Physiological and Behavioral responses of the neonate- 15 Flashcards
protect and support neonates by:
● Maintaining body heat.
● Maintaining respiratory function.
● Decreasing risk for infection.
● Assisting parents in providing appropriate nutrition and hydration.
● Assisting parents in learning to care for their newborn.
Two factors that negatively affect the transition to extrauterine respirations are:
● Decreased surfactant levels related to immature lungs.
● Persistent hypoxemia and acidosis that leads to constriction of the pulmonary arteries.
establishment of extrauterine respirations
Mechanical and chemical stimuli
initiated by compression of the thorax, which forces amniotic fluid from the lungs; lung expansion; increase in alveolar oxygen concentration; and vasodilatation of the pulmonary vessels.
Signs of Fetal Respiratory Distress
- Cyanosis
- Abnormal respiratory pattern such as apnea and tachypnea
- Retractions of the chest wall
- Grunting
- Flaring of nostrils
- Hypotonia
First breath
↑ alveolar oxygen tension (Pao2) and ↓ arterial pH → dilation of pulmonary arteries → ↓ pulmonary vascular resistance → ↑ blood flow through pulmonary vessels → ↑ oxygen and carbon dioxide exchange within the lungs
transition to neonatal circulation
The decrease in pulmonary vascular resistance causes an increase in pulmonary blood flow, and the increase in systemic vascular resistance influences the cardiovascular changes
ductus venosus
connects the umbilical vein to the inferior vena cava, closes by day 3 of life and becomes a ligament. Blood flow through the umbilical vein stops once the cord is clamped.
foramen ovale
an opening between the right atrium and the left atrium, closes when the left atrial pressure is higher than the right atrial pressure. Significant neonatal hypoxia can cause a reopening of the foramen ovale.
ductus arteriosus
connects the pulmonary artery with the descending aorta, usually closes within 15 hours postbirth. It will remain open when the lungs fail to expand or when Pao2 levels drop.
neutral thermal environment (NTE)
environment that maintains body temperature with minimal metabolic changes and/or oxygen consumption.
The neonate responds to cold by:
● An increase in metabolic rate.
● An increase of muscle activity.
● Peripheral vascular constriction.
● Metabolism of brown fat.
Brown adipose tissue (BAT) promotes
● An increase in metabolism.
● Heat production through intense lipid metabolic metabolism of BAT.
● Heat transfer to the peripheral system
Neonates are at higher risk for thermoregulatory problems related to:
● Higher body-surface-area-to-body-mass ratio.
● Higher metabolic rate.
● Limited and immature thermoregulatory abilities.
Factors that negatively affect thermoregulation are:
● Decreased subcutaneous fat.
● Decreased BAT in preterm neonates.
● Large body surface.
● Loss of body heat from evaporation, conduction, convection, and/or radiation
Evaporation
Loss of heat that occurs when water on the neonate’s skin is converted to vapors, such as during bathing or directly after birth
Conduction
Transfer of heat to cooler surface by direct skin contact, such as cold hands of caregivers or cold equipment
Convection
Loss of heat from the neonate’s warm body surface to cooler air currents, such as air conditioners or oxygen masks
Radiation
Transfer of heat from the neonate to cooler objects that are not in direct contact with the neonate, such as cold walls of the isolette or cold equipment near the neonate
Possible consequences of cold stress are:
● Hypoglycemia.
● Metabolic acidosis.
● Decreased surfactant production.
● Respiratory distress that can lead to neonatal death.
● Hypoxemia.
● Increased indirect bilirubin.
● Delayed transition from fetal to neonatal circulation.
● Weight loss.
Cold stress s/s
● Axillary temperature at or below 36.5°C (97.7°F)
● Cool skin
● Lethargy
● Pallor
● Tachypnea
● Grunting
● Hypoglycemia
● Hypotonia
● Jitteriness
● Weak suck
Hypoglycemia
Hypoglycemia is defined as a blood glucose level below 40 mg/dL in the neonate.
Risks for Hypoglycemia
- Neonates of diabetic mothers
- Neonates weighing more than 4,000 g or large for gestational age
- Post-term neonates
- Preterm neonates
- Small-for-gestational-age neonates
- Hypothermia
- Neonatal infection
- Respiratory distress
- Neonatal resuscitation
- Birth trauma
hypoglycemia s/s
- Jitteriness
- Hypotonia
- Irritability
- Apnea
- Lethargy
- Temperature instability
Functions of the liver
●carb metabolism ●amino acid metabolism ●lipid metabolism ●synthesis of plasma proteins ●blood coagulations- vit k given ●conjugation of bilirubin ●phagocytosis by kupffer cells ●storage of fat soluble vitamins ●detoxification
why there is more bilirubin in neonate
increase in the neonate’s red blood cell (RBC) turnover (shorter RBC life span) and an increased RBC count at birth. These factors contribute to a proportionally greater amount of bilirubin production.
Hyperbilirubinemia
condition in which there is a high level of unconjugated bilirubin in the neonate’s blood related to the immature liver function, high RBC count that is common in neonates, and an increased hemolysis caused by the shorter life span of fetal RBCs.
Phytonadione (Vitamin K, AquaMEPHYTON)
Indication: Prevention of hemorrhagic disease in neonate
Meconium stool:
: begins to form during the fourth gestational month and is the first stool eliminated by the neonate. It is sticky, thick, black, and odorless. It is first passed within 24 to 48 hours.
Transitional stool:
begins around the third day and can continue for 3 or 4 days. The stool transitions from black to greenish black, to greenish brown, to greenish yellow. This phase of stool characteristics occurs in both breastfed and formula-fed neonates.
Breastfed stool
yellow and semiformed. Later it becomes a golden yellow with a pasty consistency and has a sour odor.
Formula-fed stool
yellow and semiformed. Later it becomes a golden yellow with a pasty consistency and has a sour odor
Two major functions of the kidneys
control of fluid and electrolyte balance and excretion of metabolic waste.
Initially the neonate’s kidneys are immature and place the neonate, especially preterm neonates, at risk for:
over hydration
dehydration
electrolyte disorders
drug toxicity
urine output neonate
15 to 60 mL/kg of urine per day for the first few days of life. Urinary output increases to 250 to 400 mL by the end of the first month of life
Neonates are at risk for infections related to:
● Immature defense mechanism.
● Lack of experience with and exposure to organisms, which leads to a delayed response to antigens.
● Breakdown of skin and mucous membranes, which provides a portal of entry for bacteria
Major components of the immune system
active humoral immunity- B cells detect antigens and produce antibodies against them.
passive immunity- which is not permanent, is acquired either naturally or artificially.
lymphocytes-white blood cells that are primarily composed of T cells and B cells.
immunoglobulins-antibodies
neonatal assessment
This initial assessment provides the baseline data for the neonate, evaluates the neonate’s transition to extrauterine life, and assists in determining the course of nursing and medical care.
within 2 hours
Preparation for assessment
● Review the prenatal record and birth record for factors that could place the neonate at risk for complications.
● Gather the equipment needed for the assessment
● Ensure that assessment is done in an NTE
● Inform the parents of the assessment and invite them to watc
General survey then physical assessment
● A general survey of the neonate is completed before the physical assessment. This survey is best completed while the neonate is quiet.
● Observe the respiratory pattern and assess respirations and breath sounds. It can be difficult to assess respiratory rate once the neonate responds to being handled (cries) during the physical assessment.
● Observe posture.
● Assess the skin for color, birth trauma, and birthmarks.
● Observe the level of alertness/activity.
● Assess muscle tone and posture.
Dubowitz neurological exam
standardized tool that assesses 33 responses in four areas:
● Habituation (the response to repetitive light and sound stimuli)
● Movement and muscle tone
● Reflexes
● Neurobehavioral items
Gestational age assessment is commonly completed on:
● Neonates who are preterm, born before 37 weeks based on the maternal menstrual history, or post-term, born after 42 weeks by dates.
● Neonates who weigh less than 2,500 g or more than 4,000 g.
● Neonates of diabetic mothers.
● Neonates whose condition requires admission to a neonatal intensive care unit
SGA
neonates whose w
LGA
neonates whose weight is above the 90th percentile for gestational age.
Ballard Maturational Score (BMS)
calculated by assessing the physical and neuromuscular maturity of the neonate.
Pain assessment tools
commonly look at state of arousal, cry, motor activity, respiratory pattern, and facial expressions
some also include blood pressure and oxygen saturation level
Posture
extremities flexed
Head circumference
33–35.5 cm (13–14 in.)
Chest circumference
30.5–33 cm (12–13 in.) or
2–3 cm less than head circumference
Length
45–53 cm (19–21 in.)
-mold can interfere
Weight
2,500–4,000 g (5 lb 8 oz–8 lb 13 oz)
Weight loss of 5%–10% of birth weight during the first week is normal.
big babies normal in diabetic moms
temp
36.5°C-37.2°C (97.7°F–99°F) Axillary
Hypothermia or hyperthermia is related to infection, environmental extremes, and/or neurological disorders.
respirations
30–60 breaths per minute
pulse
110–160 bpm
Rate increases (to 180 bpm) with crying and decreases (to 90 bpm) when asleep.
Murmurs may be heard; most are not pathological and disappear by 6 months.
Blood pressure
50–75/30–45 mm Hg
head
Note the shape of the head.
Inspect and palpate fontanels and suture lines. Inspect and palpate the head for caput succedaneum and/or cephalohematoma
neck
The neck is short with skin folds.
Positive tonic neck reflex
Eyes
Eyes are equal and symmetrical in size and placement.
The neonate is able to follow objects within 12 inches of the visual field.
Edema may be present due to pressure during labor and birth and/or reaction to eye prophylaxes.
The iris is blue-gray or brown.
The sclera is white or bluish white.
Subconjunctival hemorrhages related to birth trauma.
Pupils are equally reactive to light.
Positive red light reflex and blink reflex.
No tear production (tear production begins at 2 months).
Strabismus and nystagmus related to immature muscular control.
Ears
Top of the pinna is aligned with external canthus of the eye.
Pinna without deformities, well formed and flexible.
The neonate responds to noises with positive startle signs.
Hearing becomes more acute as Eustachian tubes clear.
Neonates respond more readily to high-pitched vocal sounds.
Nose
The nose may be flattened or bruised related to the birth process.
Nares should be patent.
Small amount of mucus.
Neonates primarily breathe through their noses.
Mouth
Lips, gums, tongue, palate, and mucous membranes are intact, pink, and moist.
Reflexes are positive.
Epstein’s pearls are present
Lungs/chest
The chest is barrel-shaped and symmetrical.
Breast engorgement is present in both male and female neonates related to the influence of maternal hormones and resolves within a few weeks.
Clear or milky fluid from nipples related to maternal hormones.
Lung sounds are clear and equal.
Scattered crackles may be detected during the first few hours after birth. This is due to retained amniotic fluid, which will be absorbed through the lymphatics.
cardiac
point of maximal impulse (PMI) at the 3rd or 4th intercostal space.
S1 and S2 are present.
Normal rhythm with variation related to respiratory changes.
Murmurs in 30% of neonates, which disappear within 2 days of birth.
Peripheral pulses are present and equal.
The femoral pulse may be difficult to palpate.
abdomen
The abdomen is soft, round, protuberant, and symmetrical.
Bowel sounds are present but may be hypoactive for the first few days.
Passage of meconium stool within 48 hours postbirth.
The cord is opaque or whitish blue with two arteries and one vein, and covered with Wharton’s jelly.
The cord becomes dry and darker in color within 24 hours postbirth and detaches from the body within 2 weeks.
rectum
The anus is patent.
Passage of stool within 24 hours.
Genitourinary: female
Labia majora covers labia minora and clitoris.
Labia majora and minora may be edematous.
Blood-tinged vaginal discharge related to the abrupt decrease of maternal hormones (pseudomenstruation).
Whitish vaginal discharge in response to maternal hormones.
The neonate urinates within 24 hours.
The urinary meatus is midline and an uninterrupted stream is noted on voiding.
Genitourinary: male
The urinary meatus is at the tip of the penis.
The scrotum is large, pendulous, and edematous with rugae (ridges/creases) present.
Both testes are palpated in the scrotum.
The neonate urinates within 24 hours with an uninterrupted stream.
musculoskeletal
Arms are symmetrical in length and equal in strength.
Legs are symmetrical in length and equal in strength.
10 fingers and 10 toes.
Full range of motion of all extremities.
No clicks at joints.
Equal gluteal folds.
C curve of spine with no dimpling.
Neurological
Flexed position
Rapid recoil of extremities to the flexed position
Positive newborn reflexes
Acrocyanosis
hands and or feet are blue
mottling
A benign transient pattern of pink and white blotches on the skin.
Response to cold environment
circumoral cyanosis
A benign localized transient cyanosis around the mouth.
Observed during the transitional period; if it persists, it may be related to a cardiac anomaly
harlequin sign
One side of body is pink and the other side is white.
Related to vasomotor instability.
Mongolian spots
Flat, bluish discolored area on the lower back and/or buttock. Seen more often in African American, Asian, Hispanic, and Native American infants.
Might be mistaken for bruising.
Need to document size and location.
Resolves on own by school age.
Erythema toxicum
goes away without treatment
A rash with red macules and papules (white to yellowish-white papule in center surrounded by reddened skin) that appear in different areas of the body, usually the trunk area.
Can appear within 24 hours of birth and up to 2 weeks.
milia
White papules on the face; more frequently seen on the bridge of the nose and chin.
Exposed sebaceous glands that resolve without treatment.
Parents might mistake these for whiteheads.
Inform parents to leave them alone and let them resolve on own.
lanugo
Fine, downy hair that develops after 16 weeks’ gestation.
The amount of lanugo decreases as the fetus ages.
Often seen on the neonate’s back, shoulders, and forehead.
Gradually falls out.
The presence and amount of lanugo assist in estimating gestational age.
Abundant lanugo may be a sign of prematurity or genetic disorder.
Vernix caseosa
A protective substance secreted from sebaceous glands that covered the fetus during pregnancy.
It looks like a whitish, cheesy substance.
May be noted in auxiliary areas and genital areas of full-term neonates.
The presence and amount of vernix assists in estimating gestational age.
Full-term neonates usually have none or small amounts of vernix.
Jaundice
Yellow coloring of skin.
First appears on the face and extends to the trunk and eventually the entire body.
Best assessed in natural lighting.
When jaundice is suspected, the nurse can apply gentle pressure to the skin over a firm surface such as nose, forehead, or sternum. The skin blanches to a yellowish hue.
Jaundice within the first 24 hours is pathological; usually related to problem of the liver
Jaundice occurring after 24 hours is referred to as physiological jaundice and is related to increased amount of unconjugated bilirubin in the system
Molding
Elongation of the fetal head as it adapts to the birth canal Resolves within 1 week.
epstein pearls
White, pearl-like epithelial cysts on gum margins and palate Benign and usually disappears within a few weeks.
Caput succedaneum
A localized soft tissue edema of the scalp
It feels “spongy” and can cross suture lines.
Results from prolonged pressure of the head against the maternal cervix during labor.
Resolves within the first week of life.
Cephalohematoma
Hematoma formation between the periosteum and skull with unilateral swelling.
It appears within a few hours of birth and can increase in size over the next few days.
It has a well-defined outline.
It does not cross suture lines.
Related trauma to the head due to prolonged labor, forceps delivery, or use of vacuum extractor.
Can contribute to jaundice due to the large amounts of red blood cells being hemolyzed.
Resolves within 3 months.
nasal teeth
Immature caps of enamel and dentin with poorly developed roots
Usually only one or two teeth are present.
They are usually benign, but can be associated with congenital defects.
Natal teeth are often loose and need to be removed to decrease the risk of aspiration.
Initial Period of Reactivity- first 15-30 min
● Respirations are irregular and rapid and can be as high as 90 breaths per minute; the heart rate is rapid and can be as high as 180 beats per minute (bpm).
● The neonate may exhibit momentary grunting, flaring, and retractions.
● The neonate may experience brief periods of apnea and brief periods of cyanosis.
● The amount of oral mucus increases.
Period of Relative Inactivity after 30min
lasts 2 hours
Respiratory rate and heart rate decrease and can fall slightly below normal range, and oral mucus production decreases.
Second Period of Reactivity
2 to 8 hours. Neonates vacillate between active alert and quiet alert states
- ideal to start feeding
- periods of rapid respirations and increased heart rate in response to stimuli and activity
Brazelton Neonatal Behavioral Assessment Scale (BNBAS)
used to assess the neonate’s neurobehavioral system.
Habituation
The development of decreased sensitivity to a repeated stimulus such as light, sound, or heel stick. It is a protective mechanism against overstimulation
no fully developed premature neonates or in neonates with CNS abnormalities or injuries.
Orientation
The ability of the neonate to focus on visual and/or auditory stimuli. The neonate will turn his or her head in the direction of sound or will follow a visual stimulus.
This response is diminished in premature neonates.
Motor maturity
The ability of the neonate to control and coordinate motor activity. Normal findings are smooth, free movement with occasional tremors.
Movement is jerky in premature neonates and/or in neonates with CNS abnormalities or injuries.
Self-quieting ability
The ability of the neonate to quiet and comfort self. It is accomplished by sucking on the fist/hand or attending to external stimuli.
The ability is diminished in neonates with neurological injuries or in those exposed to drugs in utero.
Social behaviors
The ability of the neonate to respond to cuddling and holding.
These behaviors are diminished or absent in neonates with neurological injuries or in neonates exposed to drugs in utero.
Sleep/awake states:
These are also referred to as infant states or behavior states. There are two sleep states and four awake states.
Erythromycin Ophthalmic Ointment (0.5%)
Indication: Prophylaxis treatment for gonococcalor chlamydial eye infections
Nursing actions- fourth stage of labor
● Review prenatal and intrapartal records for factors that place the neonate at risk
● Decrease risk of cold stress
● Support respirations by clearing the mouth and nose of excessive mucus
● Use universal precautions.
● Obtain the Apgar score at 1 and 5 minutes and initiate appropriate actions based on the score
● Assess vital signs.
● 30 minutes and every hour for the remainder of the recovery period.
● Vital signs are assessed every 5 to 15 minutes for neonates with signs of distress.
● Administer O2 per institutional protocol, if the heart rate is below 100 bpm, cyanosis is present, and/or apnea occurs.
● Complete and place identifying bands on the neonate and parents before the neonate is separated from parents
● Weigh and measure the neonate.
● Complete a neonatal assessment within 2 hours of birth.
● Complete a gestational age assessment as per hospital policies.
● Obtain blood glucose levels by using a glucose monitor.
● Administer erythromycin ophthalmic ointment to each eye.
● ophthalmic neonatorum prophylaxis be administered to all newborns within 24 hours of birth.
● Administer phytonadione IM within 6 hours of birth.
● Support breastfeeding by providing a relaxing environment
● Bathe the neonate with neutral pH soap
● Promote parent–infant attachment.
● Notify the neonate’s physician or nurse practitioner of the neonate’s date and time of birth and assessment findings.
Promoting Parent-Infant Attachment
- Initiate skin-to-skin contact with a warm blanket over the neonate and parent.
- Point out and explain expected neonatal characteristics such as molding, milia, and lanugo.
- Provide alone time for the couple and their neonate by organizing care that allows for uninterrupted time.
- Delay administration of eye ointment until parents have had an opportunity to hold the baby. Once ointment is administered, the neonate is less likely to open his or her eyes and make eye contact with parents.
- Provide nursing care that reflects respect for the parents’ cultural beliefs.
Danger Signs neonatal
- Tachypnea (greater than 60 breaths per minute)
- Retractions of chest wall
- Grunting
- Nasal flaring
- Abdominal distention
- Failure to pass meconium stool within 48 hours of birth
- Failure to void within 24 hours of birth
- Convulsions
- Lethargy
- Jaundice within first 24 hours of birth
- Abnormal temperature, either abnormally high or low
- Jitteriness
- Persistent hypoglycemia
- Persistent temperature instability
Hypothermia
- Parent–infant skin-to-skin contact with a warm blanket over both the neonate and the parent or wrap the neonate in warm blankets.
- If the temperature remains below 36.5°C (97.7°F), place the neonate under a preheated warmer. Unwrap the neonate so that the skin is exposed to the radiant heat. Attach the electronic skin probe. The warmer is set at 1.5°C above the neonate’s temperature. Continue to adjust the radiant temperature in relationship to the neonate’s temperature.
- Monitor the blood glucose level as per institutional policies, as hypothermia can lead to hypoglycemia.
- Notify the physician or nurse practitioner if the neonate’s temperature does not return to normal ranges.
- Document the temperature and actions taken.
Causes of potential threat to skin integrity
pressure from labor abrasions, bruising, edema exposure to baceria adhesives dry skin diaper dermatitis
nursing actions skin
●assess skin once a shift and the perineal area at each diaper change
● changing diapers and cleaning the perineal area with water every 1 to 3 hours. Apply barrier products containing petrolatum and/or zinc oxide at each diaper change for infants at risk
●emollients every 12 hours
Phenylketonuria
inborn error of metabolism. Neonates with PKU are unable to metabolize phenylalanine, which is an amino acid commonly found in many foods such as breast milk and formula
can cause permanent brain damage and death.
Newborn screening
blood test screens for infections, genetic diseases, and inherited and metabolic disorders and is performed on all babies born in the United States
Hearing screen
Early detection of hearing loss provides parents the opportunity to seek interventions that foster language development.
Hep B vaccine
The CDC recommends that all neonates be vaccinated for hepatitis B before hospital discharge.
The CDC also recommends that neonates who have been or possibly have been exposed to hepatitis B during birth be given both the hepatitis B vaccine and hepatitis B immune globulin (HBIg) within 12 hours of birth.
Circumcision
elective surgery to remove the foreskin of the penis.
Circumcision risks
● Hemorrhage.
● Infection.
● Adhesions.
● Pain.
Circumcision contraindications
● Preterm neonates.
● Neonates with a genitourinary defect.
● Neonates at risk for bleeding problems.
● Neonates with compromising disorders such as respiratory distress syndrome.
Circumcision parent education
● Instruct parents to watch for bleeding and signs of infection and to note when their child voids.
● Inform parents that the gauze will fall off on its own and they should not pull it off. Pulling the gauze off can interfere with the healing process.
● Instruct parents to fasten diapers loosely to promote comfort by decreasing pressure on the surgical site.
● Instruct parents to notify the physician when:
● Bleeding is present (larger than the size of a quarter).
● Signs of infection are present.
● The neonate has not voided within 24 hours.
