Mod3 learning outcomes Flashcards
- Explain the importance of the development of surfactant and its role in the successful
transition of the neonate to extrauterine life.
The presence of surfactant, a phospholipid, within the alveoli assists in the establishment of functional residual capacity. This residual capacity helps keep the alveolar sacs partially open at the end of exhalation, which decreases the amount of pressure and energy required on inspiration. A lack of lubricating surfactant in the baby’s lungs can reduce elasticity and ability of lungs to expand.
- Identify the most important nursing action for the nurse to perform immediately after
delivery.
Dry the neonate thoroughly immediately after birth to decrease heat loss due to evaporation.
- Identify the factors that influence the initiation of respirations.
SLides-Initiation of respirations as the most important step at birth.
Breathing seen as early as 11 weeks ges.
During labor amniotic fluid starts to absorb 1/3 of remaining pushed out as passess thru birth canal. Stresses of L&D stimulate respiratory center of brain
Primary factors that influence extrauterine respirations are mecanical stimuli, chemical stimuli, and sensory stimuli. establishment of extrauterine respirations is the most critical and immediate physiological change that occurs in the transition. Mechanical-
change is initiated by compression of the thorax (delivery of face), which forces amniotic fluid from the lungs; lung expansion; increase in alveolar oxygen concentration; and vasodilatation of the pulmonary vessels.
Delivery of chest=expansion of chest =negative pressure =passive inspiration of air=first breath. Entry of air into alveoli replaces expelled amniotic fluid, lymphatic system reabsorbs lung fluid, crying of neonate cause intrathoracic positive pressure and alveoli remain open.
Chemical stimuli -Cessation of placental blood flow, decreased O2=mild hypoxia, increase of CO2=decrease of pH (acidosis)=stimulation of respiratory center in medulla=stimulation of respirations.
.Sensory stimuli such as exposure to temperature changes, sounds, lights, and touch also influence respirations by stimulating the respiratory center of the medulla.
Interfering factors-Prematurity , birth asphyxia- inadequate oxygen as result of nuchal cord(wrapped around neck)
), and the lack of lubricating surfactant in the baby’s lungs which can reduce elasticity and ability of lungs to expand. Premature infants (those born at less than 36 weeks gestation) are at a higher risk for respiratory distress syndrome. Given steroids to help fetal lungs develop-2 hours before birth
- Identify the three anatomical structures that enable in utero survival and how those
structures change following birth.
The transition to neonatal circulation is strongly influenced by the changes within the respiratory system. The decrease in pulmonary vascular resistance causes an increase in pulmonary blood flow, and the increase in systemic vascular resistance influences the cardiovascular changes (Fig. 15–4).
The three major fetal circulatory structures that undergo changes are the ductus venosus, foramen ovale, and the ductus arteriosus.
● The ductus venosus, which connects the umbilical vein to the inferior vena cava, closes by day 3 of life and becomes a ligament. Blood flow through the umbilical vein stops once the cord is clamped.
● The foramen ovale, which is an opening between the right atrium and the left atrium, closes when the left atrial pressure is higher than the right atrial pressure. Significant neonatal hypoxia can cause a reopening of the foramen ovale. This closure occurs when:
● Increased Pao2 → decreased pulmonary pressure → increased pulmonary blood flow → increased pressure in left atrium → closure of foramen ovale.
● The ductus arteriosus, which connects the pulmonary artery with the descending aorta, usually closes within 15 hours postbirth. It will remain open when the lungs fail to expand or when Pao2 levels drop. Closure occurs when:
● The pulmonary vascular resistance becomes less than system vascular resistance → left to right shunt → closure of ductus arteriosus.
- Explain the importance of administering vitamin K to the neonate after birth.
Blood coagulation:
● Coagulation factors II, VII, IX, and X are synthesized in the liver. Vitamin K influences the activation of these factors. During intrauterine life, the fetus receives vitamin K from its mother. After birth, the neonate experiences a decrease in vitamin K and is at risk for delayed clotting and for hemorrhage. Vitamin K is synthesized in the intestinal flora, which is absent in the newborn. The intestinal flora develops after the introduction of microorganisms, which usually occurs with the first feedings.
● A vitamin K injection is given as a prophylaxis to decrease the risk of bleeding related to vitamin K deficiency. The decline of maternally acquired vitamin K levels is greater in breastfed neonates, neonates with a history of perinatal asphyxia, and neonates of mothers who are on warfarin (Blackburn, 2012).
- Describe norms of the newborn following birth as well as how to assess and/or perform each of the following:
A. General physical assessment B. Apgar scoring C. Identification procedures D. Vitamin K administration E. Erythromycin instillation F. Weight and length determination G. Head circumference H. Behavioral assessment I. Cord care
Slides-
Respirations Rate 30–60 breaths per minute, no retractions or grunting
Apical pulse Rate 120–160 beats per minute
Temperature 97.7°F–99.3°F (36.5°C–37.4°C)
Skin color Pink body, blue extremities
Umbilical cord Contains two arteries and one vein
Gestational age Full term: >37 completed weeks
Weight 2,500–4,300 grams
Length 45–54 cm
General physical assessment-neonatal assessment done within first 2 hours after birth. Provides baseline data, evaluates transition to extrauterine life &determines course of nursing and medical care. INcludes general survey, physical assessment, gestational assessment, and pain assessment.
General survey:
Completed b4 physical assessment
While neonate is quiet.
Observe respiratory pattern/assess respirations and breath sounds, posture, skin for color birth trauma and birthmarks, level of alertness/activity, muscle tone/posture.
Physical assessment: head to toe assessment includes assessing reflexes unique to neonates-tables 15-3, 15-4, 15-5.
Also slides-is weighed upon delivery: to determine percentage of appropriate size on growth chart (and to determine is baby is LGA or SGA -both which may indicate problems or be predictors of possible issues); this also ensures proper dosages for medications if the baby needs to be transferred into the NICU; and it will help to track weight loss and weight gain to assess growth
Length is measured for similar reasons -it is important to assess for proper growth. Head circumference infant is important because it may indicate potential issues with the brain; temperature is essential and is discussed in its own section, and this is the first opportunity to gather a set of vital signs(HR respiratory rate quality effort
Physical assessment: head to toe assessment includes assessing reflexes unique to neonates-tables 15-3, 15-4, 15-5.
Posture
Unwrap the newborn and observe posture when the neonate is quiet.
Expected:
Extremities are flexed.
deviations from normal:
Extension of extremities often related to prematurity; effects of medications given to mother during labor such as magnesium sulfate and analgesics/anesthesia; birth injuries; hypothermia; or hypoglycemia
Head circumference
Measure by placing tape around the head just above the ears and eyebrows.
Measurement is usually recorded in centimeters.
Normal :
33–35.5 cm (13–14 in.)
Deviations from normal:
Microcephaly: Head circumference is below the 10th percentile of normal for newborns gestational age. This is often related to congenital malformation, maternal drug or alcohol ingestion, or maternal infection during pregnancy.
Macrocephaly: Head circumference is >90th percentile. This can be related to hydrocephalus.
Chest circumference Measure by placing tape around the chest over the nipple line.
Normal
30.5–33 cm (12–13 in.) or
2–3 cm less than head circumference
Length
Measure the length of body by securing tape on a flat surface.
Place the top of neonate’s head at the top of the tape.
Extend the body and one leg.
Measurement is taken from the top of the head to the bottom of the heel.
Normal:
45–53 cm (19–21 in.)
Deviations from normal:
Molding may interfere with accurate assessment of length.
Neonates whose length is <45 cm should be further assessed for causes such as intrauterine growth restriction or prematurity.
Weight
Figure
Clean scale before use.
Place clean paper on the scale.
Set the scale at zero.
Place the naked neonate on the scale.
Record the neonate’s weight.
Do not leave the neonate unattended while weighing.
Normal:
2,500–4,000 g (5 lb 8 oz–8 lb 13 oz)
Weight loss of 5%–10% of birth weight during the first week is normal. This is due to water loss through urine, stools, and lungs and an increase in metabolic rate. It is also related to limited fluid intake.
The neonate will regain birth weight within 10 days.
Deviations from normal:
Weight above the 90th percentile is common in neonates of diabetic mothers.
Weight below the 10th percentile is due to prematurity, intrauterine growth restriction, malnutrition during the pregnancy.
Temperature
Place a clean temperature probe in the axillary area.
Axillary temperatures are preferred because of the risks of tissue trauma, perforation, and cross-contamination associated with the rectal temperature method (Blackburn, 2012).
Normal:
36.5°C-37.2°C (97.7°F–99°F) Axillary
Deviations from normal:
Hypothermia or hyperthermia is related to infection, environmental extremes, and/or neurological disorders.
Respirations Assess respiratory rate by observing the rise and fall of the chest and abdomen for 1 full minute.
Normal:
30–60 breaths per minute
Slightly irregular
Diaphragmatic and abdominal breathing
Rate increases when crying and decreases when sleeping.
Deviations from normal:
Periods of apnea >15 seconds
Tachypnea that may be related to sepsis, hypothermia, hypoglycemia, or respiratory distress syndrome.
Respirations <30; may be related to maternal analgesia and/or anesthesia during labor.
Pulse
Figure
Assess apical pulse rate by auscultating for 1 full minute.
Assess rate and rhythm.
Use of a stethoscope designed for neonates is recommended.
Normal:
110–160 bpm
Rate increases (to 180 bpm) with crying and decreases (to 90 bpm) when asleep.
Murmurs may be heard; most are not pathological and disappear by 6 months.
Deviations from normal:
Tachycardia (> 160 bpm) indicates possible sepsis, respiratory distress, congenital heart abnormality.
Bradycardia (<100 bpm) indicates possible sepsis, increased intracranial pressure, or hypoxemia.
Blood pressure
Blood pressure is not a routine part of neonatal assessment.
Requires the use of specially designed equipment for neonates.
The blood pressure is obtained from either the arm or the leg of the neonate.
Normal:
50–75/30–45 mm Hg
Physical assessment continued: Integumentary
Integumentary/skin
Inspect the skin for color Pink proper for ethnicity), intactness, bruising, birth marks, dryness, rashes, warmth, texture, and turgor. Inspect nails.
Normal:
Figure
Skin is warm with acrocyanosis (cyanosis of hands and feet).
Milia are present on the bridge of the nose and chin (see Table 15–4).
Lanugo is present on the back, shoulders, and forehead, which decreases with advancing gestation (see Table 15–4).
Peeling or cracking is often noted on infants >40 weeks’ gestation.
Mongolian spots (see Table 15–4)
Hemangiomas such as salmon-colored patch (stork bites), nevus flammeus (port-wine stain), and strawberry hemangiomas are developmental vascular abnormalities.
Stork bites are found at the nape of the neck, on the eyelid, between the eyes, or on the upper lip. They deepen in color when the neonate cries. They disappear within the first year of life.
Nevus flammeus are purple- to red-colored flat areas that can be located on various portions of the body. These do not disappear.
Strawberry hemangiomas are raised bright red lesions that develop during the neonatal period. They spontaneously resolve during early childhood.
Erythema toxicum, newborn rash (see Table 15–4).
Deviations from normal:
Jaundice within the first 24 hours is pathological (see Chapter 17).
Pallor occurs with anemia, hypothermia, shock, or sepsis.
Greenish/yellowish vernix indicates passage of meconium during pregnancy and/or labor.
Persistent ecchymosis or petechiae occurs with thrombocytopenia, sepsis, or congenital infection.
Abundant lanugo is often seen in preterm neonates.
Thin and translucent skin, and increased amounts of vernix caseosa are common in preterm neonates.
Nails are longer in neonates >40 weeks’ gestation.
Pilonidal dimple: A small pit or sinus in the sacral area at top of crease between the buttocks; the sinus can become infected later in life.
Physical assessment :Head & Neck
Note the shape of the head.
Inspect and palpate fontanels and suture lines. Inspect and palpate the head for caput succedaneum and/or cephalohematoma (see Table 15–4).
Normal: Molding present (see Table 15–4).
Fontanels are open, soft, intact, and slightly depressed. They may bulge with crying.
The anterior fontanel is diamond shaped, approximately 2.5–4 cm (closes by 18 months of age).
The posterior fontanel is a triangle shape that is approximately 0.5–1 cm (closes between 2 and 4 months).
May be difficult to palpate due to excessive molding.
There are overriding sutures when there is increased molding.
Deviations:
Fontanels that are firm and bulging and not related to crying are a possible indication of increased intracranial pressure.
Depressed fontanels are a possible indication of dehydration.
Bruising and laceration at the site of the fetal scalp electrode or vacuum extractor.
Presence of caput succedaneum (fluid right after birth, decreases crosses over sutures) and/or cephalohematoma(doesnt cross sutures, swells hours or days later)
Neck
Lift the chin to assess the neck area.
Normal:
The neck is short with skin folds. dont palpate carotid arteries
check head lag
clavicles-intact no crepitus
Positive tonic neck reflex (see Table 15–5).
Deviations:
Webbing is a possible indication of genetic disorders.
Absent tonic neck reflex is an indication of nerve injury.
Physical assessment: Eyes/ears
Eyes
Assess the position of the eyes.
Open the eyelids and assess color of sclera and pupil size. Assess for blink reflex, red light reflex, and pupil reaction to light.
Normal:
Eyes are equal and symmetrical in size and placement.
The neonate is able to follow objects within 12 inches of the visual field.
Edema may be present due to pressure during labor and birth and/or reaction to eye prophylaxes.
The iris is blue-gray or brown.
The sclera is white or bluish white.
Subconjunctival hemorrhages related to birth trauma.
Pupils are equally reactive to light.
Positive red light reflex and blink reflex.
No tear production (tear production begins at 2 months).
Strabismus and nystagmus related to immature muscular control.
Deviations:
Absent red light reflex indicates cataracts.
Unequal pupil reactions indicate neurological trauma.
Blue sclera is a possible indication of osteogenesis imperfecta.
Ears
Figure
Inspect the ears for position, shape, and drainage.
Hearing test is done before discharge.
Normal:
canals present
Top of the pinna is aligned with external canthus of the eye.
Pinna without deformities, well formed and flexible.
The neonate responds to noises with positive startle signs.
Hearing becomes more acute as Eustachian tubes clear.
Neonates respond more readily to high-pitched vocal sounds.
Deviations:
Low-set ears are associated with genetic disorders such as Down syndrome.
Absent startle reflex is associated with possible hearing loss.
Physical assessment:
Nose/ Mouth
Nose
Figure
Observe the shape of the nose.
Inspect the opening of the nares.
Normal:
The nose may be flattened or bruised related to the birth process.
Nares should be patent.
Small amount of mucus.
Neonates primarily breathe through their noses.
Deviations:
Large amounts of mucus drainage can lead to respiratory distress.
A flat nasal bridge is seen with Down syndrome.
Nasal flaring is a sign of respiratory distress.
Mouth
Figure
Inspect lips, gums, tongue, palate, and mucous membranes.
Open the mouth by placing gentle pressure on the lower lip.
Test for rooting, sucking, swallowing, and gag reflexes (see Table 15–5).
Normal:
Lips, gums, tongue, palate, and mucous membranes are intact, pink, and moist.
Reflexes are positive.
Epstein’s pearls are present (see Table 15–4).
Deviations:
Natal teeth, which can be benign or related to congenital abnormality (see Table 15–4).
Thrush, a fungal infection, can be contracted during vaginal birth. It appears as white patches on the mucous membranes of the mouth.
Thin philtrum may be indicative of fetal alcohol syndrome.
Cleft lip and/or palate, which is a congenital abnormality in which the lip and/or palate does not completely fuse (see Chapter 17).
Physical assessment: Chest/lungs
Cardiac
Chest/lungs
Inspect shape, symmetry, and chest excursion.
Inspect the breast for size and drainage.
Auscultate breath sounds.
check heart for regularity /any adventitious sounds
Normal:
The chest is barrel-shaped and symmetrical.
note location/severity of retractions if present
Breast engorgement is present in both male and female neonates related to the influence of maternal hormones and resolves within a few weeks.
Clear or milky fluid from nipples related to maternal hormones.
Lung sounds are clear and equal.
Scattered crackles may be detected during the first few hours after birth. This is due to retained amniotic fluid, which will be absorbed through the lymphatics.
Deviations: Pectus excavatum (funnel chest) is a congenital abnormality.
Pectus carinatum (pigeon chest) can obstruct respirations.
Chest retractions are a sign of respiratory distress.
Persistent crackles, wheezes, stridor, grunting, paradoxical breathing, decreased breath sounds, and/or prolonged periods of apnea (> 15–20 seconds) are signs of respiratory distress.
Decreased or absent breath sounds are often related to meconium aspiration or pneumothorax.
Cardiac
Auscultate heart sounds; listen for at least 1 full minute.
Palpate peripheral pulses.
Normal:
Point of maximal impulse (PMI) at the 3rd or 4th intercostal space.
S1 and S2 are present.
Normal rhythm with variation related to respiratory changes.
Murmurs in 30% of neonates, which disappear within 2 days of birth.
Peripheral pulses are present and equal.
The femoral pulse may be difficult to palpate.
Deviations:
Dextrocardia: Heart on the right side of the chest.
Displaced PMI occurs with cardiomegaly.
Persistent murmurs indicate persistent fetal circulation or congenital heart defects.
Physicial assessment:
Abdomen
Rectum
Abdomen
Inspect size and shape of the abdomen.
Palpate the abdomen, assessing for tone, hernias, and diastasis recti.
Auscultate for bowel sounds.
Inspect the umbilical cord. two arteries/one vein
palpate abdomen, bowel sounds
Straight spine
sacrum dimples -can indicate neural tube defect.
Normal:
The abdomen is soft, round, protuberant, and symmetrical.
Bowel sounds are present but may be hypoactive for the first few days.
Passage of meconium stool within 48 hours postbirth.
The cord is opaque or whitish blue with two arteries and one vein, and covered with Wharton’s jelly.
The cord becomes dry and darker in color within 24 hours postbirth and detaches from the body within 2 weeks.
Deviations:
Asymmetrical abdomen indicates a possible abdominal mass.
Hernias or diastasis recti are more common in African American neonates and usually resolve on their own within the first year.
One umbilical artery and vein is associated with heart or kidney malformation.
Failure to pass meconium stool is often associated with imperforated anus or meconium ileus.
Rectum Inspect the anus.
Normal:
The anus is patent.
Passage of stool within 24 hours.
Deviations:
Imperforated anus requires immediate surgery.
Anal fissures or fistulas.
Physical assessment
Genitourinary female
Genitourinary: female
Place thumbs on either side of the labia and gently separate tissue to visually inspect the genitalia.
Assess for the presence and position of clitoris, vagina, and urinary meatus.
Normal:
Labia majora covers labia minora and clitoris.
Labia majora and minora may be edematous.
Blood-tinged vaginal discharge related to the abrupt decrease of maternal hormones (pseudomenstruation).
Whitish vaginal discharge in response to maternal hormones.
The neonate urinates within 24 hours.
The urinary meatus is midline and an uninterrupted stream is noted on voiding.
Deviations:
Prominent clitoris and small labia minora are often present in preterm neonates.
Ambiguous genitalia; may require genetic testing to determine sex.
No urination in 24 hours may indicate a possible urinary tract obstruction, polycystic disease, or renal failur
Genitourinary male
Genitourinary: male
Inspect the penis, noting the position of the urinary meatus.
Inspect and palpate the scrotum to assess for testicles. With the thumb and forefinger of one hand, palpate each testis while the other thumb and forefinger are placed over the inguinal canal to prevent the ascent of testes during assessment. Start at the upper aspect of the scrotum and move away from the body.
Normal:
The urinary meatus is at the tip of the penis.
The scrotum is large, pendulous, and edematous with rugae (ridges/creases) present.
Both testes are palpated in the scrotum.
The neonate urinates within 24 hours with an uninterrupted stream.
Deviations:
Hypospadias: The urethral opening is on the ventral surface of penis.
Epispadias: The urethral opening is on the dorsal side of penis.
Undescended testes: testes not palpated in the scrotum.
Hydrocele is enlarged scrotum due to excess fluid.
No urination in 24 hours may indicate possible urinary tract obstruction, polycystic disease, or renal failure.
Ambiguous genitalia may require genetic testing to determine sex.
Inguinal hernia.
Musculoskeletal
Slides-Check femoral pulses bilaterally Ensure equal, bilateral movement Plantar grasp reflex Babinski reflex Count toes Look between toes Webbing may be present
Ensure equal, bilateral movement Shoulder dystocia could affect movement of affected arm Palmar grasp reflex Moro reflex Count fingers Look between fingers Webbing may be present Palmar crease Single crease across palm may indicate Down’s syndrome
Musculoskeletal
Figure
Inspect extremities, spine, and gluteal folds.
Palpate the clavicles.
Perform the Barlow and Ortolani maneuvers.
Figure
Assessing range of motion for arm is especially important if there was shoulder dystocia during the birthing process.
Normal:
Arms are symmetrical in length and equal in strength.
Legs are symmetrical in length and equal in strength.
10 fingers and 10 toes.
Full range of motion of all extremities.
No clicks at joints.
Equal gluteal folds.
C curve of spine with no dimpling.
Deviations:
Polydactyly: Extra digits may indicate a genetic disorder.
Syndactyly: Webbed digits may indicate a genetic disorder.
Unequal gluteal folds and/or positive Barlow and Ortolani maneuvers are associated with congenital hip dislocation.
Decreased range of motion and/or muscle tone indicates possible birth injury, neurological disorder, or prematurity. Swelling, crepitus and/or neck tenderness indicates possible broken clavicle, which can occur during the birthing process in neonates with large shoulders.
Simian creases, short fingers, wide space between big toe and second toe are common with Down syndrome.
Neurological:
Neurological
Assess posture.
Assess tone.
Test newborn reflexes (see Table 15–5).
(Primitive responses
Based on gestational age
Absence may warrant additional testing
Some reflexes only occur in certain stages of development)
Tone-Hypotonic or hypertonic may indicate concern
Normal:
Flexed position
Rapid recoil of extremities to the flexed position
Positive newborn reflexes
Deviations:
Hypotonia: Floppy, limp extremities indicate possible nerve injury related to birth, depression of CNS related to maternal medication received during labor or to fetal hypoxia during labor, prematurity, or spinal cord injury.
Hypertonia: Tightly flexed arms and stiffly extended legs with quivering indicate possible drug withdrawal.
Paralysis indicates possible birth trauma or spinal injury.
Tremors are possibly due to hypoglycemia, drug withdrawal, cold stress.
Gestational age assessment
The Dubowitz neurological exam is a standardized tool that assesses 33 responses in four areas:
● Neonates who are preterm, born before 37 weeks based on the maternal menstrual history, or post-term, born after 42 weeks by dates.
● Neonates who weigh less than 2,500 g or more than 4,000 g.
● Neonates of diabetic mothers.
● Neonates whose condition requires admission to a neonatal intensive care unit (NICU).
● Habituation (the response to repetitive light and sound stimuli)
● Movement and muscle tone
● Reflexes
● Neurobehavioral items
The Ballard Maturational Score (BMS)
Ballard gestational age assessment tool.
The Ballard Maturational Score (BMS) is calculated by assessing the physical and neuromuscular maturity of the neonate. It can be completed in less time than the Dubowitz neurological exam and consists of six evaluation areas for neuromuscular maturity and six items of observed physical maturity (Table 15–6). The examination determines weeks of gestation and classifies the neonate as preterm (less than 37 weeks), term (37 to 42 weeks), or post-term (older than 42 weeks).
The scores from these exams provide a gestational age that is graphed based on weight, length, and head circumference to determine if the neonate is average for gestational age, small for gestational age (SGA), or large for gestational age (LGA) (Fig. 15–8).
● SGA is a term used for neonates whose weight is below the 10th percentile for gestational age.
● LGA is a term used for neonates whose weight is above the 90th percentile for gestational age.
Pain assessment
Premature Infant Pain Profile (PIPP) and Neonatal Infant Pain Scale (NIPS), have been developed to assess for neonatal pain. Pain assessment tools commonly look at state of arousal, cry, motor activity, respiratory pattern, and facial expressions. Some tools may also include blood pressure and oxygen saturation level. The tool used for assessment varies based on hospital policies and procedures.
Babies can exhibit pain in different ways
Behavioral signs
Crying
Agitation
Grimacing
Guarding Physiological signs Increase in respiratory rate Increased heart rate Increased blood pressure
Premature can respond to physiological stresses differently
(apnea, drop in oxygen saturation, bradycardia)
Different types of pain scales
Neonatal infant pain scale(NIPS)
facial expression
cry
breathing
arms
legs
alertness
00relaxed absent 1 contracted mumbling Rrate different than basal flexed stretched uncomfortable- 2-cry vigorous
Also NPASS Neonatal pain agitation and sedation scale-vitals, cry, behavior, facial ex, extremities
