nursing care of normal newborn (unit 2) Flashcards
first period of reactivity
- birth-30 min
- inc. HR
- irregular resp.
- alert, inc. motor activity
- dec. body temp
- meconium/saliva possibly
sleep period (relative inactivity)
- dec. in motor activity 30-100 min after birth
- VS recovery
- temp may dip, so need warmer
second period of reactivity
- 4-8 hours after birth
- periods of tachypnea/apnea
- periods of tachycardia
- inc. muscle tone
- inc. mucous (bulb)
- meconium
mechanical stimuli initiating breathing
- compression/recoil of chest during birth
- tactile sim during/after birth
- suctioning
sensory stimuli initiating breathing
•temp (chill)
•noise
•light
*obligate nose breathehrs
signs of respiratory distress
- nasal flaring
- retractions
- grunt w/ expiration
- accessory muscle use
- seesaw resp.
- rate < 30 or > 60
- low surfactant levels
- apnea r/t analgesics or rapid cool/warm
- diaphragmatic hernia
surfactant
- lines alveoli, inc. SA
- suff. levels 34-36 wk
- deficiency leads to RDS
- measured by L/S ratio
L/S ratio
- determines fetal pulmonary maturity
- 2 or > means more mature
- 1.5 of < means inc. r/o RDS
fetal structures that close postnatally
•foramen ovale
•ductus arteriosus
•ductus venosus
*allows unoxygenated blood to circulate thru lungs
foramen ovale
- b/t RA & LA
* allows blood to bypass pulmonary circulation
ductus arteriosus
- b/t aorta & PA
* allows majority of RV output to bypass lungs
ductus venosus
- b/t umbilical vein & IVC
* allows ½ blood from umbilical vein to bypass liver/GI tract
clamping of the cord
•umbilical arteries/vein and ductus venous are functionally closed and converted to ligaments
newborn blood volume
•300 mL
newborn H&H
•14-24 g/dL
•44%-64%
*shorter lifespan of RBC
newborn leukocytes
•WBC of 18,000
•inc. after birth, then declines rapidly
*susceptible to infection
newborn clotting factors
•levels decrease b/c unable to synthesize vitamin K
nonshivering thermogenesis
- metabolism of brown fat (inter scapular, axillae, vertebrae, kidney)
- critical newborn heat production
- rapid depletion w/ cold/stress
- PT have less brown fat
heat loss via convection
- heat from body to cooler air
* keep wrapped in blanket and warm room
heat loss via radiation
- heat from body to cooler surface
* NOT direct contact
heat loss via evaporation
- insensible water loss
- can occur via respirations
- dry baby well and delay first bath if thermoregulation issues
- only expose one body part at a time
heat loss via conduction
- heat from body to cooler surface
- direct contact
- warmer
newborn hypothermia
- common b/c have inc. heat loss d/t thin skin, vessels close to surface, little fat, and high SA to body mass ratio
- s/sx: < 36.5 or 97.7 temp; cyanosis; tacypnea
newborn heat conservation
- flexed positon
- constriction of peripheral vessels
- brown fat metab.
- crying, restless, movement
cold stress
- ineffective thermoregulation
* can lead to hypoxia, acidosis, and hypoglycemia
cold stress s/sx
- drop in temp
- RR inc.
- tachy then brady
- mottled skin; acrocyanosis
- dec. activity if RD
- inc. activity if not RD
hyperthermia
- rapid BMR increase
- increase in glucose/O2 requirements
- nonfunctioning sweat glands
- vasodilation w/ increased insensible water loss
- may lead to cerebral damage, dehydration, heat stroke, death
neutral thermal environment
•where infant can maintain stable body temp w/o increase in metabolic rate
neonate renal system
- urine @ 12 wks GA
- kidney fully developed @ 35 wks
- blood flow inc. after birth -> inc. UOP
expected infant UOP
- once in 1st 24 hr
- twice 2nd 24 hr
- 3 times 3rd 24 hr
newborn sucking coordination
- after 1500 g
* 32-34 wks GA
first stools of newborn
- meconium (24-48 hr)
- transitional (day 3)
- milk (day 4)
neonate hepatic system fxn
- iron storage
- carb metab
- bilirubin conjugation
- coagulation
iron storage
- proportional to body weight
- maternal Fe transfer from 3rd trimester stored for 4-6 months
- PT have smaller stores (2-3 months)
carbohydrate metabolism
- glucose transplacentally
- glucose dec. at birth
- neonate higher glucose needs than fetus
- glycogen stored last 4-8 wks GA
hypoglycemia in infant
• < 40 mg/dl (term) •jittery •RDS •apnea •lethargy •poor suck •seizures *if no tx, possible brain damage
infant r/o hypoglycemia
- preterm
- SGA
- LGA
- stress
- maternal diabetes
coagulation of bilirubin
•short living RBC brobken into unconjugated bilirubin (fat soluble)
•liver must convert unconjugated into conjugated for metab/excretion (water soluble)
*hepatic immaturity causes accum. of unconjugated
unbound bilirubin
- conjugated
- water soluble
- yellow pigment that may leave vascular system and go to skin, sclera, oral membranes (jaundice)
why do neonates have hyperbilirubinemia
- excess production of bilirubin
- liver immaturity
- shortened life span of RBC
- delayed feeding
- trauma
r/o hyperbilirubinemia
- prematurity
- Rh or ABO incompatibility
- cephalhematoma, bruising
- delayed/poor intake
- cold stress
- sepsis
- breast feeding
physiologic jaundice
- hyperbilirubinemia
- appears after 1st 24 hrs
- benign- not normal, but common
- s/sx 2nd-3rd day of life
- usually resolves by day 4
- bili < 12 (unless PT or BF)
pathologic jaundice
- hyperbilirubinemia
- appear w/in 1st 24 hrs
- r/t abnormalities that cause excessive RBC destruction
- bili levels higher and remain high
kernicterus
- bilirubin encephalopathy
- severe jaundice
- bili > 25 mg/dl
- causes severe neurological damage
- only ½ infants survive
BF/milk and jaundice
- BF: early onset
- milk: late onset
- r/t ineffective BF patterns or substances in milk causing reabsorption of bill from stool
apgar score
- take at 1 and 5 minutes
* highest (best) score is 10
heart rate apgar scores
0- none
1- < 100
2- > 100
respiratory apgar score
0- apnea
1- irregular/shallow
2- crying
muscle tone apgar score
0- flaccid
1- some flexion
2- well flexed
reflex irritability apagar score
0- non
1- grimace/withdraw
2- crying
color apgar score
0- central cyanosis
1- peripheral cyanosis
2- pink
ballard score
- 12 criteria that represents neuromuscular and physical maturity of newborn
- scores from -1 to 5 in each area
- must be done w/in 48 hrs
classification of gestational age
- preterm- before 37 wks
- term- 38-42 wks
- postterm- after 42 wks
postmature
- greater than 3 wks past delivery date
- placenta can begin to fail, causing dec. in O2/nutrients to fetus
- must induce to prevent fetal death
- fetus LBW, dry, long hair/nails
expected newborn weight
- 2500-4000g
- 5-10% wt loss in first few days
- regain 10-14 days
- after regain, gain 1.5 lbs/month for 5 months
expected newborn measurments
- length: 45-55 cm
- head circ.: 32-36.8 cm
- chest circ.: 30-33 cm (2-3 smaller than head)
expected newborn VS
- 97.7-98.9 deg.
- HR: 110-160
- RR: 30-60
- BP: 70/45
IUGR baby
- wt less than 10th percentile
- thin, pale, loose, dry skin
- r/t maternal dz and UPI
expected newborn integumentary system
- thin
- erythematous after birth (resolve in few hrs)
- blotchy/mottled extremities
vernix caseosa
•cheese-like substance fused w/ epidermis as protective coating
acrocyanosis
- blue hands and feet
* normal vasomotor instability
lanugo
- fine hair
* more common in darker complected persons and preterm babies
simian crease
- single palmar crease
- may be genetic (asian)
- also indicates Downs
desquamation
- peeling of skin
- indication of post maturity if present at birth
- normal few days after birth in term
milia
- nonfunctional sweat/oil glands
- look like pimples
- hyperplasia from hormones at birth
mongolian spots
- bluish-black areas of pigmentation that blanch
- back and butt
- fade gradually
- often mistaken for bruises
telangiectatic nevi (stork bites; angel kisses)
- pink, easily blanched patches
* upper eyelids, nose, upper lip, lower occipital area, nape of neck
nevus vasculosus (strawberry mark)
- capillary hemiangioma
- entire dermal and subdermal layer
- most often on head
nevus flammeus (port wine stain)
- plexus of newly formed capillaries
- red to purple
- not elevated
- do not blanch
- most frequently on face
erythema toxicum (newborn rash)
- hive-like spots that appear suddenly anywhere
* no clinical significance or tx
cephalhematoma
- collection of blood b/t skull bone and periosteum
- DOESNT cross suture
- resolves 3-6 wks
caput succedaneum
- edematous area of scalp
- most often occiput
- spontaneous disappearance 3-4 days
- labor/vacuum extraction
expected eye assessment
- blue/gray (permanent color 3-12 mo)
* tears indicate mature lacrimal gland
low set ears indicate…
•fetal alcohol syndrome
•downs
•congenital abnormalities
*should be above canthus of eye
abnormal size/shape of ears indicates
- deafness
* downs (round)
assessing patency of nares
•have baby suck while occluding one nostril at a time
•look for nasal flaring
*obligate nose breathers
circumoral cyanosis
•normal for first 24-28 hr (cardiopulmonary adaptation)
epstein’s pearls
•yellowish, white cysts that hang from newborn gums/roof of mouth
assessing neck/clavicles
- hyperextend to visualize trachea placement
* palpate along entire clavicle to rule out crepitus, edema, fracture, etc
newborn PMI
- 4th ICS LMCL (visible)
* auscultate for min while sleeping
newborn BP range
- 60-80/40-50 mmHg
* take in arms and legs on first VS check
RR indicating RDS
•apnea lasting > 15-20 sec.
“true apnea”
pectus excavatum
•sternum bows inward
pectus carinatum
•sternum bows outward
newborn diastasis recti
- d/t weakness of fascia b/t rectus abdominus muscles
- not a herniation- will disappear
- most often seen when crying
checking anal patency
- passage of meconium
* first rectal temp
newborn female genitalia assessment
- labia majora and minora visible
- light pink
- central orifice b/t labia minora
- clitoris covered by labia in adducted position
newborn male genitalia assessment
•tight foreskin •urethra should be midline -hypospadias (under) -epispadias (top) •observe urine stream for patency •descended testes •check for hydroceles (assume. fld. around testes)
difference b/t hydroceles and inguinal hernias
- hydroceles cannot be reduced b/c fluid in enclosed space
- hernias can be reduced w/ digital pressure
- bay have bowl sounds over hernia mass
talipes eqinovarus
•club foot
tonic neck
•fencing
moro
- startle reflex w/ spreading of arms and legs and crying
* indicates proper CNS fxn
Babinski reflex
- stimulation of sole of foot causes big toe extension and other toe fanning
- normal in newborn b/c neurologically immature
galant reflex
- hold baby prone while supporting belly w/ hand
- stroke along one side of spine
- body should curve toward stroked side
erythromycin ophthalmic ointment
•prophylaxis against ophthalmia neonatorum in the event of maternal infection with gonorrhea or chlamydia
vitamin K (IM)
- given to newborn b/c sterile intestines don’t produce
* prevents hemorrhagic dz
newborn immunizations
•hep B series initiated
•hepatitis B immune globulin (HBIG) if exposed to HBsAg positive mom
-also give pos. mom hep B vaccine
screening before newborn DC
•hearing •genetic -PKU -congenital hypothyroidism -galactosemia -hemoglobinopathies
galactosemia
•absence of NZ for conversion of milk sugar to glucose
signs of circumcision site infection
•red •warm •swollen •draining pus *yellow, non draining scab is NORMAL and will resolve in wk
criteria for newborn DC
•normal exam/VS •feed successfully 2x •pass urine/stool •no excessive circumcision site bleeding •no sig. jaundice *48 hr stay vag. *96 hr stay C/S
cord care
- Early - check for bleeding/oozing, security of cord clamp
- Remove clamp at 24 hrs if end dry
- Keep the cord dry and keep the top of the diaper folded under
- Avoid submerging in water until the cord falls off (sponge bath)
breast feeding
- start immediately
- on demand or q2-3 hr
- alternate breasts (10 min each)
bottle feeding
- start 2-4 hrs
* on demand or q3h
skin to skin (SNS) contact benefits
- improves BF
- thermoregulation
- calm mom and baby
- stimulates digestion
- regulates HR and RR
infant caloric intak 1st 3 months
- 110 kcal/kg/day
* human milk/formula 20 kcal/oz (67 kcal/100 mL)
what site recommended for newborn IM injections
•anterolateral thigh
When performing nursing care for a newborn after birth, which of the following nursing interventions is the highest priority?
•covering head with cap
*r/o cold stress, so need to prevent heat loss via evaporation
A newborn was not dried completely after delivery. The nurse understands that what causes the newborn to lose heat?
•evaporation
why is it important to keep the nipple full of formula when bottle feeding
•prevents newborn from swallowing air when sucking
how to know if newborn receiving enough to eat
- content b/t feedings
- gains weight
- 6-8 wet diapers/day
