WH Newborn Flashcards
During passage through the birth canal, fluid is expressed out of the lungs (via the nares) and as the baby fully delivers, the lungs will with fair (rebound thoracic expansion). The temperature change from inside the mother’s body to room air stimulates the respiratory center (as may light, sounds, smells, and touch). Mild hypoxia and increasing C02 leads to acidosis which triggers the respiratory center of the medeulla oblongata in the brain
What causes the baby to breathe at birth?
Breathing is fast and shallow nitally as the alveoli expand (30-60 breaths/min) and irregular. May pause breathing for 15 secs then breathe again. Preferentially breathe through their noses and nares may need suctioning. When using bulb suction, suction the mouth first, then nares
Newborn respiration
S/s: Retractions, Apnea, Cyanosis, tachypnea, grunting, nasal flaring, gasping, stridor, seesaw breathing, crackles
Signs of respiratory distress
Prematurity: lack of surfacant to maintain open alveoli. Preemies often do well in the first few minutes, but then cannot maintain their airway and increased effort of respiration and can worsen quickly.
Sedative taken by mother prior to birth
Cesarean birth without labor
Fetal hypovolemia or anemai (abruption, uterine rupture, RH isoimmunization, etc)
White boys
Perinatal asphyxia (non-reassuring FHR, tight nuchal cord, cord prolapse, etc)
Risk factors for respiratory distress
With apnea or gasping at one minute of life, baby is taken to preheated warmer for positive pressure ventilations. With labored breathing or cyanosis at one minute, O2 sat monitoring and oxygen therapy are initiated. Supplemental oxygen can be given via face mask, endotracheal tube, oxygen hood, or nasal cannula.
Treatment of Resp Distress
Resp issues due to lack of surfacant
Respiratory Distress Syndrome (RDS)
Pulmonary edema from delayed clearing of fluids
Transient Tachypnea of the Newborn (TTN)
Asphyxia before delivery leads to meconium passage and aspiration, then can lead to obstruction, inflammation or infection
Meconium aspiration syndrome
The first breaths dilate the pulmonary vasculature, increasing blood flow and pressure to the left atrium, resulting in the closure of the foramen ovale. (These changes happen whether you clamp the umbilical cord or not - it is the expansion of the airway, not the cord clamp, that matters) The ductus arteriosis closes more slowly, over several days or weeks.
Circulatory changes that happen when the lungs expand
Normal rate is 110-160 (apical pulse over 1 min when at rest). Heart rate is assessed quickly at delivery (counted for 6 seconds), if under 100 at one minute of life, positive pressure ventilations and O2 saturation monitoring are initiated. If 30 secs later, its bleow 60, the baby should be intubated. Physiologic murmurs are common (no cyanosis, pallor, apnea, or feeding difficulty)
Newborn heart rate
First critical nursing intervention done for baby at birth
Assessing for tone and respiratory effort
Second essential nursing intervention done for baby at birth
Dry the baby! Drying the baby prevents cold stress as well as stimulates the baby to breathe
“cold stress” caused by heat loss (via evaporation, conduction, convection, and radiation). Increases oxygen demand and glucose metabolism.
S/s: skin palor, mottling, cyanotic trunk, tachypnea
Infants need to be rewarmed slowly for 2-4 hours if symptomatic
Hypothermia
Can also be dangerous. Newborns do not sweat so excessive heat can lead to seizure, brain damage, or death. A theroneutral environment is best, placing skin to skin under a blanket.
Babies needing to be unwrapped for assessment or procedures should be in a preheated radiant warmer. Normal newborn temp 97.7-99.5. Teaching: dress the infant in the same layers as an adult, protect from drafts, dry quickly after a bath
Hyperthermia
4 heat loss mechanisms
Conduction, convection, evaporation, radiation
Identification: banding and footprints. Alarm system activation. Teaching parents/caregivers about safety: “back to sleep”, infants transport in crib whenever outside the room, infant must be band matched whenever taken from or returned to the room, no co-sleeping in hospital, not recommended at home. No pillows or stuffed toys in crib, not recommended at home. No pillows or stuffed toys in crib, no loose blankets. Hospital security measures to prevent abduction.
Newborn Safety
Vitals, weight, measurements (length, head/chest/abdomen circumferences). Initial head-toe exam for deformities, reflexes and maturity assessments. Vitals (HR, RR, temp) q 15-30mins to assess transition then q4-8h. Close assessment of nutrition and elimination including daily weight. Q shift nursing assessment and daily pediatrician exam. Routine assessments are completed before discharge for hearing, cardiac defects, PKU and metabolic disease, jaundice
Newborn routine assessment
Visual assessment for gestational age assessment. Assesses posture, joint flexibility, arm recoil, scarf sign, heel to ear for neuromuscular maturity
Assesses skin texture, lanugo, foot creases, breast tissue, eyes open, ear cartilage and genitalia for maturity
Very useful when EDD is not known or with late prenatal care
New Ballard Score
Parents often want to know lb and oz but medical protocols use grams. Post term/postdates pregnancy = postmature baby
Newborn weight
between 10th and 90th percentile for that gestational age
Appropriate for gestational age (AGA)
Below 10th percentile for gestational age and population
Small for Gestational Age (SGA)
Above 90th percentile for gestational age and population.
Large for gestational age (LGA)
Diagnosed before birth. very low birth weight. Common complication known during pregnancy
IGUR
Erythromycin ointment within the first hour to prevent ophthalmic infection from gonorrhea or chamydia.
Vitamin K IM injection is given routinely within 6 hours of birth to increase clotting factors and prevent pathologic bleeding.
Hepatitis B vaccine offered and routinely given before discharge
Newborn meds “eyes and thighs”
Scales: CRIES, SUN, NIPS.
Observe for irritability, poor sleep, limb withdrawl, thrashing, fist clenching, muscle rigidity, crying, wimpering
Rapid or shallow respirations, decreased O2 saturation, tachycardia, hypertension
Pallor or flushing, diaphoresis
Increased muscle tone, dilated pupils
Newborn Pain
first stools, thick and green, transitioning to brown by day 3
Meconium
Diapers should be checked and changed prior to each feeding to protect the skin, clean with wipes or soap and water. Infants may void 2-6 times per day intially and then up to 8 times per day. They lose up to 10% of birth weight in the first few days.
Newborn Elimination
Once home, baby should void at least 6 times/day, newborns fed breastmilk should stool 3 or more times per day, formula fed infants will stool less often, as little as once every 1-2 days. Keep skin clean and dry to prevent skin breakdown. Leave the umbilical cord open to air. Fold the diaper to sit below it. It will dry up and fall off like a scab in several days. infants can be tub bathed once the cord has fallen off (before then, sponge bath only)
Teaching for Newborn Elimination
Wipe from front to back to keep stool away from urethra, petroleum and gauze are applied with every diaper change to the circumcised penis until healed, leave the uncircumcised penis alone (do not attempt to retract the foreskin)
Special instructions for newborn elimination
Optimal food source for babies. Exclusive for 6 months and ongoing for 12 months or more is best. Its free, requires no prep, more easily digested and enhances bonding. Reduces risk of SIDS, allergies and childhood obesity. Shows a decrease risk for ovarian and breast cancer for women who feed their babies this way. Babies should be fed q2-3 hours during the day adn at laest q4h at night initially during this type of feeding. Colostrum (early milk) contains passive immunity from lgA antibodies
Breastmilk
Lactation constultants are experts in in this field and are available at most large hospitals and in the community. Le Leche League is a community based support group for this. Should be initated as soon as the newborn is stable. Stimulation of the nipples releases oxytocin and triggers the “let down” reflex that releases the milk. Women should be comfortable, have hydration available and clean hands before starting to latch the baby. Proper positioning is essential for a correct latch. Signs that a baby wants to feed include rooting, mouth to hand and sucking motions
Breastfeeding
Expressed milk, donor milk, or formula can all be given via bottles. Formula fed infants may feed less frequently : every 3-4 hours at first. Hold the infant while bottle feeding, do not prop the bottle. Bottle fed infants may feed rapidly and need to burp more than breastfed babies. Pediatricians recommend vitamin D supplementation for all babies and iron supplements at 4 months for breastfed babies and solids are introduced at 6 months of age. Review importance of clean hands, careful preparation of formula and washing of supplies
Bottle feeding
Blood glucose per protocol, metabolic screening and PKU genetic testing mandated in all states, serum or transcutaneous bilirubin, hearing screening, cardiac testing
Routine newborn testing
Removal of the foreskin of the penis. Anesthesia is often used by more newly trained providers. Performed by either the obstetrician or the pediatrician (varies regionally). Performed second or third day of life or delayed for any medical concerns or for religious preferences. Not done with family history of Von Willebrand’s disease (infant tested first). Not done with hypospadias or epispadias (abnormal urethral location). Always done AFTER the first void to ensure normal urinary function. Assess after procedure for bleeding, swelling and ability to void, apply petroleum and gauze with diaper changes
Circumcision
Benefits: decreased STD risk and cancer risk from HPV, easier hygiene
Risks: hemorrhage, infection, swelling, urethral fistula, excessive tissue removal, adhesions
Benefits and Risks of Circumcision
Blood sugar less than 40 by heel stick.
Risk factors: prematurity, gestational diabetes, cold stress, respiratory distress, SGA, LGA
Routine monitoring of blood sugars: follow protocols for high-risk infants
Newborn hypoglycemia
S/s: jitteriness, twitching, weak cry, irregular respiratory effort, cyanosis, lethargy, eye rolling, seizures
Treatment: Immediate feeding, oral sucrose gel or IV management per protocol
S/s and Treatment of newborn hypoglycemia
elevation of serum bilirubin leading to jaundice
Hyperbilirubinemia
Yellowing of skin and sclera caused by deposits of unconjugated bilirubin. First appears in face and then descends the body as the bilirubin levels rise
Jaundice
Common yellowing, especially in breastfed babies. Presents after 72 hours of life and resolves day 5-10
Physiologic Jaundice
Jaundice from underlying disease. Presents before 24 hours of life or persists beyond day 14. Usually caused by blood incompatibility or infection
Pathologic jaundice
Bilirubin deposits in the brain resulting in permanent neurologic damage
Acute bilirubin encephalopathy
More extensive neurologic damage with severe cognitive impairment
Kernicterus
Risk factors: RBC breakdown, blood incompatibility, maternal diabetes, bruising or bleeding, prematurity
Nursing: Monitor serum bilirubin levels and assess skin for progressing jaundice. Direct comb’s test will assess for maternal antibodies for the Rh factor in the newborn. Maintain adequate hydration and feedings. Phototherapy
Risk factors and Nursing Interventions for Jaundice
Light therapy to the skin which converts bilrubin to a form that is more readily excreted in the urine and bile
Phototherapy
birth trauma that can result in brain bleed
Skull fracture
birth trauma that results in swelling of the soft tissues of the scalp
Caput succedanem
Birth trauma that causes blood collection between periosteum and the skull
Cephalohematoma
Birth trauma resulting in nerve damage that causes arm weakness and decreased sensation
Brachial plexus injury
Birth trauma that can cause crepitus over the clavicle, limited ROM, absent Moro reflex
Fractured clavicle
Causes: Macrosomia, abnormal presentation, prolonged or precipitious labor, CPD, multiples, forceps or vacuum extraction, external version, cesarean birth, shoulder dystocia
Risk factors for birth trauma
Increased risk for hypothermia, hypoglycemia and poor feedings
Small infants (SGA)
Increased risk for birth trauma, hypoglycemia
Large infants (LGA)
Increased risk for meconium aspiration, birth trauma, and perinatal mortality
Postmature infants
Maternal use of addictive substances during pregnancy that leads to this at birth. Know substance include opiates, heroin, methadone, marijuana, amphetamines, alcohol
Monitor infant using scoring system which assesses neurologic, metbaolic or GI manifestations such as high pitched cry, incessant crying, increased muscle tone, distrubed sleep, apnea, poor feedings, vomiting, excessive sucking
Newborn substance withdrawal
Swaddle for comfort. Offer pacifier for self soothing. Monitor feedings and elimination closely. Reduce environmental stimuli (decrease noise and lights). Morphine and phenobarbitol can be given to control CNS irritability and seizures
Nursing interventions for newborn substance withdrawal
The first 28 days outside the wound
The neonatal period
Fine, downy hair that covers the body and face of the fetus from week 16 of gestation and on. Most abundant in week 20 and then begins to shed into amniotic fluid.
Lanugo
Heat loss due to evaporation of liquid from the body. Dry neonates thoroughly after birth. Stabilize their temp prior to the bath, and bathe them in warm environment
Evaporation
Transfer of heat by direct contact with a cooler object. Place infants on prewarmed surfaces or keep them skin to skin with the mother
Conduction
Heat transfer from the newborn to the surrounding air. Keep the ambient room temp at least 72. Avoid having air currents from open windows and fans
Convection
Transfer of heat from or to the newborn from or to nearby surfaces. Keep infant away from cool windows or exterior walls.
Radiation
A thick white creamy substance secreted by fetal sebaceous gland. At birth, limited into skin folds but may be distributed more diffusely and can be rubbed into the skin or washed off in bath
Vernix
Small white sebacous glands on newborns body. Typically resolve in 2-4 weeks without treatment. Discourage attempts to remove
Milia
Area of bluish black pigmentation that can appear like a bruise; more common in infants with darker skin and on the back and butt, but also may appear on infants with lighter skin and on other body parts. Not associated with trauma. Document carefully to avoid suspicions of abuse in future exams. May expand for first year before it resolves
Congenital dermal melanocytosis “Mongolian spots”
A red rash with white papules and red macules that may occur over any body part but most commonly occurs on trunk. Appears betwen 24h and 2 weeks postpartum. Benign and may last up to 3 weeks. Not uncomfortable for infant and no treatment
Erythema toxicum
Flat, pink, blanchable areas of skin commonly occuring on nape of neck, nose, eyelids, and upper lip and are usually symmetric. Facial lesions resolve in first few years. Neck lesions may persist into adulthood. benign
Telangiectatic nevi (stork bites)
A nonblanchable discoloration of the skin mostly found on the neck and face that is typically flat and pink at birth but darkens and becomes textured with time. Often removed by surgery or laser treatment
Nevus flammeus (port-wine stain)
When the mouth or cheek is touched, the infant turns toward the stimulus and opens the mouth. Is weak or absent if the infant is sated. Disappears in 3-12 months
Rooting reflex
The infant curls the fingers around an object placed in the hand. Lasts about 3-4 months
Palmar grasp reflex
Turning the infants head quickly to one side causes the infant to extend the arm and leg on that side and to flex the arm and leg on the other side. lasts for 3-4 mo; if longer, is concerning for cerebral palsy
Tonic neck reflex
When startled by a loud noise or a small controlled drop of the head and neck (supported), the infant abducts and extends the arms with the hands forming the shape of a C. The legs may also respond. After the initial startle, the imbs adduct and relax. Complete response until 8 wk. Partial response as long as 6 mo. Beyond 60 is suspicious for neurodevelopment.
Moro reflex
When a finger or hard instrument strokes along the plantar lateral aspect of the sole and then across the ball of the foot in a continuous motion, the newborn extends the toes and dorsiflexes the large toe. Lack of response warrants neuro assessment. Reflex normally goes away by 1 y. Adults curl the toes.
Babinski reflex
When held upright by the torso, such that the feet touch the surface, the infant stimulates the walking movement. Term infants walk on the soles; preterm infants walk onn the toes. Disappears within a month postpartum
Stepping reflex
