discomfort associated with injection. What should the nurse explain to the mother in response to her statement?
a) This cannot be prevented
b) Infants do not feel pain as adults do
c) This is not a good reason for refusing immunizations
d) You can breastfeed while the injection is being given
d) You can breastfeed while the injection is being given
An 18-month-old has just received routine immunizations. What information would the nurse give to the parents before they leave the office? Select all that apply.
a) Minor symptoms can be treated with acetaminophen
b) Minor symptoms can be treated with aspirin
c) Call the office if the toddler develops a high fever or seizures
d) Discomfort at the immunization site and mild fever are common
e) The parents should restrict toddler activity for the remainder of the day
a) Minor symptoms can be treated with acetaminophen
c) Call the office if the toddler develops a high fever or seizures
d) Discomfort at the immunization site and mild fever are common
What part of the vaccine stimulates an immune response?
a) Immunogen
b) Adjuvant
c) Additives
d) Preservative
a) Immunogen
What of the following statements are true about
Hepatitis B Immune Globulin (HBIg)? Select all that apply.
a) HBIg is given to an infant born to a mother who has acute or chronic Hepatitis B infection
b) HBIg provides immediate protection
c) HBIg provides long-term passive immunity
d) If the infant is born to an infected mother or to a mother who is a carrier, hepatitis B vaccine and HBIg should be given within 12 hours of birth.
a) HBIg is given to an infant born to a mother who has acute or chronic Hepatitis B infection
b) HBIg provides immediate protection
d) If the infant is born to an infected mother or to a mother who is a carrier, hepatitis B vaccine and HBIg should be given within 12 hours of birth.
In anaphylaxis, how many body systems are usually involved?
a) One
b) Two
c) Three
d) Four
b) Two
A 12-month-old is in to Clinic to receive immunization.
He has just received two injections. The child is upset
and is crying hard; then is suddenly silent. Facial flushing
and perioral cyanosis deepens. The child then resumes
crying. Which of the following reactions did this child
develop post immunization?
a) Fainting
b) Breath holding
c) Anxiety
d) Anaphylaxis
b) Breath holding
What are the steps to performing a metabolic newborn screening?
Wash hands
Explain to parents what you are doing
Warm heel first with a cloth soaked in warm water wrapped around foot or use of a disposable heel warmer for 5-10 minutes
Repeat hand hygiene and put on gloves
Clean area with skin antiseptic and allow to dry
Restrain infant foot and then puncture correct site using a spring-loaded automatic puncture device
How can the pain of performing a metabolic newborn screening be managed?
- have parent hold child
- breastfeeding
- use sugar drops
What often helps with obtaining enough blood from the heal stick used for the metabolic newborn screening?
Warming the area for 5-10 minutes to dilate the blood vessels in the area
Can be accomplished by a cloth soaked withwarmwater (not hot) and wrapped loosely around the foot provides effective warming. Disposableheelwarmers are available from a variety of companies; they should be used with care to prevent burns.
What type of device should be used to puncture a babies heal during the metabolic newborn screening?
A spring-loaded automatic puncture device causes less pain and requires fewer punctures than a manual lance blade; therefore, manual lance blades should not be used on newborns.
What is SIDS?
When does it peak?
Sudden Infant Death Syndrome
SIDS refers to the sudden and unexpected death of an apparently healthy infant usually under 1 year of age, which remains unexplained even after a full investigation” (PHAC, Joint Statement).
Peaks between 2 and 4 months
What risk factors are associated with SIDS?
MEMORY: SIMPLE
S - sleeping prone
I - Indigenous
M - male
P - premature
L - low birth weight
E - exposure to cigarette smoke (prenatal and postnatal)
What are ways to prevent a baby from dying of SIDS?
Sleep on their back
Limit smoke exposure
Do not co-sleep due to risks of parents falling asleep
Cool room - overheating is a risk factor
Swaddling - should be discontinued once baby tries to turn over
Firm bed - so on a crib mattress, not adult mattress, couch etc.
Supervised tummy time - strengthens neck so baby is less likely to get pinned by a blanket or crib
Safe cribs
-No toys or blankets in the crib
-No bumper pads
-Only one light blanket
-Pacifier – keeps them from going into too deep of a sleep
Room sharing
-Concerns SIDS might be due to immature brain stem, they go to sleep and don’t wake up
-Co-sharing is thought to provide another point of reference that is breathing, their body will unconsciously pick up
What is positional plagiocephaly?
A flattened area that may develop on the back of the head when infants are left supine while awake or in an infant seat for prolonged periods of time, rather than on their tummy
What is a flattened area on the back of the head that occurs when infants spend prolonged periods of time on their back?
Positional plagiocephaly
What can happen as the result of prolonged pressure on one side of the skull that occurs prior to the sutures closing?
The posterior occiput flattens over time; a transient typical bald spot will develop. As a result of prolonged pressure on one side of the skull, that side becomes misshapen; mild facial asymmetry may develop. The sternocleidomastoid muscle may tighten on the preferential side, and torticollis may also develop.
What is the initial treatment for torticollis and plagiocephaly?
What happens if it does not resolve within 4-8 weeks of beginning treatment?
Physiotherapy exercises to loosen the tight muscle and changing head position from side to side during feeding, carrying, and sleep
If not resolved, a customized helmet may be worn to decrease the pressure on the affected side of the skull
Why is it not suggested to have babies sleeping in a side laying position?
Anatomically, they have a barrel chest and flat, curveless spine, making it easier to role from the side to prone position
What is tummy time?
Supervised time when the conscious infant is placed prone on the floor; should be several times per day for increasing lengths of time
Benefits
- build neck muscles
- prevent misshaped head
- develop muscles needed for crawling
What is the current term for shaken baby syndrome?
Traumatic head injury due to child maltreatment (THI-CM)
What is THI-CM?
What can this lead to?
Traumatic head injury due to child maltreatment (THI-CM)
“THI-CM is defined broadly to include traumatic injury to the head (skull and/or brain and/or intracranial structures), which may also be accompanied by injury to the face, scalp, eye, neck or spine, as a result of the external application of force from child maltreatment” (Public Health Agency of Canada, 2020).
Shaking a baby causes a whiplash motion during which the brain repeatedly hits the front and back of the skull causing severe traumatic brain injury
THI –CM leads to severe lifelong injuries and death – signs and symptoms include lethargy, vomiting, inability to cry
What is the number 1 trigger for THI-CM?
What is vital to help prevent it?
Traumatic head injury due to child maltreatment (THI-CM)
Inconsolable crying is the number one trigger - Parents can get overwhelmed with being unable to stop infant crying
Educating parents about what to do when infant is crying is vital to help prevent THI-CM
What is the program used to educate new parents about infant crying and the danger of shaking a baby?
Period of PURPLE Crying
P - peak of crying - baby may cry more each week with the most at 2 months, then less at 3-5 months
U - unexpected - may cry and we don’t know why
R - resists soothing - baby may not stop crying, regardless of what you try
P - pain-like face - crying babies look like they are in pain, even when they are not
L - long lasting - crying can last as much as 5 hours a day or more
E - evening - may cry more in later afternoon/evening
According to CPS, what can we do to help a baby that is crying?
MEMORY: SOBBERS
S - Snuggle - holding your baby won’t spoil them; they may not want to be passed around though
O - Oscillating movements - sway, walk in a wrap/stroller, or a car ride
B - Bundle - wrap or swaddle them
B - Bath in warm water
E - ensure needs are met - change, feed, too hot/cold, check for fever
R - Remove stimuli - turn off lights, soft music/white noise may help
S - sucking - breastfeeding or pacifier
What physiologic adaptations need to occur for the newborn shortly after birth?
What are the consequences if they do not adapt?
Bilirubin metabolism - hyperbilirubinemia; jaundice in the newborn
Thermoregulation - cold stress; hypothermia
Glucose metabolism - hypoglycemia
What type of hemoglobin can be removed from the body?
Conjugated
What has to occur for unconjugated bilirubin from being soluble and excretable?
Conjugated
What happens to the hemoglobin when RBCs are broken down?
Splits into
heme - > iron
globin - > unconjugated bilirubin which must be conjugated before it can be excreted
What type of bilirubin leads to hyperbilirubinemia?
Unconjugated bilirubin
What is another term for unconjugated bilirubin?
Indirect bilirubin
What happens to the unconjugated bilirubin that does not bind or is unbound in the bloodstream?
Leaves vascular system and enters other extravascular tissues such as skin, sclera, and oral mucous membranes
Crosses blood brain barrier - can cause neurotoxicity
What are the 4 physiologic reasons for jaundice?
MEMORY: FAIL
F - fewer bilirubin binding sites
A - ability of liver to conjugate is reduced
I - Intestines change conjugated bilirubin to unconjugated
L - large RBC mass, short RBC lifespan
What refers to elevated serum bilirubin levels and is toxic to the brain?
Hyperbilirubinemia
What is bilirubin and how is it formed?
Bilirubin is a yellow substance formed when hemoglobin (the part of red blood cells that carries oxygen) is broken down as part of the normal process of recycling old or damaged red blood cells.
Bilirubin is carried by the blood stream to the _______ and is processed by attaching it to another chemical substance in a process called _______.
Liver
Bile
Processed bilirubin is called _________ while unprocessed bilirubin is called ____________.
Conjugated bilirubin
Unconjugated bilirubin
Once bilirubin is processed, it can be excreted as part of the ______ in the _________.
bile
duodenum
If bilirubin cannot be processed and excreted by the liver and bile ducts quickly enough, it builds up in the blood stream, resulting in _________
Hyperbilirubinemia
What is jaundice and what is it caused by?
Yellowing of the skin, scleral, and mucous membranes from a build up of bilirubin
____% of term infants and _____% of preterm infants develop jaundice in the __________ of life, typically a(n) ___________ hyperbilirubinemia
60% term, 80% preterm
1st week
unconjugated
How are infants screened for hyperbilirubinemia?
All infants in the first 24 hours of life
-total serum bilirubin (TSB)
-transcutaneous bilirubin
What are the risk factors for hyperbilirubinemia?
MEMORY: poor liver is BOMBARDED
B - breastfeeding (exclusive or partial)
O - over signs of jaundice ≤ 24 hours or before discharge at any age
M - male sex
B - bruising, cephalohematoma, etc.
A - age of mother ≥ 25
R - really early baby (premature)
D - descent either Asian or European
E - extremely sick sibling with hyperbilirubinemia
D - dehydration
Describe breastfeeding jaundice? How does this compare to breast milk jaundice?
Both are forms of unconjugated hyperbilirubinemia - physiologic jaundice
Breastfeeding Jaundice
- early onset - 1st week after birth
- insufficient milk intake leads to dehydration resulting in hemoconcentration of bilirubin
- fewer bowel movements increases the enterohepatic circulation of bilirubin
Breastmilk Jaundice
- later onset - after 1st week of life
- bilirubin levels peak during weeks 2-3 of life
- can persist for 3-12 weeks
- cause unknown
- it is thought that substances in breast milk interfere with the breakdown of bilirubin
What is prematurity jaundice? What is it more likely to need?
jaundice that occurs in preterm infants (<37 weeks)
More likley to require phototherapy
What is the management for unconjugated hyperbilirubinemia - physiologic jaundice?
- phototherapy (use AAP nomograms to determine the need for phototherapy - based on TSB and age in hours)
- continue breastfeeding
- supplemental PO or IV fluids (PO preferred)
How does phototherapy help with unconjugated hyperbilirubinemia - physiologic jaundice?
Makes bilirubin water soluble by inducing a conformational change
Why is it important to treat unconjugated hyperbilirubinemia - physiologic jaundice?
To prevent kernicterus/acute bilirubin encephalopathy
What are the hemolytic causes of pathologic unconjugated hyperbilirubinemia?
Intrinsic
- G6PD deficiency (form of IEM - inform error of metabolism, they are missing an enzyme that helps RBCs function correctly and without it results in hemolytic anemia)
- Hereditary spherocytosis (makes the RBCs a sphere shape)
- Thalassemia (genetic, reduced or absent Hb production)
Extrinsic
- Drugs
- Iso-immune (ABO, Rh)
- Sepsis
What are the causes of non-hemolytic pathologic unconjugated hyperbilirubinemia?
- sepsis (also an extrinsic hemolytic cause)
- hypothyroidism
- cephalohematoma
- Gilbert syndrome (liver processes bilirubin too slowly)
- Crigler-Najjar (a genetic IEM, inborn error of metabolism, that results in a lack of an enzyme preventing the breakdown of bilirubin)
What test need to be done when pathologic unconjugated hyperbilirubinemia is suspected?
Coombs test - looks for antibodies that destroy RBCs
CBC with differential
Blood smear - looks for abnormal appearance of RBCs (hereditary spherocytosis is an intrinsic hemolytic cause and it makes round RBCs)
Blood culture - sepsis is a non-hemolytic and extrinsic hemolytic cause
What are the causes of conjugated hyperbilirubinemia?
Intrahepatic
- Drugs (i.e. antibiotics)
- Infections
- Genetic/Metabolic
Extrahepatic
- biliary atresia (have to rule this out; one or more bile ducts are abnormally narrow, blocked, or absent)
- choledochal cysts
- perforated bile ducts
- tumor/mass
- cystic fibrosis
- galactosemia
Conjugated bilirubin is excreted into the small intestines via the bile where it undergoes microbial breakdown and is removed from the body during defecation. Sometimes, however, what happens in the intestines that can result in physiologic jaundice?
the conjugated bilirubin undergoes deconjugation making it unconjugated again. This is then reabsorbed into the enterohepatic circulation
Physiologic jaundice appears after _____ of age and typically appears ____ to _____ days after birth. It generally resolves within _______ and requires _______ for treatment.
24 hours
2-3 days
1 week
nothing (premature babies are the most likely to need phototherapy)
A full term infant developed jaundice during the first week of life but it has not resolved at 2 weeks of age. What is done now?
Investigation for other causes of hyperbilirubinemia besides physiologic jaundice
What is the degree of jaundice determined by?
Total serum bilirubin measurements = unconjugated + conjugated
What is the most serious consequence of high conjugated bilirubin levels?
Kernicterus - brain damage due to accumulation of bilirubin in the brain
What is kernicterus?
brain damage due to accumulation of bilirubin in the brain
Excessive indirect serum bilirubin may lead to ______ because bilirubin readily crosses the blood-brain barrier
neurotoxicity
High levels of _______ bilirubin can possibly reach toxic levels resulting in a severe condition called kernicterus
unconjugated
Which babies are more at risk for developing kernicterus?
- premature
- seriously ill
- given certain medications
What can happen if kernicterus is left untreated?
significant brain injury resulting in
- encephalopathy
-developmental delay,
-cerebral palsy
-hearing loss
-seizures
- death
How does the nurse check for jaundice?
Blanch the skin over a bony prominence
After pressure is released, does the area appear yellow before normal color appears?
Can also check oral mucous membranes if not sure
The Canadian Paediatric Society (Position Statement FN 2007-02) recommends that all infants have a ______ or _______ measured in the first _______ of life or earlier in the presence of clinical jaundice
TSB (total serum bilirubin)
TcB (transcutaneous bilirubin)
72 hours
What is TcB and how is this tested?
transcutaneous bilirubin
It estimates the TSB (total serum bilirubin)
Device used three times on the sternum
What information do you need when using a nomogram to determine the infants risk of developing jaundice?
The bilirubin value recorded on the TcB monitor and the postnatal age in hours
What is phototherapy and when is it used?
Exposure to high intensity light (blue wavelengths) to reduce serum bilirubin in levels
Instituted when the TSB level reaches the treatment threshold appropriate for the newborn’s gestational age and age in hours
How should the nurse ensure that the baby receives adequate therapy from phototherapy?
How long are babies left under the lights for?
Baby is placed under lights and undressed down to the diaper to expose as much skin as possible and turned frequently (every 2 hours). Protective eye coverings are applied. Ensure light is at appropriate distance.
Left under lights for variable periods of time but typically 2 days a week depending on how much the bilirubin levels in the blood need to be lowered
How do we ensure that phototherapy is working?
Periodically measuring bilirubin levels in the blood
While jaundice is likely to improve, it is not a reliable guide
What treatment can help prevent kernicterus?
Phototherapy
What treatment can be used to reverse the damage caused by kernicterus?
Nothing, once the brain injury has occurred it is permanent
What assessments should be completed for infants receiving phototherapy?
Monitor vitals q4h
Occasionally discontinue and remove eye patches (q2-3 h)
Assess intake and output (weigh diapers; weigh infant daily)
Assess skin and provide care prn
Assess serum bilirubin levels as ordered
Encourage parent-newborn attachment
In severe cases of hyperbilirubinemia, can phototherapy be used in conjunction with an exchange transfusion?
Yes
What other condition is closely related to cold stress? Why is this?
Closely linked to hypoglycemia – when they are engaging in thermogenesis but babies cannot shiver, so they will start going to brown fat storage, but these are emergency stores
What are the 4 types of heat loss that babies are prone to?
Evaporation – loss of moisture, including amniotic fluid from their body
Conduction – heat loss to direct contact with a cold surface; put a pad down when we weigh them, don’t bathe them in metal sinks
Radiation – loss of heat to non-direct surface
Convection – loss of heat to fan, air draft etc
What are the effects of cold stress on a newborn?
- Peripheral vasoconstriction – pale, cool, mottled skin
- Lethargy, inactivity
- Weakness, hypotonia
- Depleted brown fat stores
- Respiratory distress
- Blood flow is shunted from the brain
- Can reopen the right/left shunt in the heart
- Metabolic acidosis
- Hypoglycemia
What interventions should the nurse perform if it is noted that the newborn is suffering from cold stress?
Put baby in an incubator/warmer
Monitor and treat other associated conditions such as hypoxia, hypoglycemia and apnea
Who is the most vulnerable to cold stress?
Preterm infants
What must be balanced for babies to regulate their temnperature?
Loss of heat to the environment balanced with the production of heat
Why are neonates so prone to heat loss and consequent hypothermia? How is particularly vulnerable?
High surface area to volume ratio
Low-birth-weight neonates because this ratio is even higher
Describe evaporation and the newborn
Occurs when amniotic fluid evaporates from the skin. Evaporative losses may be insensible (from skin and breathing) or sensible (sweating). Other factors that contribute to evaporative loss are the newborn’s surface area, vapor pressure and air velocity. This is the greatest source of heat loss at birth.
What is the greatest source of heat loss at birth for newborns?
Evaporation
Describe conduction and the newborn
Occurs when the newborn is placed naked on a cooler surface, such as table, scale, cold bed.
The transfer of heat between two solid objects that are touching, is influenced by the size of the surface area in contact and the temperature gradient between surfaces.
Describe convection and the newborn
Occurs when the newborn is exposed to cool surrounding air or to a draft from open doors, windows or fans, the transfer of heat from the newborn to air or liquid.
Newborn Thermoregulation is affected by the newborn’s large surface area, air flow (drafts, ventilation systems, etc), and temperature gradient.
Describe radiation and the newborn
Occurs when the newborn is near cool objects, walls, tables, cabinets, without actually being in contact with them. The transfer of heat between solid surfaces that are not touching. Factors that affect heat change due to radiation are temperature gradient between the two surfaces, surface area of the solid surfaces and distance between solid surfaces. This is the greatest source of heat loss after birth
What is a newborns attempt to generate heat called?
Thermogenesis
What are the mechanisms/sources of generating heat that can be utilized by the newborn?
Metabolic processes
Voluntary muscle activity
Peripheral skin vasoconstriction
Non-shivering thermogenesis - breaking down brown fat
Describe metabolic processes as mechanism/ source of neonatal thermogenesis
- The brain, heart, and liver produce the most metabolic energy by oxidative metabolism of glucose, fat and protein.
- The amount of heat produced varies with activity, state, health status, environmental temperature.
Describe voluntary muscle activity as mechanism/ source of neonatal thermogenesis
- Increased muscle activity during restlessness and crying generate heat.
- Conservation of heat by assuming a flexed position to decrease exposed surface area.
Describe peripheral vasoconstriction as mechanism/ source of neonatal thermogenesis
- In response to cooling, peripheral vasoconstriction reduces blood flow to the skin and therefore decreases loss of heat from skin surfaces.
Describe non-shivering thermogenesis as mechanism/ source of neonatal thermogenesis
- Heat is produced by metabolism of brown fat.
- Thermal receptors transmit impulses to the hypothalamus, which stimulate the sympathetic nervous system and causes norepinephrine release in brown fat (found around the scapulae, kidneys, adrenal glands, head, neck, heart, great vessels, and axillary regions).
- Norepinephrine in brown fat activates lipase, which results in lipolysis and fatty acid oxidation.
- This chemical process generates heat by releasing the energy produced instead of storing it as Adenosine-5-Triphosphate (ATP).
- The rich blood supply to the borwn fat helps transfer this heat to the rest of the neonates body
- Increases metabolic rate and oxygen consumption 2-3 times
What is usually triggered at a mean skin temperature of 35-36C?
Non-shivering thermogenesis
What is the newborns primary method of heat production?
non-shivering thermogenesis (brown fat metabolism)
Why are infants with respiratory insufficiency such as infant respiratory distress syndrome so vulnerable to cold stress?
Because the primary method of heat production is the breakdown of brown fat that increases the metabolic rate and oxygen consumption by 2-3 times. When an infant has a respiratory issue, this may result in hypoxia and neurologic damage
Where is brown adipose tissue (BAT) stored?
nape of the neck, between the scapulae, and around the kidneys and adrenals
What is the optimal temperature zone for neonates?
What factors affect the optimal temperature?
Neutral thermal environment (thermoneutrality)
This is defined as the environmental temperature at which metabolic demands (and thus caloric expenditure) to maintain body temperature in the normal range (36.5 to 37.5° C rectal) are lowest.
The specific environmental temperature required to maintain thermoneutrality depends on whether the neonate is wet (eg, after delivery or a bath) or clothed, its weight, its gestational age, and its age in hours and days.
What underlying conditions may result in hypothermia?
Sepsis, drug withdrawal, intracranial hemorrhage
While less frequent than hypothermia, hyperthermia is defined as a body temperature over _____ .
37.5C
What are external causes of hyperthermia in a newborn and what are the symptoms?
Inappropriate use of an external heat source
Symptoms
-flushed skin
-hands a feet warm to the touch
-posture of extension (remember neonates usually flex to decrease the surface area to keep them warm)
What are internal causes of hyperthermia in a newborn and what are the symptoms?
Sepsis
Symptoms
-pale
-hands and feet are cool
Should all babies receive BGL screening?
No, not needed for healthy, term babies
While neonatal hypoglycemia cannot be defined as a single value of glucose applicable to all clinical situations and to all infants, a plasma glucose concentration of less than _____ appears to be abnormal for term and preterm infants and requires intervention
2.6 mmol/L
Which babies are at risk for hypoglycemia and should be routinely screened for BGL?
- IDMs (infants of diabetic mothers)
- preterm infants (< 37 weeks gestation)
- SGA (small for gestational age) infants
- LGA (large for gestational age) infants > 90th percentile should be considered at risk
If a newborn is considered at risk for hypoglycemia, when should the screening be initiated?
Asymptomatic - after at least one effective feeding, at 2 hours of age, and should be encouraged to feed regularly thereafter
Symptomatic - unwell babies require immediate glucose testing
What are the signs and symptoms of neonatal hypoglycemia?
- jitteriness
- lethargy
- cyanosis
- high-pitched or weak cry
- poor feeding
- hypotonia
- temperature instability
- respiratory distress
- apnea
- seizures
What are ways to prevent neonatal hypoglycemia for at risk newborns?
- frequent monitoring via heel stick
- early initiation of feedings
- maintain NTE (neonatal thermal environment) (Put the infant skin-to-skin)
What is the interval between the birth of the newborn and the return of the reproductive organs to their normal nonpregnant state?
Postpartum
What is postpartum defined as?
interval between the birth of the newborn and the return of the reproductive organs to their normal nonpregnant state
What is steps of the postpartum assessment?
MEMORY: BUBBLE-LE
B = Breasts (firmness) and nipples
U = Uterine fundus (location; consistency)
B = Bladder function (amount; frequency)
B = Bowel function (passing gas or bowel movements)
L = Lochia (amount; colour
E = Episiotomy/Laceration or Caesarean birth incision (perineum: discomfort; condition of repair, if done)
L = Legs (peripheral edema)
E = Emotional status (mood, fatigue)
When assessing a postpartum mothers vital signs, what is considered normal for the temperature and what is considered a deviation?
Normal:
- Within normal range (36.2° C – 38° C)
- Some, slight fever up to 38° C in first 24 hours
Deviations:
- After 24 hours, above 38° C is abnormal
When assessing a postpartum mothers vital signs, what is considered normal for the pulse and what is considered a deviation?
Normal:
- elevated for first hour after childbirth then decreases to 60-100 bpm
Deviation:
- rapid pulse
When assessing a postpartum mothers vital signs, what is considered normal for the respirations and what is considered a deviation?
Normal:
- 16-24/min should decrease to normal prebirth range
Deviation:
- hypoventilation
When assessing a postpartum mothers vital signs, what is considered normal for the blood pressure and what is considered a deviation?
Normal:
-consistent with BP baseline during pregnancy
- orthostatic hypotension for first 48 hours
Deviation:
- pregnancy-induced hypertension
Is orthostatic hypotension for the first few days after giving birth normal?
yes for 48 hours
A postpartum mother is noted to have a fever of 38C 6 hours after giving birth, is this normal?
Yes (normal for slight fever up to 38C for the first 24 hours)
When is the ideal time to initiate breastfeeding?
as soon as possible after birth; recommended to place newborn in uninterrupted skin-to-skin contact for 1-2 hours after birth as they will be alert and ready to nurse during this time
What assessments should the nurse provide during the first breastfeeding of a newborn?
- appearance of breasts and nipples
- basic breastfeeding technique
- teaching about feedings cues
- ensure a good latch and sucking ability
When is suppression of lactation necessary?
What can be done to facilitate this?
What is a side effect that may occur as part of this process?
Person has decided not to breastfeed or newborn death
How to accomplish it:
- well-fitted support bra continuously fo r72 hours after birth
- avoid breast stimulation (avoid warm water on breasts, sucling, expressing milk)
Side effect:
- breast engorgement 72-96 hours after birth
How can breast engorgement be treated?
- ice (15 min on, 45 min off)
- fresh green cabbage leaves on the breasts that are replaced when they wilt
- mild analgesic/anti-inflammatory may be used to reduce discomfort
What is highly correlated with positive breastfeeding outcomes, including initiation, duration, and exclusivity?
Maternal confidence, also called breastfeeding self-efficacy
Describe the changes to the feel of the breasts on palpation during the first week after giving birth?
Days 1-2: soft
Days 2-3: slightly firm (associated with filling)
Days 3-5: full, soften with breastfeeding
Describe the normal uterus postpartum? What is abnormal?
Normal:
-firm, midline
-at level of umbilicus in the first 24 hours
- involutes 1-2 cm/day
Deviation:
- soft, boggy, higher than expected - related to uterine atony
- lateral deviation - related to distended bladder
What is the most frequent cause of excessive bleeding, in the immediate postpartum period, after childbirth?
Why does this contribute to PPH?
uterine atony (i.e., failure of the uterine muscle to contract firmly)
If uterine atony occurs, the relaxed uterus distends with blood and clots, blood vessels in the placental site are not clamped off, and excessive bleeding results.
What are the two most important interventions for preventing excessive bleeding in a postpartum mother?
- good uterine tone
- preventing bladder distention
About how long does it take until the abdominal wall returns to almost it’s prepregnant state?
6 weeks although striae may persist
What is diastasis recti?
A condition during pregnancy in which the abdominal walls seperate
If the abdominal walls separate during pregnancy, what is this called?
diastasis recti
What might large amounts of lochia in a postpartum mother indicate?
Uterine atony, vaginal or cervical laceration
What might a foul odour of lochia in a postpartum mother indicate?
Infection
Describe lochia rubra
- dark red colour
- occurs for the first 3 days
- a few small clots, no larger than a loonie, particularly in the first few days
- blood, decidual and trophoblastic debris
Describe lochia serosa
- pinkish or pinkish brown colour
- days 3-10
- no clots
- leukocytes, old blood, serum and tissue debris
Describe lochia alba
- creamy white or yellowish white
- days 10-14; can last 4-8 weeks
- no clots
- leukocytes, decidua, epithelial cells, mucus, serum, and bacteria
Describe scant bleeding on a hygiene pad post partum?
less than 5 cm
Describe light bleeding on a hygiene pad post partum?
5-10 cm
Describe moderate bleeding on a hygiene pad post partum?
10-15 cm
Describe heavy bleeding on a hygiene pad post partum?
> 15 cm
What is the normal appearance of the perineum postpartum?
What is abnormal?
Normal:
- minimal edema
- laceration or episiotomy with wound edges approximated
Deviation:
- pronounced edema, bruising, hematoma
What is the normal appearance of a Caesarean wound postpartum?
What is abnormal?
Normal - dressing is clean and dry, suture line intact
Abnormal - redness, edema, warmth, drainage - these are all indications of infection
What is the signs of an infected episiotomy?
Warm, red, and drainage
In what position should the mother be so the episiotomy and repair is visible?
side lying
What is the most common type of postpartum hematoma?
Vulvar, thankfully they are also generally visible
What are vaginal postpartum hematomas associated with?
forceps, episiotomy, or primigravidity
What is the least common type of postpartum hematoma?
retroperitoneal
May be life-threatening
lacerated a vessel attached to the hypogastric artery
When does the breastfeeding mother experience her first postpartum menses?
depends on breastfeeding pattern but mean time is about 6 months
How does the first postpartum period compare to pre-pregnancy periods?
Generally heavier
How soon can ovulation occur for women how are not breastfeeding?
When does the non breastfeeding mother experience her first postpartum menses?
Ovulation: As early as 27 days after giving birth
Periods: Mean time is 7-9 weeks after giving birth with 70% resuming it by week 12
When can sexual intercourse resume?
Once the perineal area is comfortable and lochia has stopped
What is dyspareunia?
Painful intercourse
Lasting or recurring genital pain that occurs just before, during, or after sex
What is the term for painful intercourse that can result in lasting or recurring genital pain that occurs before, during, or after sex?
Dyspareunia
Is breastfeeding a reliable means of birth control?
No, consider contraceptive options early in the postpartum period
What is the result of a full bladder in the post partum mother? Why does this occur?
Can cause uterine atony and excessive bleeding after childbirth.
A full bladder causes the uterus to be displaced above the umbilicus and well to one side of the midline in the abdomen. It also prevents the uterus from contracting normally.
What are the intrapartum risk factors for urinary retention?
- epidural anesthesia
- extensive vaginal or perineal lacerations
- episiotomy
- instrument-assisted birth
- prolonged labour
- after removal of in-dwelling catheter
What are the nursing interventions for helping the immediate postpartum patient to avoid bladder distention
- assist to washroom or use bedpan
- encourage urination (run water, pour warm water over perineum, shower, sitz bath etc.)
- analgesics if needed (fear of pain may prevent voiding)
- sterile catheter insertion if needed as a last resort
Describe the renal function post partum
Reduced initially, returns to normal within a month
Describe the normal changes to the urinalysis in the postpartum mother?
glucosuria disappears
increased BUN
pregnancy induced proteinuria resolves
ketonuria may occur
What might occur if the postpartum mother experiences a decreased sensation to void?
Incomplete emptying of the bladder leading to bladder distention and urinary retention; this can increase the risk of UTI
How long might it take for the postpartum mother to experience her first BM after giving birth?
a few days; it’s pretty normal to not have one for the first 2-3 days after giving birth
Why are postpartum patients at risk for constipation?
- medications (opioids, mag sulphate etc.)
- dehydration
-immobility
-perineal lacerations/episiotomy
-hemorrhoids
What nursing interventions promote normal bowel elimination in the postpartum mother?
- education for measures to prevent constipation
- ambulating
- increasing fiber
- increasing water intake
may need stool softeners, especially with extensive perineal repairs
Which postpartum mothers are most at risk for developing gas distention?
more common in c-section moms
What interventions can help with gas distention in the postpartum mother?
- ambulation
- rock in a rocking chair
- anti-gas medications may be needed
c-section moms should also avoid
- drinking carbonated beverages
-use of straw
- foods that tend to produce gas (i.e. legumes and broccoli)
For immobilized postpartum motheres, especially after c-section, may have what ordered?
anti-embolic stockings (TED hose) or sequential compression devices (SCD) boots
if longer than 8 hours, in bed exercises should be done to promote circulation in the legs
*Alternate flexion and extension of feet.
*Rotate ankles in circular motion.
*Alternate flexion and extension of legs.
*Press back of knee to bed surface; relax.
High risk patients for VTE may need a LMW heparin
Which postpartum mothers are susceptible to VTE?
- BMI > 40
- unexpected c-section
-advanced maternal age (>35) - VTE occurred during pregnancy
Why are postpartum mothers considered to be in a hypercoagulable state?
Because their clotting factors and fibrinogen remain elevated after birth
Why are postpartum mothers more at risk of developing a VTE?
They are in a hypercoagulable state because their clotting factors and fibrinogen remain elevated after birth
About how many mothers experience postpartum blues or baby blues?
What are symptoms of this?
50-80% of the time
Symptoms (usually resolve in a few days to a week)
- lability, crying for no reason
- feelings of being overwhelmed
- depression
- let-down feeling
- restlessness
- fatigue
- insomnia
- headache
- anxiety
- sadness
- anger
- loss of appetite
Describe the timeline and treatment of baby blues
Begins a few days after giving birth, lability peaking around day 5 and subsiding by day 10
They are transient, mild, and time limited, and do not require treatment other than reassurance
What signs in the mother can suggest potentially serious psychological complications and should be reported to the HCP?
*Unable or unwilling to discuss labour and birth experience
*Refers to self as ugly and useless
*Excessively preoccupied with self (body image)
*Markedly depressed
*Lacks a support system
*Partner or other family members react negatively to baby
*Refuses to interact with or care for baby (e.g., does not name baby, does not want to hold or feed baby, is upset by vomiting and wet or dirty diapers) (cultural appropriateness of actions must be considered)
*Expresses disappointment over baby’s sex
*Sees baby as messy or unattractive
*Baby reminds mother of family member or friend they do not like
*Has difficulty sleeping
*Experiences loss of appetite
What are Rubin’s Three Phases of the mother during the postpartum period?
Taking in
- days 1-2
- dependent behaviour
Taking hold
- starts days 2-3, lasts 10 days to several weeks
- becomes preoccupied with the present
Letting go
- re-establishes relationships with other people and moves forward accepting the parenting role
Which of Rubin’s phases has the mother preoccupied with the present?
Taking hold
starts day 2-3 and lasts for 10 days to several weeks
Which of Rubin’s phases do nurses see on the postpartum unit with a brand new mother?
Taking in
- days 1-2
- dependent behaviour
In which of Rubin’s phase does the postpartum parent open up their circle beyond their immediate family and new baby to re-establish relationships with other people?
Letting go
- re-establishes relationships with other people and moves forward accepting the parenting role
What is the process by which a parent comes to love and accept a child and a child comes to love and accept a parent?
Attachment
What is attachment and how is it developed?
The process by which a parent comes to love and accept a child and a child comes to love and accept a parent
Attachment is developed and maintained through proximity and interaction with the infant
Includes mutuality
When the parents provide sensitive and loving care and the infant has an organized strategy to deal with distress, what type of attachment develops?
Secure
When the parents provide insensitive care and often reject their infant but their infant has an organized strategy to deal with distress, what type of attachment develops?
Insecure-avoidant
When the parents provide insensitive, inconsistent care and the infant has an organized strategy to deal with distress, what type of attachment develops?
Insecure-resistant (sometimes also called anxious)
When the parents provide atypical care and the infant has a disorganized way of dealing with distress, what type of attachment develops?
Insecure-disorganized
In what type of attachment style does the child become distressed when the parent leaves, but is easily comforted when the parent returns?
Secure
In what type of attachment style does the child now become distressed when the parent leaves and ignores or avoids the parent when they return as the child’s covert way of managing their anxiety?
Insecure avoidant
In what type of attachment style does the child become distressed when the parent leaves, and seeks to punish the parent for leaving when the parent returns by displaying over feelings such as anger?
Insecure resistant (may also be called anxious resistant)
In what type of attachment style does the child not have a predictable pattern of attachment and includes the child who displays signs of depression and disturbing behaviour?
Insecure disorganized
Describe the stages of developing an attachment between parents and the infant?
Asocial or Pre-Attachment Stage
- Birth to 3 months
- Baby is forming bonds but relationship with objects and humans are similar
Indiscriminate Attachment Stage
- 6 weeks to 7 months
- baby displays more observable social behaviour
- preference for people over objects
-prefers familiar adults
- no stranger danger or separation anxiety
Specific or Discriminant Stage
- 7-11 months
- stranger anxiety displayed
- separation anxiety from on particular adult
Multiple Attachments
- 24 months +
- Babies show affection to other adults who regularly spend time with them
What are the 4 types of infant-parent attachment?
3 organized types - secure, avoidant, resistant
1 disorganized
What is the quality of attachment that an infant develops with a specific caregiver is largely determined by?
Caregivers response to the infant when the infants attachment system is “activated” like when they feel hurt, upset, frightened etc.
What shapes the reactions of siblings to the new baby?
- temporary separation from the mother
- changes in mother/father’s behaviour
- infant coming home
__________ is one of the leading causes of maternal death worldwide and occurs in about 5% of all births.
Postpartum hemorrhage (PPH)
What is PPH and how is it defined?
Postpartum Hemorrhage
PPH is any blood loss that has the potential to cause hemodynamic instability (no defined volume)
PPH is often defined as the loss of 500mL or more of blood after vaginal birth and 1 000mL or more after Caesarean birth, although normal blood loss for some patients approaches these amounts.
PPH may be defined as a 10% decline in hemoglobin concentration and the need for a transfusion
What is primary PPH?
What is the most common cause?
What is this associated with?
AKA early PPH, occurs within 24 hours after giving birth
Most common cause - uterine atony
Associated with and condition that causes the uterus to be overstretched and contracts poorly after birth
- high parity
- polyhydramnios (excessive amniotic fluid)
- fetal macrosomia (large baby)
- multiple gestation
What is secondary PPH?
What can cause this?
AKA late PPH, occurs after 24 hours but less than 12 weeks postpartum
Due to retained products, infection, or both. This causes subinvolution of the uterus (delayed return of the enlarged uterus to normal size and function)
What are the 4 main risk factors for PPH?
- uterine tone
- trauma
- tissue
- thrombin
Early identification and treatment of PPH is very important so we actively manage it. How is this active management accomplished?
- oxytocin as preventative
- gentle cord traction
- immediate fundal massage after complete birth
What can we do if the uterus is hypotonic after birth?
What happens if the bleeding persists?
Aim is to increase contractility and minimize blood loss and includes
- fundal massage
- empty bladder
- IV oxytocin
Persistent bleeding may require:
- misoprostol (synthetic prostaglandin)
- blood products
- oxygen
- bimanual compression
What should be done if PPH is recognized but the uterus is firm?
Source of the bleeding just be identified via visual or manual inspection and laboratory findings
What teaching should be provided to the postpartum mother during discharge regarding PPH?
- signs of normal involution
- potential complications
- importance of prompt assessment if PPH occurs
What is any clinical infection that occurs within 42 days after miscarriage, induced abortion, or birth?
Postpartum infection or puerperal infection
What are common postpartum infections?
- endometritis
- wound infections (c-section, episiotomy)
- mastitis
- UTI
- respiratory tract infections
Who is most at risk for developing a puerperal infection?
AKA postpartum infection is more common in
-obesity
- concurrent medical/immunosuppressive conditions
- c-section or other operative birth
- prolonged rupture of membranes
- prolonged labour
- internal fetal monitoring
What is an infection in the lining of the uterus?
Endometritis
What is endometritis? Where does it usually originate? Who is most at risk?
Infection of the lining of the uterus
Usually begins at the placenta site but can spread
Higher risk with c-section birth
What are symptoms of endometritis??
Fever
Increased pulse
Chills
Anorexia
Nausea
Fatigue and lethargy
Pelvic pain
Uterine tenderness
Foul smelling profuse lochia
You have a postpartum patient that just returned to the hospital after only being discharged yesterday, 24 hours after she gave birth via c-section. She has been feeling unwell since last night, is running a fever, and reports pelvic pain and copious amounts of foul smelling vaginal discharge. What is the likely cause?
Endometritis
When are prophylactic antibiotics used after childbirth?
How does this change for heavier mothers with a larger BMI?
caesarean section and possible 3rd and 4th degree tear
BMI over 35 may have a doubled dose of antibiotics
What is the treatment of a wound infection such as the caesarean incision, laceration, or episiotomy sites?
antibiotics
wound debridement
vital signs
promote good hygiene
Your patient was released from hospital two days ago after a vaginal delivery of her first baby girl. Baby girl was 8lbs and healthy, but did cause a 3rd degree tear. Mom states she has had a sore perineal area since giving birth but over the last 24 hours it has begun to feel more painful, she is now running a fever, and she has noticed a bunch of vaginal discharge that is sort of pinkish thick white. What is the most likely cause?
A wound infection of her tear/laceration
What is mastitis?
What are the symptoms?
How is it treated?
Breast infection
Symptoms
- usually preceded by inflammatory edema and engorgement
- unilateral symptoms
- chills/fever
- malaise
- tenderness/pain
- redness
- axillary adenopathy (swollen lymph nodes)
Treatment
- antibiotics
- comfort (head/cold application, supportive bra)
What should the nurse teach the new mother in order to avoid mastitis?
ensure good latch and good hygiene
A mother just had her baby 2 weeks ago but her new baby has been having trouble latching. Afraid of being judged for not knowing what to do, she didn’t tell anyone about it, even when her breasts became engorged last week. Yesterday she started to feel run down but assumed that was normal with a new baby at home. Today she woke up and her breast has an area that is red and very sore and she’s worried something is wrong. What do you think is happening to this patient?
Mastitis
A new mother has been prescribed antibiotics for her mastitis and been told to wear a supportive bra and alternate hot/cold application to relieve some of the pain. She is concerned about being able to breastfeed while doing this. What should the nurse tell her?
It is ok to keep breastfeeding
If treatment for mastitis is delayed, what can it progress to?
Breast abscess
What is PMD and what does it include?
Perinatal mood disorders
- anxiety
- depression
- psychosis
Despite birth being a happy time, how many mothers struggle with PMD? When does this occur?
PMD - Perinatal mood disorders
1 in 7 women affected but is often unreported
Can happen during pregnancy or within the first 12 months after birth
What is the distinguishing factor between baby blues and a perinatal mood disorder?
Baby blues usually resolves within 2 weeks and does not disrupt the postpartum patient’s ability to care for themselves and their baby
Perinatal mood disorders generally last longer and can be so severe that they are not able to care for themselves or their baby
Can the non-birth partner also experience a perinatal mood disorder?
Yes
Risk factor is having a partner that also has postpartum depression
What are the symptoms of a non-birth partner experiencing a perinatal mood disorder?
Fatigue
Frustration, anger
Irritability
Indecisiveness
Withdrawal from social situations
What are the major symptoms of postpartum depression?
- begin within a year of giving birth
- same as baby blues (lability, crying spells, loss of appetite, difficulty sleeping etc.) but they last longer and are more severe
- thoughts of self harm or harming the baby
- not having any interest in the baby
What are the major signs of postpartum psychosis?
- seeing or hearing things that are not there
- feelings of confusion
- rapid mood swings
- trying to hurt self or baby
You are teaching your new parents about the symptoms of perinatal mood disorders. When should you advise the patient and their partner to contact their healthcare provider?
- baby blues continuing for more than 2 weeks
- symptoms of depression getting worse
- difficulty performing tasks at home or at work
- inability to care for self or baby
- thoughts of harming self or baby
Which mothers would you be the most concerned about developing a PMD?
What are other risk factors you should evaluate for?
Greatest risk - history of anxiety or depression
Other risk factors:
- Younger age
- Unintended pregnancy
- History of premenstrual dysphoria
- Family history of mood disorders
- Marital status/marital discord
- Victim of violence
- Lower socioeconomic status
- Lack of social support
- Lower education level
- Substance use
- Stressful life events in the year before pregnancy
- Birth complications
- Feeling incompetent, a loss of self, and lonely
- Preterm birth, low birth weight, or sick baby
- Psychosocial problems
- And interpersonal difficulties
With postpartum depression, mothers may feel ______ about being depressed, but _______ help is usually necessary.
Guilty
outside
What are the treatments for PPD?
Postpartum depression
- supportive care
- medication (antidepressant/antianxiety)
- ECT
- physiotherapy
- alternative therapies
- hospitalization
What type of perinatal mood disorder is the least common but places women at high risk of suicide?
Postpartum Psychosis (PPP)
What are the symptoms of postpartum psychosis
MEMORY: IF DIAPERED :)
- Impulsive
- Fatigue
- Delirium
- Insomnia
- Auditory or visual hallucinations
- Paranoid or grandiose delusions
- Emotionality labile
- Restlessness
- Extreme deficits in judgement
- Disorientation
What is the treatment for postpartum psychosis?
- hospitalization
- antipsychotics and mood stabilizers (this may mean breastfeeding is no longer an option)
- ECT may also be included
If the mother wants to see her baby, it is likely beneficial to do so
What is most likely to improve outcomes for postpartum psychosis?
early detection and aggressive treatment
Define growth
An increase in the number and size of cells that results in an increase is size and weight
What is an increase in the number and size of cells that results in an increase is size and weight?
Growth
Define development
Gradual change and advancement. When someone becomes more mature, learns, ‘expanding of a person’s capacities’
What is gradual change and advancement, i.e. when someone becomes more mature, learns, ‘expanding of a person’s capacities’?
Development
Define maturation
Gaining competence and adaptability. When someone can function at a higher level
What is gaining competence and adaptability. When someone can function at a higher level?
Maturation
Define differentiation
When cells and structures are modified to achieve specific characteristic
Develop from simple to complex activities and functions
What is the term for when cells and structures are modified to achieve specific characteristic, generally from simple to complex activities and functions?
Differentiation
What term is about gaining capacity in cognition?
Development
What is the term for a young person being more able to complete skills and gaining confidence from this?
Maturation
What is the term for cells and structures that are modified to achieve specific characteristics such as the development of primary and secondary sex characteristics as children enter puberty?
Differentiation
What are directional trends?
Growth and development happen in a direction
For example head to toe: Babies have better control of their head before they have control of their hands and feet
What is the term used for development that happens in a direction, such as a child having control of their head before their hands, and their hands before their feet?
Directional trends
What are sequential trends?
There is a sequence to development
For example: Babies babble before they talk
What is the term for development that happens in an ordered manner, such as sitting, then crawling, then standing and then walking?
Sequential trends
What are developmental trends?
The time it takes to develop
It is different for each individual but there are also periods of accelerated development
What is the term used when we look at the time it takes to develop a skill such as the ability to write?
Developmental trend
What are sensitive periods?
A time where an individual is more susceptible to influences (positive or negative)
What term is used to describe periods where a child is more prone to internal and external influences, such as the ability to develop a strong attachment occurs in the first 4 weeks and failure to do so can actually result in permanent damage to the infant-child relationship?
Sensitive periods
What do we need to do when comparing a premature baby to a growth chart?
We need to look at their adjusted age, so how old they would be if they had been born at 40 weeks because the growth chart doesn’t accommodate for that.
When is there concern over a change for a child’s weight, height, or head circumference on growth charts?
A drop of more than 1 percentile line for height and weight make them more at risk for failure to thrive so they will need more monitoring
For head circumference, more than 5% off their percentile line is a red flag immediately
How long is head circumference measured for?
36 months old or any other time the size is questionable as they get older
What evidence can be shown by growth charts that would be a cause for concern?
- disproportionate height and weight
- not growing at the expected rate
- sudden increase/decrease in growth
How do we measure the height of a baby?
Ensure legs are extended and foot is flat against the end and the head is flat against the tip; this is the hardest measurement to be consistent about
How old does the child have to be before they can stand up to take their height?
Whenever they can stand independently and follow directions, so there isn’t a specific age
Why are there different charts for girls and boys even though their secondary sex characteristics and differentiation has not occurred?
Girls tend to be smaller, so if they were all on the same chart, girls would appear undersized
Which psychologist described 8 conflicts or problems that an individual aims to master during specific periods of their development?
Erik Erikson
Erik Erikson’s Psychosocial Developmental theory consists of ____ phases, each with 2 components, the ______ outcome, and the ________ outcome
8
favorable
unfavorable
What is the first stage of Erik Erikson’s Psychosocial Development Theory?
When does this occur?
What occurs in this stage?
Trust vs mistrust
birth to 1 year
- Most important attribute to a healthy personality
- Loving care is important in developing trust
- Mistrust develops when trusting promoting experiences are lacking
What is the second stage of Erik Erikson’s Psychosocial Development Theory?
When does this occur?
What occurs in this stage?
Autonomy vs shame and doubt
1 - 3 years
- Increasing need to control their bodies, themselves, and environment
- Imitating others
- Feeling doubt or shame happen when children feel small and self- conscious and when their choices are disastrous, when they are shamed or forced to be dependent
- Favorable outcome: self-control and willpower
What is the third stage of Erik Erikson’s Psychosocial Development Theory?
When does this occur?
What occurs in this stage?
Initiative vs guilt
3-6 years
- Have an ‘inner voice’
- Strong imagination!
- Will explore with all their senses
- Guilt comes when children have goals or do activities that go against their parents/others and then feeling like those activities are bad which produce a sense of guilt
What is the fourth stage of Erik Erikson’s Psychosocial Development Theory?
When does this occur?
What occurs in this stage?
Industry vs inferiority
6-12 years
- Are workers and producers
- Want to do projects that they can complete (achievement)
- Learn to compete and cooperate
- Inadequacy and inferiority can happen when too much is expected of them or they believe they ‘can’t measure up’
What is the fifth stage of Erik Erikson’s Psychosocial Development Theory ?
When does this occur?
What occurs in this stage?
Identity vs role confusions
12-18 years
- Rapid physical changes
- Become very concerned with their appearances
- Inability to solve core conflicts result in role confusion
- Devotion and fidelity are outcomes that demonstrate success
What are the 5 stages of Erikson’s Psychosocial Development Theory that we covered and what ages did they occur at?
The other 3 occur in adulthood so we didn’t cover it
1 - trust vs mistrust (0-1 year)
2 - autonomy vs shame and doubt (1-3 years)
3 - initiative vs guilt (3-6 years)
4 - industry vs inferiority (6-12 years)
5 - identity vs role confusion (12-18 years)
Which of Erikson’s stages is the following:
As babies, if their needs are not consistently met they learn to not trust the parent will come when they need and they don’t trust that their needs are valid. On the other hand, loving parents that consistently respond to needs develops a trust and bond with the baby.
Stage 1
Trust vs mistrust (0-1 years)
Which of Erikson’s stages is the following?
A toddler consistently uses the word no and is trying out making choices. When choices are bad, but they are met with reassurance and more opportunities to succeed next time, they develop a sense of self control but if they are made to feel small from their choices, they become self conscious.
Stage 2
Autonomy vs shame and doubt (1-3 years)
Which of Erikson’s stages is the following?
A child is attempting to explore and experiment, even attempting to be a leader. If a child is encouraged to try things, even if they do need a little help, they will feel accomplished, but if they are made to feel bad for wanting to do the activities, such as when they go against their parents, they feel as though they should not have tried
Stage 3
Initiative vs guilt (3-6 years)
Which of Erikson’s stages is the following?
The child is learning new skills such as reading and writing and they are learning to cooperate and compete with their peers. If the child has a supportive environment that holds reasonable expectations of them, they will become more competent. Unfortunately, if the parents expect too much of the child and the expectations are not achievable to the child, a sense of hopelessness can develop.
Stage 4
Industry vs inferiority (6-12 years)
Which of Erikson’s stages is the following?
The child experiences puberty and is attempting to find their place in the world and in their relationships with their friends and family groups.
Stage 5
Identify vs role confusion (12-18 years)
In which of Erikson’s stages is the infant uncertain about the world in which they live, and looks towards their primary caregiver for stability and consistency of care.
Stage 1
Trust vs mistrust (0-1 years)
In which of Erikson’s stages is the child focused on developing a sense off personal control over physical skills and a sense of independence?
Stage 2
Autonomy vs shame and doubt (1-3 years)
In which of Erikson’s stages is the child asserting themselves more frequently through directing play and other social interaction?
Stage 3
Initiative vs guild (3-6 years)
In which of Erikson’s stages is the child starting to compare themselves with their peers to gauge their abilities and worth?
Stage 4
Industry vs inferiority (6-12 years)
In which of Erikson’s stages is the adolescent searching for a sense of self and personal identify through an intense exploration of personal values, beliefs, and goals?
Stage 5
Identity vs role confusion (12-18 years)
Language development happens at different rates for each child, but _____ are typically spoken first. At all phases of language development, more is _________ than can be _______.
Nouns
Understood
Communicated
Why is it important to speak with your child at or above the level you believe them to be at?
At all phases of language development more is understood than can be communicated
Which children in the family often speak sooner and with a wider vocabulary than their siblings?
The first child
Why does the child learn the names of the person that gives them what they need?
Because it manipulates them into getting those needs met (not malicious manipulation lol)
Describe self concept
How someone describes themselves
Develops gradually
Includes body image and self esteem
Describe body image? How is this expressed as infants and toddlers?
Evolves and changes during development; very complex
Infants - become aware that their body is separate from others
Toddlers - identify their body parts
Describe self esteem. How do children assess their self-esteem?
The value an individual puts on themselves
Changes with development
Assessed based on:
- competence
- sense of control
- moral worth (good vs bad person)
- worthiness of love and acceptance
Play starts through _______ where infants learn to do something to get a response.
Socialization
What does the repetition in play such as throwing a toy over and over important for a child’s development?
Skills and competence that come with mastery
Describe the sequential trend of play
Onlooker play 0-6 months - watch others playing
Solitary play 6-12 months - play alone with different toys but in the same area as other children
Parallel play 12-18 months - play independently with similar toys as other children in the area
Associative play - 18-36 months - play together but no organization
Cooperative play - 3 years+ - organized play in a group (like the ability to play as part of a ball team)
In what type of play does the infant just watch other children as they play?
Onlooker play (0-6 months)
In what type of play would a child be playing with blocks in the same area as a child playing with cars but they are not playing together?
Solitary play (6-12 months)
In what type of play are 2 children playing with blocks but they are not actually interacting or engaging with each other?
Parallel play (12-18 months)
In what type of play are children able sit on the floor and play with blocks but there is no organization or goal to the play such as building a tall tower?
Associative play (18-36 months)
In what type of play are children able to play soccer but when the ball is kicked all of the children on the field chase it?
Associative play (18-36 months)
In what type of play are children able to play house and assign each participating child a role in the “family” ?
Cooperative play (3 years +)
What are the functions of play that are so important for a child’s growth and development?
Sensorimotor
Intellectual
Socialization
Creativity
Self-awareness
Therapeutic value
Moral value
Describe the sensory development that occurs as a function of play
- muscle development, energy release
- exploration and movement
- fine/gross motor movements
Describe the intellectual development that occurs as a function of play
- learning (shapes, colours, etc.) significance and associations
- problem solving
- language
Describe the social development that occurs as a function of play
- establish relationships, learn roles
- give and take
- right from wrong
- prosocial behaviour
- cooperative play
- empathy
Describe the creativity that occurs as a function of play
What can it be hindered by?
- experiment, fantasy, exploration
- can be hindered by conformity and peer pressure
Describe the self-awareness that occurs as a function of play
- develop a self-identity
- regulate behaviour
- test themselves and try roles
Describe the therapeutic value that occurs as a function of play
- express emotions
- release impulses
- experiment and test fearful situations
- Communicate needs, fears, desires, etc.
Describe the moral value that occurs as a function of play
right vs wrong reinforced through peer interaction
What can support and enhance development and be used as tools to help children assimilate to their culture
Toys
What does utilizing toys in play teach the child?
sharing, empathy and cooperation; resources need to be shared and not just for the one child; moves out of the ego perspective of all of the things are for my use only
What factors can influence development of the child?
heredity - disorders and characteristics like height and personality
neuroendocrine factors - growth
interpersonal relationships - emotional/intellectual development
socioeconomic status
environmental hazards
stress in childhood (i.e. ACEs)
How does heredity influence the development of the child?
- hereditary disorders
- genetics - height, weight, temperament, personality traits
How does neuroendocrine factors influence the development of the child?
Hypothalamic-pituitary factors influence growth
How does interpersonal relationships influence the development of the child?
Emotional, intellectual, and personality development
For small children, their nuclear family and relationship models creates the foundation of what the child understands about what relationships are like
How does socioeconomic status influence the development of the child?
Perhaps related to lack of resources or knowledge
How does environmental hazards influence the development of the child?
Exposure to hazards like chemical residues, radiation, water or food contamination, etc.
How does stress in childhood influence the development of the child?
Some children are more vulnerable to stressors
Includes ACEs exposure
What is a recent change to the influence on childhood development that can influence both the parents and the child?
Media
Internet and social media use now needs to be incorporated in parent education and support
How does the parent and infant communicate before they develop language?
Non verbal communication from babies (cooing, smiling, crying)
Non verbal communication to babies (cuddling, soothing)
Derive comfort from voice, even if they don’t understand the words
How can a parent more effectively communicate with their youngster during early childhood?
Communication should be focused on them (“You can do…” “This will feel cold”) because children are egocentric
Children may point or pull pull away
Very literal at this age
Why are more people avoiding immunizing their children?
Based on the criticism and fear they are receiving these days
What provides a guide as to when immunizations should be given?
Immunization schedule - it’s different from province to province and varies between countries
What is an antibody?
A protein found in the blood that is produced in response to foreign substances (e.g. bacteria or viruses) invading the body. Antibodies protect the body from disease by binding to these organisms and destroying them.
What is a protein found in the blood that is produced in response to foreign substances (e.g. bacteria or viruses) invading the body and protect the body from disease by binding to these organisms and destroying them?
Antibody
What is active immunity?
The production of antibodies against a specific disease by the immune system. Active immunity can be acquired in two ways, either by contracting the disease or through vaccination. Active immunity is usually permanent, meaning an individual is protected from the disease for the duration of their lives.
What is the production of antibodies against a specific disease by the immune system?
Active immunity
What are the 2 ways to develop an active immunity?
- vaccines
- contracting the disease
What are antigens?
Foreign substances (e.g. bacteria or viruses) in the body that are capable of causing disease. The presence of antigens in the body triggers an immune response, usually the production ofantibodies.
What is the foreign substance (i.e. bacteria or virus) in the body that are capable of causing disease and who’s presence triggers the immune system to produce antibodies?
Antigens
What is community or herd immunity?
A situation in which a sufficient proportion of a population is immune to an infectious disease (through vaccination and/or prior illness) to make its spread from person to person unlikely. Even individuals not vaccinated (such as newborns and those with chronic illnesses) are offered some protection because the disease has little opportunity to spread within the community.
What is immunological memory?
The ability of theimmune systemto respond more rapidly and effectively to pathogens that have been encountered previously, and reflects the preexistence of a clonally expanded population ofantigen-specificlymphocytes
What is the ability of theimmune systemto respond more rapidly and effectively to pathogens that have been encountered previously, and reflects the preexistence of a clonally expanded population ofantigen-specificlymphocytes?
Immunological memory
What is passive immunity?
Protection against disease through antibodies produced by another human being or animal.
Passive immunity is effective, but protection is generally limited and diminishes over time (usually a few weeks or months).
For example, maternal antibodies are passed to the infant prior to birth.
These antibodies temporarily protect the baby for the first 4-6 months of life.
Which type of immunity is often permanent? Which type of immunity is generally limited and diminishes over time?
Permanent - active immunity
Temporary - passive immunity
In Alberta, when should children recieve their vaccinations?
2 months
4 months
6 months
12 months
18 months
4 years
Grade 6
Grade 9
In Alberta, when is hepatitis B vaccines given?
2 months
4 months
6 months
But this is a recent change so all children born before 2018 will get 3 doses over 6 months in grade 6
Why might a newborn baby in Alberta be given the hepatitis B vaccine at birth?
If they are at high risk from contracting it due:
- parent with hep-B
- parent hep-B status unknown
- Someone living in the home has hep-B
What should be given if the newborn is born to a mother who has a current hepatitis B infection or is a chronic carrier?
hepatitis B vaccine and hepatitis B immune globulin (HBIG) should be given within 12 hours of birth.
If a newborn requires a Hep-B vaccine, what are the drug options? What are the doses of each? What dosing schedule is used when immunizing a newborn?
Recombivax HB 5mcg/0.5mL
Engerix-B 10mcg/0.5mL
Given at birth, 1 month, and 6 months
How does Hep-B immune globulin work?
Why would this be given to a newborn baby?
What is the dosage?
Action: Hepatitis B immunoglobulin (HBIG) provides a high titre of antibody to hepatitis B surface antigen (HBsAg).
Indication: The HBIG vaccine provides prophylaxis against infection in newborns born to HBsAg-positive mothers.
Newborn Dosage: Administer one 0.5-mL dose intramuscularly within 12 hours of birth.
What are inactivated or killed vaccines?
What vaccine is an example of this type?
Contains micro organisms (bacteria/viruses) that have been killed, but still capable of inducing the body to produce antibodies
Example: inactivated polio virus vaccine
What type of vaccine contains micro organisms (bacteria/viruses) that have been killed, but still capable of inducing the body to produce antibodies?
Killed vaccine (inactive)
I.e. inactivated polio virus vaccine
What are toxoid vaccines?
What vaccine is an example of this type?
A toxin treated by heat or chemical to weaken its toxic effects but retains its antigenicity
Example: tetanus toxoid
What type of vaccine is composed of a toxin treated by heat or chemical to weaken its toxic effects but retains its antigenicity?
Toxoid
i.e. tetanus toxoid
What are live virus vaccines?
What vaccine is an example of this type?
Vaccine contains a microorganism in live, but attenuated, or weakened form
Example: MMR
What are recombinant forms of vaccines?
What vaccine is an example of this type?
An organism has been genetically altered for use in vaccines
Example: Hepatitis B
What are conjugated forms of vaccines?
What vaccine is an example of this type?
An altered organism joined with another substance to increase the immune response
Example: Hemophilus influenza type b (Hib)
What type of vaccine contains a microorganism in live, but attenuated, or weakened form?
Live virus vaccine
i.e. MMR
What type of vaccine contains an organism has been genetically altered for use in vaccines?
Recombinant forms
i.e. hepatitis B
What type of vaccine contains an altered organism joined with another substance to increase the immune response?
Conjugated forms
i.e. Hemophilus influenza type b (Hib)
What might be put in a vaccine in order to improve the safety and efficacy of the vaccine?
Proteins
Adjuvants
Preservatives
Antibiotics
Stabilizers
What is an adjuvant in vaccines?
What are the only ones available in Canada currently?
What can happen if they are injected Sub Q rather than IM?
A substance added to a vaccine to enhance the immune response by degree and/or duration making it possible to reduce the amount of immunogen per dose or the total number of doses required to achieve immunity
aluminum salts
injection site reactions
What are preservatives in vaccines?
Which are available in Canada?
Why is their controversy to their use?
Chemicals added to multidose vials to prevent serious secondary infections as a result of bacterial or fungal contamination
thimerosal - an ethyl mercury derivative, phenol, 2 phenoxyethanol
Controversy re: theoretical risk of thimerosal risk of brain damage – has been refuted
What are additives in vaccines?
What is an example of this in Canada?
Other substances added to vaccines to:
- Support growth and purification of specific immunogens and or the inactivation of toxins
- Confirm product quality or stability
E.g. Gelatin
What study claimed that vaccines cause autism? What is the result of this?
Wakefield study
Study fully retracted and Wakefield’s name was erased from the medical registry
What is the process where the vaccine is kept at the appropriate temperature?
What can happen if it is not maintained?
Cold chain
Can destroy or reduce the effectiveness of the vaccine
How long after receiving a vaccine should the child wait in the office prior to leaving in the event of a reaction?
Usually 15 minutes
30 minutes for children with a history of anaphylaxis
When is a vaccine contraindicated?
A person with a history of anaphylaxis after previous immunization of the same vaccine or to any component of the vaccine or its container
Refer to an allergist to determine specific cause and to assess if vaccines should be avoided and for how long
What is a precaution to a vaccine? What usually happens if this condition exists?
A condition that may increase the risk of an adverse reaction following immunization or that may compromise the ability of the vaccine to produce immunity
In general, vaccines are deferred when a precaution exists
Why can happen if significantly immunosuppressed individuals are given a live vaccine?
Other than live vaccines, can these people receive all other vaccines?
If significantly immuno-compromised, live viral or bacterial vaccines may cause serious adverse events because of uncontrolled replication of the virus or bacteria
Immunosuppressed people cannot have live vaccines (precaution/contraindication)
Other types - Yes they can, even a less than optimal response may provide important benefit to such patients, who are also at high risk of morbidity and mortality due to vaccine-preventable infection
Should pregnant patients receive a live vaccine? Why?
If a pregnant woman receives a live vaccine, the infection with the vaccine strain virus or bacteria might affect the fetus
Safety data for other live virus vaccines in pregnant women are very limited
They should not received live vaccines during pregnancy unless their risk from the illness is clearly greater than the potential risk from the vaccine
What considerations should be made when giving a vaccine to a patient with a history of Guillain-Barre syndrome (GBS) with onset within 8 weeks of a previous immunization?
Subsequent doses of the same vaccine should only be given if the benefit of vaccine outweighs the potential risk of recurrence of the GBS is vaccine is given
What vaccines can be given to pregnant women?
Inactivated viral vaccines, bacterial vaccines and toxoids can be used safely in pregnancy
Why are pregnant women considered a vulnerable population when it comes to infections?
They have an altered immune response and for some infections
Are at increased risk of infection and at risk of increased risk of severe outcomes once infected.
How does breastfeeding vs formula feeding affect the immunization schedule?
It doesn’t they should still receive the recommended vaccines according to the routine immunization schedule
What types of reactions may be seen with inactivated antigens? What can be done to help?
Symptoms occur within hours/days
- Local tenderness
- Erythema (redness)
- Swelling
- Low grade fever
- Behavioural changes (drowsy, reduced appetite)
Usually acetaminophen can help with symptoms
Why do MMR and other live vaccines have reactions that last so long (30-90 days)?
Because they multiply for days or weeks
What is a serious, potentially life-threatening allergic reaction to foreign antigens that is associated with vaccines?
Anaphylaxis
You just provided an infant with their routine vaccinations. They became upset, crying hard, and then becoming suddenly silent and stop breathing. They are flushed in the face but have peripheral cyanosis that deepens as they continue to not breathe. Eventually, the child loses consciousness and then they begin breathing again. What just happened?
Breath holding spell
You gave a 12 year old their grade 6 routine vaccinations. They appeared fine as they received the vaccine but just as you finish up, they become pale, diaphoretic, and tell you they don’t feel very well. He suddenly slumps in the chair and appears to be unconscious. It only lasts a minute or so before he begins to recover. What just happened?
Syncope
What is induction of labour? When is this done?
Chemical or mechanical initiation of labour
Done when continuing the pregnancy could pose risk to mother or baby and no contraindications exist for artificial rupture of membranes
Elective: done when there are no medical reasons (discouraged)
What are the chemical options for initiating labour? How do they work?
Prostaglandins: Cervidil vaginal insert
- Ripens the cervix: causes it to soften and begin to dilate and efface
Oxytocin
- Used to induce or augment labour
- Given IV
- Uterinetachysystole: (lots of contractions 6 in 10 minutes)
What are the mechanical methods that may be used to initiate labour?
Balloon catheter: ripens and dilates the cervix
Dilators: Absorb fluid, expand, causing the cervix to dilate
Membrane sweeping: separates the membrane from the wall of the cervix and causes release of prostaglandin and oxytocin
Artificial rupture of membranes
-Cervix must be ripe
-Often done with oxytocin administration
Self-induce: nipple stimulation, sex, walking, drinking castor oil, acupuncture
When might ventouse (suction) or forceps be used during labour?
Pt cannot push out baby because of an underlying health condition (such as preeclampsia)
there are concerns about baby’s heart rate
baby is in an awkward position
baby is fatigued and there are concerns that they may be in distress
Pt is having a vaginal delivery of a premature baby – forceps can help protect baby’s head from the pressure/friction of the perineum
Pt requires an epidural for pain relief during labour
What are the risks of a ventouse or forceps birth?
To mom
- vaginal tearing (which can be deep enough to involve the anus/rectum)
- episiotomy
To baby
- a mark on baby’s head (chignon) being made by the ventouse cup – this usually disappears within 48 hours
- a bruise to baby’s head (cephalohaematoma) – this can happen during a ventouse assisted delivery, but the bruise is usually nothing to worry about and should disappear with time
- marks from forceps on baby’s face – these usually disappear within 48 hours
- small cuts on baby’s face or scalp – these affect 1 in 10 babies born using assisted delivery and heal quickly
- yellowing of baby’s skin and eyes jaundice, and should pass in a few days
How are forceps used during an assisted vaginal birth?
Blades cover the ears and go around the baby’s head like 2 tablespoons would hold an egg
They lock in place to prevent compression of the fetal head (see red arrows)
Rotation (and slight traction) is applied during contractions
What about the mother/birth need to be done prior to using forceps during labour?
- cervix fully dilated
- bladder emptied
- presenting part engaged
- ruptured membranes
What should the mother be assessed for after an assisted vaginal birth?
- lacerations
- uterine retention
- hematomas
What should the baby be assessed for after being delivered using forceps?
- bruising
- palsy
- hematoma
What should the baby be assessed for after being delivered using a vacuum cup?
- cephalohematoma
- scalp lacerations
- subdural hematoma
Your patient is delivering her baby at 33 weeks gestation and the doctor needs an assistive device to help the delivery. What type of assistive device is he likely to grab and why?
For an assisted birth at less than 36 weeks pregnant, forceps may be recommended over ventouse. This is because forceps are less likely to cause damage to baby’s head, which is softer at this point in pregnancy.
Why might a birth be completed via c-section vs vaginal delivery?
scheduled
- labour/vaginal birth contraindicated (i.e. abnormal baby positioning, previous c-sections)
- labour should not be induced (hypertensive disorders)
- placenta previa
- active herpes or HIV with high viral load
- placenta previa
unplanned/emergent
- complications in labour (i.e. fetal distress, placental issues)
- dysfunctional labour
- placental abruption
What are the maternal complications of a Caesarean section?
- Aspiration
- Hemorrhage
- Atelectasis (Collapsed lung)
- Endometritis
- Wound dehiscence
- Infection
- UTI
- Bladder injuries
- Anaesthesia complications
What are the newborn complications of a Caesarean section?
- Potentially be born premature if due date was not accurate
- Asphyxia if uterus and placenta are poorly perfused
- Fetal injuries (related to scalpel)
- Respiratory problems
While you are in the OR watchin the Caesarean section for a 25 year old mother with her first child, you watch her baby boy be removed without any complications. The baby starts to cry immediately, and looks wonderfully healthy. What should be done as soon as possible?
skin to skin with the mother or partner
Your patient has just been returned from the OR where she delivered her healthy baby girl. What should the nurse do to provide care for the mother and baby?
- assess vitals of mom and baby
- assess incision and check for signs of infection
- monitor for blood loss from incision and vagina
- Ensure patent airway
- monitor urine output
- monitor IV
- assess post op pain levels
- skin to skin contact with baby and encourage breastfeeding
- support ambulation once mom has feeling back in her legs
- education regarding diet
What is a VBAC and what is the criteria for it?
Vaginal Birth After Caesarean Section (VBAC)
- Low-transverse caesarean birth
- ‘adequate’ pelvis
- No other uterine scars or history of previous rupture
- Available physicians during active labour and ready to preform a caesarean section if necessary
What is a prolapsed cord? What can this lead to?
Umbilical cord is below the presenting part, most commonly seen after rupture of membranes
Can lead to
- fetal hypoxia
- newborn asphyxia
- neurological brain injury
- death
Your patient just had her membranes rupture. You check her perineal area and cervix and note that the umbilical cord is presenting. What is this? What do you do?
Prolapsed cord
EMERGENCY! - get help
Help woman into Trendelenburg position with a blanket/pillow under the hips or in a knees to chest, face down type position as this will take the pressure off the cord until it can be corrected
Describe the grasping find motor development of infants
1 month - hands closed
3 months - hands open and will hold something if given
5 months - can voluntarily hold something (they can pick up a soother and put it in their mouth, it’s less than graceful but it works)
8-9 months - pincer grasp develops (thumb and finger to pick something up
When should babies begin to be able to hold their head beyond the plane of their body?
3 months
By 4 months they can lift their head 90 degrees
When do babies learn to roll over?
5 months - roll from front to back
6 months - roll from back to front
Describe the gross motor development milestones to sitting
7 months - sit up alone leaning forward
8 months - sit unsupported
10 months - can go from prone to sitting up unassisted
Describe the gross motor development milestones to moving
9 months - crawling forward
9-10 months - stand while holding onto furniture and can hold themselves up
11 months - walk while holding on to furniture
12 months - walk while holding a hand, may take 1st independent steps
12-13 months - walk along with a wide stance
18 months - run (falls easily though haha)
2 years - jumping
What is object permanence and when do babies develop it?
6 months - the know something they cannot see still exists
When do babies experience separation anxiety?
From 6-8 months
Closely linked to object permanence
You are doing a checkup on a 4 month old baby and the mother asks about introducing solid foods. What should you advise her?
- can introduce foods at 6 months
- offer foods high in iron
- do not delay trigger foods that are believed to cause allergies
- most calories will still come from breastmilk/formula
- foods should not be mixed in a bottle
- introduce foods one at a time
What physiological adaptations have occurred in infants at 6 months that now makes it safe to try solid foods?
- The GI tract has matured and is ready for solids
- Teeth begin to come and can help with chewing
- Head control is well developed (babies can sit up supported)
- Swallowing is better coordinated
- Voluntary grasping occurs
Between 12-36 months, there is a lot of exploration; _____ slows down but ______ continues to develop
Growth
Senses
What is demonstrated through increased manual dexterity?
Fine motor development
Describe the language development in toddlers
1 year
- can speak about 4 words
- 1 word sentences (“up”)
2 years
- can speak about 300 words
- 2-3 word sentences (“hold ball”)
3 years
- simple sentences and masters grammar rules
- learn 5-6 new words/day
- count to 3
Describe the development of task independence in toddlers
15 months - can feed themselves (its messy lol)
2 years
- use a spoon
- dress/undress with minimal assistance
2-3 years
- chores such as putting toys away
What is the most major task of toddlerhood?
Toilet training
When does voluntary control of anal and urethral sphincters occur?
Between 18-24 months
About how many hours of sleep per night do school age children need?
9-12 hours per night
When does puberty typically start?
age 10 in girls
age 12 in boys
Puberty in girls usually starts with the appearance of __________ and after about 2 years, _______ begins.
breast buds (after age 8)
menarche (10.5-15 years)
