Term Newborn Flashcards
Categories involved in the APGAR scoring system?
What are the scoring numbers?
Heart Rate Respiratory Effort Muscle Tone Reflex Irritability Color
Scoring goes from 0, 1, 2
APGAR Heart rate
0 - absent
1 - below 100
2 - above 100
APGAR Respiratory Effort
The effort - not the rate.
0- absent
1 - irregular
2 - good crying
APGAR Muscle tone
0 - flaccid
1 - some flexion
2 - active motion
APGAR Reflex irritability
What tool will they use?
0 - absent/none
1 - grimace
2 - vigorous crying
Use the bulb to cause a gag reflex
APGAR Color
0 - pale blue
1 - body pink w blue extremities
2 - completely pink
What is the Max APGAR score?
How long can APGAR scores be carried out?
10
10 minutes
- most babies will be 8 or 10
- might see a 10 baby if natural birth
Who is really the only person who can’t assign an apgar score?
OB
Suctioning used to clear the mouth and nose after birth?
What else does this do?
DeeLee Suctioning
Can measure gastric secretions too which can warn you about a GI obstruction
- 5 to 10 is average
What do periods of reactivity describe?
How the baby is doing outside the utero cavity
When does the First Period of reactivity occur?
First period happens 30 minutes after delivery
First period of reactivity newborn behavior
Awake, active, and hungry using the suck reflex. Will try to start breastfeeding due to Oxytocin - which is helped bu skin to skin that happens here too.
First period of reactivity newborn vitals
HR 160-180
Irregular Respirations 60 - 80
Due to them being a little stressed and trying to clear fluid from their lungs
First period of reactivity assessment findings
Grunting
Retractions
Nasal flaring
Crackles
Also do due to trying to clear lungs.
- They should stabilize
What phase comes after the first period of reactivity? How long is it?
Sleep phase where things can stabilize 1-2 hours
Second period of reactivity comes after? How long is that?
Second period of reactivity comes after the sleep phase.
2-8 hours
What is the second period of reactivity known as?
Known as Stormy phase
- gagging
- vomit
- may not do well at breastfeeding bc now, they’re trying to get rid of fluid.
- just need to be able to suction and clear it out with bulb syringe at head of bed
When do the alveolar ducts appear?
When do the primitive alveoli ducts appear?
20-24 weeks gestation
More apparent ducts form 24-28 weeks gestation.
When does the surfactant develop?
By 28-32 weeks
And this is why babies who are 35+ do fairly well bc at 35 they can replace it
What does surfactant do?
Lowers surface tension & helps alveoli open
What if the infant doesn’t have decent surfactant?
We have exogenous surfactant that we can give them
Fetal breathing movements help the fetas practice for breathing. What is essential for this to occur?
Amniotic fluid and lung fluid
Without it, you have hypo-plastic lungs and babies die.
Mechanical changes that baby adapt to breathing and remove the 80-110 mL still in their lungs?
Chest compression & chest squeezing during exiting vagina
Gasp & forced exhalation
Crying
Suctioning
Chemical changes that explain mild decels right before delivery?
Increased CO2
Decreased pH
Decreased O2
Helps them take first breath.
We don’t want them to be overly stressed tho with decels
What action by us cuts off all oxygen from mom to baby?
Cord clamping and from here, they need to breath on their own.
What are some thermal changes that occur?
What if they get too cool or hypothermic?
The baby in utero is warm but outside it is cold. This change stimulates nerves to drive breathing
If hypothermic, causes respiratory depression. We will get them under a warmer to avoid this.
Sensory changes that help breathing when born?
Baby experiences gravity, touch, voices, lights - all very stimulus like
It increases the baby’s drive to breath
What is the Silverman Anderson index tool?
Helps you decide how a baby is doing after birth respiratory wise
Grade 2 of Silverman Anderson index
2 - Retractions and lagging on inspiration. The xiphoid will be depressed. The nares flare open so they can get more air. Can hear their expirations with you naked ear
Grade 1 of Silverman Anderson index
1 - Slight lag with less retractions, less depression of xiphoid, and minimal flaring.
Will hear expirations with stethoscope
Grade 0 of Silverman Anderson index
0 - Abdomen and chest rise and fall together. No retractions. No xiphoid issue. No nasal flaring. No grunting heard
Perfectly normal
What if a baby is a grade 2 or 3 on the Silverman index?
What else can you consider?
As long as they move up on scale within hour or so , then they are ok. If it doesn’t improve - send to nicu.
Respiratory rate & O2 sats
What type of breathers are babies?
What age are babies able to mouth breath incase of an obstructtion?
Nose breathers with abdominal muscles- and if there is an obstruction they can’t eat either.
3 weeks of age is when they can mouth breathe
How should the abdomen and chest rise and fall?
They should rise and fall together
What is the cause of less surfactant?
Preterm delivery babies who are born early may have less. This can be an issue in breathing
Persisting hypoxemia and acidosis leads to….
Pulmonary arteries will be dilated at first but then go to constricted which isn’t good
Indicators of respiratory diseress
Tachypnea comes first (greater than 60 in infants)
Apnea and cyanosis
Flaring nostrils
Hypotonia - poor muscle posture
Grunting
Retractions
Seesaw respirations
Hypotonia
poor muscle tone and posture
PFC meaning
Persistant Fetal Circulation
- due to pulmonary vessel constriction
- and the ductus and foramen ovale aren’t closing
This is not good. PDA = patent ductus
- you want these to close eventually
Will hear rushing sound
What is infant hemoglobin and hematocrit like?
What about hr?
What happens to fetal hemoglobin after delivery?
Higher attraction to O2 to keep them from becoming hypoxic
Heart rate is higher to prevent hypoxia as well
Fetal H&H is replaced with adult H&H bc they won’t need it anymore
Normal breathing rate for infant
What will the rhythm be like?
Why do you need to count for 1 full minute?
30-60 breathes per minute
Shallow diaphragmatic breathing
Irregular in depth and rhythm
Due to irregularity in breathing bc they do it periodically. Breath pause breath for like 5-15 seconds. No change in color or HR
How long is pause in breathing if they have apnea ?
More than 20 seconds
Bradycardia & pale
Hemoglobin level
Hematocrit
14-20
43-63%
- polycythemia if it is higher than 63. means thick blood. Not a good thing bc it increases workload of heart
- acrocyanosis will be prolonged
wbc
10,000 - 30,000
platelets
150,000 - 350,000
- same as adults
Lab that can tell you if baby was hypoxic in utero?
Reticulocytes : 3 - 7 %
- immature red blood cell. if theirs is high, it means they had hypoxic episodes of utero
Blood vol
82 - 83 ml/kg
- you can calculate this
Glucose levels
45-94 in infant
- if lower than 45 they are hypoglycemic
What should resting HR in infants be?
What is the low while sleeping
120-160 bmp
80 bpm is low
How long do you listen for murmurs.
What is the trend with audible murmurs and heart defects?
What else should you check?
Full minute
The serious heart defects aren’t heard as well due to their hole being so big, it doesn’t make a noise. Small hole has more resistant and makes it louder
Do o2 sat on the baby around 24 hrs of age - but definitely before dismissal.
right arm right leg
What should the femoral and brachial pulses be like?
What does cap refill be like?
Will you do a newborns BP?
Check femoral and brachial pulses need to be equal without lag.
Less than 2-3 seconds
No not if they’re not in nicu. We focus on O2 sats.
Abnormal Cardiac findings list
Tachycardia Persistent murmur Abnormal pulses Poor perfusion via cyanosis Abnormal precordial activity
Circumoral cyanosis
Cyanosis around mouth
Abnormal precordial activity
Feeling a thrill - that is not good
What are murmurs due to?
What percent are transient or short term?
Turbulent blood flow due to turbulent blood flow from hole
90% so murmurs in first couple days of life aren’t a huge deal unless they don’t go away
Who turns over their rbc quicker? Adults or newborns?
Newborns at 70-90 versus
Adults at 120
What is the jaundice in newborns caused from?
Sort of like we mentioned already.. the rbc of newborns has higher turn over. And thus they get broken down causing the hyperbilirubin color
How can delayed cord clamping affect the baby?
Treatment?
Increased jaundice bc the cord is their line to rbc
Treatment is phototherapy btw
Core temp?
What should we do to keep newborn warm?
What can they wear?
inner temp
Balance between heat produced and environment
Make environment temp warm, skin to skin, and heat lamp to avoid hypothermia.
Give them a cap to wear on their head since they lose a lot of heat there
Challenges to NB temps stability
Less subcutaneous fat
Thin epidermis/skin
No fat to cushion vessels (like head)
Poor posture, flaccid doesn’t hold heat in
LGA or 9ibs - does better w cold . They can overheat actually
SGA and preterm - less fat so less tolerate of cold . will need higher environmental temp
Types of heat loss in newborns
Convection
Radiation
Evaporation
Conduction
Small or large body surface compared to mass?
Large body surface area compared to mass
Convection
Radiation
Air or draft that cools baby temp
Cooler objects NEAR the baby (not touching)
- nursery in center of hospital
Evaporation
Conduction
Wet skin
Something directly in contact w baby skin - cold surface, hands, stethoscope
Heat production in NB
Can they shiver?
Commonly done by moving around that increases metabolic activity
They can. It is uncommon but it is only happens with significant drop
Chemical thermogenesis?
Where is brown fat located?
Non-shivering thermogenesis is caused by cool environment causes them to burn their brown fat (2-6% of body weight) for heat
Trunk over adrenals and chest
Can brown fat be replaced?
No so we try to be conservative and protect them from burning it too fast
- it’ll eventually be used up tho
How long do newborns iron stores last?
4-6 months. Depends on moms prenatal care
What gives the baby the rounded tummy?
Glycogen in liver - which is a good thing. Flat tummy means prone to hypoglycemia
When does the liver conjugate the bilirubin?
Remember - the rbc turnover from infant to adult?
This applies here.
Bilirubin will conjugate once they are born (used to rely on mom)
What is the newborns intestinal flora like?
Treatment
Intestinal flora will be sterile & so they can’t make pro-thrombin for vit K! And they are at risk for bleeding
Give vit k around 2 hrs of age
.5 mL IM
- clean skin first
What if the infant isn’t given vit k?
Hemorrhage
or may not be able to do any procedure if baby needs it
Conjugation of bilirubin means?
What must bilirubin pass through to be conjugated?
From going to fat soluble to water soluble bilirubin
Attach to albumin in order to pass through liver
What happens to bilirubin once in liver?
GT enzyme attaches gluco chain to bilirubin for conversion to make it into water soluble now
So what all is unconjugated bilirubin?
Fat soluble
Indirect
Pre-liver
What all is conjugated bilirubin
Water soluble
Direct
Post liver
indirect bilirubin level
direct?
When will jaundice appears when than tho?
- 8
- 2
indirect serum levels are greater 5-7.0
But remember - the baby is like this bc of the turnover. Not necessarily bc something is wrong. this is just the mechanism of breakdown of heme (recycle) and bilirubin
How does jaundice present?
Head to toe first. And then check for dependent jaundice by turning them over
Kerniticus
Consequence?
Hyperbilirubin that crosses over blood brain barrier. Brain cells turn yellow
Permanent irreversible brain damage!!! don’t get sued
How to reduce hyperbilirubemia?
Feeding the baby. This causes them to poop it out and not get absorbed again
- so if mom says she is feeding the baby but the stool isn’t colored, then something isn’t adding up
What is physiologic jaundice?
Do all aged newborns have albumin?
Increased absorption of bilirubin is caused by wat?
Accelerated destruction of fetal RBCs that increases bilirubin to the immature liver
No - premies have lack of albumin often. This makes it more prevalent
Increased absorption if they aren’t stooling - remember.
What is pathologic jaundice?
How do we know?
What will levels be like?
When the patho is not right . Some condition probably caused it
Onset before 24 hrs (since physiologic is after this). A rapid onset
Patho jaundice has way higher levels than 12-14. And it lasts longer
Patho reasons to cause Patho jaundice due to Unconjugated or Indirect bilirubin
Rh abnormality ABO abnormalities Sepsis Cephalhematoma Hemangiomas Hypoxic insults Polycythemia Swallowed blood in delivery Increased bilirubin recycling
Explain Rh reason for patho jaundice
Unconjugated or Conjugated direct
RH - mom lacks protein on her rbc when she has an rh+ baby which causes her to produce antibodies that want to destroy baby rbc - which causes destruction of rbc and high bilirubin
Unconjugated or Indirect
Explain ABO patho jaundice Unconjugated or Indirect
Mom is O and baby is A or B. And if you have O, then the antibodies attack here too.
Explain Sepsis patho jaundice
Unconjugated or Conjugated
Sepsis decreases rbc and induces anemia.
Unconjugated
Explain rbc disorders for patho jaundice
Unconjugated or conjugated?
Sickle cell
anemia
-Abnormal rbc get destroyed at faster rate
Unconjugated or Indirect
Cephalhematoma for patho jaundice
Unconjugated or Conjugated?
(bleed in head from trauma near periosteum) - which breaksdown since it is outside the bloodstream and thus bilirubin is produced
Unconjugated or Indirect
Hemangiomas for patho jaundice
Congugated or uncongugated?
Birth defect - big angiomas
Unconjugated
or indirect
Hypoxic insults for patho jaundice
Unconjugated or conjugated?
Slows hepatic function and can’t convert bilirubin
Unconjugated or Indirect
Polycythemia for patho jaundice
Unconjugated or Conjugated?
High rbc in blood than expected so more wil be destroyed
Unconjugated or Indirect
Swallow blood in delivery for patho jaundice
Unconjugated or Conjugated
Happens in delivery and they just have to break it down and causes jaundice
Unconjugated or Indirect
Increases bilirubin recycle for patho jaundice
Unconjugated or Conjugated
Because you don’t poop - maybe due to obstruction or not feeding baby
Unconjugated or Indirect
Causes of patho jaundice wit Direct or Conjugated Bilirubin
Neonatal hepatits Intestinal obstruction Ischemic necrosis Parenteral feeds Metabolic disorders Hematologic disorders Ductal Disorders - biliary atresia - tumors
It can pass through the liver but it is not excreted. And direct means the bilirubin that has passed . Excretion issue of post liver
Which happens first? Breast feeding jaundice or breast milk jaundice
Breast feeding jaundice or poor breast feeding.
And then the breastmilk jaundice or composition
Breast feeding jaundice
treatment?
Jaundice due to baby being dehydrated bc you aren’t feeding them enough and bilirubin concentration increases. 1st week of birth
Do 15 min on one breast and 15 min on another. Supply and demand
- stimulate the breast more!!!
Breast milk jaundice
treatment?
Some moms have high free fatty acid and hormone levels and this causes baby bilirubin to be high
- rare but peaks 2-3 weeks later
- You’ll give baby formula. But you will pump and dumb to keep your supply going
How to asses for hyperbilirubemia or jaundice?
Blanch
Draw blood
- we draw levels of all newborns within 24 hrs & use bili tool
What type of instruction do you absolutely have to give on jaundice?
And what else?
Verbal and WRITTEN bc of brain damage possibility due to kerniticus (cerebral palsy, retardation)
- avoid lawsuit by doing this
Have them sign the document for proof!! And document yourself
How to check for jaundice in dark skin?
Mucous membranes
And baby will get sleepy
but do labs
Treatment for hyperbilirubemia?
Feed them more
Phototherapy
Exchange transfusion
Phototherapy
Exchange transfusion?
Blue light or fiber optic blanket that converts bilirubin in skin
Exchange transfusion gives blood and take blood. It specifically takes the rbc coated with antibodies to stop bilirubin production
GI
What happens to blood glucose when cord id clamped?
What if baby is LGA or SGA?
Cutting cord makes blood glucose drop for first 1-2 hours.
Monitor LGA or SGA blood sugars . Feed them too or else their blood sugar drops to hypoglycemic
GI
What reflexes are present at delivery?
Sucking, swallowing, empty stomach, and bowel sounds
GI
what is the stomach capacity
Stomach capacity is tiny. Less than 30 mL. By day three it is 90 ml.
GI
conditions?
Regurgitation
Projectile vomiting - from pyloric stenosis
GER - not the disease tho
GI
what removes the mucus and reduces vomiting during transition period
DeLee suctioning
GI
When should they urinate?
When should they stool?
urinate 24 hrs
stool 48 hrs
Weight loss following birth
Do we expect all newborns to lose a little bit of weight?
Yes. Should be between 5-8%.
If it is more than 10% then lactation nurses step in especially if they haven’t gained the weight back by 14 days
- lose, plateua, regain
Weight loss following birth
What if the newborn never goes through a weight loss phase?
Fluid retention may be occurring and it is unusual
If a newborn fails to lose weight in the first couple days, what is the reason?
Fluid retention
Kidneys
What are the newborns nephron tubules like compared to adults?
How does the GFR affect excretion?
What will pee appear like?
Their tubules are underdeveloped (until they turn 2)
Urine won’t be concentrated and they pee in small amounts due to low GFR.
Pee will be often, small amount, odorless, and have no color
Kidneys
Why are diapers orange colored
treatment if needed
Orange diaper bc of uric crystals. Sort of like a flush of the system. It is not blood.
- remind parents that al babies do this mostly. Hydrate them
Kidneys
What is pseudomenstraution
Female infant having blood tinged mucus due to moms hormone drop . Just means female anatomy working
Tests to assess the hips
What do these tests look for?
What gender is this more common in?
More common in which position?
Barlow - adduct bring in and press down
Ortolani - abduct hips and feel for dislocation
Hip Dysplasia or congenital dislocation of hip
- shouldn’t hear a clunk
More common in females
More common in those in breech position
IgG
Cross from mom to baby in last months of PG
and is largest group
- so if you are preterm, you won’t give them this
igM
We draw this from baby. If elevated, means septic baby.
igA
What systems does it protect
Baby drinks this with moms breast milk.
- protects gi, gu, and respiratory systems
What is self quieting and do baby’s have this ability?
Who can’t do this?
Can calm themselves & yes the baby can do this
Baby with a mom who smoked, drugs, caffeine
What is habituation?
Means baby can block the response of repetitive stimuli.
Baby is done w you
What is orientation?
Baby can look at your face , stare and become fixed
they might look away if they are bored
Baby auditory ability?
To hear and respond to voices in some way
A baby’s Olfactory ability?
Can detect and taste their moms breastmilk
Baby prefers sweet things over sour
When should you introduce pacifier if you are breastfeeding?
What if the baby is bottlefeeding?
After you have established breastfeeding so maybe a week later.
If you use one too early you can have nipple confusion
Bottle-feeders can use it whenever tho bc no difference.
Do babies like tactile touch?
How long can you swaddle for?
Yes! they love to be touched, held, and swaddled
- swaddle for first couple months of life only due to hurting their ability to role over.
Difference between Cephalhematoma and Caput Succedaneum?
Cephalhematoma
- collection of blood between bone and perisoteal
- does not cross suture line
- fairly firm to touch
- no treatment
Caput Succedaneum
- collection of fluid
- will cross the line
- no treatment
Acrocyanosis
Blue hands and feet from sluggish capillaries in peripheral
Only lasts a day or so
Erythema toxicum
Who has it more?
Newborn rash that is red.
Starts on the trunk then spreads all over and then goes away
More common in those with light or sensitive skin
Malia
Baby acne in the Tzone area.
Use warm water to clean only. No squeezing . just clogged pores
Mongolian spots
Darkened spots in noncaucasian babies. Look like a bruise but fades by preschool or school
Stork Bites or nevi
From dilated capillaries at the nape of the neck or above eyes
VIT K injection instructions
Clean, vastus lateralis, no aspiration
Gonorrhea and Chlamydia treatment
Is it required?
Instructions?
What happens if erythromycin ointment isn’t working for Chlamydia?
What if discharge from med isn’t clear but green?
Erythromycin ointment in eyes
Required. If they decline , must sign waiver
Massage to improve distribution
Give oral erythromycin or sulfa for chlamydia if not working
Means it is an infection .
The med itself would be clear but if infected then it is green
Hep B administration for newborn time?
What if mom is hep B positive?
Hep B antidote?
Given in hospital within 24 hrs to newborn . Vit k in one leg, hep b in other
Mom needs hep B immunoglobulin that is weight based
Epineprhine
Is circumcision recommended by AAP
No - they say parents should have the option.
Methods for circumcisoin
Gomco/yellen
Mogen
Plastibell - ring will be left behind and will fall off 7-10 days later
Which infants get Hearing screening
Done on every infant
How does the neonatal lab draw?
What conditions does it screen for?
State mandated. We send ours to Topeka . Fill in circles with blood
biotinidase deficiency adrenal hyperplasia congenital hypothyroidism cystic fibrosis Hemoglobinopathy Aminoacid disorder Fatty acid disorder Organic acid disorder
CCHD purpose
when do you do it
where do you do it
pass?
repeat?
score needed to repeat?
failing score?
Whats next if you fail
Picks up hypoxia with pulse oximetry - bc it is an early sign of heart issue
Do it around 24 hrs of age
Right hand and right foot
Pass = greater than 95% in each extremity as well as less than 3% difference between extremities
Repeat = between 90 and 95
Fail = less than 90
echo is next
Who does the hearing screen?
Why do they need to follow up?
Audiologist tech does it on floor
Do it before they leave
Need to follow up so it doesn’t affect language development
Safe sleep?
ABC?
Can you use a sleep sack?
Pacifier?
should baby be in a car seat with lot of clothes on?
Can infant be in car seat for very long?
Avoid sids or accidental suffocation
- not a fate thing
Alone, Back, Crib
- not in parent bed
- on the back
- nothing else in the crib
sleep sack is ok
pacifier can help reduce it
remove blanket and heavy clothing
No- plagiocephaly or flat head
and torticollis - neck is pushed to one side
plagiocephaly - do tummy time
When should tummy time be started
begin first week of life when baby is awake
supervise them tho
vaccinations
encourage them
9 ways to calm newborn
Swaddling - only for 2 months Shushing Sidelying or tummy position Swinging gently Sucking Sensoorial or voice sucrose
