Newborn Assessment Flashcards
Physiological changes of a newborn
Pulmonary gas exchange
A neonatal cardiovascular pattern
A stable serum glucose level
Thermoregulation
We want to assess and monitor neonatal adaptations in order to detect complications such as …
Hypoxia Cold stress Hypoglycemia Infection Polycythemia Hyperbilirubinemia
What assessments do we complete on a newborn?
Vital signs, especially temperature (BPs are rarely done) BPs only done when were suspicious of cardiovascular anomalies Nutrition Elimination Transition to extrauterine life Activity state Umbilical cord If indicated: Glucose monitoring Bilirubin Circumcision assessment
APGAR SCORING purpose
Indicative of the need for resuscitation, not the degree of asphyxia
Infants are scored at one and five minutes and if needed at ten minutes
what are we looking at when doing APGAR scoring?
heart rate respirations muscle tone reflex irritability color
heart rate (apgar)
0 = absent 1 = < 100 2 = > 100
respirations (apgar)
0 = absent 1 = weak cry hypoventilation 2 = good, strong cry
muscle tone (apgar)
0 = limp 1 = some flexion 2 = active motion
reflex irritability (apgar)
0 = no response 1 = grimace 2 = cry, withdrawal
color (apgar)
0 = blue or pale
1 = body pink, extremities blue
2 = completely pink
** acrocyanosis is normal in the newborn for the first few days **
pulmonary adaptation
The fetal lungs secrete lung fluid throughout pregnancy
Production of lung fluid diminishes 2 to 4 days before the onset of spontaneously occurring labor
Induced labor → infant may not have diminished lung fluid
80 to 100 mL remain in the passageway of a full-term newborn
During labor and birth, fetal chest is compressed and this squeezes part of the fluid out “vaginal squeeze”
This fluid must be expelled or absorbed after delivery
This fluid can often be heard in the lungs at delivery as fine crackles
Infants who have difficulty clearing the fluid are at risk to develop a respiratory complication called transient tachypnea of the newborn (TTN)
Retained fluid in the alveoli of the lungs
C-section: at greater risk for TTN b/c there is no vaginal squeeze
Compression of chest → recoil chest → mechanically triggers respiration
Increase in alveolar PO2 opens alveolar blood vessels → increases vascular flow
Initiation of respirations
** explain image **
What is the normal O2 sat for a newborn in the first minute of life?
65%
Goes up 5% every minute for the first 5 minutes
goes up 90-95% at 10 minutes
Does vaginal or c-section birth have the greatest risk for TTN (TRANSIENT TACHYPNEA OF THE NEW BORN)
c-section because there is no vaginal squeeze
What is the first breath
inspiratory gap!
triggered by increased PCO2 and decrease in pH and PO2 receptors
What triggers the brain’s respiratory center?
changes trigger aortic and carotid chemoreceptors
what types of hormonal stimuli occur?
prostaglandins are released by the placenta throughout pregnancy and suppress respiration
with the clamping of the cord prostaglandin levels drop and there is an increase in respiratory drive
Mechanical stimuli
Natural result of a normal vaginal birth is the “vaginal or thoracic squeeze” released at the delivery of the chest allowing for lung expansion
What can happen when there is a significant decrease in environmental temp after birth
Stimulates skin nerve endings
Newborn responds with rhythmic respiration
Why do we avoid excessive cooling of the infant?
excessive cooling of the infant may lead to profound depression of respiration as the result of “cold stress”
sensory stimuli during intrauterine life
Dark
Sound dampened
Fluid-filled environment
Weightless
sensory stimuli newborn experiences at delivery
Light
Sounds
Effects of gravity
Abundance of tactile, auditory, and visual stimuli of birth
respirations
Normal newborn respiratory rate: 30 to 60 breaths per minute
Initial respirations may be mainly diaphragmatic shallow and irregular depth and rhythm
Respiratory rate may increase with crying
It is important to count respirations with a stethoscope in the newborn for a full minute
Periodic breathing is common especially in the first few hours of life. It consists of pauses lasting from 5-15 seconds
Pauses of longer than 20 seconds are apnea- always need additional assessment
signs of respiratory distress (7 signs)
increased/decreases respiratory rate <30->60 seconds
Flaring of nares
Expiratory grunting
Primary respiratory issue for newborns is potential for alveoli to collapse
Try to keep alveoli inflated → close off epiglottis as it exhales to maintain surface tension in the lung
Retractions
Use accessory muscles to assist in respiration
Color changes
Circumoral cyanosis- general cyanosis
Circumoral cyanosis- cyanosis around the mouth- normal bc tissue is so thin and vascular
General cyanosis (in the trunk) is not normal
See-saw breathing
Alternating effort between abdomen and chest
additional problems/signs of respiratory distress
Decreased muscle tone More relaxed, less flexed Problems with temperature regulation Baby is breathing out warm, moist hair Takes in cool air and lowers temperature Increased SA of baby for cooling → drops temperature Increased water loss
CV adaptation
Requires the transition from fetal to neonatal circulation with the change from placental to pulmonary gas exchange
Fetal circulation differs from neonatal circulation
The fetal lungs are essentially nonfunctional. Most blood bypasses the lungs and is shunted to other parts of the body
What vein does the oxygenated blood return to the fetus from the placenta
placental vein
how does the blood travel
Oxygenated blood returns to the fetus from the placenta through the placental vein. Much of the blood (40-60%) bypasses the liver via the ductus venosus and enters the inferior vena cava
As it enters the right atrium, 50-60% is shunted across the atrium through the foramen ovale to the left atrium
Fetal circulation
There is low systemic resistance and high pulmonary resistance. 60% of the blood from the right ventricle is shunted through the ductus arteriosus to the umbilical arteries and toward the placenta
There are openings & shunts in the fetus that begin to close off as the baby is delivered and starts its neonatal circulatory pattern
Difference between fetal circulation and neonate circulation
fetal = low systemic resistance and high pulmonary resistance neonate = low pulmonary resistance and higher systemic resistance
what causes neonate circulation to be low pulmonary resistance and higher systemic resistance?
The initiation of respirations by the infant and the clamping of the cord at birth shifts the resistance in the circulation
What causes pressure closure change of the foramen ovale in the heart
change in neonate circulation resistance
Foremen ovale
opening between the atrium
what constricts in neonate circulation?
the ductus arteriosus
CV assessment
start with general color assessment
acrocyanosis
occurs in the first 7-10 days, not unusual for the hands and feet to remain blue
circumoral cyanosis
blue tint to the skin surrounding the lips, but not on the lips. This is normal and simply the blue color of the veins just below the skin in this area. You may notice this blue tint most of the time. When the arterial blood in this area diminishes for various reasons, you will see the blue tint
Noticeable after feedings
when is circumoral cyanosis noticeable
after feedings
general cyanosis
blue tint to the skin that covers the face, trunk, and extremities. It is associated with poor oxygenation of the tissues and is an ominous sign. Can be respiratory or cardiac in origin
Heart rate (General information)
taken apically at the 4th intercostal space, left
Assessed for a full minute
Normal: 110-160 at rest
May drop to 100 when asleep
May accelerate up to 180 when stressed
Crying may increase rate
Consistently high >180 or low <100 warrants further investigation
What should you do if you hear a heart murmur?
this is not uncommon, most are nonpathological and disappear by 6 months
HOWEVER all murmurs warrant further investigation and assessment
hearing a murmur is the most common means of recognizing cardiac disease
what are abnormal findings accompanied by a heart murmur
poor feeding, cyanosis, pallor or apnea
Total blood volume
varies with amount of placental transfusion received by the newborn during expulsion of placenta
82.3 ml/kg of body weight at 3 days life with early cord clamping (before 30 sec of life)
92.6 ml/kg at three days with early cord clamping (after 30 seconds of life)
In the normal size infant this would be about 1 to 1 ½ cup of blood total
What increases blood volume (loss?)
delayed cord clamping
what forces blood from the baby back to the placenta
vaginal squeeze
what happens when you clamp the cord immediately
not enough time for blood flow to come back to the baby and restabilize blood volume
how long do you wait before clamping?
30 seconds
Newborn lab values
Hemoglobin- 14-20 g/dL (↑)
Need to capture as much O2 as possible
Hematocrit- 43-64%
WBCs- 10,000-30,000 (↑)
blood sample sites
Peripheral blood flow can be sluggish and create RBC stasis
Hgb and Hct levels are higher in capillary blood than in venous blood
Blood vessels taken from venous samples are more accurate than capillary samples
Break down RBCs because of oxygen rich environment → excrete bilirubin
Bilirubin needs to be protein-bound to be excreted from the body
normal glucose levels in newborn
40-80 mg/dL in the first 6 hours of life
45-90 mg/dL after that
what happens if glucose levels are below 40 to 45
treated with either glucose gel, a feeding or 10% dextrose in sterile water
hypoglycemia in newborns
Persistent hypoglycemia can result in neurological damage in the newborn
Hypoglycemia results from inadequate availability of glucose (poor feeding), abnormal endocrine regulation (infants of diabetic mothers) or increased utilization of glucose (cold stress, infection)
Hypoglycemia can be life threatening and can result in seizures and learning disabilities
Hyperglycemia is more common in premature and small for gestational age infants
S/S of hypoglycemia
S/S are frequently absent despite extremely low blood glucose levels:
Jitteriness (most common)
Also seen with withdrawals
Hypothermia
Diaphoresis (especially face and forehead)
Hypotonia
Irritability, tremors, muscle twitching, seizures
Abnormal cry
Poor feeding
Lethargy
Respiratory distress, tachypnea, apnea
Cyanosis, tachycardia, cardiac failure, cardiac arrest
normal temp
97.6
rarely elevated
abnormal temp
below 97.6
can lead to significant distress from cold stress
temp assessment
Can be assessed by axillary skin method, continuous skin probe, rectal route
Axillary is preferred method
Research indicates tympanic and digital axillary methods are accurate indicators of body temperature
inappropriate thermoregulation
Inappropriate management of heat stress and cold stress in neonates is associated with metabolic complications such as hypoglycemia, increased O2 consumption, increased lactic acid production, increased metabolic acidosis and death
heat loss in newborns can occur through
conduction, convection, radiation and evaporation
conduction
on a surface that transmits heat
Conduction occurs if the baby is placed on a cold surface (weighing scale or cold mattress)
convection
lose heat to air that is circulating around it
Convection occurs when a newborn is exposed to cooler surrounding air. Heat loss increases with air movement, and a baby risks getting cold even at a room temperature of 86F if there is a draught. (89-92 if the infant is nacked and 75-80 if the infant is dressed)
radiation
lose heat to cooler objects in the area (wall)
Radiation occurs when there is a transfer of warmth from the baby to cooler objects in the vicinity (a cold wall or window) even if the baby is not actually touching them
evaporation
when baby gets first bath
when baby comes out in amniotic fluid
what is the main form of heat loss
evaporation
main form of heat loss initially due to amniotic fluid evaporating from the baby’s body
first step in neonatal resuscitation
rigorous drying of the baby
hypothermia
Cold stress is a body temperature rectally of less than 97.6F with symptoms
If you get a temperature of 97.6 or lower, you repeat the temp under the other arm
The infant needs to either but put in skin to skin temperature with the mother or placed in a radiant warmer
Smaller and preterm infants are at greater risk
hypothermia S/S
Body cold to touch Hypoglycemia Restlessness, irritability, tachypnea Pallor or mottling Lethargy, decreased activity, hypotonia Central cyanosis, acrocyanosis Poor feeding, weak suck Bradycardia Feeble cry, shallow/irregular respirations, apnea
Nonshivering Thermogenesis
occurs when skin receptors perceive a drop in environmental temp
what happens when a newborn shivers
metabolic rate doubles
↑ glucose utilization
Potential for hypoxia
increased muscle activity
BAT (brown adipose tissue)
primary source of heat in hypothermic newborn
appears in fetus at 26 to 30 weeks
increases until 2 to 5 weeks after birth
newborn response to hypothermia
increase metabolism, which is done by breaking down their BAT stores
where is BAT located
around the scapula, kidneys, adrenals, head, neck, heart, great vessels and axilla
Treatment of Thermogenesis
Prevention is best!
Dry infant immediately after birth
Use hat
Keep room warm
Use skin to skin with mom or radiant warmer
Delay bathing until >98
Rewarm after bath
Dress appropriately and use blankets as needed
Educate parents
Monitor temps and symptoms
Return to the radiant warmer if temp is unstable
BAT metabolism
increased metabolism with hypoglycemia
increased oxygen metablism with tissue hypoxia
fatty acid production and metabolic acidosis with increased serum bilirubin
increased local temperature and increased axillary temperature
digestion and elimination
Newborn has enough intestinal and pancreatic enzymes to digest simple carbohydrates, proteins, and fats- newborn cannot digest starch
By birth, newborn has experienced swallowing, gastric emptying, and propulsion
Breast milk, which is 90% digestible, is digested in 2-3 hours
Cows milk formula is digested in 3-4 hours
elimination (meconium)
Meconium is formed in utero
Newborn passes meconium within 48 hours- frequency of bowel movements vary
voiding
93% void by 24 hours after birth and 100% void by 48 hours after birth- initial bladder volume is 6 to 44 mL of urine
how many diapers (1st, 2nd, 3rd day)
Minimum first day: 1 diaper
2nd day: 2 diapers
3rd day: 3 diapers etc.
6-8 wet diapers a day after 6 days
what happens if a newborn does not void within 48 hours
nurse should assess adequacy of fluid intake, bladder distention, restlessness, and symptoms of pain
immunological adaptation (plus fever)
Immune system isn’t full activated until after birth- newborn has poor hypothalamic response to pyrogens
Fever not reliable indicator of infection- in newborn period, hypothermia is more reliable indicator of infections
passive immunity from the mother
Lasts 4 weeks
Passive acquired immunity occurs during the third trimester
Preterm infant may be more susceptible to infection
newborns own immunity
Breastfed newborn may have additional passive immunity from mother
Newborns start to produce secretory IgA in the intestinal mucosa at four weeks
Norms (length and weight)
Length 18-22, avg 20”
Weight 2500-4000g (5lb 8oz- 8lb 13oz), avg 3405g (7lb 8 oz)
what is birthweight influenced by
ethnic origin, maternal weight and age
how much weight can a newborn lose in the first few days
10%
size for gestational age
is based on size of the baby for the specific weeks of pregnancy at the time of delivery
Small for gestational age (SGA) at term, weight <10% (6lb)
Large for gestational age (LGA) at term, weight >10% (>9lb)
HEAD
Circumference (12.5-14”)- ¼ size of body (disproportionately large)
Fontanelles anterior- diamond shaped, soft (soft spot)
Posterior- triangle, midline
Posterior fontanelle may be closed
Overriding sutures
Plates in the skull can slip under each other- has the potential to compress and elongate through maternal pelvis
Molding- coning of the head
Cephalo hematoma- bleeding into the scalp r/t trauma
More distinct in edging
Subgaleal hemorrhage- bleeding between the scalp and the skull, results from use of vacuum extract when delivering
Caput succedaneum- generalized swelling of the scalp itself, tends to cross the suture lines
Hematomas will not cross suture line
pink tones
due to high hgb and hct
jaundice
often occurs after 24 hours (before 24 hours is always abnormal)
excess RBCs broken down
pallor
not normal in the newborn, could be an indicator of blood loss, anemia or hypoxia
sometimes pallor can be the result of normal genetic coloring
cyanosis
cyanosis of the hands and feet is a normal finding
Cyanosis of trunk and body is not a normal finding → might be indicative of hypoxia
turgor
slight dryness esp. Extremities
Poor indicator of hydration in the newborn
Preterm → juicy skin
Post babies → dry, peely skin
vernix
a cheesy, fatty substance that covers the fetus’ skin and protects it after 24 weeks. The vernix starts to breakdown and disappear at 38 weeks gestation
milia
congested sebaceous glands that resemble “whiteheads” usually seen on the nose, cheeks, or chin of the newborn
lanugo
fine downy hair on the infants body
MORE PRETERM = MORE LANUGO
Storky bites
temporary areas of increased vascularization often seen on the back of the neck, eyelids and forehead. These are usually temporary
Back of neck- most common site
erythema toxicum
normal newborn rash often seen generalized over the body. It is not abnormal
post date effects on skin
very dry, parchment like skin
mongolian spots
a blueish discoloration which resembles deep bruising
Common over dorsal area and buttocks
More common in people of far east, Mediterranean, and African descent
*document to prevent false reporting of abuse in the family
nose
flat, babies are nose breathers
Sneezing is common in the newborn
Deviated septum- can be either a nose that was compressed to one side during pregnancy or a bony deformity
Glabellar reflex
eyes blink on touching bridge of nose (tap 4-5 times)
Baby will habituate to this
mouth and throat
it is normal for infants to have no teeth present (natal teeth)
Their teeth would be lower central incisors if they had them
The palate & lip should be intact without clefts
The infant is born with rooting and sucking reflexes
rooting reflex
when you stroke near the mouth/lips, infant turns toward that side and opens mouth in search of food
disappears after 4-7 months
sucking reflex
something is put in the mouth, baby sucks on it
extrusion reflex
tongue thrusting
seen when the baby is full from feeding
when the tongue is touched, the infant will push the tongue outward or forward
epstein pearls (cysts)
sometimes seen on the roof of the mouth
pale yellow/white in color
eyes
clear positive cornea red reflex rules out newborn cataracts Clear eye discharge r/t eye prophylaxis Treat w erythromycin ointment Scleral hemorrhage common
blink reflex
when cornea is touched
not tested unless suspicious of baby having diminished reflexes
pseudostrabismus
r/t underdeveloped eye muscles
false lazy eye, corrects over time
doll eye reflex
present at delivery
eyes open on coming to sitting, head initially lags
Baby uses shoulders to right head position
ears
position in line with inner and outer canthus of eye
Recoil of the ear pinna is an assessment for gestational age
Bring the top of the ear forward
In a term baby, it will come back because it has adequate cartilage
hearing
the infant can hear at birth and should react to sound
Diminished hearing until after 24 hours, then we will do screening
skin tags
in front of the ear have a correlation with renal anomalies
skin depression
in front of ear have a correlation with hearing deficit on that side
chest
1:1 contour Circumference 12-13” Breast engorgement Breast bud .5cm-1cm at term Should be palpable Nipple to nipple > 7.5- supernumerary nipples
abdomen
umbilicus clamped for the 1st 24 hrs 2 arteries + 1 vein (AVA)
The abdomen should normally be slightly rounded
Assess for bowel sounds
Should have BM in first 24 hrs
Assess voiding
Should void in first 24 hrs
“Brick dust” on urination r/t uric acid
Assess femoral arteries in the crease of the groin bilaterally
caving in abdomen
concerned about poorly formed esophagus, contents of abdomen move into chest (diaphragmatic hernia)
distended abdomen
things can’t get out? Enlargement of spleen or liver, often attributed to bowel
genitalia (male)
Male should have 2 descended testes, related to maturity
Scrotum edematous
Scrotum should have ridges
Assess for hypospadias or epispadious- urinary meatus opening that is below/ underside or upperside of penis
Assess for hydrocele- excess amount of amniotic fluid in the scrotum
Male infants may be circumcised
genitalia (Female)
Female infants should have the labia slightly edematous and touching a term
Flatter and more open → more preterm
Pseudo menstruation- can occur in response to the withdrawal of hormones after delivery
back and rectum
Assess for patent anus and spine
Assess for a pilonidal dimple at the base of the spine
Mongolian spots- deep blue discolorations that look similar to bruising on the lower back, buttocks and upper thighs
Check to make sure that the leg folds are equal on both sides
extremities
normally flexed with maturity
ROM
Acrocyanosis
Reflexes
Clubbing of the feet
Abnormalities such as polydactyly, Syndactyly
Assess for abnormal flatness or roundness of feet
Assess for fixed posturing of the fingers or toes
Newborn pain assessment (FLACC)
FACE LEGS ACTIVITY CRY CONSOLABILITY
face (flacc)
0- no particular expression or smile
1- occasional grimace or frown, withdrawn, disinterested
2- frequent to constant frown, clenched jaw, quivering chin
legs
0- normal position or relaxed
1- uneasy, restless, tense
2- kicking or legs drawn up
activity
0- lying quietly, normal position, moves easily
1- squirming, shifting back and forth, tense
2- arched, rigid, jerking
cry
0- no cry, awake or asleep
1- moans or whimpers, occasional complaint
2- crying steadily, screams or sobs, frequent complaints
consolability
0- content, relaxed
1- reassured by occasional touching, hugging, or “talking to”, “distractible”
2- difficult to console or comfort
sleep states
Quiet (deep) sleep
Active sleep (REM)
Length of cycle depends on age of newborn
Growth hormone secretion depends on regular sleep patterns
awake states
Drowsy
Quiet alert- best time to interact with newborn
At rest, eyes open
Most capable of responding to their environment
Active alert
Crying
first periods of reactivity
Period lasts about 30 minutes Newborn is awake and active Appears hungry and has a strong reflex Natural opportunity to start breastfeeding Vital signs are elevated
second period of reactivity
Period of reactivity lasts 4 to 6 hours in normal newborn
The heart and respiratory rates increase, nurse needs to be alert for apenic periods
Newborn passes meconium
Newborn sucks, roots, and swallows
position and behavior
Newborns tend to stay in a flexed position and will resist straightening
Hands remain clenched
Infant will sleep a majority of time and wake for feeding- easily consoles when upset
Some behavioral capabilities of newborn that assist in adaptation to extrauterine life include
Habituation
Self-quieting ability
Brings hands up to face, suck on fingers
alert states
First 30 to 60 minutes after birth, many newborns display quiet alert state
Nurses should use alert states to encourage bonding and breastfeeding
Increasing wakefulness indicates maturing ability to maintain consciousness
Use alert states to facilitate feedings
visual ability
Normal visual sensory-perceptual abilities of newborn are
Newborn is able to be alert, follow, and fixate on complex visual stimuli for short periods of time
Orientation- preference for sharp contrast between dark and light more so than colors at birth
The focal distance is approximately 18 inches, with a range from 6 to 24 inches
auditory ability
Newborn auditory sensory-perceptual abilities of the newborn areL
Newborns are able to be alert and search for appealing auditory stimulus
Newborns can process and respond to visual and auditory stimulation
Habituation
Preference for high pitched voices
olfactory, taste suckling, tactile
Olfactory- newborns are able to select people by smell
Taste and suckling- newborn able to respond to selectively different tastes
Newborn very sensitive to being touched, cuddled, and held
Newborn able to attend to and interact with environment
prophylaxis
Eye prophylaxis Vitamin K Newborns do not have ability to store it Part of clotting cascade Hepatitis B
screening
Hearing Metabolic screening Transdermal bilirubin/serum bilirubin O2 saturation Drug screening Glucose Gestational age
pupillary
the pupil’s response to light
sucking mechanism
Front of tongue laps on finger
Back of tongue massages middle of the finger
Esophagus pulls on tip of finger
This reflex disappears at about 12 months
palmer grasp
give one forefinger to each hand- baby grasps both then pulls baby to sitting with each forefinger
The palmar grasp usually disappears by 5-6 months
plantar grasp
stroke inner sole and the toes curl around (“grasp”) examiner’s finger. The plantar reflex usually lessens by about 8 months
It will disappear by 9-12 months
babinski
stroke outer sole and the toes spread with great toe dorsiflexion
Disappears at about 12 months
moro
the startle reflex, usually triggered by a loud noise or if the infant’s head falls backward
The infant will spread his arms and legs out widely and extend his neck
He will then quickly bring his arms back together and cry
The moro reflex is usually present at birth and disappears by 3-6 months
fencing
tonic neck, a postural reaction, is present at birth
With the infant lying on his back, turn his head to one side, this will cause the arm and leg on the side that he is looking toward to extend or straighten, while his other arm and leg will flex
This reflex usually disappears by 4-9 months
incurvation
gallant reflex, if the infant is on his stomach and you stroke neck to spinal cord (paravertebral area) on his middle to lower back, it will cause his back to curve towards the side that you are stroking.
Present at birth and disappears by 3-6 months
step
holding the infant under the arms, support the head, and allow the feet to touch a flat surface, the infant will appear to take steps and walk.
Usually disappears by 2-3 months
Reappears as he learns to walk at around 10-15 months
