OB Module 1: Part 2 - The Newborn Flashcards
The newborn experiences many physiological changes when transitioning to extra uterine life, these changes involve establishment of what things?
- Pulmonary Gas Exchange
- Neonatal Cardiovascular Pattern
- Stable Serum Glucose Level
- Thermoregulation
Assessment and monitoring of neonatal adaptation is needed for early detection of what complications?
Hypoxia
Cold Stress
Hypoglycemia
Infection
Polycythemia
Hyperbilirubinemia
What are some of the Key Newborn Assessments
- VS, especially temperature, but BP is rarely done
- Nutrition
- Elimination
- Transition to extrauterine life
- activity state
- umbilical cord status
7/8/9. (Only if indicated) Glucose monitoring, bilirubin, circumcision assessment
Apgar Score
This score is indicative of the need for resuscitation, NOT the degree of asphyxia in a newborn
Each factor is scored 0, 1, or 2 and a lower number indicates need for resuscitation
When are infants apgar scored?
At 1 and 5 minutes of life, and if needed at 10 minutes
What are the 5 factors apgar scored?
Heart Rate
Respirations
Muscle Tone
Reflex Irritability
Color
Fetal lungs secrete ___ ___ throughout pregnancy
lung fluids
When does lung fluid production diminish in the fetus?
2-4 days before the onset of SPONTANEOUSLY OCCURRING LABOR (may not all be gone if we induce labor)
How much lung fluid remains in the passageway of a full term newborn?
80-100 mL of lung fluid
(This will need to be expelled or absorbed after delivery)
How is part of the lung fluid pushed out of the infant?
During labor and birth, fetal chest is compressed and this squeezes part of the fluid out
This is called VAGINAL SQUEEZE
What 2 ways is the remaining infant lung fluid disposed of?
- Vaginal Squeeze
- Absorption by the lymphatic system
Why can you hear fine crackles over the lungs in the newborn?
Because of the lung fluid remaining there
Transient Tachypnea of the Newborn (TTN)
A repsiratory complication at risk of developing in infants that have difficulty clearing the remaining lung fluid
Why are C Section babies at higher risk for TTN
They did not get the vaginal squeeze to force some fluid out
Why is the chest recoil so important to the initiation of infant resp. stimulation?
It can mechanically stimulate the first breath and respiration (chest recoil occurs during vaginal squeeze)
What are some Chemical Stimuli that initiative infant respiration?
- Increased PCO2 and decreased pH and PO2 from inspiratory gasp
- Changes in aortic and carotid chemoreceptors which trigger the brains respiratory center
- Hormonal - prostaglandin drop
Inspiratory Gasp
first infant breath
triggered by increased PCO2 and decreased pH and PO2
How does a drop in prostaglandins contribute to respiration in the newborn?
It is released by the placenta during pregnancy to suppress respiration, but with the clamping of the cord - the levels drop and there is a rise in inspiratory drive
How does PO2 rise in the newborn?
It starts at 65% in the first minute of life, and then increases 5% every minute for 5 minutes and then is at 90-95% at ten minutes
Skin goes cyanotic to pink remarkably fast
What is the mechanical stimuli that initiates infant respiration?
Natural result of a normal vaginal birth as the “vaginal or thoracic squeeze” is released at the delivery of the chest allowing for lung expansion
What is the thermal stimuli that initiates infant respiration
Significant decrease in environmental temperature after birth stimulates skin nerve endings leading to the newborn responding with rhythmic respiration
Excessive cooling of the infant may lead to…
profound respiratory depression as a result of “cold stress”
Sensory Stimuli: How does Intrauterine life differ from Newborn Experiences at delivery?
Intrauterine: Dark, sound dampened, fluid filled environment, weightless
Newly Born: Light, sounds, gravity effects, abundance of tactile/auditory/visual stimuli
Normal newborn respiratory rate is __ to ___ breaths per minute
30 to 60 BPM
Initial newborn respirations may be what in regard to depth and rhythm?
diaphragmatic, shallow, irregular
VERY ERRATIC - listen for a minute
Respiratory rate of the newborn increases with ___
crying (easy to get respirations then but increases the rate)
In a newborn it is important to do what when counting respirations?
count for a full minute since its so erratic
Is apnea in a newborn abnormal?
Apnea 5-15 seconds is not abnormal (periodic breathing) but pauses longer than 20 seconds are apnea that needs additional assessment
Periodic Breathing
a common breathing pattern in the first few hours of life
It consists of pausing lasting from 5 to 15 seconds (apnea)
S/S of Respiratory Distress in the Newborn Include…
increased/decreased respiratory rate <30->60
flaring of nares
expiratory grunting
see-saw breathing
retractions
color changes
circumoral cyanosis – general cyanosis
decreased muscle tone
problems with temperature regulation
increased water loss
The first sign of respiratory distress in an infant is usually?
Flaring of the nostrils (followed by expiratory grunting)
What is the primary resp. issue for a newborn that can lead to distress?
potential for the alveoli to collapse causing larger areas of the lungs to collapse later
What may a baby do to keep alveoli inflated?
Close the epiglottis while exhaling to try and keep the alveoli inflated
It sounds like humming and is done to keep surface tension
This appears as the second sign of resp. distress, expiratory grunting
Acrocyanosis
a common finding in newborns of cyanosis of the hands and feet
Circumoral Cyanosis
A not uncommon finding of cyanosis around the mouth in newborns due to the fact the tissue is thin and highly vascular in this area
Is cyanosis in the trunk abnormal?
Yes, you need to then monitor O2 Saturation
See Saw Breathing
A later sign of resp. distress where the abdomen and chest effort is alternating in breathing
Why and When does temperature regulation become a problem in resp. distress?
Moist warm air is leaving quickly while cool air is coming in
occurs later down the road
Also since muscle ton is relaxing, the infant cools faster from increased surface area
Cardiovascular adaptation requires the transition from __ to __ circulation (which differ0 with the change from ___ to __ gas exchange
fetal to neonatal
placental to pulmonary
The fetal lungs are essentially ___. Most blood does what in utero?
nonfunctional. Most blood bypasses the lungs and is shunted to other parts of the body
Foramen Ovale
opening between the right and left atriums in the fetus
How does oxygenated blood return in fetal circulation?
Oxygenated blood returns to the fetus from the placenta through the placental vein.
40-60% of Fetal Blood bypasses…
the liver via the DUCTUS VENOSUS and enters the inferior vena cava
As the fetal blood enters the right atrium, what happens next?
50-60% of the blood is shunted across the atrium through the foramen ovale to the left atrium
How does pressure differ in fetal circulation?
There is LOW systemic resistance and HIGH pulmonary resistance
60% of fetal blood from the right ventricle…
is shunted through the ductus arteriosus to the umbilical arteries and toward the placenta
What things change and why do they change from fetal to neonatal circulation?
Openings and Shunts (like the ductus venosus, ductus arteriosus, foramen ovale) close and the pulmonary pressure becomes less than the systemic pressure leading to neonatal blood flow
This occurs due to the pressure changes that occur
What causes the pressure resistance in circulation shift from fetal to neonatal circulation?
Initiation of respirations by the infant and clamping of the cord changes it to low pulm. res. and high systemic res.
The shift of circulatory resistance cause a pressure closure ….
of the foramen ovale in the heart. The ductus arteriosus begins to constrict almost immediately after
How does blood flow in neonatal circulation
right atrium –> right ventricle –> pulmonary arteries –> lungs –> pulmonary veins –> left atrium –> left ventricle –> aorta
The newborn cardio assessment should start with …
a general color assessment (especially oral mucosa and trunk)
Acrocyanosis
occurs in the first 7-10 days
it is not unusual for the hands and feet to remain blue
Circumoral Cyanosis
blue tint to the skin surrounding the lips, but not on the lips
this is normal and is simply the blue color of the veins just below the skin in this area
You may notice this blue tint most of the time
When the arterial blood in this area diminishes for various reasons, you will see the blue tint of the veins underneath
Does not include mucosa
General Cyanosis
blue tint to the skin that covers the face, trunk, and extremities
Associated with poor oxygenation of the tissues and is an ominous sign
Can be respiratory or cardiac in origin
How is newborn heart rate assessed?
Taken apically at the FOURTH INTERCOSTAL SPACE, LEFT
Listened to FOR A FULL MINUTE
What is normal apical heart rate of a newborn?
110-160 BPM at rest
Can be 80-100 when asleep
Can be up to 180 when stressed
___ may increase heart rate and respiratory rate
crying
What heart rates warrant further investigation?
consistently high (above 180) or low (below 100)
Heart Murmurs in Newborns
Not an uncommon finding
Most non pathological and disappear by 6 months
Although newborn murmurs are not uncommon…
ALL MURMURS WARRANT FURTHER INVESTIGATION AND ASSESSMENT
Hearing a murmur in a newborn is the most common means of recognizing cardiac disease
What may make a murmur an abnormal finding in a newborn?
if accompanied by poor feeding, cyanosis, pallor, or apnea
Estimated Blood Volume of a Term Infant
80 mL/kg of body weight (or 92 mL/kg if you delay clamping like you should)
How may blood volume in a newborn vary?
Varies with amount of placental transfusion received by the newborn during expulsion of placenta (the vaginal squeeze forces blood back into the placenta temporarily so do not clamp the cord immediately - wait 30s to a few minutes to allow blood flow back)
Blood volume increases by ___% with delayed cord clamping
50%
Peripheral blood flow in the newborn can be ___, and cause …
sluggish, and cause RBC stasis (increased stasis)
You should not take blood samples from the ___ in a newborn
periphery (since it is slow)
H&H levels are ___ in ___ blood than ___ blood
H&H levels are higher in capillary blood than in venous blood
Blood samples taken from ___ samples are more accurate than those taken from __ samples
venous; capillary
In the new O2 rich environment, what may occur for the babies RBCs?
Breakdown from the extra RBC, leaving bilirubin which causes Jaundice
Bilirubin needs to be bound to a protein that is excreted but there is only so much
If the breakdown is excessive, there can be hyperbilirubinemia and we may need to help treat
(Wanna see jaundice after a few days, not immediately at birth)
How does Newborn blood lab values differ?
- total blood volume 82.3 to 92.6 ml/kg depending on clamp time at three days of life
- H&H are both higher than adults (14-20 dL and 43-64%) - this is to catch more oxygen coming to it
- WBCs are elevated
- Blood glucose is elevated (40-80 or 45-95 mg/dL at 6 hours of life)
these are all at delivery values
What is normal glucose levels in the newborn?
Between 40-80 mg/dL ion the first 6 hours of life and then 45-90 mg/dL after that
What glucose levels are hypoglycemic in the newborn and how can it be treated?
Glc below 40-45 mg/dL
Treated with feeding or a 10% dextrose in sterile water feeding
Persistent hypoglycemia in the newborn can result in …
neurological damage in the newborn
Newborn Hypoglycemia results from what things?
Inadequate availability of glucose (poor feeding)
Abnormal endocrine regulation (infants of diabetic mothers)
Increased utilization of glucose (cold stress, infection)
___ is the primary fuel for the newborn and is stored in the ___ as ____
glucose; liver; glycogen
Hypoglycemia can be __-__ and can result in ___ and ___ ___
life-threatening; seizures; learning disabilities
Which is more common in premature and small for gestational age infants, hypo or hyperglycemia?
Hyperglycemia
S/S of Infant Hypoglycemia
S/S of hypoglycemia are frequently absent despite extremely low blood glucose levels though!
Jitteriness
Hypothermia
Diaphoresis
Hypotonia
Irritability, tremors, muscle twitching, seizures
Abnormal cry
Poor feeding
Lethargy
Resp. distress, tachypnea, apnea
Cyanosis, Tachycardia, cardiac failure, cardiac arrest
What is the most common symptom of hypoglycemia? Second most common?
Most common: Jitteriness (but this is also a withdrawal symptom)
2nd: Hypothermia
Normal Newborn Temperature
> 97.6 F
Rarely elevated
Below 97.6 F is abnormal and can lead to significant distress from cold stress
Temperature instability indicates ___
infection (or even hypoglycemia)
What is the preferred method to take newborn temperature? What are some alternatives?
Preferred: Axillary
Alternative: Axillary, Continuous skin probe, Rectal
Newborn temperature is rarely ___ in regard to infection
elevated
Research indicates ___ and ___ methods are accurate indicators of body temperature
tympanic and (digital) axillary
Heat Stress or Cold Stress is related to ___ issues
metabolic
like hypoglycemia, increased O2 consumption, increased lactic acid production, increased metabolic acidosis and death
Heat loss in the newborn can occur through what 4 mechanisms?
Conduction
Convection
Radiation
Evaporation
Conduction
Loss of heat when the newborn touches something and heat is moved to that object or surface
Occurs if the baby is placed on a cold surface like a weighing scale or cold mattress
Convection
Loss of het to air that is circulating and is cooler/Newborn is exposed to cooler surrounding air
Heat loss increased with air movement
Radiation
Loss of heat from the infant when heat moves to cooler objects in the general area like the walls or window
Transfer of warmth from the baby to cooler objects in the vicinity even if they baby is not actually touching them
Evaporation
Loss of heat from moisture on the skin evaporating away
This is highly significant when the infant first is born and after the first bath!!
___ is the main form of heat loss initially due to the amniotic fluid on the baby’s body
evaporation
What is the first step of neonatal resuscitation?
Very vigorous drying of the baby - the cutaneous stimulation helps and this gets rid of amniotic fluid to prevent further complication with cold stress
In regard to convection, a baby risks getting cold even at a room temperature of ___C(___F) if there is a draft. This changes to __-__F if the infant is naked and ___-___F if the infant is dressed)
30C(86F)
89-92 F Naked
75-80 F Dressed
What exactly is cold stress?
cold stress is a body temperature rectally of less than 97.6F w/ symptoms
What should you do if you get a newborn temp of 97.6 F or lower?
First, repeat under the other arm. If the reading is still low report to the nurse immediately. The infant will either need skin to skin temperature contact with the mother or be placed in a radiant warmer
What kind of infants are at greater risk for cold stress?
smaller and preterm infants
Symptoms of Hypothermia
Body cold to touch
Hypoglycemia (no fuel to make heat)
Restlessness, irritability, tachypnea
Pallor or mottling
Lethargy, decreased activity, hypotonia
central cyanosis, expanding acrocyanosis
Poor feeding, weak suck
Bradycardia
Feeble cry, shallow/irregular respirations, apnea
Non-shivering Thermogenesis
Shivering that occurs when skin receptors perceive a drop in environmental temperature
The newborn will shiver and double the metabolic rate and increase muscle activity
All of this is done to generate heat
What is the primary source of heat in the hypothermic newborn?
BAT - brown adipose tissue (Fat)
BAT
Brown Adipose Tissue (Fat)
Primary source of heat in the hypothermic newborn
Less plentiful and available to Premes rather than Full Term Infants
When does BAT appear in the fetus? How long will it increase after birth?
Appears in fetus at 26-30 weeks, increases until 2 to 5 weeks after birth
How do newborns respond to hypothermia?
They increase their metabolism by breaking down their limited BAT stores
In what areas is BAT located?
around the:
scapula
kidneys
adrenals
head
neck
heart
great vessels
axilla
BAT Metabolism leads to what things? And what do these results lead an infant vulnerable to?
- Increased metabolism –> Hypoglycemia vulnerable
- Increased O2 Metabolism –> Tissue hypoxia vuln.
- FA production –> metabolic acidosis vuln –> increased serum bilirubin
- Increased local temp –> increased axillary temp (may seem stable erroneously)
___ is the best treatment for Hypothermia
PREVENTION
Treatments for Hypothermia
Prevention
Dry infant immediately after birth
Use a hat
Keep room warm
Use skin to skin with mom or a radiant warmer
Delay bathing until over 98F consistently
Rewarm after bath
Dress appropriately and use blankets as needed
Educate parents
Monitor temps and symptoms
return to the radian warmer if temperature is unstable
Why are babies sometimes not bathed until after 24 hours of birth?
To allow needed bacterial colonization
The newborn has enough intestinal and pancreatic enzymes to digest what things?
Simple carbohydrates
Proteins
Fats
What thing can a newborn not digest?
Starch
By birth, what actions of digestion and absorption have the newborn experienced?
Swallowing
Gastric Emptying
Propulsion
Breast milk is __% digestible and is digested in __-__ hours
90%; 2-3 hours
Compared to breast milk, cows milk formula is digested in __-__ hours
3-4 hours
Meconium
first newborn stool
formed in utero and is made over several weeks
passed within 24 hours usually but must be out by 48 hours (frequency of bowel movement varies)
How do meconium stool, breast milk stool, and cows milk stool compare?
Meconium - extremely dark green or black and it is sticky and adheres to the baby so we need to assure we get it all off
Breast milk - pale yellow, no obvious curdling, small in amount since 90% is digested
Cows milk - curdling and yellow - larger in amount
Initial newborn bladder volume is __ to __ mL of urine
6-44 mL
__% of newborns void by 24 hours after birth, and ___% void by 48 hours after birth
93;100
How may diapers are normally seen on days 1, 2, 3, 4, 5, 6+ after birth?
1 - 1 diaper
2 - 2 diaper
etc…
day 6+ its about 6-8 wet diapers a day
What is the immune system like for the fetus and newborn?
The immune system is not fully activated until after birth, so the newborn has poor hypothalamic response to pyrogens
___ is not a reliable indicator of infection - in the newborn period, ___ is a more reliable indicator of infections
fever; hypothermia
You rarely see a temperature elevation until a week or two after birth because…
there is no pyrogen reaction from hypothalamic response
Passive Newborn Immunity
Lasts 4 weeks
Passive immunity occurs and is gained during the third trimester and through antibodies in the mothers breast milk
Why are preterm infants more susceptible to infection?
Antibodies move from the mom to fetus in the last 4 weeks of pregnancy - this is why premes are at higher risk for infection since they lost some of that time or all of it
Breastfed newborns may have additional what?
passive immunity from mother
Newborns start to produce secretory ___ in the intestinal mucosa at _ weeks
IgA; 4 weeks
Normal Length of an Infant
18-22”
Average 20”
Normal Weight of Infant
2500-4000g (5 lbs 8 oz- 8 lbs 13 oz)
Average is 3405 g (7 lbs 8 oz)
Birth Weight is influenced by …
ethnic origin
maternal weight and age
overall size
A newborn transitioning to extrauterine nutrition can lose how much birth weight in the first few days?
as much as 10% of its birth weight
SGA
Small for gestational age at term
weight <10 percentile - this is less than 6 pounds
LGA
Large for gestational age at term
weight >10 percentile - this is more than 9 pounds
There are ___ associated with either SGA or LGA
complications
What is the average size of a newborn’s head?
Circumference is about 12.5 to 14 inches - that is about 1/4 of the bodies size!!!
What sort of things should be checked about the head on the newborn assessment?
Circumference
Fontanelles
Overriding Sutures
Checks for issues like cephalo hematoma, subgaleal hemorrhage, and caput succedaneum
Fontanelles
Openings in the skull where the sutures have not closed yet (normal finding) and is the “soft spot”
There is an anterior and posterior one
Anterior Fontanelle
Diamond shaped opening toward the front of the dorsal side of the skull
Posterior Fontanelle
Triangle shaped opening toward the back of the skull but it CAN be closed at delivery so you may be unable to palpate
Overriding Sutures
Craniosyntosis where the skull plates close/overlap and cause pressure for the ever growing brain
The fetal skull is a series of plates that can slip one over and under the other to allow the skull to compress and elongate to get through to pelvis usually
Molding
Coning of the head that occurs in the head of the newborn at delivery
Cephalo/a Hematoma
Area of bleeding into the scalp following delivery related to trauma of the scalp
Has more distinct edges than caput succedaneum
Subgaleal Hemorrhage
Bleeding between the scalp and skull that often occurs from the use of a vacuum extractor (hematoma)
This occurs on a more superficial layer than an epidural hematoma which is below the skull bones while subgaleal is above
distinct edges are here but it is much larger than a cephalo/a hematoma
Caput Succedaneum
swelling of the scalp itself
tends to cross the suture line (right to left side)
Less defined edges
How does Caput and Succedaneum differ from Hematomas in the newborn?
Caput Succadaneum - will cross suture lines (go over fontanelle regions)
Hematomas will not cross suture lines since the vessels do not cross over
What skin colors could be seen in newborns?
Pink
Jaundice
Pallor
Cyanosis
Pink Skin Tone
normal skin tone in the majority of the average newborn body
it is pink because of high hemoglobin and hematocrit
Jaundice and the Newborn
Common AFTER 24 hours, but BEFORE 24 hours is abnormal
Pallor and the Newborn
NOT NORMAL IN THE NEWBORN
can be an indicator of blood loss, anemia, or hypoxia
Sometimes pallor can be the result of normal genetic coloring, so make sure to view the parents as well!
Cyanosis and the Newborn
Acrocyanosis is normal (hands and feet)
However, Cyanosis of the trunk and body is not normal, and may be indicative of hypoxia
What sort of findings might you see upon a newborn skin assessment?
Turgor
Vernix
Milia
Lanugo
Stork Bites
Erythema
Post Date Effects on Skin
Mongolian Spots
Newborn Skin Turgor
slight dryness, especially in the extremities
Skin turgor is a good indicator of ___ rather than ___ in newborns
gestation (how far along baby was in pregnancy); hydration
How may skin differ between pre term, full term, and post term infants
Pre term tends to have juicy skin, term babies are a little dry or normal skin consistency, post term skin tends to by dry and peeling
Vernix
a cheesy, fatty substance that covers the fetus’ skin and protects it from the water environment of the womb starting at 24 weeks
Begins to breakdown and disappear at 38 weeks
What might it mean if there is little or a lot of vernix?
Little - may mean that they are post term
Lot - may be pre term
Milia
Congested sebaceous glands that resemble “whiteheads” usually seen on the nose cheeks or chin of the newborn
Lanugo
Fine downy hair on the infant’s body
Common on ears, upper back, on face
The more pre term they are the more likely and more amount of lanugo they may have, but it is also indicative of certain ethnic groups too
Stork Bites
Temporary areas of increased vascularization often seen on the back of the neck, eyelids, and forehead
These are usual
Erythema Toxicum
normal newborn rash often seen generalized over the body
Not an abnormal finding
It is slightly raised and red, not abnormal but does need to be documented
What are the post date effects on skin for a newborn
very dry
parchment like skin
cracking at joints common
peeling of kin
Mongolian Spots
a blueish discoloration which resembles deep bruising.
Common over dorsal area and buttocks, sometimes upper thigh posteriorly
Mongolian sports are more common in people of far east, Mediterranean, and African descent
Needs documentation to make sure no one misconstrues it as child abuse
What should be seen about the newborn nose on assessment?
Flat
Babies are nose breathers
Sneezing is common
Should have normal glabellar reflex and habituation
may see a deviated septum
Glabellar Reflex and Habituation
Eyes blink upon touching the bridge of the nose but they will habituate to the stimuli over time
What is the benefit of habituation in the newborn?
It allows the newborn to notice and interpret stimuli, and to tune out things that they do not need to be neurologically bombarded by (that’s why maybe a loud house has a baby that grows used to it while a quiet house has an easily disturbed baby)
What may constant and frequent sneezing be indicative of in an infant?
While sneezing is normal, this constant and frequent amount may be indicative of withdrawal
Deviated Septum
This can be either a nose that was compressed to one side during pregnancy or delivery, or a bone deformity
Its slightly off if you look at the septum
What are normal mouth and throat findings in a newborn?
Normal to have no teeth, or maybe natal teeth
Palate and lip should be cleft-less
Rooting, sucking, and extrusion reflex present
Possible Epstein Pearls
Rooting Reflex
If the newborn is stroked near the lips , the baby will open the mouth toward that side of being stroke to search for a nipple
Sucking Reflex
If a finger or nipple or something like a binky is placed in the infant mouth than it will begin to suck
Extrusion Reflex
Reflex that occurs when the infant is full from feeding
It will do tongue thrusting to push out the nipple
Epstein Pearls
Cysts
Small, pale, yellow or white in color
Sometimes are seen on the roof of the mouth
What are normal eye assessment findings in a newborn?
Clear
Positive Cornea red reflex, blink reflex, dolls eye reflex present
Pseudo Strabismus
Clear eye discharge
Scleral hemorrhage
Eyes should be straight plane across face (not tilted up or down)
Neonatal eyes can see…
at the time of delivery
What is the focal distance of a newborn’s eyesight?
The distance between the crick of a mother’s elbow and the mother’s face (very short at first)
What is, psychologically, the one goal in the first year of life for the infant?
To learn to trust that one individual will be responsible for their care and feeding - learn to trust who can care for them
Blink Reflex
Reflex, kinda like glabellar, where we check whether the infant blinks if the cornea is touched
But this reflex is only done if the healthcare professional is suspicious of decreased reactions
Cornea Red Reflex
A finding in newborns that should be positive
It rules out newborn cataracts
Pseudo Strabismus
“False Lazy Eye”
They had lived in a dark environment so they have underdeveloped eye muscles
Doll’s Eye reflex
Should be present at delivery
When the head is moved to the left or right the eyes will remain stationary (thus moving in relation to the head) when positive
What is interesting about the clear eye discharge of a newborn?
- The parents tend to do some sort of treatment of the eye since there is abnormal stuff from delivery on it
- If there is gonorrhea or chlamydia issues then an ointment can be applied
- A lot of this discharge is r/t eye prophylaxis
Scleral Hemorrhage
A common finding in the newborn from the vaginal squeeze
It causes a bursting of vessels in the white of the eye
How should the eyes be spaced on a newborn?
The eyes should be spaced so there is a middle space between them about the size of an imaginary third eye
What are normal findings on assessment of newborn ears?
Position should be in line with the inner and outer canthus of the eye
It should recoil
Hearing should be present
What are some abnormal findings on assessment of newborn ears?
Skin tags
Skin depression
Abnormal position of the ears may be indicative of…
various disorders
Why do we check newborn ear recoil?
It is an assessment for gestational age
If it is adequate, there should be recoil if the pinna comes forward because of adequate cartilage formation
How should hearing be immediately after birth for the newborn?
It should be present, but in the first 24 hours there is often amniotic fluid, cells, vernix that can initially diminish sounds
We do a hearing exam after 24 hours because of this
Should still be able to react to noise
Skin tags on Newborns
May be in front of ear or on pinna
Correlated with a renal abnormality
Skin Depressions in front of the ear in Newborns
A finding that correlates with hearing deficit on the affected side
What findings are normal upon assessment of the newborn chest?
Proper contour
proper chest circumference
Breast bud present in girls
proper nipple spacing
Possible supernummary nipples
Breast engorgement is ___ in the neonatal period
rare
What is the normal infant chest contour ratio?
1:1
The average infant chest circumference is __-___ inches
12-13”
Breast buds on infants are usually how big at term?
0.5-1 cm
Nipple to nipple spacing is about ___ cm apart
7.5 cm
Supernummary Nipples
Extra nipples
Tend to follow the nipple line on either side down
Normal Abdomen findings in the newborn?
Umbilicus clamped
Abdomen slightly rounded
Bowel sounds present
Voiding check
Brick Dust urination
Femoral Arteries normal bilaterally
When is the umbilicus clamped?
for the first 24 hours
What is the setup for the umbilical cord?
AVA
2 Arteries and 1 Vein
The infant abdomen should normally be ___ ___
slightly rounded
A newborn should have ___ in the first 24 hours
BM (and voided)
Brick Dust Urination
A not abnormal finding that must be documented
It is a bloody looking (but not actually bloody) color urine from high uric acid concentration
What are normal findings in a male infant genitalia assessment?
2 descended testes - r/t maturity
Scrotum may look comparably large/edematous - and should have rugae
Check for absence of hypospadias, epispadias, hydrocele
Possible to see circumcision
Hypospadias
Condition where the opening of the penis is on the underside rather than the tip
Epispadias
Condition where the opening of the penis is on the upperside rather than the tip
Hydrocele
Excessive amniotic fluid buildup in the scrotum
May appear edematous
What are normal female genitalia infant findings in newborns?
Infants should have the labia slightly edematous and touching at term
Pseudo menstruation can occur
The more flat the infant labia…
the more pre term she is
Pseudo Menstruation
can occur in response to the withdrawal of hormones after delivery
Small amounts of bloody mucus may comes out days immediately after delivery
What are common back and rectum findings upon assessment of the newborn?
Patency of anus and spine
Absence of a dimple at the base of the spine
Possible Mongolian spots
Leg folds equal on both sides + average length legs
Pilonidal Dimple
A possible abnormal dimple at the base of the spine that could be an opening to the spinal column (could lead to infection)
What is an important thing that is assessed during assessment of the lgs?
Hips
Check for congenital hip dysplasia
The newborn extremities should be …
normally flexes with maturity
What things about the newborn extremities needs to be assessed?
ROM
Acrocyanosis
Reflexes
Clubbing of the Feet
Abnormalities suck as Polydactyly and Syndactyly
Assess for abnormal flatness or roundness of feet
Assess for fixed posturing of the fingers or toes
Abnormal Findings upon newborn Extremity Assessment
Clubbing of Feet
Simian Crease
Roundness of Feet (looks charcot like)
Syn and Poly dactyly
Fixed posturing of the fingers
Simian Crease
a crease horizontally through the middle of the hand indicative of some other abnormal condition
Syndactyly
less than the normal number of fingers and toes
Polydactyly
More than the normal number of fingers and toes
What criteria are assessed in a newborn pain assessment?
Face
Legs
Activity
Crying
Consolability
A higher pain assessment score indicates..
more pain
Infant States of Awareness
- Sleep States
- Awake States
What are the 2 sleep states in infants
Quiet Sleep
Active Sleep (REM)
Active Sleep
REM Sleep state for infants
Can see them sucking in this state
A deep sleep follows
What are the 4 awake states in infants
Drowsy
Quiet Alert
Active Alert
Crying
Drowsy
Waking up or falling asleep - between the quiet alert and sleep states
Quiet Alert
resting, eyes open, looking around environment
calm
Active Alert
agitated infant more likely to go into crying
What is the best state to perform newborn assessments and reflexes?
Quiet Alert
Newborns are capable of observing ___ and ___ to it
environments and responding to it
The reason that the best time to do newborn assessment is the quiet alert state is because…
they are most capable of responding to their environment at this time
The best position for the mother to have with the baby during quiet alert is…
En face positioning
There are ___ periods of reactivity in the newborn
2
The First Period of Reactivity
About 30 min to an hour (maybe longer), occurs right after birth of baby
Newborn is awake and active
Appears hungry (best time to breastfeed) and has a strong reflex
Natural opportunity to start breastfeeding
Vital signs are elevated at this time
The Second Period of Reactivity
Period of reactivity lasting 4-6 hours in a normal newborn
The baby “crashes and burns” making breast feeding hard as they are now overwhelmed with new stimuli
1st Period –> 4-6 hours of deep sleep –> 2nd Period where baby is acutely alert, first meconium passes and another great period to begin breast feeding will begin
Newborn will suck root and swallow in this period, pass meconium, and the heart and respiratory rates increase, so the nurse will be alert for apneic periods
What position does a newborn tend to stay in?
Tend to stay in a flexed position and will resist straightening
Hands will remain clenched
What is the typical behavior pattern for a newborn?
Will sleep a majority of the time, and wake for feeding - is easily consoled when upset
What are some behavioral capabilities of newborns that assist in adaptation to extrauterine life?
- Habituation
- Self Quieting Ability
The Self Quieting Ability
Baby is able to quiet themselves by doing something like putting their thumb in the mouth to silence them
Newborn Sleep States
Deep or quiet sleep and active rapid eye movements (REM)
Length of sleep cycle depends on ___
age (of the newborn)
Newborns need time to sleep because …
growth hormone secretion depends on regular sleep patterns
Alert States
1st 30-60 m after birth, many newborns display quiet alertness
Nurses use alert states to facilitate feedings and encourage bonding and breastfeeding
In the alert state, increasing wakefulness indicates what?
maturing ability to maintain consciousness
A newborn is able to be alert, follow, and fixate on complex visual stimuli…
for short periods of time
Infant (visual) orientation shows preference for what?
sharp contract between dark and light more so than colors at birth
The focal distance of an infant is approximately?
18 inches with a range from 6-24 inches
Newborns can process and respond to visual and auditory stimulation, and should be able to be alert and search for appealing auditory stimulus. What kind of auditory stimulus is more appealing to them?
High pitch voices (ex: baby talk) - which is repeated and undergoes habituation
Olfactory wise, newborns are able to …
select people by smell (can smell mom)
In regards to taste and suckling, a newborn is able to …
respond selectively to different tastes (mothers milk v other milk)
Newborns are very sensitive and like being ___, ___, and ___
touched, cuddled, and held
Newborns are able to attend to and interact with ___ ___
their environment
What sort of prophylaxis can a newborn be given after screening?
Eye prophylaxis
Vitamin K
Hepatitis B (3 Hep B shots with maternal consent)
Why is Vitamin K given as a newborn prophylaxis?
They cannot process yet without the proper gut bacteria that gives off Vit K usually, and since Vitamin K is a clotting factor we want to give it to prevent rupturing followed by stroke
What sort of screening tests are done on infants?
Hearing
Metabolic Screening (43 tests in NYS)
Transdermal Bilirubin/Serum Bilirubin (check for abnormal jaundice)
O2 Sat
Drug Screening
Glucose (if appropriate)
Gestational Age
What does O2 sat screen for?
Pre Symptomatic Cardiovascular Defects
Why do we screen for gestational age in the newborn?
To see whether physical findings correlate to where the baby should be
Important Infant Eye related Reflexes
Glabellar
Pupillary
Doll’s Eye
Glabellar Reflex
The newborn’s eyes will blink with the first 4-5 taps on the bridge of the nose
(Followed by habituation reflex where it will stop blinking)
Pupillary Reflex
Infant pupils should respond to light
Doll’s Eye Reflex
Baby eyes will come open in sitting position
Head is initially lagging but the baby will use shoulders to correct head position
Eyes will stay fixed as head is moved meaning there is eye movement
Important Infant Mouth related Reflexes
Sucking
rooting
Extrusion
Sucking Reflex
Mechanism in 3 steps:
- Front of tongue laps on finger
- Back of tongue massages middle of the finger
- Esophagus pulls on tip of finger
When does the sucking reflex disappear?
12 months
Rooting Reflex
if you touch the newborn on either side of the cheek, the baby will turn to find breast
When does the rooting reflex disappear?
around 4-7 months
Extrusion Reflex
When the tongue is touched, the infant will push the tongue outward or forward
Palmar Grasp Reflex
You can give one forefinger to each infant hand - they will grasp them both
You are then able to pull the baby to a sitting position with those forefingers
When does the palmar grasp reflex disappear?
by 5-6 months
Plantar Grasp Reflex
If you stroke the inner sole, the toes will curl (“grasp”) around the examiner’s finger
When does the Plantar grasp reflex disappear?
It lessens by 8 months, but will usually disappear by 9-12 months
Babinski Reflex
If you stroke the outer sole of the infant, the toes will spread with the great toe undergoing dorsiflexion (going up)
When does the Babinski reflex disappear?
Usually it disappears around 12 months
Moro Reflex
“Startle Reflex” - Present at birth
It can be triggered usually by a loud noise or if the infant’s head falls backward
The infant will spread their arms and legs widely and extend the neck. They will then bring their arms back together and cry.
When does the Moro reflex disappear?
around 3-6 months
Fencing Reflex
“Tonic Neck” Reflex
A postural reaction present at birth
If the baby is lying on the back, turn the head to one side - this causes the arm and leg on the side that they are looking to extend or straighten while the other side will flex
When does the Fencing Reflex disappear?
by 4-9 months
Incurvation Reflex
“Gallant Reflex” - present at birth
If infant is on stomach and you stroke the neck to the spinal cord (paravertebral area) on the middle to lower back, it will cause the back to curve toward the side that is being stroked
When does the incurvation reflex disappear?
by 3-6 months
Step Reflex
When holding the infant under the arms, support the head, and allow the feet to touch a flat surface. The infant will appear to take steps and walk.
When does the Step Reflex disappear?
by 2-3 months
When does the step reflex reappear?
as they learn to walk around 10-15 months
