Module 5: Harley

Question 1

Late preterm infants are born at a gestational age between

Answer 1

34 weeks, and 36 weeks and 6 days.

Question 2

Normal Newborn: General Appearance

Answer 2

Well-flexed, full range of motion, spontaneous movement

Common variations:

Legs extended with frank breech

Signs of potential distress or deviations from expected findings:

Posture limp
Asymmetry of movement
Persistent tremor, twitching

Question 3

Temperature

Answer 3

Range 36.5 to 37 axillary

Common variations:

Crying may elevate temperature
Stabilizes in 8 to 10 hours after delivery

Signs of potential distress or deviations from expected findings:

Temperature is not reliable indicator of infection
A temperature less than 36.5

Question 4

Heart rate

Answer 4

Range 120 to 160 beats per minute

Common variations:

Heart rate range to 100 when sleeping to 180 when crying
Color pink with acrocyanosis
Heart rate may be irregular with crying

Signs of potential distress or deviations from expected
findings:

Although murmurs may be due to transitional circulation-all murmurs
should be followed-up and referred for medical evaluation
Deviation from range
Faint sound

Question 5

Respiration

Answer 5

Range 30 to 60 breaths per minute

Common variations:

Bilateral bronchial breath sounds
Moist breath sounds may be present shortly after birth

Signs of potential distress or deviations from expected findings:

Asymmetrical chest movements
Apnea >15 seconds
Diminished breath sounds
Seesaw respirations
Grunting
Nasal flaring
Retractions
Deep sighing
Tachypnea - respirations > 60
Persistent irregular breathing
Excessive mucus
Persistant fine crackles
Stridor (Crowing respiratory sound)

Question 6

Blood Pressure - not done routinely

Answer 6

Factors to consider:

Varies with change in activity level
Appropriate cuff size important for accurate reading
Average newborn (1 to 3 days) oscillometry pressure value: 65/41 in both upper and lower extremities

Sign of potential distress or deviations from expected findings:

Calf systolic pressure 6 to 9 mm Hg less than systolic pressure in upper extremities may be indicative of coarctation of the aorta

Question 7

Head Circumference

Answer 7

33 to 35 cm

Expected findings:
Head should be 2 to 3 cms larger than the chest

Question 8

Chest circumference

Answer 8

30.5 to 33 cm

Common variations:

Molding* of head may result in a lower head circumference measurement
Head and chest circumference may be equal for the first 24 to 48 hours of life

Question 9

Weight range

Answer 9

2500 - 4000 gms (5 lbs. 8oz. - 8 lbs. 13 oz.)

Question 10

Length range

Answer 10

48 to 53 cms (19 - 21 inches)

Question 11

Skin

Answer 11

Expected Findings:
Skin reddish in color, smooth
and puffy at birth
At 24 - 36 hours of age, skin flaky, dry and pink in color
Edema around eyes, feet, and genitals
Turgor good with quick recoil
Cord with one vein and two arteries
Cord clamp tight and cord drying
Hair silky and soft with individual strands
Nipples present and in expected locations
Nails to end of fingers and often extend slightly beyond
Vernix caseosa - The white, cheesy substance covering the newborn’s body. Often present only in the skin folds.
Lanugo - Fine downy body hair usually distributed over shoulders, sacral area, and back of newborns. Usually disappears before birth or shortly after birth.

Common variations:
ACROCYANOSIS
The result of sluggish peripheral circulation.

MONGOLIAN SPOTS
Patch of purple-black or blue-black color distributed over coccygeal and sacral regions of infants of African-American or Asian descent. Not malignant. Resolves in time.

MOTTLING
Generalized red and white discoloration of skin of chilled infants with fair complexion.

PHYSIOLOGICJAUNDICE
Hyperbilirubinemia not associated with hemolytic disease or other pathology in the newborn. Jaundice that appears in full term newborns 24 hours after birth and peaks at 72 hours. Bilirubin may reach 6 to 10 mg/dl and resolve in 5 to 7 days.

MILIA
Tiny white papules (plugged sebaceous glands) located over nose, cheek, and chin.

ERYTHEMA TOXICUM

Petechiae/ bruises over presenting part.
Petechiae: Pinpoint, flat hemorrhages often visualized on head, face, and chest. Associated with rapid onset of pressure followed by immediate release of pressure during birthing process.
Bruises/Ecchymoses: Larger than petechia, hemorrhagic areas associated with rapid delivery or breech birth.
Skin tags usually around ears or digits (tied off)
Harlequin coloring - The color of the newborn’s body appears to be half red and half pale. This condition is transitory and usually occurs with lusty crying. Harlequin Coloring may be associated with to an immature vasomotor reflex system.

Signs of potential distress or deviations from expected findings:
Jaundice (within 24 hours of birth) - Unconjugated bilirubin circulating in the blood stream that is deposited in the skin. Skin color may range from yellow to orange to greenish hues.
General cyanosis
Circumoral cyanosis between feedings
Petechiae or ecchymoses other than on presenting part
All rashes with exception of
erythema toxicum
Pigmented nevi
Yellow vernix
Hemangioma
Pallor

Question 12

Gestational Age Assessment

Answer 12

gestational age is an important factor in determining an infant’s vulnerability. While all infants are vulnerable because all organ systems are immature (either structurally and/or functionally) at birth, premature infants are particularly vulnerable because their organ systems are not only immature, but so much so that extrauterine life poses a severe threat to the functioning of those systems.

After her assessment, Ruth concluded that Harley could be closer to 36 weeks than 38 weeks. She re-plotted his weight, head circumference, and length accordingly.

Previously Harley charted in the 3rd percentile for weight and gestational age. Re-plotting his weight based on 36 weeks now places him in the 10th percentile in weight and the 50th percentile in head circumference and length.

She explained her findings to Linda and then phoned the physician, summarizing her findings and conclusions.

Question 13

Late preterm infants are at risk for problems in every system; this is due to the immaturity of their organ systems.

Answer 13

-Respiratory

Respiratory Distress Syndrome (RDS), Transient Tachypnea of the Newborn (TTN)

-Cardiovascular

Patent Ductus Arteriosus (PDA)

-Neurological
Intraventricular Hemorrhage (IVH)

-Gastrointestinal
Necrotizing Enterocolitis (NEC), feeding difficulties

-Genitourinary
fluid and electrolyte imbalances

-Metabolic
hypothermia, hyperbilirubinemia

-Immune
sepsis

Question 14

PWSCOA

Answer 14

Pink, Warm, Sweet, Clean, Organized and Attached.

Question 15

Pink

Answer 15

establish and maintain respirations

initial breaths are shallow and irregular
normal respiratory rate is 30-60 breaths per minute
infants are nasal breathers
monitor respirations and work of breathing

Question 16

Warm

Answer 16

regulate temperature

• thermoregulation: the balance between heat loss and heat production
• thermogenesis: primarily from brown fat
• large surface to body ratio
• changes in environmental temperature will affect infant

heat loss happens by

-evaporation (about 20%):
loss of heat as water evaporates from the infant’s body
dry the NB immediately after birth to prevent heat loss
loss of heat through conversion of a liquid to a vapor

-conduction (about 5%):
loss of body heat in direct contact with cool surfaces
do not place NB on cold surfaces like the weighing scale
transfer of body heat to a cooler solid object in contact with the body

-convection (about 40%):
loss of heat due to cool air
wrap the NB immediately with blanket and promote flexion to minimize body surface exposed to cool air
flow of heat from body surface to cooler surroundings

-radiation (about 40%):
loss of heat to cool surfaces not in contact with the body
wrap the NB immediately with blanket and promote flexion
transfer of body heat to a cooler solid object not in contact with the body

-monitoring of temperature

Question 17

Sweet

Answer 17

maintain blood sugar

early access to breast, bottle, NG/OG feeds or intravenous therapy for nutrition
monitoring of blood sugar levels
monitoring of intake

Question 18

Organized

Answer 18

maintain an optimum state

an organized infant is one that is free of stress; this allows for optimal growth as stress consumes a minimum number of calories
pace handling
limit invasive procedure if possible; if not, provide supportive care
bundle care to allow for long periods of uninterrupted sleep

Question 19

Attached

Answer 19

promote attachment with family

facilitate care by parents
skin-to-skin (kangaroo) care
family-centered care

Question 20

Respiratory Distress

Answer 20

Infants who are borderline premature may experience a mild degree of Respiratory Distress Syndrome (RDS). This problem is directly related to their prematurity: lower levels of surfactant, fewer alveoli, fewer capillaries, weak respiratory muscles, and a compliant rib cage. If well managed, this does not usually progress and can be easily managed in the first few days of life. If not well managed, it may progress and the infant will tire and begin to experience the more serious consequences of hypoxia, hypercapnia, and acidosis. RDS in these infants can be serious enough to warrant mechanical ventilation.

Other respiratory problems Harley could experience are: pneumonia and transient tachypnea of the newborn (TTN), also called “wet lung.”

Question 21

What is the difference between RDS and TTN?

Answer 21

RDS is a problem of immature lungs: few alveoli, few capillaries, soft rib cage, weak muscles and, most importantly, lack of surfactant. RDS typically affects preterm infants, and the lower the gestational age, the more likely RDS is to develop.

TTN is a problem of inadequate clearage of lung fluid immediately after birth. TTN typically affects infants born by c­section birth and, particularly, those born without labor.

Question 22

What infants are most at risk for pneumonia? Why?

Answer 22

Preterm infants are most at risk because their immune systems are immature. They have less IgG (passed transplacentally in the last trimester), and they are likely to be intubated and experience other invasive procedures.

Other infants at risk are those born to mothers who are Group B streptococcus positive, have a UTI, fever, or prolonged rupture of membranes.

Any infant who is ill and/or is in the NICU is at increased risk. Handling, by multiple caregivers, and invasive procedures threaten to introduce microorganisms. Colonization can quickly become infection and, just as quickly, sepsis.

Term newborns are less at risk as their immune systems are somewhat more developed, but are still immature. Until age 3, children’s immune systems are growing and developing.

Question 23

What can be done to keep Harley “pink”?

Answer 23

To keep Harley pink:

monitor with pulse oximetry
keep oxygen saturations 88–95%
position on abdomen with head of bed slightly elevated
maintain axillary temperature between 36.4–37.2° C
feed according to rate of breathing (60–70: tube feed if no contraindications; 70–90: NPO with IV)
minimize handling
prevent pneumonia with clean and aseptic techniques
provide comfort and other developmentally supportive measures
facilitate skin-to-skin care with parents as is appropriate

Question 24

Respiratory Support

Answer 24

Regardless of the cause, Harley’s oxygen saturations and respiratory rate should be monitored and supplemental oxygen provided, as needed. Ventilation should be supported by positioning him prone with the head of his bed elevated. Frequent respiratory assessment is warranted as Harley’s respiratory status could deteriorate.

Question 25

Hypothermia

Answer 25

Maintaining a neutral thermal environment is one of the key physiologic challenges a newborn infant faces after delivery. While in utero, heat production by the fetus results in a fetal temperature that is approximately half a degree higher than maternal temperature. After birth, the newborn infant is exposed to a much different environment. The risk of hypothermia is real and potentially dangerous and significantly affects both mortality and morbidity. Providing warmth and minimizing heat loss should be an important component of neonatal care.

Hypothermia in infants is a temperature of less than 36.3° C.

Question 26

All infants are at risk for hypothermia due to:

Answer 26

limited CNS control over temperature
limited ability to shiver or vasoconstrict
larger surface area to body mass ratio

Question 27

Preterm infants, in addition to the above have:

Answer 27

less white and brown fat
less ability to flex
higher insensible water loss

Question 28

Consequences of Cold Stress

Answer 28

• increased metabolic rate
• increased consumption of glucose resulting in hypoglycaemia
• failure to gain weight
• metabolism of brown fat

Question 29

increased metabolic rate

Answer 29

decreased surfactant production and hypoxemia leading to respiratory distress

When the metabolic rate of a neonate is increased, the need for oxygen also increases. As cold stress progresses, surfactant production also diminishes; thereby, impeding lung expansion. As a result hypoxemia will be noted and mild respiratory distress can become severe hypoxia if oxygen must be used for heat production.

Question 30

increased consumption of glucose resulting in hypoglycemia

Answer 30

When the metabolic rate rises for the body to produce heat, the glucose requirement also increases. As the demand of glucose surges, the body compensates for this need by converting glycogen stores to glucose. When glycogen stores are converted to glucose, they may be quickly used up, resulting in hypoglycemia.

Question 31

failure to gain weight

Answer 31

Infants who must use glucose for temperature regulation and maintenance have less available supply for growth and development.

Question 32

metabolism of brown fat

Answer 32

metabolic acidosis; increases the risk of jaundice

When brown fats are metabolized in the presence of insufficient oxygen supply, increased acid production will result. Rising amount of acids causes metabolic acidosis, which can be a life-threatening condition. Aside from that, elevated fatty acids in the blood can interfere with the transport of bilirubin to the liver for conjugation; thus, increasing the risk of jaundice in a newborn.

Question 33

What is a normal temperature range for a newborn infant?

Answer 33

Axilla temperature should be between 36.3 and 37.2º C

Skin temperature should be between 36.5 and 37.5º C

Question 34

Harley’s temperature has been below normal. What factors can you identify that may be contributing to this?

Answer 34

small size — decreased fat stores/brown fat, large body surface to weight ratio, poor feeding/lack of intake resulting in decreased ability to generate heat
not yet 24 hours old, immature CNS response, lack of ability to regulate temperature
radiant and convective heat loss due to cool ambient temperature
evaporative heat loss from respiratory distress/dry environment/uncovered while feeding/visiting

Question 35

How frequently would you check Harley’s temperature and for how long would you continue to monitor it?

Answer 35

Q1H until stable and normal, then Q3–4H with handling.

Question 36

Nursing care aimed at minimizing hypothermia should include:

Answer 36

monitoring temperature Q1H until stable, then Q3–4H with handling
maintain temperature 36.3°–37.2° by axilla
prevent heat loss by evaporation, radiation, convection, and conduction
use an incubator and skin to skin to provide heat
wean to a cot with clothes, blankets, and a hat when stable

Question 37

Feeding Difficulties:

Late preterm infants may:

Answer 37

• be sleepy and requiring waking for feeding
• need assistance to latch effectively and stimulation throughout the feed in order to take in sufficient calories for growth
• tire easily
• have immature suck/swallow reflexes; this results in an inability to feed without assistance and gavage feeds may be necessary

Question 38

Hypoglycemia

Answer 38

Premature infants are at risk for hypoglycemia due to decreased glycogen stores. Monitoring serum glucose levels and assessing for signs of hypoglycemia are important aspects of assessment. Low glucose levels may result in supplementation of feeds or scheduled feeding times to ensure that levels remain stable.

Question 39

Why do you think Ruth is concerned about Linda’s comments?

Answer 39

misconception that if her mother didn’t have enough breast milk, she wouldn’t
bottling is the best way of getting fathers involved in an infant’s care
apparently unaware of hazards of early introduction of bottles and continued use of bottles

Question 40

List key points you would include in your discussion regarding breast-feeding and supplementation with Linda and Simon.

Answer 40

clarify that just because her mother didn’t have enough milk that it doesn’t mean she won’t, that we have a lot of strategies to deal with breast-feeding problems, and that low milk supply is usually easily remedied with attention to simple measures such as position and latch
discuss supply and demand principle of breast-feeding and how bottles can interfere with this
ensure that Linda and Simon are well informed regarding benefits of breast-feeding: i.e., allergy prevention
discuss role that fathers can play in care other than feeding: diapering, bathing, settling babe to sleep, playing, quiet time
ensure that Linda is well informed regarding potential hazards of introducing bottles before breast-feeding is well established and that bottling once per day may decrease duration of breast­feeding
teach and support pumping to establish milk supply
explain how supplements are given, including alternative methods of supplementation, such as cup feeding and gavage
provide them with some choice from options available
support their choice once you know they have made a well­ informed choice
clarify any concerns they have

Question 41

What Would You Monitor and How Frequently?

Answer 41

Due to the fact that Harley is unstable at the moment your assessment monitoring should include:

temperature q 1 hour until stable
thorough hands on assessment when awake or when disturbed for feeds
head-to-toe assessment
hands off assessment about q 2 hours until stable
color, sleep/wake state. RR, work of breathing, tone

Question 42

Calculating Fluids

Answer 42

For calculating Harley’s fluids, we will use the recommended guideline provided in your text of 80 ml/kg/day. Monitoring his fluid balance will also be done by assessing Harley’s weight, urine output, serum sodium, tissue turgor, fontanelles, mucous membranes, and vital signs.

How do we calculate how much Harley needs to eat, or have in IV fluids, on an hourly and daily basis? A simple equation will help you figure this out.

The equation is:

Step 1: Convert infant’s weight from grams to kilograms (1,000 gm = 1 kg).
This is because the guidelines and physician’s orders are generally in kilograms.

Step 2: Multiply the physician’s order (or the guideline being used) by the infant’s weight.

Step 3: Divide by 24 hours in order to get an hourly intake.

This then tells you what the fluid requirement is on an hourly basis.

If the infant is on IV fluids, this hourly amount is the rate at which you would run the IV.
If an infant is feeding every three hours, you can multiply the hourly rate by three to determine how much fluid the infant needs on a three-hourly basis.

Question 43

Which weight do you use to calculate your fluids?

Answer 43

Birth weight – use for the first few days as the infant will lose weight
Daily weight – is used once the infant’s weight surpasses the birth weight

Question 44

C-section

Answer 44

• Overall the rate is between 20–40% off all deliveries
• Although infant mortality is declining, the rate of TTN (Transient Tachypnea of the Newborn, or “wet lung”) increases as more c­sections, particularly those without labor, are performed.

Question 45

Calculate fluids to determine how much you would feed Harley. This time use 100 ml/kg/day as your fluid order. How much does he need in 24 hours?

Answer 45

235

Question 46

Calculate fluids to determine how much you feed Harley. This time use 100 ml/kg/day as your fluid order. How much does he need in one hour?

Answer 46

9.8

Question 47

Calculate fluids to determine how much you would feed Harley. This time use 100 ml/kg/day as your fluid order. If you decide to feed Harley every three hours, how much should he receive at each feed?

Answer 47

29

Question 48

An undressed infant placed directly on a weighing scale will lose heat by:

Answer 48

Conduction

Question 49

Preterm infants, are at risk for hypothermia due to:

Answer 49

• Less white and brown fat stores
• Less ability to flex
• High insensible water losses

Question 50

A risk for Transient Tachypnea of the newborn is a c-section without labour:

Answer 50

True

Question 51

TTN is defined by a soft rib cage, weak muscles, and most importantly lack of surfactant

Answer 51

False

Question 52

Non-shivering thermogenesis is the main mechanism of heat production in neonates.

Answer 52

True

Question 53

Infants are nasal breathers

Answer 53

True

Question 54

The consequences of cold stress are: Question you got wrong double check answer

Answer 54

• Hypoxia
• Increased consumption of glucose
• Decreased surfactant production

Question 55

Late preterm infants are defined as:

Answer 55

34-36 + 6 wks gestation

Question 56

The doctor has ordered an hourly intake of 3 mls per hour. How much would you give if you were feeding every 3 hrs?

Answer 56

9 mls

Question 57

During a hands off assessment, some of the parameters that you can assess are:

Answer 57

• Color

- Work of breathing