PART 2 Mat nursing
Eye care
Instill antibiotic ointment or solution in eyes as soon as possible after delivery to prevent ophthalmia neonatorum. Recommended giving within an hour from birth
Lips and palate
Intact- cleph platae, sucking reflex Epstein's pearls- white bumps
Quiet state
Looking around Checking everything out Begins to focus on something then either start crying or go to sleep
Pulse
Accurate pulses may be difficult to obtain Radial, carotid, popliteal, pedal pulses Take apical pulse for one minute Adult range reached by age 16 years
Vitamin K
Administer intramuscularly within 1 hour after delivery to prevent hemorrhagic disorders
Ears
Aligned with outer canthus of eye
Umbilical cord care
Apply clamp 1 in. from skin.Assess for redness or drainage with every diaper change.Alcohol or triple dye may be applied to cord for drying. Not any more in most facilities. Cord should fall off in ~14 days. Sponge baths only until the cord falls off.
Temperature
Axillary, rectal, oral Use electronic, tympanic thermometer, or chemical tapes Normal temperature ranges are same as for adult
Thermoregulation - Methods of Heat
Cold stress Convection Radiation Evaporation Conduction
Neonates must produce and maintain enough heat to prevent cold stress
Cold stress can have serious and even fatal effects to the neonates.
Skin
Ecchymosis, petechiae,pinpoint hemorrhages )after difficult delivery Vernix caseosa,Lanugo,Physiologic jaundice,Mongolian spot,Telangiectatic nevi or stork bite,Milia, Erythema toxicum neonatorum
Tonic neck reflex
Elicited by rotating the infants head from midline to one side. The infant should respond by extending the arm on the side to which the head is turned and flexing the opposite arm. The lower extremities respond similarly.
Palmar/Plantar grasp reflex
Elicited by the examiner placing his finger on the palmar surface of the infant's hand and the infant's hand grasps the finger. Attempts to remove the finger result in the infant tightening the grasp
Rooting reflex
Elicited by the examiner stroking the cheek or corner of the infant's mouth. The infant's head turns toward the stimulus and opens its mouth
Sucking reflex
Elicited by the examiner stroking the lips of the infant; the infant's mouth opens and the examiner introduces their gloved finger and sucking starts. This reflex does not begin until about the 32nd week of pregnancy and is not fully developed until about 36 weeks. Premature babies may have a weak or immature sucking ability because of this.
Stepping reflex
Elicited by touching the top of the infant's foot to the edge of a table while the infant is held upright. The infant makes movements that resemble stepping.
Sleep state
Eyes closed 20 to 22 hours per day Periods of REM (rapid eye movement) May startle or jerk
Crying
Method of communication The only method Indicates needs: Hungry Wet Cold
Signs
Nasal flaring Expiratory grunting Retractions (intercostal, subcostal, substernal) Apneic spells Tachypnea RR >60 Central cyanosis
Chest
Nipples may secrete whitish fluid (witches' milk)Heart murmurs may be normal Diaphragmatic breathing pattern Respirations are irregular with brief periods of apnea
Respirations
Observe abdomen for diaphragmatic respirations!!!!!!!!!! Report respirations greater than 60 Adult ranges reached by 16 years
Nose
Patent and flattened
Pain
Physiological responses to pain Tachycardia, tachypnea, pupil dilation, pallor
Discuss the Apgar score
Rapid evaluation of the infant's adaptation to life.Assessed at 1 minute and 5 minutes of age Score of 0 to 2 is assigned for the following: Heart rate Respiratory rate Muscle tone Reflex irritability Color
Environmental conditions in the delivery room
temperature and the ambient temperature of delivery room, air flow through the room, and contact with cold surfaces that lead to significant evaporative, radiant, convective, and conductive heat losses
Indicators of pain
Restlessness, short attention span, sleep disturbance,Facial grimacing, crying, posturing, anorexia
Neck
Short, with several skin folds- looking for fat folds nuacal fold
Behavioral States of the Neonate
Sleep state Quiet alert Crying
Eyes
Strabismus- creepy eye movment Small hemorrhages in sclera
Delivery room care
Suction airway. Monitor respiratory status. Monitor for circulatory changes. Begin thermoregulation to prevent cold stress. Heat loss by convection, radiation, evaporation, conduction,Assign Apgar score and Ballard score.Apply identification bands and footprint,Obtain height and weight; measure head and chest
Extremities
Symmetrical bilaterally Five digits without webbing or syndactyly Muscle tone strong, with full range of motion Femur seated in acetabulum
Moro or startle reflex
The examiner holds the infant so that one hand supports the head and the other supports the buttocks. The reflex is elicited by the sudden dropping of the head in her hand. The response is a series of movements: the infant's hands open and there is extension and abduction of the upper extremities. This is followed by anterior flexion of the upper extremities. An absent or inadequate Moro response on one side : hemiplegia, brachial plexus palsy, or a fractured clavicle
Female Genitalia
The female genitals may be slightly swollen Blood-tinged mucus may be discharged from the vagina 3 to 5 days after birth (pseudomenstruation
Respiratory System
The first breath taken helps expand the collapsed lungs The physician assists the first respiration by holding the infant's head down and removing mucus from the passages to the lungs The newborn's cry should be strong and healthy The most critical period for the neonate is the first hour of life, when the drastic change from life within the uterus to life outside the uterus takes place
Meconium
The first stool; is a mixture of amniotic fluid and secretions of the intestinal glands It is dark green, thick, and sticky, is passed 8 to 24 hours after birth, and continues for about 3 days
Male Genitalia
The genitals are undeveloped at birth The testes of the male child descend into the scrotum before birth Undescended testicle(s) not always an abnormal finding! May continue to descend into scrotum up to 2-3 months after delivery. The penis is covered by a sleeve of skin called the foreskin or prepuce
Radiation
The transfer of heat to cooler objects that are not in direct contact with the neonate is called the heat loss by radiation. When infants are placed near cold windows or walls heat is lost by radiation. Even neonates placed in incubators losses heat to the walls of the incubator if it is cold even if the surrounding air temperature is warm. Ways to prevent heat loss by radiation: Incubators must have double walls. Cribs and incubators should be placed away from the walls and windows.
Conduction
When a neonate comes in direct contact with an object cooler than their skin heat loss by conduction occurs. Heat loss by conduction occurs when an infant is placed on a cooler surface or touching them with a cool object or hands. Ways to prevent heat loss by conduction: Warming the objects that will touch an infant. Placing an infant against the mother's skin helps prevent conductive heat loss.
Convection
When heat is transferred to the air surrounding the infant heat loss by convection takes place. If an air conditioner is kept on or when people move around near the infant increase loss of heat occurs. Ways to prevent heat loss by convection: Keeping the newborn out of drafts. Maintaining warm environmental temperature. Keeping a preterm neonate in an incubator.
Evaporation
When wet surfaces are exposed to the air evaporation occurs. Heat is lost when the surface dries. At birth the neonate is bathed with amniotic fluid. As the amniotic fluid dries up on the infant's skin (evaporation), the infant loses heat. The same occurs in bathing an infant. Ways to prevent heat loss by evaporation: Drying the infant as quickly as possible after birth. Drying the infant immediately after bathing.
Babinski reflex
stroking the lateral aspect of the plantar surface of the foot is extension of the great toe and fanning of the other toes.