Nursing Management of Newborn Flashcards
Signs that Indicate a Problem
- Nasal flaring, chest retraction
- Grunting, labored breathing
- Generalized cyanosis, flaccid body posture
- Abnormal breathing/respiratory rates
- Abnormal HR/newborn size
Initial Newborn Assessment
- APGAR score
- Length/weight, vital signs
- Gestational age assessment
- Physical maturity
- Neuromuscular maturity
Apgar Score
used to evaluate a newborn’s physical condition at 1 and 5 minutes after birth
When may an additional Apgar score be done?
At 10 minutes if the 5 minute score is less than 7 points
What are the 5 parameters of the Apgar score?
A-appearance P-pulse G-grimace A-activity R-respiratory
A
appearance; color
P
pulse; heart rates
G
grimace; reflex irritability
A
activity; muscle tone
R
respiratory; respiratory effort
How is the newborn HR obtained?
taking an apical pulse for 1 minute
When are newborn respirations counted?
when they are quiet and sleeping
What tool is typically used to establish gestational age?
Ballard Scale
What physical maturity areas are assessed for the Ballard Scale?
Skin texture Lanugo Plantar creases Breast tissue Eyes and ears Genitals
What are the 6 maneuvers the newborn must perform to establish neuromuscular maturity with the Ballard Scale?
Posture Square window Arm recoil Popliteal angle Scarf sign Heel to ear
Preterm/premature
born prior to 37 weeks gestation
Term
born between 38 and 42 weeks
Postterm/postdates
born after 42 weeks
Postmature
born after 42 weeks and demonstrating signs of placental aging
SGA
small for gestational age
LGA
large for gestational age
AGA
appropriate for gestational age
Immediate Newborn Period Nursing Interventions
Maintaining airway patency
Ensuring proper identification
Administering prescribed meds
Maintaining thermoregulation
What is the order of suctioning for newborns?
mouth then nose
During the immediate newborn period what 2 drugs are commonly ordered?
Vitamin K and erythromycin
What will Vitamin K do for the newborns?
promote blood clotting
What can happen if their is a vitamin K deficiency?
hemorrhage
Why is eye prophylaxis medication mandatory for all newborns in the US?
to prevent ophthalmia neonatorum
What is caused by Ophthalmia Neonatorum?
neonatal blindness
How often should the newborns temp be taken for the first 2 hours?
q 30 minutes
Nursing interventions to promote Thermoregulation
- dry newborn immediately after birth
- wrap in warmed blankets
- skin to skin w/ mom ASAP
- use warmed cover on scale
- warm stethoscope and hands before exam
- delay initial bath until temp is stable
When should a physical exam not be started on the newborn?
when the newborn is crying or appears to be upset
When is the initial newborn physical exam performed?
within 24 hours after brith
Anthropometric Measurements
length, weight, head circumference, chest circumference
What is the average length of most newborns?
50 cm = 20 inches
What is the baby’s weight affected by?
racial origin genetics maternal age size of the parents maternal nutrition placental perfusion
What is the average newborn head circumference?
32-38 cm/13-15 inches
Average newborn chest circumference
30-36 cm/12-14 inches
Skin Assessment
color, texture, turgor, integrity
Acrocyanosis
persistent cyanosis of fingers, hands, toes, and feet w/ mottled blue or red discoloration and coldness
What are some common skin variations?
vernix caeosa stork bites milia Mongolian spots erythema toxicum harlequin sign nevus flammeus nevus vasculosus
Vernix Caeosa
thick white substance that protects the skin of the fetus
Stork Bites
superficial vascular areas found on the nape of the neck, eyelids, between the eyes and and upper lip
Milia
multiple pearly-white or pale yellow unopened sebaceous glands frequently found on newborns nose
What is milia called when it is found in the newborn’s mouth and gums?
Epstein pearls
Mongolian Spots
benign blue or purple splotches that appear on the lower back and buttocks
-may occur as multiples on legs/shoulders
Erythema Toxicum
“newborn rash”
benign, idiopathic, generalized, transient rash; small papules/pustules
Harlequin Sign
dilation of blood vessels on only one side of the body giving the newborn the appearance of wearing a clown suit
Nevus Flammeus
port-wine stain
Nevus Vasculosus
strawberry mark/hemangioma
Head Assessment
size
fontanels
variations in size/appearance
abnormalities
What are considered common variations of the newborn head size/appearance?
Caput succedaneum
Molding
Cephalhematoma
Molding
elongated shaping of fetal head to accommodate passage through birth canal
What are Abnormalities to watch for in the newborn head?
Microcephaly
Macrocephaly
Large fontanels
Small or Closed fontanels
Face Assessment
nose, mouth, eyes, and ears
Neurologic Status Assessment
Alertness
Posture
Muscle tone
Reflexes
What will general newborn care involve?
Bathing/hygiene Diaper care Cord Care Circumcision care environmental safety measures prevention of infection
What are the traditional reasons for why nurses bathe the newborn?
- physical assessment
- reduce effect of hypothermia
- allow mom to rest
How should the newborn sleep?
on their back
What are the typical newborn screens?
PKU
Congenital hypothyroidism
Galactosemia
Sickle cell anemia
PKU
autosomal recessive inherited deficiency in one of the enzymes necessary for metabolism of phenylanine to tyrasine
Congenital Hypothyroidism Screen
deficiency of thyroid hormone necessary for normal brain growth, calorie metabolism, and development
Galactosemia Screen
absence of the enzyme needed for conversion of the milk sugar galactose to glucose
Sickle Cell Anemia Screen
recessively inherited abnormality in hemoglobin structure
What is the most common birth disorder in the US?
hearing loss
What are the common concerns during newborn transition?
Transient tachypnea
Jaundice
Hypoglycemia
When does transient tachypnea occur in newborns?
the fetal liquid in the lungs is removed slowly or incompletely
What is used to relieve transient tachypnea?
low dose oxygen therapy
Nursing Interventions for Transient Tachypnea
Provide oxygen
Ensuring warmth
Observing respiratory status frequently
Allowing time for pulmonary capillaries and the lymphatics to remove remaining fluid
What will be seen with physiologic jaundice?
yellow skin, mucous membranes, and sclera w/in the first 3 days of life
Hypoglycemia
BG level < 30 mg/dL or a plasma concentration of < 40 mg/dL in the first 72 hours of life
S/S of hypoglycemia
Mostly asymptomatic jitteriness lethargy cyanosis apnea seizures high-pitched/weak cry hypothermia poor feeding
Treatment of Hypoglycemia
Administration of rapid acting source of glucose such as sugar/water mix or early formula feeding
What does the newborn’s caloric needs range from?
110-120 cal/kg of body weight
Fluid requirements for newborns
100-150 mL/kg daily
What should be done before feeding the newborn?
- determine ability to suck/swallow
- clear any mucous
- auscultate bowel sounds/check for abdominal distention
- inspect anus for patency
How often are mothers encouraged to feed their newborns at home?
q 2-4 hours
LATCH Method
L- how well infant latches A- amount of audible swallowing T- nipple type C- level of comfort H- amount of help mom needs
