OB exam 3

Cord Care

Observe for bleeding, redness, drainage, or foul odor from the cord stump and report it to your newborn's primary care provider immediately. Avoid tub baths until the cord has fallen off and the area has healed. Expose the cord stump to the air as much as possible throughout the day. Fold diapers below the level of the cord to prevent contamination of the site and to promote air-drying of the cord. Observe the cord stump, which will change color from yellow to brown to black. This is normal. Never pull the cord or attempt to loosen it; it will fall off naturally.

Mechanisms Of Heat Exchange

-Conduction: transfer of heat from object to object when the two objects are in direct contact with each other -Convection: flow of heat from body surface to cooler surrounding air or to air circulating over a body surface -Evaporation: loss of heat when a liquid is converted to a vapor -Radiation: loss of body heat to cooler, solid surfaces in close proximity but not in direct contact The newborn's temperature may decrease 3 to 5 degrees within minutes after leaving the warmth of the mother's uterus

Body Temp Regulations Overheating

Overheating: Large body surface area Limited insulation Limited sweating ability The newborn's primary method of heat production is through nonshivering thermogenesis, a process in which brown fat (adipose tissue) is oxidized in response to cold exposure.

Neonatal Abstinence Syndrome

Newborns of women who abuse tobacco, illicit substances, caffeine, and alcohol can exhibit withdrawal behavior. Withdrawal symptoms occur in 60% of all newborns exposed to drugs . Drug dependency acquired in utero is manifested by a constellation of neurologic and physical behaviors and is known as neonatal abstinence syndrome. Al-though often treated as a single entity, neonatal absti-nence syndrome is not a single pathologic condition. Typical newborn behaviors include CNS hypersensitivity, autonomic dysfunction, respiratory distress, temperature instability, hypoglycemia, tremors, seizures, abnormal cry patterns, feeding difficulties, and gastrointestinal disturbances. Neonatal abstinence syndrome has both medical and developmental consequences for the newborn. Frequently, the first inkling of drug use appears in the newborn when symptoms of withdrawal begin within 72 hours after birth. Assess the newborn for signs of neonatal abstinence syndrome using the acronym WITHDRAWAL to focus the assessment: W = Wakefulness: sleep duration less than 3 hours after feeding I = Irritability T = Temperature variation, tachycardia, tremors H = Hyperactivity, high-pitched persistent cry, hyperreflexia, hypertonus D = Diarrhea, diaphoresis, disorganized suck R = Respiratory distress, rub marks, rhinorrhea A = Apneic attacks, autonomic dysfunction W = Weight loss or failure to gain weight A = Alkalosis (respiratory) L = Lacrimation (Hamdan, 2012) S/S CNS Dysfunction Tremors Generalized seizures Hyperactive reflexes Restlessness Hypertonic muscle tone, constant movement Shrill, high-pitched cry Disturbed sleep patterns Metabolic, Vasomotor, and Respiratory Disturbances Fever Frequent yawning Mottling of the skin Sweating Frequent sneezing Nasal flaring Tachypnea >60 bpm Apnea Gastrointestinal Dysfunction Poor feeding Frantic sucking or rooting Loose or watery stools Regurgitation or projectile vomiting

Cold Stress Interventions

Prewarming blankets and hats to reduce heat loss through conduction Keeping the infant transporter (warmed isolette) fully charged and heated at all times Drying the newborn completely after birth to prevent heat loss from evaporation Encouraging skin-to-skin contact with the mother if the newborn is stable Promoting early breast-feeding to provide fuels for nonshivering thermogenesis Using heated and humidified oxygen Always using radiant warmers and double-wall isolettes to prevent heat loss from radiation Deferring bathing until the newborn is medically stable, and using a radiant heat source while bathing Avoiding the placement of a skin temperature probe over a bony area or one with brown fat, because it does not give an accurate assessment of the whole body temperature (most temperature probes are placed over the liver when the newborn is supine or side-lying)

Newborn Reflexes

Reflexes commonly assessed in the newborn include sucking, Moro, stepping, tonic neck, rooting, Babinski, palmar grasp and plantar grasp reflexes. Spinal reflexes tested include truncal incurvation (Galant reflex) and anocutaneous reex (anal wink). The sucking reflex is elicited by gently stimulating the newborn's lips by touching them. The Moro reflex, also called the embrace reflex, occurs when the neonate is startled. Assess the stepping reflex by holding the newborn upright and inclined forward with the soles of the feet touching a flat surface The tonic neck reflex resembles the stance of a fencer and is often called the fencing reflex. The tonic neck reflex resembles the stance of a fencer and is often called the fencing reflex. The Babinski reflex should be present at birth and disappears at approximately 1 year of age. It is elicited by stroking the lateral sole of the newborn's foot from the heel toward and across the ball of the foot.

Breastfeeding Guidelines

Review pg 612 table 18.4

Fetal Alcohol Syndrome

Microcephaly (head circumference <10th percentile)* Small palpebral (eyelid) fissures* Abnormally small eyes Intrauterine growth restriction Maxillary hypoplasia (flattened or absent) Epicanthal folds (folds of skin of the upper eyelid over the eye) Thin upper lip* Missing vertical groove in median portion of upper lip* Short upturned nose Short birth length and low birthweight Joint and limb defects Altered palmar crease pattern Prenatal or postnatal growth ≤10th percentile* Congenital cardiac defects (septal defects) Delayed fine and gross motor development Poor eye-hand coordination Clinically significant brain abnormalities* Mental retardation Narrow forehead Performance substantially below expected level in cognitive or developmental functioning, executive or motor functioning, and attention or hyperactivity; social or language skills* Inadequate sucking reflex and poor appetite* Diagnosis of fetal alcohol syndrome requires the presence of three findings: 1. Documentation of all three facial abnormalities 2. Documentation of growth deficits (height, weight, or both <10th percentile) 3. Documentation of CNS abnormalities (structural, neurologic, or functional)

Newborn Behavioral Patterns

-First period of reactivity Birth to 30 minutes after birth Newborn is alert, moving, may appear hungry This period is characterized by myoclonic movements of the eyes, spontaneous Moro reflexes, sucking motions, chewing, rooting, and fine tremors of the extremities. Muscle tone and motor activity are increased . Respiration and heart rate are elevated but gradually begin to slow as the next period begins. -Period of decreased responsiveness 30 minutes to 120 minutes old Period of sleep or decreased activity Movements are less jerky and less frequent. Heart and respiratory rates decline as the newborn enters the sleep phase. The muscles become relaxed, and responsiveness to outside stimuli diminishes. During this phase, it is difficult to arouse or interact with the newborn. No interest in sucking is shown. -Second period of reactivity 2 to 8 hours Newborn awakens and shows an interest in stimuli Heart and respiratory rates increase. Peristalsis also increases. Thus, it is not uncommon for the newborn to pass meconium or void during this period.

Vital SIgns

-Temperature 97.7-99.5° F (36.5-37.5° C) -Heart rate (pulse) to 180 during crying 120-160 bpm; can increase.(apical pulse 1 full min) -Respirations 30-60 breaths/minute at rest; will increase with crying -Blood pressure 50-75 mm Hg systolic, 30-45 mm Hg diastolic Heart and respiratory rates are usually assessed every 30 minutes until stable for 2 hours after birth. Once stable, the heart rate and respiratory rates are checked every 8 hours.

Apgar

A appearance (color) P pulse (heart rate) G grimace (reflex irritability) A activity (muscle tone) R respiratory (respiratory effort) Evaluate a newborn's physical condition at 1 minute and 5 minutes after birth. An additional Apgar assessment is done at 10 minutes if the 5-minute score is less than 7 points Each parameter is assigned a score ranging from 0 to 2 points. A score of 0 points indicates an absent or poor response; a score of 2 points indicates a normal response. A normal newborn's score should be 8 to 10 points. The higher the score, the better the condition of the newborn. If the Apgar score is 8 points or higher, no intervention is needed other than supporting normal respiratory efforts and maintaining thermoregulation. Scores of 4 to 7 points signify moderate difficulty and scores of 0 to 3 points represent severe distress in adjusting to extrauterine life.

Post Term Newborn

A pregnancy that extends beyond 42 weeks' gestation (294 days) produces a postterm newborn. Other terms used to describe this late birth is a postmature infant. Postterm newborns may be LGA, SGA, or dysmature (newborn weighs less than established normal param-eters for estimated gestational age [IUGR]), depending on placental function. Postterm newborns typically exhibit the fol-lowing characteristics: Dry, cracked, peeling, wrinkled skin Vernix caseosa and lanugo are absent Long, thin extremities Creases that cover the entire soles of the feet Wide-eyed, alert expression Abundant hair on scalp Thin umbilical cord Limited vernix and lanugo Meconium-stained skin and fingernails Long nails Also be alert for other typical complications associated with a post term newborn, such as perinatal asphyxia (caused by placental aging or oligohydram-nios [decreased amniotic fluid]), hypoglycemia (caused by acute episodes of hypoxia related to cord compres-sion which exhausts carbohydrate reserves), hypothermia (caused by loss of subcutaneous fat), and polycythemia (caused by an increased production of red blood cells to compensate for a reduced oxygen environment), and be prepared to initiate early interventions

Imperforate Anus

An imperforate anus is a gastrointestinal system malformation of the anorectal opening and is identified in the newborn period. The rectum may end in a blind pouch that does not connect to the colon, or it may have fistulas (openings) between the rectum and the perineum. The defect can be further classified as a high or low type, depending on its level. The level significantly influences the outcome in terms of fecal continence as well as management Surgical intervention is needed for both high and low types of imperforate anus. Surgery for a high type of defect involves a colostomy in the newborn period, with corrective surgery performed in stages to allow for growth. Sur-gery for the low type of anomaly, which frequently includes a fistula, involves closure of the fistula, creation of an anal opening, and repositioning of the rectal pouch into the anal opening. A major challenge for either type of surgical repair is finding, using, or creating adequate nerve and muscle structures around the rectum to provide for normal evacuation In the infant with suspected imperforate anus, assess for common signs of intestinal obstruction, which may occur as a result of the malformation. These include abdominal distention and bilious vomiting.

PKU

Autosomal recessive inherited deficiency in one of the en-zymes necessary for the metabolism of phenylalanine to tyrosine—essential amino acids found in most foods Irritability, vomiting of protein feedings, and a musty odor to the skin or body secretions of the newborn; if not treated, mental and mo-tor retardation, seizures, microcephaly, and poor growth and development Lifetime diet of foods low in phenylalanine (low protein) and monitoring of blood levels; special newborn formulas available: Phenex and Lofenalac Universally screened for in the United States; testing is done 24-48 hours after protein feeding (PKU)

Respiratory Distress Syndrome

Despite improved survival rates and advances in perinatal care, many high-risk newborns are at risk for respiratory problems, particularly respiratory distress syndrome (RDS), a breathing disorder resulting from lung immaturity and lack of alveolar surfactant. Since the link between RDS and surfactant deficiency was discovered more than 30 years ago, tremendous strides have been made in understanding the pathophysiology and treatment of this disorder. The introduction of prenatal steroids to accelerate lung maturity and the development Despite improved survival rates and advances in peri-natal care, many high-risk newborns are at risk for respiratory problems, particularly respiratory distress syndrome (RDS), a breathing disorder resulting from lung immaturity and lack of alveolar surfactant. Since the link between RDS and surfactant deficiency was discovered more than 30 years ago, tremendous strides have been made in understanding the pathophysiology and treatment of this disorder. The introduction of prenatal steroids to accelerate lung maturity and the development Nursing assessment focuses on keen observation to identify the signs and symptoms of respiratory distress. In addition, assessment aids in differentiating RDS from other respiratory conditions, such as TTN or group B streptococcal pneumonia. Review the history for risk factors associated with RDS. The most common risk factor for the development of RDS is premature birth. Additional risk factors particularly in the term infant include cesarean birth in the absence of preceding labor (related to the lack of thoracic squeez-ing), male gender, and maternal diabetes. he newborn with RDS usually demonstrates signs at birth or within a few hours of birth. Observe the infant for expiratory grunting, nasal flaring, chest wall retractions (Fig. 24.2), see-saw respirations, and gener-alized cyanosis. Auscultate the heart and lungs, noting tachycardia (rates above 150 to 180), fine inspiratory crackles, and tachypnea (rates above 60 breaths per minute).T he Silverman-Anderson Index is an assessment scoring system that can be used to evaluate five param-eters of work of breathing as it assigns a numerical score for each parameter. Each category is scored as "0" for normal, "1" for moderate impairment, or "2" for severe impairment. Parameters assessed are retractions of the upper chest, lower chest, and xiphoid; nasal flaring; and expiratory grunt. Normally functioning infants should have a cumulative score of 0, whereas critically ill and severely depressed infants will have scores closer to 10

Esophageal Atresia/Tracheoesophgeal FIstula

Esophageal atresia and tracheoesophageal fistula are gastrointestinal anomalies in which the esophagus and trachea do not separate normally during embryonic development. Esophageal atresia refers to a congenitally interrupted esophagus where the proximal and distal ends do not communicate; the upper esophageal segment ends in a blind pouch and the lower segment ends a variable distance above the diaphragm Tracheoesophageal fistula is an abnormal communication between the trachea and esophagus. When associated with esophageal atresia, the fistula most commonly occurs between the distal esophageal segment and the trachea. The incidence of esophageal atresia is 1 per 3,000 to 4,500 live births. Esophageal atresia and tracheoesophageal fistula are thought to be the result of incomplete separation of the lung bed from the foregut during early fetal development. A large percentage of these newborns have other congenital anomalies involving the vertebra, kidneys, heart, and musculoskeletal and gastrointestinal systems most have several anomalies. Review the maternal history for hydramnios. Often this is the first sign of esophageal atresia because the fetus can-not swallow and absorb amniotic fluid in utero, leading to accumulation. Soon after birth, the newborn may exhibit copious, frothy bubbles of mucus in the mouth and nose, accompanied by drooling. Abdominal distention develops as air builds up in the stomach. In esophageal atresia, a gastric tube cannot be inserted beyond a certain point because the esophagus ends in a blind pouch. The newborn may have rattling respirations, excessive salivation, and drooling, and "the three C's" (coughing, choking, and cyanosis) if feeding is attempted. The presence of a fistula increases the risk of respiratory complications such as pneumonitis and atelectasis due to aspiration of food and secretions READ MGMT of 872

Birth Weight

Fetal growth is influenced by maternal nutrition, genetics, placental function, environment, and a multitude of other factors. Assigning size to a newborn is a way to measure and monitor the growth and development of the newborn at birth. Newborns can be classified according to their birthweight and weeks of gestation. Knowing the group into which a newborn fits is important. Appropriate for gestational age (AGA) describes a newborn with a weight that falls within the 10th to 90th percentile for that particular gestational age . Infants who are appropriate for gestational age have lower morbidity and mortality than other groups. Small for gestational age (SGA) describes newborns that typically weigh less than 2,500 g (5 lb 8 oz) at term due to less growth than expected in utero. A newborn is also classified as SGA if his or her birthweight is at or below the 10th percentile as correlated with the number of weeks of gestation. Large for gestational age (LGA) describes newborns whose birthweight is above the 90th percentile on a growth chart and who weigh more than 4,000 g (8 lb 13 oz) at term due to accelerated growth for length of gestation. The following terms describe other newborns with marginal weights at birth and of any gestational age: Low birthweight: less than 2,500 g (5.5 lb) Very low birthweight: less than 1,500 g (3 lb 5 oz) Extremely low birthweight: less than 1,000 g (2 lb 3 oz)

Gestational age variations

Gestational age is typically measured in weeks: a newborn born before completion of 37 weeks is classified as a preterm newborn and one born after completion of 42 weeks is classified as a postterm newborn . An infant born from the first day of the 38th week through 42 weeks is classified as a term newborn. As of 2006, a new classification has been added, the late preterm newborn (near term)—one that is born between 34 weeks and 36 weeks, 6 days of gestation . Preterm infant—born before 37 completed weeks of gestation Late preterm infant (near term)—34 to 366/7 weeks Full term infant—38 through 41 completed weeks of gestation Postterm infant—42 weeks or more

Bathing and Hygeine

Immediately after birth, drying the newborn and remov-ing blood may minimize the risk of infection caused by hepatitis B, herpesvirus, and HIV, but the specific benefits of this practice remain unclear bathing is postponed until thermal and cardiorespiratory stability is ensured After bathing, place the newborn under the radiant warmer and wrap him or her securely in blankets to prevent chilling. Check the baby's temperature within an hour to make sure it is within normal limits. If it is low, place the newborn under a radiant heat source again.After the initial bath, the newborn may not receive another full one during the stay in the birthing unit. The diaper area will be cleansed at each diaper change, and any milk spilled will be cleaned. Clear water and a mild soap are appropriate to cleanse the diaper area. The use of lotions, baby oil, and powders is not encouraged Powders should not be used because they can be inhaled, causing respiratory distress. Instruct parents that a bath two or three times weekly is sufficient for the first year; more frequent bathing may dry the skin. Parents should not fully immerse the newborn into water until the umbilical cord area is healed—up to 2 weeks after birth. Encourage parents to give the infant a sponge bath until the umbilical cord falls off and the navel area is healed completely. If the newborn has been circumcised, advise parents to wait until that area has also healed Until then, clean the penis with mild soap and water and apply a small amount of petroleum jelly to the tip to prevent the diaper from adhering to the penis. Instruct parents to apply the diaper loosely and place the newly circumcised male infant on his side or back to prevent pressure and irritation on the penis box 18.1 594 pg

Circ Care

Immediately after circumcision, the tip of the penis is usually covered with petroleum jelly-coated gauze to keep the wound from sticking to the diaper. Continued care of this site includes: Assess for bleeding every 30 minutes for at least 2 hours. Document the first voiding to evaluate for urinary obstruction or edema. Squeeze soapy water over the area daily and then rinse with warm water. Pat dry. Apply a small amount of petroleum jelly with every diaper change if the Plastibell was used; clean with mild soap and water if other techniques were used. Fasten the diaper loosely over the penis and avoiding placing the newborn on his abdomen to prevent friction.

Intraventricular Hemorrhage

Intraventricular hemorrhage (IVH) is defined as bleeding that usually originates in the subependymal germinal matrix region of the brain, often extending into the ventricular system IVH occurs in 20% to 50% of infants with birthweight less than 1500 g and/or born at less than 35 weeks' gestation. It is uncommon in term neonates but may occur with birth trauma or asphyxia. Complications resulting from IVH include hydrocephalus, seizure disorder, periventricular leukomalacia (an ischemic injury resulting from inadequate perfusion of the white matter adjacent to the ventricles), cerebral palsy, learning disabilities, vision or hearing deficits, and cognitive impairment IVH is classified according to a grading system of I to V (least severe to most severe). The prognosis is guarded, depending on the grade and severity of the hemorrhage. Generally, newborns with mild hemorrhage (grades I and II) have a much better developmental outcome than those with severe hemorrhage (grades III and IV) The signs of intraventricular hemorrhage vary significantly and some infants may display no clinical signs. Assess for risk factors such as: Preterm birth Low birth weight Acidosis Asphyxia Unstable blood pressure Seizures Acute blood loss or hypovolemia Respiratory distress with mechanical ventilation, intubation, apnea, hypoxia, or suctioning Use of hyperosmolar solutions or rapid volume expansion Evaluate the newborn for an unexplained drop in hematocrit, pallor, and poor perfusion as evidenced by respiratory distress and oxygen desaturation. Note seizures, lethargy or other changes in level of consciousness, weak suck, high-pitched cry, or hypotonia. Palpate the anterior fontanel for tenseness. Assess vital signs, noting bradycardia and hypotension. Evaluate laboratory data for changes indicating metabolic acidosis or glucose instability. Frequently a bleed can progress rapidly and result in shock and death. Prepare the newborn for cranial ultrasonography, the diagnostic tool of choice to detect hemorrhage. Care of the newborn with IVH is primarily sup-portive. Correct anemia, acidosis, and hypotension with fluids and medications. Administer fluids slowly to prevent fluctuations in blood pressure. Avoid rapid volume expansion to minimize changes in cerebral blood flow. Keep the newborn in a flexed, contained position with the head elevated to prevent or minimize fluctuations in intracranial pressure. Continuously monitor the newborn for signs of hemorrhage, such as changes in the level of consciousness, bulging fontanel, seizures, apnea, and reduced activity level. Also, measuring head circumference daily to assess for expansion in size is essential in identifying complications early.

Care of LGA Newborn

Large for gestational age is also termed macrosomia. The infant's weight is over 4,000 g (>9 lb). LGA infants may be preterm, term, or postterm. Up to 10% of all infants are designated as LGA at birth Because of the newborn's large size, vaginal birth may be difficult and occasionally results in birth injury. In addition, shoulder dystocia, clavicular fractures, and facial palsies are common. The incidence of cesarean births is very high with LGA newborns to avoid arrested labor and birth trauma. read page 808

NEC

Necrotizing enterocolitis (NEC) is a serious gastrointestinal disease occurring in newborns. It is the most common and most serious acquired gastrointestinal disorder among hospitalized preterm neonates and is associated with significant acute and chronic morbidity and mortality. NEC occurs in up to 2.4 cases per 1,000 live births, affecting as many as 40% to 50% of newborns with birth weights less than 1,000 g. Attempts to improve gastrointestinal function and reduce the risk of NEC include enteral antibiotics, judicious administration of parenteral fluids, human milk feedings, antenatal corticosteroids, enteral probiotics (Lactobacillus acidophilus), and slow continuous drip feedings. Also observe the newborn for common signs and symptoms, which may include: Abdominal distention and tenderness Bloody or hemoccult-positive stools Diarrhea Temperature instability Feeding intolerance, characterized by bilious vomiting Signs of sepsis Lethargy Apnea Shock

Cold Stress

Newborns can experience heat loss through all four mechanisms, ultimately resulting in cold stress. Cold stress is excessive heat loss that requires a newborn to use compensatory mechanisms (such as nonshivering thermogenesis and tachypnea) to maintain core body temperature. The consequences of cold stress can be quite severe. As the body temperature decreases, the newborn becomes less active, lethargic, hypotonic, and weaker. All newborns are at risk for cold stress, particularly within the first 12 hours of life. Preterm newborns are at the greatest risk for cold stress and experience more profound effects than full-term newborns because they have fewer fat stores, poorer vasomotor responses, and less insulation to cope with a hypothermic event. Cold stress in the newborn can lead to the following problems if not reversed: depleted brown fat stores, increased oxygen needs, respiratory distress, increased glucose consumption leading to hypoglycemia, metabolic acidosis, jaundice, hypoxia, and decreased surfactant production

Body Temp Regulation

One of the most important elements in a newborn's survival is obtaining a stable body temperature to promote an optimal transition to extrauterine life. On average, a newborn's tem-perature ranges from 97.9° to 99.7° F (36.5° to 37.5° C). Thermoregulation is the process of maintaining the balance between heat loss and heat production. Heat loss factors: -Thin skin; blood vessels close to the surface -Lack of shivering ability; limited stores of metabolic substrates (glucose, glycogen, fat) -Limited use of voluntary muscle activity -Large body surface area relative to body weight -Lack of subcutaneous fat; little ability to conserve heat by changing posture -No ability to adjust own clothing or blankets to achieve warmth -Infants cannot communicate that they are too cold or too warm

Pathological Jaundice

Pathologic jaundice is manifested within the first 24 hours of life when total bilirubin levels increase by more than 5 mg/dL/day and the total serum bilirubin level is higher than 17 mg/dL in a full-term infant. A few conditions that contribute to red blood cell breakdown and thus higher bilirubin levels include polycythemia, blood incompatibilities, and systemic acidosis. These altered conditions can lead to high levels of unconjugated bilirubin, possibly reaching toxic levels and resulting in a severe condition called kernicterus. Hyperbilirubinemia is a great concern because of the potential for brain injury. The spectrum of bilirubin-induced neurologic dysfunction ranges from acute bilirubin encephalopathy to the devastating and irreversible chronic bilirubin encephalopathy or kernicterus. Acute bilirubin encephalopathy describes the effects of hyperbilirubinemia in the first weeks of life. Clinical signs include lethargy, poor feeding, poor tone, a poor Moro reflex with incomplete flexion of the extremities, and a high-pitched cry. As symptoms of acute bilirubin encephalopathy worsen, the newborn progresses to apnea, seizures, coma, and death. Chronic bilirubin encephalopathy or kernic-terus is characterized by four clinical manifestations: movement disorder (aethetosis, dystonia, spasticity, hy-potonia), auditory dysfunction (deafness), oculomotor impairment, and dental enamel hypoplasia of deciduous teeth. Unconjugated bilirubin enters the brain and acts as a neurotoxin causing long-term neurologic sequelae.The most common condition associated with patho-logic jaundice is hemolytic disease of the newborn sec-ondary to incompatibility of blood groups of the mother and the newborn. The most frequent conditions are Rh factor and ABO incompatibilities.

Persistent Pulmonary Hypertension

Persistent pulmonary hypertension of the newborn, previously referred to as persistent fetal circulation, is a cardiopulmonary disorder characterized by marked pulmonary hypertension that causes right-to-left extrapulmonary shunting of blood and hypoxemia. Persistent pulmonary hypertension can occur idiopathically or as a complication of perinatal asphyxia, meconium aspiration syndrome, maternal smoking, maternal obesity, maternal asthma, pneumonia, congenital heart defects, metabolic disorders such as hypoglycemia, hypother-mia, hypovolemia, hyperviscosity, acute hypoxia with delayed resuscitation, sepsis, and RDS. It occurs in 2 to 6 newborns per 1,000 live births of term, near-term, or postterm infants Normally, pulmonary artery pressure decreases when the newborn takes the first breath. However, interference with this ability to breathe allows pulmonary pressures to remain increased. Hypoxemia and acidosis also occur, leading to vasoconstriction of the pulmonary artery. These events cause an elevation in pulmonary vascular resistance. Assess the newborn's status closely. A newborn with per-sistent pulmonary hypertension demonstrates tachypnea within 12 hours after birth. Observe for marked cyanosis, grunting, respiratory distress with tachypnea, and retractions. Auscultate the heart, noting a systolic ejection harsh sound (tricuspid insufciency murmur), and mea-sure blood pressure for hypotension resulting from both heart failure and persistent hypoxemia . Measure oxygen saturation via pulse oximetry and report low values. Prepare the newborn for an echocardiogram, which will reveal right-to-left shunting of blood that confirms the diagnosis. When caring for the newborn with persistent pulmonary hypertension, pay meticulous attention to detail, with continuous monitoring of the newborn's oxygenation and perfusion status and blood pressure. The goals of therapy include improving alveolar oxygenation, inducing metabolic alkalosis by administering sodium bicar-bonate, correcting hypovolemia and hypotension with the administration of volume replacement and vasopressors, and anticipating use of ECMO when support has failed to maintain acceptable oxygenation. Provide immediate resuscitation after birth and administer oxygen therapy as ordered. Early and effective resuscitation and correction of acidosis and hypoxia are helpful in preventing persistent pulmonary hyperten-sion. Monitor arterial blood gases frequently to evaluate the effectiveness of oxygen therapy.

Newborn Skin Variations

Petechiae may be the result of pressure on the skin during the birth process. Forceps marks may be observed over the cheeks and ears. A small puncture mark may be seen if internal fetal scalp electrode monitoring was used during labor. Common skin variations include: Vernix caseosa is a thick white substance that protects the skin of the fetus. It is formed by secretions from the fetus's oil glands and is found during the first 2 or 3 days after birth in body creases and the hair. It does not need to be removed because it will be absorbed into the skin. Stork bites or salmon patches are superficial vascular areas found on the nape of the neck, on the eyelids, and between the eyes and upper lip Milia are unopened sebaceous glands frequently found on a newborn's nose. They may also appear on the chin and forehead. When they occur in a newborn's mouth and gums, they are termed Epstein's pearls. They occur in approximately 60% of newborns Mongolian spots are blue or purple splotches that appear on the lower back and buttocks of newborns. Erythema toxicum (newborn rash) is a benign, idiopathic, generalized, transient rash that occurs in up to 70% of all newborns during the first week of life. It consists of small papules or pustules on the skin resembling ea bites. The rash is common on the face, chest, and back. Harlequin sign refers to the dilation of blood vessels on only one side of the body, giving the new-born the appearance of wearing a clown suit. Nevus flammeus, also called a port-wine stain, commonly appears on the newborn's face or other body areas. It is a capillary angioma located directly below the dermis. It is flat with sharp demarcations and is purple-red. Nevus vasculosus, also called a strawberry mark or strawberry hemangioma, is a benign capillary hemangioma in the dermal and subdermal layers. It is raised, rough, dark red, and sharply demarcated.

Phototherapy

Phototherapy involves expos-ing the newborn to ultraviolet light, which converts unconjugated bilirubin into products that can be ex-creted through feces and urine. Phototherapy is the most common treatment for hyperbilirubinemia and has virtually eliminated the need for exchange transfu-sions in newborns now Used for babies who are jaudice

Physiologic Jaundice

Physiologic jaundice is very common in newborns, with the majority demonstrating yellowish skin, mucous membranes, and sclera within the first 3 days of life. Jaundice is the visible manifestation of hyperbilirubinemia. It typically results from the deposition of unconjugated bilirubin pigment in the skin and mucous membranes. In most infants, an increase in bilirubin production (e.g., due to hemolysis) is the primary cause of physiologic jaundice, and thus reducing bilirubin pro-duction is a rational approach for its management. The AAP has recently released guidelines for the prevention and management of hyperbilirubinemia in newborns: Promote and support successful breast-feeding prac-tices to make sure the newborn is well hydrated and stooling frequently to promote elimination of bilirubin. Advise mothers to nurse their infants at least 8 to 12 times per day for the first several days. Avoid routine supplementation of nondehydrated breast-fed infants with water or dextrose water because that will not lower bilirubin levels . Ensure that all infants are routinely monitored for the development of jaundice and that nurseries have established protocols for the assessment of jaundice. Jaundice should be assessed whenever the infant's vital signs are measured but no less than every 8 to 12 hours. Before discharge, complete a systematic assessment for the risk of severe hyperbilirubinemia. Provide early and focused follow-up based on the risk assessment. When indicated, treat newborns with phototherapy or exchange transfusion to prevent acute bilirubin encephalopathy Measures that parents can take to reduce the risk of jaundice include exposing the newborn to natural sunlight for short periods of time throughout the day to help oxidize the bilirubin deposits on the skin, providing breast-feeding on demand to promote elimination of bilirubin through urine and stooling, and avoiding glucose water supplementation, which hinders elimination.

New Ballard Score

READ THE PAGES INDICATED IN STUDY GUIDE A LOT OF INFO

Respirations

Respirations: 30-60 breaths/minute; irregular, shallow, unlabored; short periods of apnea (<15 sec); symmetrical chest movements In some cases, periodic breathing may occur, which is the cessation of breathing that lasts 5 to 10 seconds without changes in color or heart rate . Periodic breathing may be observed in newborns within the first few days of life and requires close monitoring. In some cases, periodic breathing may occur, which is the cessation of breathing that lasts 5 to 10 seconds without changes in color or heart rate . Periodic breathing may be observed in newborns within the first few days of life and requires close monitoring.

Iron Fortified Formula

The AAP recommends that bottle-fed infants be given iron supple-mentation, because iron levels are low in all types of formula milk. This can be achieved by giving iron-fortified formula from birth. The breastfed infant draws on iron reserves for the first 6 months and then needs iron-rich foods or supplementation added at 6 months of age. The AAP also has recommended that all infants (breast- and bottle-fed) receive a daily supplement of 400 IU of vitamin D starting within the first few days of life to prevent rickets and vitamin D deficiency. It is also recommended that fluoride supplementation be given to infants not receiving fluoridated water after the age of 6 months

Bowel Elimination

The evolution of a stool pattern begins with a newborn's first stool, which is meconium. Meconium is composed of amniotic fluid, shed mucosal cells, intestinal secretions, and blood. It is greenish black, has a tarry consistency, and is usually passed within 12 to 24 hours of birth. The first meconium stool passed is sterile After feedings are initiated, a transitional stool develops, which is greenish brown to yellowish brown, thinner in consistency, and seedy in appearance. Newborns who are fed early pass stools sooner, which helps to reduce bilirubin buildup Thee last development in the stool pattern is the milk stool. Its characteristics differ in breast-fed and formula fed newborns. The stools of the breast fed newborn are yellow-gold, loose, and stringy to pasty in consistency, and typically sour-smelling. The stools of the formula-fed newborn vary depending on the type of formula ingested. They may be yellow, yellow-green, or greenish and loose, pasty, or formed in consistency, and they have an unpleasant odor.

Stomach and Digestion

There is a rapid gain in physiologic capacity during the first 4 days of life. After the first 4 days, the anatomic and physiologic capacities more closely approximate each other. Researchers have found that for the first 24 hours after birth, the newborn's small stomach does not stretch to hold more, as it will even a day or two later. Small, frequent feedings set up a healthy eating pat-tern right from the start The cardiac sphincter and nervous control of the stomach is immature, which may lead to uncoordinated peristaltic activity and frequent regurgitation. Immaturity of the pharyngoesophageal sphincter and absence of lower esophageal peristaltic waves also contribute to the reflux of gastric contents. Avoiding overfeeding and stimulating frequent burping may minimize regurgitation. Limited ability to digest complex car-bohydrates and fats, because amylase and lipase levels are low at birth. As a result, newborns excrete a fair amount of lipids, resulting in fatty stools. Normally, term newborns lose 5% to 10% of their birth weight as a result of insufficient caloric intake within the first week after birth, shifting of intracellular water to extracellular space, and insensible water loss. To gain weight, the term newborn requires an intake of 108 kcal/kg/day from birth to 6 months of age

Transient Tachypnea of the Newborns

Transient tachypnea of the newborn (TTN) is a condition involving a mild degree of respiratory distress. It is described as the retention of lung fluid or transient pulmonary edema. It usually occurs within a few hours of birth and resolves by 72 hours of age. TTN occurs in approximately 0.5% of all live births. Astutely observe the newborn with respiratory distress because TTN is a diagnosis of exclusion. Initially it might be difficult to distinguish this condition from respiratory distress syndrome or group B streptococcal pneumonia, since the clinical picture is similar. However, the symptoms of transient tachypnea rarely last more than 72 hours. Closely assess the newborn for signs of TTN. Within the first few hours of birth, observe for tachy-pnea, expiratory grunting, retractions, labored breathing, nasal flaring, and mild cyanosis. Mild to moderate respiratory distress is present by 6 hours of age, with respiratory rates as high as 100 to 140 breaths per minute. Also inspect the newborn's chest for hyperextension or a barrel shape. Auscultate breath sounds, which may be slightly diminished secondary to reduced air entry. (TTN) is supportive. As the retained lung fluid is absorbed by the infant's lymphatic system, the pulmonary status improves. Nursing management focuses on providing adequate oxygenation and determining whether the newborn's respiratory manifestations appear to be re-solving or persisting. Provide supportive care while the retained lung fluid is reabsorbed. Administer intravenous (IV) fluids and/or gavage feedings until the respiratory rate decreases enough to allow safe oral feeding. Provide supplemental oxygen via a nasal cannula or oxygen hood to maintain adequate oxygen saturation. Maintain a neutral thermal environment with minimal stimulation to minimize oxygen demand.Provide ongoing assessment of the newborn's respiratory status. As TTN resolves, the newborn's respiratory rate declines to 60 breaths per minute or less, the oxygen requirement decreases, and the chest x-ray shows resolution of the perihilar streaking. Provide reassurance and progress reports to the parents to help them cope with this crisis.

Administering Oxygen (ROP)

Use of large concentrations of oxygen and sustained oxygen saturations higher than 95% while on supplemental oxygen have been associated with the development of retinopa-thy of prematurity (ROP) and further respiratory complications in the preterm newborn For these reasons, oxygen should be used judiciously to prevent the development of further complications. A guiding principle for oxygen therapy is it should be targeted to levels appropriate to the condition, gestational age, and postnatal age of the newborn. Current common practice is to maintain oxygen saturations in the high 80s to mid-90s, though a wide variation in practice may still occur

Nursing Assessment of neonatal infection

infants will have some risk factors and the presenting symptoms are many and nonspecific, including poor feeding, breathing difficulty, apneas and bradycardia, gastrointestinal problems, increased oxygen requirement or ventilator support needs, lethargy or hypotension, decreased or elevated temperature, unusual skin rash or color change, persistent crying, or irritability. Adding to the challenge of correctly identifying the infection, the list of conditions to consider in the differential diagnosis is extensive, including metabolic and congenital abnor-malities Nursing assessment focuses on early identification of a newborn at risk for infection to allow for prompt treatment, thus reducing mortality and morbidity. Be aware of the myriad risk factors associated with newborn sepsis. Among the factors that contribute to the newborn's overall vulnerability to infection are poor skin integrity, invasive procedures, exposure to numerous caregivers, and an environment conducive to bacterial colonization. Few newborn infections are easy to recognize because manifestations usually are nonspecific. Early symptoms can be vague because of the newborn's inability to mount an inflammatory response. Often, the observa-tion is that the newborn does not "look right." Assess the newborn for common nonspecic signs of infection, including: Hypothermia Pallor or duskiness Hypotonia Cyanosis Poor weight gain Irritability Seizures Jaundice Grunting Nasal flaring Apnea and bradycardia Lethargy Hypoglycemia Poor feeding (lack of interest in feeding) Abdominal distention Since infection can be confused with other newborn conditions, laboratory and radiographic tests are needed to confirm the presence of infection. Be prepared to coordinate the timing of the various tests and assist as necessary.Evaluate the complete blood count with a differential to identify anemia, leukocytosis, or leukopenia. Elevated C-reactive protein levels may indicate inflam-mation. As ordered, obtain x-rays of the chest and abdomen, which may reveal infectious processes located there. Blood, cerebrospinal fluid, and urine cultures are indicated to identify the location and type of infection present. Positive cultures confirm that the newborn has an infection.