Normal Newborn Flashcards
How old is a neonate?
The first 28 days of life
When is the highest rate of mortality?
1st 24 hours of life
What is the most critical time after birth?
1st hour of life
When is the APGAR done?
1 minute and 5 minutes of life
Why is an APGAR done?
Is an immediate assessment to evaluate transition to extrauterine life
-Done by the nurse
What does the first A in APGAR stand for?
Activity (muscle tone)
0 = absent
1 = Arms and legs flexed
2 = Active movement
What does the P in APGAR stand for?
Pulse
0 = Absent
1 = Below 100 bpm
2 = Over 100 bpm
What does the G in APGAR stand for?
Grimace (reflex irritability)
0 = Flaccid
1 = Some flexion of extremities
2 = Active motion (sneeze, cough, pull away)
What does the second A in APGAR stand for?
Appearance (skin color)
0 = Blue, pale
1 = Body pink; extremities blue
2 = Completely pink
What does the R in APGAR stand for?
Respiration
0 = Absent
1 = Slow, irregular
2 = Vigorous cry
Severely Depressed APGAR score
0 - 3
Moderately Depressed APGAR score
4 - 6
Excellent Condition APGAR score
7 - 10
General Survey of Newborn
- Posture - normal resting position is flexed
- Color
- Activity
- Anomalies that may cause distress (extra digit, tuft of hair on spine)
- Bruising or other consequences of delivery
- State of alertness
Normal Temperatures for newborns
- 9 F - 99.7 F
36. 5 C - 37.5 C
Normal HR for Newborn
110 - 160
Normal RR for Newborn
30 - 60
Which VS should be taken first on newborn patients?
Respiratory rate because hopefully they won’t be crying at the beginning of the assessment.
What is not normally assessed in healthy term newborns?
- BP
2. Pulse oximetry
Pain Scales
- NIPS (Neonatal Infant Pain Scale)
- FLACC (3 months - 7 years)
- PIPP (Premature Infant Pain Profile)
- N-PASS (for premies)
When to re-asses for NIPS
Re-asses Q1hr if scoring 4 or > on NIPS
Non-pharmacological pain interventions
- Swaddling
- Pacifier
- Sucrose
- Skin to skin contact with parent/caregiver
Normal newborn weight
2500 - 4000 g
* Newborns lose 10% of birthweight in first few days, regain in approximately 10 days
Preterm
36 weeks and 6 days or less
Early Term
37 0/7 wks to 38 6/7 wks
Full Term
39 0/7 wks to 40 6/7 wks
Late Term
41 0/7 wks to 41 6/7 wks
Post Term
42 0/7 wks and beyond
Maintaining Airway (due to secretions)
- Moved by gravity, coughing, and sneezing
- Use bulb syringe
- If choking, turn on side
- Suction mouth, then nose
- Put suction to side of mouth instead of center to prevent eliciting gag reflex
- Teach parents use of bulb suction
Newborn lung sounds right after birth
Crackles may be heard as lymphatics continue to drain fluid for up to an hour
Lung expansion is dependent upon what?
- Contraction of chest wall
2. Secretion of surfactant
S/Sx of Respiratory Distress
- Cyanosis (central)
- Tachypnea
- Expiratory grunting
- Sternal retractions
- Nasal flaring
- Stridor
- Seesaw or paradoxical breathing
- RR < 30 or > 60
- Apnea > 15 seconds
Significant changes to the cardiovascular system after birth
- Decreased pulmonary vascular resistance facilities increase blood flow to the lungs
- Decreased pressure in pulmonary artery (PA) and right side of heart
- Increased blood flow from lungs to left side of heart causes closure of foramen ovale (FO)
What does clamping the cord do to the circulation of the newborn?
Causes conversion of umbilical arteries and vein: ductus venosus, and hypogastric arteries to occlude and become ligaments
When should the HR be reevaluated frequently?
When the HR is consistently greater than 180 or less than 80
Normal newborn blood pressure
50/30 - 75/45
PMI
Left of midclavicular line on the left side of chest at 4th intercostal space
All murmurs should be evaluated if it persists for how long after birth?
12 hours
- If accompanied by poor feeding, apnea, cyanosis, or pallor, then investigate further
- Most have no significance and disappear by 6 months
What is nonshivering thermogenesis?
Metabolism of brown fat and increase of metabolic activity
What is responsible for the depletion of brown fat?
Cold stress
The 4 Modes of Heat Loss
- Convection
- Radiation
- Evaporation
- Conduction
Convection
Loss to cooler air currents (drafts)
Radiation
Indirect transfer from body to cooler surfaces (near cold window or in a cold room)
Evaporation
Evaporation from wet skin (after birth or after bath)
Conduction
Direct heat loss to cooler objects (weighing on scales)
How to Control Loss of Heat
- Skin to skin contact
- Warm blankets
- Swaddle
- Cap on head
- Dry thoroughly
- Avoid drafty areas and cold exam tables/scales
- Help maintain flexed positioning
- Optimal thermal environment
- Radiant warmers
Effects of Cold Stress
They can become less active, lethargic, hypotonic, and weaker
Cold stress can lead to what?
- Depleted fat stores
- Increased oxygen needs -> respiratory distress -> hypoxia
- Increased glucose consumption -> hypoglycemia
- Metabolic acidosis
- Jaundice
First 4 things to do after delivery
- Dry and stimulate
- Suction
- Skin to skin
- Clamp cord
Newborn blood volume
Approximately 80 mL/kg
- Affected by timing of cord clamping
How long do newborn hemoglobin RBCs last?
80 to 100 days
Iron Stores in Newborns
Fetal iron stores to sustain normal RBC production for 4-5 months in term infant
-Transient physiologic anemia may occur at 4-5 months
Clotting Factors in Newborn
Decreased clotting factor levels during first few days of life
- Sterile gut unable to synthesize vitamin K so an injection if given
What is Caput Succedameum?
Localized edema (serous fluid) that crosses suture lines, pitting edema, and petechia
What causes caput succedameum?
- Prolonged labor
2. Vacuum extraction
How long does it take for caput succedameum to dissipate?
3 days
What is cephalhematoma?
Localized effusion of blood beneath the periosteum of the skull
How long does cephalhematoma last?
It appears 2-3 days after birth and lasts weeks to months
Cause of cephalhematoma
Traumatic birth
What can result from cephalhematoma?
Hyperbilirubinemia (from breakdown on RBCs)
What is desquamation?
Peeling of skin
- It is a normal finding
- Common at birth in post term babies
- In term newborn, it can occur a few days after birth
Newborn assessment findings of their breasts
- Swelling of the breast tissue is term infants of both sexes caused by increased maternal estrogen
- Nipples should be symmetric
- Breast tissue and areola size increase with gestation
- Witch’s milk
Skeletal System of the newborn
- More cartilage than ossified bone at birth
- Molding
- Gains head control at approximately 3 months
Fontanels
Anterior and Posterior
Anterior Fontanel
Diamond shaped, 4-6 cm in diameter, and closes by 18-24 months
Posterior Fontanel
Triangle shaped, 0.5-1 cm in diameter, and closes by 6-12 weeks
Moro Reflex
Also called the startle reflex
To elicit this reflex, place the newborn on his or her back. Support the upper body weight of the supine newborn by the arms, using a lifting motion, without lifting the newborn off the surface. Then release the arms suddenly. The newborn will throw the arms outward and flex the knees; the arms then return to the chest. The fingers also spread to form a C. The newborn initially appears startled and then relaxes to a normal resting position.
Palmar and Plantae Grasp Reflex
- Elicit the palmar grasp reflex by placing a finger on the newborn’s open palm. The baby’s hand will close around the finger. Attempting to remove the finger causes the grip to tighten. The grasp should be equal bilaterally.
- The plantar grasp is similar to the palmar grasp. Place a finger just below the newborn’s toes. The toes typically curl over the finger.
Tonic Neck Reflex
Also called the fencing reflex
Test this reflex by having the newborn lie on the back. Turn the baby’s head to one side. The arm toward which the baby is facing should extend straight away from the body with the hand partially open, whereas the arm on the side away from the face is flexed and the fist is clenched tightly. Reversing the direction to which the face is turned reverses the position.
Sucking Reflex
Thesucking reflexis elicited by gently stimulating the newborn’s lips by touching them. The newborn will typically open the mouth and begin a sucking motion. Placing a gloved finger in the newborn’s mouth will also elicit a sucking motion
Rooting Reflex
Elicit therooting reflexby stroking the newborn’s cheek. The newborn should turn toward the side that was stroked and should begin to make sucking movements
Babinski Reflex
TheBabinski reflexshould be present at birth and disappears at approximately 1 year of age. It is elicited by stroking the lateral sole of the newborn’s foot from the heel toward and across the ball of the foot. The toes should fan out. A diminished response indicates a neurologic problem and needs follow-up.
Stepping Reflex
Assess thestepping reflexby holding the newborn upright and inclined forward with the soles of the feet touching a flat surface. The baby should make a stepping motion or walking, alternating flexion and extension with the soles of the feet.
Milia
Pearly-white or pale yellow unopened sebaceous glands frequently found on a newborn’s nose. They may also appear on the chin and forehead. As most lesions break spontaneously within the first few weeks of life, no therapy is indicated.
Stork Bite
(Telangiectatic nevi)
Found on the nape of the neck, on the eyelids, and between the eyes and upper lip. They are considered a normal variant, and most fade and disappear completely within the first year.
Mongolian Spots
Blue or purple splotches that appear solitary on the lower back and buttocks of newborns, but may occur as multiple over the legs and shoulders. The spots are caused by a concentration of pigmented cells and usually disappear spontaneously within the first 4 years of life. They should not be confused with bruises caused by trauma.
Erythema toxicum
It consists of small papules or pustules on the skin resembling flea bites. It is often mistaken for staphylococcal pustules. The rash is common on the face, chest, and back. It does not require any treatment and disappears in a few days.
Port Wine Stain
Although is does not grow in area or size, it is permanent and will not fade. Although they may occur anywhere on the body, the majority are located in the head and neck areas.
Strawberry Hemangioma
(Nevus Vasculosus)
It is raised, rough, dark red, and sharply demarcated. It is commonly found in the head region within a few weeks after birth and can increase in size or number. These hemangiomas tend to resolve by age 3 without any treatment.
Newborn Breasts
- Swelling of the breast tissue in term infants of both sexes caused by increased maternal estrogen
- Nipples should be symmetric
- Breast tissue and areola size and increase with gestation
- Witch’s milk may be present
When does a newborn gain head control?
Approximately 3 months
When does the coordinated suck/swallow appear?
33-34 weeks gestation
Stomach capacity of newborn
0.5 - 1 ounce
Meconium
The first stool composed of amniotic fluid, shed mucosal cells, intestinal secretions, and blood
Transitional stool
3rd day; composed of greenish brown to yellowish brown, thinner, and seedy
Breast milk stool
Yellow-gold, loose or stringy, sour-smelling
Formula stool
Yellow, yellow-green, or greenish, loose, pasty, or formed, unpleasant odor (differs according to formula)
Benefits of feeding newborn as soon as possible
Newborns that are fed early pass stools sooner, which helps to reduce bilirubin buildup.
Amount of Wet Diapers
- First urine in the first 24 hours
- In the next 2-3 days there should be 2-3 wets/day
- Minimum of 6-12 diapers per day
- Fluid requirements are greater: 100-150 mL/kg/day
Liver in the newborn
Liver is important for iron storage, carbohydrate metabolism, conjugation of bilirubin, and coagulation
Jaundice
- Normal newborns have increased hemolysis of RBCs
- Leading to build-up of bilirubin
- Immature liver must process increased bilirubin production
- If the liver can’t keep up then jaundice occurs
Newborn Genitalia
- Males: inspect urinary meatus and testes
- Females: inspect for urinary meatus, labial inguinal hernia, and pseudomenstruation
- Both genders inspect anus
- Both genders inspect for ambiguous genitals
Newborn Safety
- Matching ID bracelets on mom and baby at birth
- Foot printing at birth
- Transport to and from nursery in cribs
- SIDS prevention
- Never leave alone on elevated surface
- Monitor if not in room when even lying on safe surface
- Code pink
SIDS prevention (ABCs)
A - Alone
B - “back” to sleep
C - Crib
Eye Prophylaxis
- Instillation of prophylactic medication to the eyes
- Precautionary measure against gonorrheal or chlamydial infections obtained by neonate from birth canal
- Mandatory in the U.S.
- To prevent ophthalmia neonatorum which can cause blindness
Vitamin K Prophylaxis
- 0.5-1 mg of vitamin K IM
- Vastus lateralis - 25G, 5/8 needle, 90 degrees
- Given within first 1 to 2 hours of birth
- Healthy newborns able to produce own vitamin K by day 8
Umbilical Cord Care
- Clamp 30-60 seconds after birth
- Goal of cord care is to prevent or decrease risk of hemorrhage and infection
- Clamp removed once stump drying and before discharge home
- Fold diaper to allow it to air dry
- No full bath until cord falls off around 7-10 days
Nursing Implications for Circumcision
- NPO 2-3 hours before procedure
- Monitor for bleeding, urine output, and signs of infection
- Comfort infant afterwards
- Tylenol Q4h
- Monitor for first void
- Normal yellow exudate in 24 hours lasting 2-3 days, do not remove it
- Apply a small amount of petroleum jelly with every diaper change
Newborn Screening
- All states screen for PKU and hypothyroidism
2. Done 24 hours after the first feeding to allow for newborn reaction to protein to be noted
How much do newborns sleep per day?
15 hours/day
Newborn Vision
- Eyes structurally incomplete at birth with immature musculature
- No accommodation until approximately 3 months
- Clearest visual distance 8-10 inches
- Visual acuity similar to adult by 6 months
- Vision is the least mature sense at birth
Newborn Hearing
- When amniotic fluid drains, hearing similar to adult
- Different frequencies elicit varying reactions
- Responds readily to mother’s voice
- Hearing loss common major abnormality at birth
- Hearing screens done before discharge
Benefits of Breastfeeding for Mom
- Decreased PP bleeding and more rapid uterine involution
- Reduced risk of breast, uterine, and ovarian cancers
- Quicker weight loss
- Decreased risk of postmenopausal osteoporosis
- Unique bonding
Benefits of Breastfeeding for Baby
- Decreased incidence and severity of infections
- Decreased rate of SIDS, DM, lymphoma, leukemia, Hodgkin disease, asthma, allergies, and obesity
- Enhanced IQ and eye development
- Calorie content adapts to infant’s needs
If breastfeeding, encourage mom to …
- Feed on demand every 1-4 hours
- Allow to latch and finish before offering other side
- If pumping, pump each time a bottle is given to keep up milk supply (minimum of 6-8 times per day)
Concerns during breastfeeding
- Be careful with meds - what mom takes affects the baby
- Exercising can cause milk to taste different
- Foods will make milk taste different adn affect baby
- Can breastfeed when mom is sick
Formula Feeding (amount)
Bottle feeding is started within 4 hours after birth
- 15-30 mL Q3-4h for first 2 days
- 90-150 mL per feeding by the second week of life
Concerns with bottle feeding
- Hold upright
- Burp frequently
- No bottle propping
- Type of bottle and nipple is parent preference
- Throw away after each feeding
Formula Preparation
- Can be refrigerated
- Use a bottle warmer or separate cup with heated water to warm
- Do not use microwave or heat on stove due to risk for hot spots
Weaning
- Introduce foods at 4-6 months to decrease risk of allergies
- Use formula milk or breast milk for at least one year as milk source.
What is the newborn’s first immunization?
Hep B
