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NU472 > Week 3: Reproduction, Newborn Care & Prematurity > Flashcards

Week 3: Reproduction, Newborn Care & Prematurity Flashcards

1
Q

Newborn Skin, Hair & Nails

A

Skin

  • Thin, smooth skin that may be ruddy = well-perfused
  • Vernix = white, creamy protective biofilm covering the baby during last trimester and delivery

Lanugo = thin hair all over body

Nails should be fully grown
- Short nails may indicate prematurity

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2
Q

Newborn mouth, throat, nose and sinus

A

Mouth

  • Assess tonsils when crying
  • No saliva until 3-4 months
  • Once saliva comes in, infant drools a lot because they don’t know how to swallow secretions

Nose

  • Newborns are obligate nose breathers
  • Use bulb syringe and show parents how to clear secretions from nose and mouth
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3
Q

Newborn Lungs

A

Lungs should be fully developed in full term infants

@ birth, the decrease in pulmonary pressure at birth closes the foramen ovale –> ductus arteriosus closure within first hours of life

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4
Q

Newborn breasts

A

Usually enlarged d/t mom’s hormones (estrogen)

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5
Q

Newborn heart (sounds, assessment, HR)

A

Heart sounds should be normal
- Systolic murmur possible and normal

Assessment
- check apical pulse @ 4th intercostal space, just L of midclavicular line

HR

  • Newborn: 120-160 bpm
  • 6 months: ~120 bpm
  • 1 year: ~110 bpm
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6
Q

Newborn Peripheral Vascular System

A

Ruddy complexion indicates good perfusion

  • Cyanosis may indicate cold –> place baby under warmer
  • If warmer doesn’t resolve cyanosis, check for heart defects

Femoral pulses

  • If weak: check for coarctation of aorta
  • If bounding: check for patent ductus arteriosus
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7
Q

Newborn abdomen (appearance)

A

Cylindrical

Visible peristalsis could indicate pyloric stenosis

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8
Q

Newborn genitalia

A

Females

  • Labia and clitoris may appear engorged d/t mom’s hormones
  • External genitalia should return to normal size within weeks

Males

  • Testes drop @ 8 months gestation
  • Assess for both testes
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9
Q

Newborn anus, rectum & prostate

A

Meconium should pass within 24 hours

If no meconium during that time, check for anal patency

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10
Q

Early Gross Motor Development

A

Newborn: turn head side to side when prone

3-4 mo: no head lag, can push up to prone

5 mo: rolling

6-7 mo: sit unsupported

9 mo: pull to stand

10 mo: crawls

12 mo: walk with hand holding

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11
Q

Early Fine Motor Development

A

Newborns: grasp reflex is present at birth

1 mo: grasp reflex strengthens

3 mo: grasp reflex fades; infant can hold a rattle

5 mo: voluntary grasping

7 mo: hand-to-hand transfers

9 mo: pincher grasp develops, helping infants pick up smaller objects

12 mo: build a block tower

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12
Q

Sensory Perception Development (visual, auditory, olfactory, tactile)

A

Visual
- Unfocused, with colors indistinguishable until 8 mo

Auditory
- Newborns can distinguish sounds and turn towards noise

Olfactory
- Smell is fully developed at birth, and newborns are comforted by the smells of their parents

Tactile
- touch is developed at birth, and especially sensitive in lips and tongue

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13
Q

Language development

A

Newborns
- Can really only cry; different pitched cries indicate different needs

1 mo: cooin

3-4 mo: laughing, babbling, consonant sounds

6 mo: imitations

8 mo: combined syllables (mama, dada)

9 mo: understands “no-no”

10 mo: Mama and Dada said with meaning/understanding

12 mo: 2-4 words

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14
Q

Newborn health assessment - Apgar score

A

Appearance

  • 0: Cyanotic, pale
  • 1: pink body with acrocyanotic extremities
  • 2: pink body + extremities

Pulse

  • 0: absent
  • 1: < 100 bpm
  • 2: >100 bpm

Grimace/reflex irritability (stroke back or soles of feet)

  • 0: no response
  • 1: grimace, some motion
  • 2: crying, cough

Activity/muscle tone (extend legs and arms and observe degree of flexion and resistance in extremities)

  • 0: flaccid, limp
  • 1: flexion of extremities
  • 2: active flexion

Respirations

  • 0: absent
  • 1: slow, irregular
  • 2: good, lusty cry

Scores (taken at 1 + 5 mins, + 10 mins prn)

  • < 8 indicates a poor transition
  • => 8 indicates good transition
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15
Q

Newborn health assessment - vital signs (normal limits, abnormality indications)

A

Axillary temp

  • Normal: 97.5-99 degrees
  • <97.5: sepsis
  • > 99: infection

Apical pulse @ 4th intercostal space

  • Normal: 120-140 @ rest
  • <100 or >180 may indicate heart problems

Respirations
- Normal: 30-60 breaths per minute

Lung sounds
- Clear, easy and non laborious

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16
Q

Newborn health assessment - weight, length, head circumference and chest circumference normal limits

A

Weight: 2500-4000g

Length: 44-55cm

Head circumference: 33-35.5 cm

Chest circumference: 30-33 cm

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17
Q

New Ballard Scale

A

assesses neuromuscular and physical maturity for gestational age estimate

Results

  • < 35 indicates prematurity
  • > 45 indicates post maturity

Square window sign - bend wrist toward ventral forearm until resistance, then measure the angle

  • Normal range: 0-30 degrees
  • Premature range: < 30 degrees

Scarf sign - lift arm across chest to opposite shoulder until resistance and compare elbow to midline

  • Normal/FT range: elbow < midline
  • Preterm: elbow at midline or further
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18
Q

Newborn health assessment - tonic neck/fencing, rooting and palmar reflexes (assessing, reaction, duration, absence or persistence indication)

A

Tonic neck

  • Duration: appears at 2 mo, disappears at 4-6 months
  • Persistence > 6 mo: brain damage
  • Assessing: turn nb head to one side until jaw reaches shoulder
  • Reaction: arm and leg on side nb is facing extend, while opposite arm and leg flex (fencing position)

Rooting

  • Duration: present at birth, gone by 3-4 mo
  • If absent at birth: serious CNS disease
  • Assessing: while wearing gloves, touch cheek or upper/lower lip
  • Reaction: infant’s head turns toward touched side and opens mouth

Palmar

  • Duration: present at birth, gone by 3-4 mo
  • If absent at birth: prematurity or neurological defects
  • If present >4 months: cerebral dysfunction
  • Assessing: press finger against newborn’s palm; test both palms
  • Reaction: Grasps finger
    • Asymmetry: cerebral dysfunction
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19
Q

Visual Acuity Assessments

A

Eyes
- External eye (position, slanting, epicanthal folds, swelling/discharge)

  • Visual acuity –> checking if nb can fixate on an object
  • @ birth, visual acuity = 20/100-400
  • @ 4 weeks: nb can fixate on object
  • @ 6-8 weeks: nb can follow object
  • @ 3 mo: nb can reach for object
  • @ 1 yo, visual acuity = 20/200
  • Extraocular muscle tests (Herschberg test = shine light at nb cornea)
    • Normal: light reflects symmetrically in pupils
    • Abnormal: un= reflection may indicate strabismus (lazy eye)
  • Ophtalmoscopic exam
    • HCP typically performs
    • Goal: looking for red lens when shining light into eye; no red lens may indicate cataracts
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20
Q

Newborn health assessment - subsequent physical assessments (genitalia and anus)

A

Males

  • Inspect penis and meatus
    • Hypospadias = meatus on underside of penis-scrotum
    • Epispadias = meatus on top of penis - thorax
    • Check for rashes and lesions
    • Determine if foreskin is retractable OR if circumcision site looks ok
  • – Phimosis = unretractable foreskin
  • Inspect/palpate scrotum and testes
    • check both testes are descended; if not, may indicate cryptorcanism (retraction into inguinal canal) which is normal
    • hydrocele = fluid accumulation along spermatic cord, aeb swelling; resolves by 1 yo

Females

  • Inspect external genitalia
    • Appearance: pink and moist
    • Maternal hormones causes…. enlarged labia; red/pink discharge; orange urine
  • Ambiguous genitalia = enlarged clit fused with labia majora

Anus/Rectum

  • Inspect anus using gloved hand to spread nb cheeks
    • Assess patency, lesions and meconium
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21
Q

General newborn care parent teaching (bathing & hygiene)

A

2-3 baths/week during 1st year

Avoid…

  • lotions
  • baby oil
  • NO POWDER (d/t aspiration risk)

Sponge bathe quickly until umbilical area and circumcision are healed

Keep baby warm & safe
- gather all supplies beforehand to allow for quick bathing and no unattended time

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22
Q

Nursing Interventions: elimination and diaper care

A

6-12 diapers/day = adequate hydration

Meconium passes within 48 hours

Transition stools appear by day 3 of feeding

  • Breast fed stool: mustard yellow, soft, seedy
  • Formula fed stool: yellow-brown, soft, pasty

***use gloves

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23
Q

Nursing Interventions: cord care

A

Frequently assess for and notify PCP of….

  • bleeding
  • discharge
  • redness
  • foul odor

Keep clamp in place until UC dries out, usually within hours after birth

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24
Q

Parent teaching: cord care

A

Healing

  • Dries out within hours of delivery
  • Blackened in 2-3 days
  • Sloughs off and heals within 7-10 days

Notify PCP if noticing bleeding, discharge, redness or odor

Avoid tub baths until healed; sponge bathe only

Expose to air often

Fold diaper to avoid irritation

NEVER PULL OR ATTEMPT TO LOOSEN, allow UC to fall off on its own

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25
Q

Circumcision (definition, methods, nursing interventions)

A

= surgical removal of all/part of foreskin
– strongest factor = dad’s circumcision status

Methods
- Gomco clamp (most common)

Pre-operative requirements

  • Infant >= 12 hours old
  • Infant has received vitamin K prophylaxis
  • Infant has voided 1+x
  • No food for 1+ hour prior
  • Parental consent obtained
  • Correct ID of infant
  • Pain relief!!!!! (sucrose paci, EMLA, nerve block)

Post-op requirements

  • Apply petroleum jelly to area after px to prevent sticking to diaper
  • Assess bleeding q30 min x2 hours
  • Document first void to assess for obstruction/edema
26
Q

Parent teaching: circumcision care

A

Use petroleum jelly generously during diaper changes
- Fasten diaper loosely

Do not submerge until area is healed, sponge bathe for 7-10 days
- Squeeze soapy water over area and rinse with warm water –> pat dry

Avoid placing on abdomen

27
Q

Nursing interventions to enhance bonding

A

Immediate skin-to-skin contact after initial nb assessment

Cluster care to allow for uninterrupted bonding

Demonstrate how to wake newborn gently for feedings

Offer commendations and suggestions

Soothing an upset newborn

  • feeding and burping
  • rubbing back and speaking softly; swaying side to side
  • make eye contact
  • get outside for fresh air
  • change position (only with supervision)
  • singing, poetry, music, reading
  • lots of physical contact :)
  • swaddling
28
Q

Small for gestational age (definition, common risk factors, intrauterine conditions, SGA characteristics)

A

Weight < 2500 g (5lb8oz) at term, OR below 10th percentile on growth chart

R/fs: smoking, drug use, chronic maternal illness, multiples, genetic disorders

Intrauterine conditions

  • <28 weeks gestation: overall growth restriction, never catch up in size
  • > 28 weeks gestation: intrauterine malnutrition, will catch up with optimal post natal nutrition

IUGR = when fetus does not meet expected growth patterns in utero

  • Asymmetric = brain growth develops normally but body does not
  • Symmetric = brain and body both have poor growth rates

Characteristics

  • disproportionately large head
  • wasted extremities, sunken abdomen
  • reduced subcutaneous fat storage
  • jittery d/t hypoglycemia ***
  • wizened appearance with lots of lanugo
  • poor muscle tone over butt and cheeks
  • thin umbilical cord
29
Q

Large for gestational age

A

Weight > 4000 g (8lb13oz) at term, or greater than 90th percentile

30
Q

Low birth weight

A

Weight < 2500 g (5.5lb)

31
Q

Very low birth weight

A

Weight < 1500 g (3lb5oz)

32
Q

Extremely low birth weight

A

Weight < 1000 g (2lb3oz)

33
Q

SGA Common Problems: Perinatal asphyxia (patho, s/s, NIs)

A

Patho

  • Poor tolerance to stress of labor
  • Placental insufficiency & hypoxia
  • Difficulty adjusting to extrauterine life

S/s

  • Fetal distress (decels) during labor
  • low Apgars
  • Possible meconium in amniotic fluid

NIs

  • Assess for maternal risk factors
  • Initiate resuscitation post delivery
34
Q

Meconium Aspiration (risk factors, etiology, assessment findings, nursing implications)

A

Risk factors:
SGA
Postterm –> r/o pneumonia and perinatal asphyxia
Chronic intrauterine hypoxia

Etiology:
Release of meconium into amniotic fluid before birth

Inhalation of meconium-containing amniotic fluid

Often d/t fetus struggling with respiratory efforts –> bearing down and expelling meconium

Assessment:
Green amniotic fluid with ROM during labor

Green staining of umbilical cord or fingernails

Difficulty initiating respirations

Nursing Interventions:
Initiate resuscitation ASAP

Suction airways

Support ventilation

35
Q

Newborn Hypoglycemia (risk factors, patho, s/s, nurse interventions)

A

Risk factors:
SGA
LGA
Postterm

Patho:
SGA –> inc metabolic rate and lack of adequate glycogen stores to meet newborn’s metabolic needs

LGA –> commonly associated with diabetic moms; abrupt cessation of mom’s high blood glucose supply with birth; limited ability to breakdown glucagon

Postterm –> hypoxia r/t depleted glycogen stores; placental insufficiency r/t placental aging

S/S:

SGA

  • lethargy
  • tachycardia
  • respiratory distress

LGA

  • Jittery
  • Drowsy
  • Poor feedings
  • Hypothermia
  • Diaphoresis
  • Weak cry
  • Seizures

Postterm

  • Hypotonia
  • blood glucose < 40 for term, < 20 for preterm

Nursing Interventions:

  • Monitor blood glucose (q1h)
  • Maintain f+e
  • Initiate oral feedings if possible, or administer 10% dextrose in water IV
36
Q

Newborn dehydration s/s

A
  • sunken fontanelles
  • scaphoid abdomen
  • sunken abdomen or prominent rib cage
37
Q

SGA Nursing Management

A
  • weight, length and head circumference
  • serial blood glucose monitoring
  • vs monitoring
  • early and frequent oral feedings OR 10% IV dextrose in water
  • Monitor for polycythemia
    • s/s: HCT > 65%; tachypnea; ruddy skin; weak sucking reflex
  • Anticipatory guidance for parents
38
Q

Maternal conditions likely to cause LGA newborns

A

Most common r/f: Maternal DM or glucose intolerance

  • poor placental perfusion (FGR)
  • multiparity
  • prior hx of macrosomic infant
  • > 40 weeks gestation
  • maternal obesity
  • male fetus
  • genetics
39
Q

Common LGA newborn issues

A

Birth trauma
- s/s visible deformities

Hypglycemia
- s/s: blood glucose <40; lethargic; irritable/jittery

Polycythemia
- s/s HCT >65%

Hyperbilirubinemia
- s/s: jaundice, tea colored urine, clay colored stool

40
Q

Nursing Interventions for Phototherapy

A
  • keep eyes covered
  • monitor for polycythemia and hypoglycemia
  • hydrate and feed early
41
Q

Prematurity =

A

= any birth less than 37 weeks gestation

= body system immaturity affects transition to extrauterine life

42
Q

Premature newborn assessment characteristics

A
  • weight <5.5 lb, scrawny appearance with poor muscle tone
  • lots of lanugo and vernix
  • fused eyelids
  • absent or few creases in soles and palms
  • barely visible breast and nipple tissue
  • minimal scrotal rugae; large labia and clitoris
43
Q

Preterm nursing management

A

oxygenation

thermal regulation

nutrition and fluid balance

infection prevention

stimulation

pain management

growth and development

parental support - high risk status for perinatal loss

discharge prep

44
Q

Preterm resuscitation evaluation

A

Rapid resuscitation assessment (if any are no, begin resus)

  • Newborn HR >100?
  • Gestational age? Color of meconium fluid?
  • Breathing or crying?
  • Good muscle tone?

ABCDs

  • Airway
    • Suction mouth, nose then trachea if meconium-stained
  • Breathing
    • Ventilate for apnea, gasping or pulse <100 bpm
  • Circulation
    • Start compressions if HR <60 after 30 seconds of PPV
    • 3 compressions: 1 breath q2 seconds
  • Drugs
    • Give epi if HR <60 after 30 seconds of PPV and compressions
  • Epinephrine
    • 1:10,000 concentration (0.1-0.3 mL/kg IV)

Resuscitate until newborn is…

  • Crying vigorously
  • HR > 100
  • Pink tongue
45
Q

Preterm newborn thermal regulation

A

Use radiant warmer and cluster care to reduce stimulation/O2 requirements

Avoid…

  • drafts near newborn (convection)
  • warm everything before touching newborns (conduction)
  • keep isolettes away from cold sources (radiation)
  • keep newborn dry and delay 1st bath until temperature is stable (evaporation)

Assess temp q1h until stable

Monitor for hypothermia complications

  • Respiratory distress/cyanosis
  • lethargy
  • hypoglycemia
  • abdominal distention
  • apnea
  • bradycardia
  • metabolic acidosis

Monitor for hyperthermia complications

  • tachycardia
  • tachypnea
  • apnea
  • warm to touch
  • flushed skin
  • weak or absent cry
  • CNS depression
46
Q

Preterm newborn nutrition and fluid management

A
  • daily weights plotted on growth charts
  • monitor I&Os
  • assess fluid status
    • daily weights
    • urine output
    • BUN, creatinine, hct, electrolytes
    • skin turgor
    • fontanelles (sunken = dehydrated; bulging = overhydrated)
  • assess for enteral feeding intolerance
    • measure abdominal girth
    • auscultate bowl sounds
    • measure gastric residuals before next feeding
47
Q

Preterm infection prevention

A

Infection = most common cause of morbidity/mortality in NICU

  • preterm births at increased risk d/t…
    • lack of maternal antibody transfers
    • thin/fragile skin
    • asphyxia at birth

HANDWASHING EDU

Early identification of infec

  • apnea
  • temperature instability
  • tachycardia and tachypnea
  • poor feeding
  • respiratory distress

Nursing interventions

  • take off jewelry
  • avoid tape on newborn skin
  • hand hygiene and glove wearing during changes/baths/feedings
  • abx as rx’d
  • avoid coming to work when ill
48
Q

Preterm appropriate stimulation

A

Cluster care to keep O2 requirements low

Sensorimotor interventions

  • rocking, massage, holding
  • nonnutritive sucking, breastfeeding
  • skin-to-skin
  • swaddling
  • music

Overstimulation in NICU can lead to

  • decreased HR and RR
  • periods of apnea
49
Q

Managing preterm newborn pain (NIs, goals, s/s, pharma and nonpharma tx)

A

Assess pain frequently, as newborns cannot rate or share pain

Goals

  • minimize amount, duration and severity of pain
  • assist with coping
  • avoid overstimulation by clustering care
  • use pharm agents prn

S/S

  • sudden, high-pitched cry
  • facial grimacing
  • increased m. tone
  • oxygen desaturation
  • increased pulse, BP, RR
  • body posturing (squirming, kicking)
  • limb withdrawal and thrashing
  • fussiness, irritability

Nonpharma pain management

  • gentle handling with rocking and cuddling
  • rest periods
  • kangaroo care/skin-to-skin during px
  • breast-feeding
  • sucrose paci
  • swaddling

Pharma pain management

  • Narcotics limited (usually morphine or fentanyl IV)
  • Acetaminophen for mild pain
  • Benzos for sedatives
  • topical anesthetics
50
Q

Preterm growth and development (NIs, self-regulation)

A

Cluster care to conserve energy, reduce noise

Self-regulation promotion

  • Flexed, swaddled positions to simulate in utero environment
  • Skin-to-skin contact
  • Sucrose paci
  • Objects to grasp

Welcome parents into NICU

51
Q

Preterm parental support

A
  • relaxation techniques and coping strategies (breathing, guided imagery)
  • review events since birth with parents
  • encourage parental involvement in NICU, frequent visits
  • validate anxieties as normal response to stress
  • provide anticipatory guidance for home care
52
Q

Preterm discharge preparation

A

Assess physical status of mom and newborn

  • s/s of complications
  • infant should by physiologically stable

Parental education

  • s/s complications
  • infant care and safety
  • CPR
  • breast, bottle or gavage feeding edu
  • provide support and stability
  • demonstrate special care techniques (dressing changes, ostomy care, chest PT, suctioning)
53
Q

Preterm labor (define)

A

= regular uterine contractions with cervical effacement and dilation between 20-37 weeks gestation

54
Q

Therapeutic management of preterm labor

A

Risk predictions based on gestational age

Antibiotic prophylaxis for women with group B strep
- usually done @ 37 weeks

Corticosteroids to decrease r/o respiratory distress
- given between 24-34 weeks

Pharm: Tocolytic drugs

  • no clear first-line drugs
  • tocolytics may prolong pregnancy for 2-7 days –> enough time to admin steroids to promote fetal lung maturity AND promote uterine relaxation
55
Q

Risk factors for preterm labor

A

Black patients (2x risk)

Maternal age extremes (<16, >40)

Low SES, low edu

Substance use (cigs, alcohol, cocaine)

Poor maternal nutrition

Hx of prior preterm birth (3x the risk)

Low or high pregnancy weight for height

Pre-existing DM or HTN

Multiples

PROM

Late or no prenatal care

Short cervix, cervical insufficiency

STIs, bacterial vaginosis

56
Q

Assessing preterm labor

A

Subtle signs

  • change or inc in vaginal discharge
  • pelvic pressure
  • low, dull backache with menstrual like cramps
  • UTI symptoms
  • GI upset
  • uterine contractions w or w/o pain >6x/hour

Contraction pattern
- 4 contractions q 20 minutes, or 8 contractions/hour

Lab testing

  • CBC
  • Urinalysis
  • Amniotic fluid analysis
  • Fetal fibronectin
  • Cervical length via US
    • > = 3 cm –> delivery within 14 days unlikely
    • <= 2.5 cm –> increased r/o preterm birth
57
Q

Fetal fibronectin test

A

Evaluates whether vaginal discharge contains fetal fibronectin and can predict rupture of membranes within 7-14 days
- + > 0.05 mcg/mL

+ result: indicates fetal fibronectin is present in cervical secretions
– if + comes between 22-34 weeks, inc risk of premature birth w/in 7 day

  • result: indicates that preterm labor in next 2 weeks is unlikely
58
Q

Pt edu re: preterm labor

A

S/s:

  • uterine contractions, cramping or low back pain
  • increased pelvic pressure
  • increased vaginal discharge, or leaking of fluid from vagina
  • n/v/d

If you experience any of the above…

  • stop and rest for 1 hour
  • empty bladder
  • lie down on side
  • drink 2-3 glasses of water
  • feel abdomen during contractions, and describe to HCP as mild (tip of nose), moderate (tip of chin) or strong (forehead)
59
Q

Mongolian spot

A

Usually seen in Black or Asian babies

= benign birthmark over the lumbar/sacral region

Bluish green - black color

60
Q

Normal Breath Sounds in a Neonate

A

Obligate nose breathers

RR: 30-60 breaths per minute

Breath sounds

  • may sound louder than usual d/t fine skin of neonate
  • should be bilaterally clear and equal
  • hyperresonance over lungs
  • no labored breathing, nasal flaring, adventitious sounds
61
Q

Imperforate anus (when to suspect)

A

= no butthole

suspect if no poop for 48 hours pp

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