Normal Newborn

Question 1

Newborn Transition: Critical System Changes

Answer 1

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

Question 2

Transition to Neonatal Circulation:

Answer 2

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

Question 3

Transition: Thermoregulatory System

Answer 3

Main goal = Neutral thermal environment (NTE): maintains body temperature and minimizes metabolic changes and/or O2 consumption

Question 4

Factors that Negatively Effect Thermoregulation:

Answer 4

• 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

Question 5

Cold Stress

Answer 5

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

Question 6

Transition: Metabolic System

Answer 6

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

Question 7

Transition: Hepatic System

Answer 7

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)

Question 8

Transition: GI System

Answer 8

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)

Question 9

Transition: Renal System

Answer 9

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)

Question 10

Transition: Immune System

Answer 10

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

Question 11

Nursing Care of Neonate in first 4 hours of life

Answer 11

• 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

Question 12

Newborn Vital Signs

Answer 12

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

Question 13

Newborn Skin Characteristics

Answer 13

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)

Question 14

Newborn Birth Marks

Answer 14

-congenital dermal melanocytosis (previously called Mongolian spots): looks like bruises, fade by age 4, note and document them

Question 15

Newborn Head

Answer 15

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

Question 16

Newborn Eyes

Answer 16

Cry is commonly tearless since lacrimal ducts are immature

observe for opacities

red retinal reflex

Question 17

Newborn Nose

Answer 17

check patency

obligate nose breathers for first few months

Question 18

Newborn Mouth

Answer 18

lip should be pink and touch produces suck

Question 19

Newborn Ears

Answer 19

top should be parallel to outer and inner canthus of eye

low-set ears related to: syndrome and renal issues

Question 20

Newborn Chest

Answer 20

common to have engorged breasts in males and females

Question 21

Newborn Cry

Answer 21

strong, lusty, medium pitch

high-pitched, shrill cry = abnormal
-may indicate neurologic disorder, hypoglycemia, withdrawal from substance

Question 22

Newborn Respirations

Answer 22

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.

Question 23

Newborn Abdomen

Answer 23

should be soft and rounded,

cylindrical and protrudes slightly

no cyanosis, few blood vessels apparent

Question 24

Newborn Umbilical Cord

Answer 24

dry, shriveled, blacked by 2nd-3rd day

sloughs off w/in 7-10 days

cord bleeding is abnormal

foul-smelling drainage is abnormal

Question 25

Newborn Genitals

Answer 25

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

Question 26

Newborn Anus

Answer 26

Verify patency

Note passage of meconium

If baby does not have fistula = imperforate anus or rectal atresia

Question 27

Newborn Extremities

Answer 27

polydactyly = extra digit
syndactyly = webbing

single palmar crease associated with down syndrome

brachial palsy: erb-duchenne paralysis (arm lies limply at side)

Question 28

Newborn Legs and Feet

Answer 28

look for equal and symmetric folds, hip dislocation/instability, club foot

Question 29

Newborn Back

Answer 29

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

Question 30

Assessment of Neurologic Status

Answer 30

• position (looking for bilateral movements)
• eye movement
• muscle tone (slightly hypertonic, symmetric)
• differentiate tremors from convulsions
• seizures look like: chewing, swallowing, deviations, rigidity, flaccidity

Question 31

Assess CNS Integration

Answer 31

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

Question 32

Protective Reflexes

Answer 32

blink
yawn
cough (clears airway)
sneeze (clears nasal passage)
draw back from pain

Question 33

Reflexes

Answer 33

• 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

Question 34

Pain Assessment

Answer 34

PIPP: premature infant pain profile
NIPS: neonatal infant pain scale

get points for: state of arousal, cry, motor activity, respiratory pattern, facial expressions

Question 35

Behavioral Characteristics

Answer 35

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)

Question 36

Gestational Age Assessment

Answer 36

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

Question 37

Newborn Weight Loss

Answer 37

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

Question 38

Gestational Age Characteristics

Answer 38

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)

Question 39

Nursing Care: 4 hours to discharge

Answer 39

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

Question 40

Lab Tests and Dx Tests

Answer 40

Newborn screen (state and national requirements)
obtain blood sample
newborn hearing screening

Question 41

Circumcision

Answer 41

contraindications: abnormality with genitalia, esp hypospadias
risk: elective surgery

Question 42

Breastfeeding Advantages

Answer 42

decreased:

• diarrhea
• respiratory infections
• RSV
• otitis media
• necrotizing enterocolitis
• childhood obesity
• cost

*breastfeeding based on supply and demand (increased prolactin from anterior pituitary)

Question 43

Breastfeeding Stages of Human Milk

Answer 43

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

Question 44

Bottle Feeding: Teaching Topics

Answer 44

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

Question 45

Warning s/sx

Answer 45

• 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