Normal Newborn Flashcards
Newborn Transition: Critical System Changes
Adequate respiratory gas exchange in conjunction with marked circulatory changes are crucial to successful transition to extrauterine life.
Two systems critical for transition in baby: respiratory and circulatory
Transition to Neonatal Circulation:
Triggered by clamping of umbilical cord:
decrease pulmonary resistance -> increased pulmonary blood flow -> increased systemic vascular resistance
- Ductus venosus: closes by day 3
- Foramen ovale
- Ductus arteriosus: closes by 15hrs of life
Transition: Thermoregulatory System
Main goal = Neutral thermal environment (NTE): maintains body temperature and minimizes metabolic changes and/or O2 consumption
Factors that Negatively Effect Thermoregulation:
- decreased subcutaneous fat
- decreased brown fat in preterm infants (brown fat is put down on 3rd trimester)
- large body surface: influenced by positioning or premie
- loss of heat from convection, radiation, conduction, and/or evaporation
Cold Stress
occurs when:
decrease in environmental temp -> decrease in body temp -> increased HR and RR -> increased O2 consumption, depletion of glucose, decreased surfactant -> respiratory distress
can delay transition from fetal to neonatal circulation
RF: prematurity, SGA, hypoglycemia, prolonged resuscitation efforts, sepsis
S/Sx: temp <36.5C, cool skin, lethargy, pallor, tachypnea, grunting, hypoglycemia, hypotonia or jitteriness, weak suck
Transition: Metabolic System
Newborn brain is reliant on glucose.
Fetus stores glycogen during pregnancy, after birth neonate must regulate own insulin and glucose.
Hypoglycemia (<45mg/dl):
RF = infants of diabetics moms, LGA, preterm and postterm neonates, SGA, hypothermic infants, and those that are stressed (ie. infection, respiratory distress, birth trauma, etc)
S/Sx: jitteriness or hypotonia, irritability, apnea, lethargy, temp instability
Transition: Hepatic System
Bilirubin conjugation: increased RBC hemolysis (RBC turnover = 8 wks) and increased RBC count at birth.
Indirect (unconjugated) bilirubin: fat soluble form gets converted to direct bilirubin by liver enzymes
Direct (conjugated) bilirubin: water soluble form that can get excreted in urine and stool.
Hyperbilirubinemia (jaundice): high level unconjugated bilirubin d/t immature liver function, high RBC count and hemolysis of RBC’s
Blood coagulation (comes from liver fxn)
Transition: GI System
Gastric capacity expands from 5ml-60ml by day 7.
- Meconium: w/in 24-48hrs (black tarry, thick, odorless)
- Transitional: begins around day 3 and lasts 3-4 days, green/brown or green/black
- Breastfed: yellow and pasty (with curds)
- Formula fed: more formed, paler yellow to brown
-Diarrhea: loose and green (reach out to pediatrician for risk of dehydration)
Transition: Renal System
Kidneys take over for placenta after birth.
Neonates at risk for: over-hydration, dehydration, electrolyte disorders (Na+)
May take up to 24 hour for first pee.
Urine may be cloudy or have pink stains (brick dust spots) from urate crystals (normal)
Transition: Immune System
fever not reliable indicator of infection - actually more likely to have hypothermia
only IgG crosses placenta providing passive immunity during third trimester (so premies more susceptible to infection).
begin immunizations by 2 months of age so newborn can develop active acquired immunity
Nursing Care of Neonate in first 4 hours of life
- universal precautions
- maintain body heat (dry immediately, put hat on)
- support respirations
- APGAR score
- vital signs
- identifying band
- neonatal assessment
- gestational age assessment
- admin erythromycin opthalmic ointment (protect against gonorrhea/chlamydia exposure)
- administer Vitamin K
- promote parent-infant attachment
Newborn Vital Signs
HR: 110-160
RR: 30-60
Temp: 36.5-37.2
*take HR and RR for full minute
**if cardiac anomaly suspected - perform BP on all extremities
Newborn Skin Characteristics
pink tinge is normal
variances:
- crying that increases cyanosis: heart and lung problems suspected
- acrocyanosis (bluish color in hand and feet): common and resolves in 24-48 hrs
- central cyanosis: metabolic, cardiac, neurologic, pulmonary or infection suspected
- mottling (blotchy discoloration): hours to weeks or comes ad goes, can be from chilling, prolonged apnea, sepsis or hypothyroidism
- jaundice: advances head to toe (report if less than 24 hours of age)
- erythema toxicum: new born rash (common)
- milia: exposed sebaceous glands (normal)
Newborn Birth Marks
-congenital dermal melanocytosis (previously called Mongolian spots): looks like bruises, fade by age 4, note and document them
Newborn Head
general:
- asymmetrical from molding (bones overlap to navigate pelvis with vaginal birth)
- abnormal = micro or macrocephaly
fontanelles:
- anterior: junction of frontal and parietal bones that makes diamond shapes (closes by 18 months)
- posterior: parietal and occipital bone, triangle shape (closes by 8-12 wks)
* anterior larger than posterior
can have:
- cephalhematoma: collection of blood between surface of bone and periosteal membrane (does not cross suture line) - not usually present (big risk for jaundice b/c it’s a collection of broken down RBCs)
- caput succedaneum: edematous swelling from difficult labor or VAVD, usually resolves in a few days, overrides/crosses the sutures
Newborn Eyes
Cry is commonly tearless since lacrimal ducts are immature
observe for opacities
red retinal reflex
Newborn Nose
check patency
obligate nose breathers for first few months
Newborn Mouth
lip should be pink and touch produces suck
Newborn Ears
top should be parallel to outer and inner canthus of eye
low-set ears related to: syndrome and renal issues
Newborn Chest
common to have engorged breasts in males and females
Newborn Cry
strong, lusty, medium pitch
high-pitched, shrill cry = abnormal
-may indicate neurologic disorder, hypoglycemia, withdrawal from substance
Newborn Respirations
predominately diaphragmatic
note: hyper or hypoexpansion, airway noises, epidsodic breathing
* irregular breathing is normal. also may have crackles while they work fluid from birth out of lungs. Nasal flaring is bad.
Newborn Abdomen
should be soft and rounded,
cylindrical and protrudes slightly
no cyanosis, few blood vessels apparent
Newborn Umbilical Cord
dry, shriveled, blacked by 2nd-3rd day
sloughs off w/in 7-10 days
cord bleeding is abnormal
foul-smelling drainage is abnormal
Newborn Genitals
females: pseudomenstruation is normal (discharge as they withdraw from hormones)
males: look for correctly positioned orifices, symmetry of scrotum, cryptorchidism (one or both testes hasn’t descended into scrotum), hydrocele (fluid in scrotum), phimosis
Newborn Anus
Verify patency
Note passage of meconium
If baby does not have fistula = imperforate anus or rectal atresia
Newborn Extremities
polydactyly = extra digit syndactyly = webbing
single palmar crease associated with down syndrome
brachial palsy: erb-duchenne paralysis (arm lies limply at side)
Newborn Legs and Feet
look for equal and symmetric folds, hip dislocation/instability, club foot
Newborn Back
look for straight, flat spine
nevus pilosus “hairy nevus”” = associated with spina bifida
pilonidal dimple: ensure no connection to spinal canal
*follow all the way down to gluteal folds
Assessment of Neurologic Status
- position (looking for bilateral movements)
- eye movement
- muscle tone (slightly hypertonic, symmetric)
- differentiate tremors from convulsions
- seizures look like: chewing, swallowing, deviations, rigidity, flaccidity
Assess CNS Integration
gloved finger in mouth to elicit sucking reflex
-when the suck, assess hearing and vision responses by noting sucking changes, should be brief cessation of sucking
full term infant should be able to suck, swallow, and breathe at the same time
Protective Reflexes
blink yawn cough (clears airway) sneeze (clears nasal passage) draw back from pain
Reflexes
- tonic neck reflex: fencing reflex, turn head to one side and extend arm and leg on same side
- grasping reflex: grasp something in their hand
- moro reflex: startle reflex, bring arms to center, expending and spreading fingers out
- rooting reflex: touch cheek and they’ll move head to that side
- sucking reflex
- trunk incurvation: galant reflex, run finger along spinal column, spine will curve toward whichever side you’re on
*reflexes develop in utero, dissipate by 3-6 months of life, if they persist it could be an indicator of a neurological problem
Pain Assessment
PIPP: premature infant pain profile
NIPS: neonatal infant pain scale
get points for: state of arousal, cry, motor activity, respiratory pattern, facial expressions
Behavioral Characteristics
Periods of reactivity:
- initial period of reactivity: alert, active, RR can be as high as 90, HR as high as 180
- period of relative inactivity (30min - 2hrs): sleep state
- second period of reactivity (2-8hrs)
Gestational Age Assessment
determined based on LMP, u/s, and/or neonatal maturational exam
happens w/in first 4 hours of life
Ballard Maturation Score
Age categories:
- below 10th percentile = SGA
- appropriate or average for gestational age (AGA)
- above 90th percentile = LGA
- important to know b/c SGA and LGA have more risks for hypoglycemia and other complications
Newborn Weight Loss
formula fed: infants lose up to 5% of birth weight in first week of life
breast fed: can lose up to 10 w/in first week b/c of small volume of colostrum they receive (takes a while for milk to fully come in and for baby to adjust to breast feeding)
regain lost weight by 10-14 days of life
Gestational Age Characteristics
resting posture: more flexion as EGA advances
skin:
-lanugo decreases as GA increases
vernix decreases with maturity
transparency (earlier they are born, the more see-through their skin is)
plantar sole: creases start at the top and progress toward heel as EGA advances
areola and breast but tissue increases (0.5-1cm at term)
ears: more cartilage as infant gets older so if you flip pinna forward it will spring break more briskly w/ older EGA.
genitals:
- male: rugae cover entire scrotum and testes are in lower scrotum at term
- female: labia majora covers labia minora and clitoris at term
hair: at term hair is silky single strands (matted and tufts in preterm)
skull firmness increases as baby matures, bones are hard in term baby
nails: appear and cover nail bed (nails beyond fingertips may indicate postterm baby)
Nursing Care: 4 hours to discharge
vital signs (temp regulation) continued assessment newborn bath (not required) promote parent-infant attachement promote sibling attachment prevent infant abduction
instruct parents to place neonate on back
assist with feedings
provide info on care
provide info on normal newborn characteristics
Lab Tests and Dx Tests
Newborn screen (state and national requirements)
obtain blood sample
newborn hearing screening
Circumcision
contraindications: abnormality with genitalia, esp hypospadias
risk: elective surgery
Breastfeeding Advantages
decreased:
- diarrhea
- respiratory infections
- RSV
- otitis media
- necrotizing enterocolitis
- childhood obesity
- cost
*breastfeeding based on supply and demand (increased prolactin from anterior pituitary)
Breastfeeding Stages of Human Milk
stage 1: colostrum (2-3 days after delivery)
stage 2: transitional milk (3-10 days) milk & colostrum
stage 3: mature milk
-foremilk: higher water content, low in fat
-hindmilk: rich in fat, richer in calories
let-down reflex: oxytocin triggers reflex that promotes hind milk to come down so they don’t just get foremilk. triggered by stretching of nipple and compression of areola
*negative feedback look: if breasts not emptied less milk will be made
Bottle Feeding: Teaching Topics
formula prepared with room temp sterile water
frequency and amount of feedings: 15-30ml q 3-4hrs
position: bottle upside down and nipple should be full so they are ingesting air
burp: halfway through feeding
Warning s/sx
- rectal temp: >38, <36
- more than 1 episode of forceful vomiting or frequent vomiting over 6 hour period
- refusal of two feedings in a row
- lethargy, difficulty awakening baby
- cyanosis w/ or w/o feeding
- absence of breathing >20s
- inconsolable, high pitch continuous cry
- discharge, bleeding, foul odor from umbilical cord, circumcision, or any openings
- two consecutive green/watery or black stools
- fewer than 6-8 wet diapers per day after 4 days old
- fontanels are sunken or bulging
