Newborn assessment

physical assessment: umbilical cord

3 vessels- 2 arteries and one vein a single artery may be associated with an increased incidence of congenital anomalies Diameter of cord varies. Quantity of Wharton's jelly may be an indicator of nutritional status Cord begins to dry soon after birth, falls off at 7-10 days redness, foul odor or wetness of the cord may indicate omphalitis Herniation into the umbilical cord is a significant findings. There may be obvious omphalocele - comes off within 7-10 days - usually kids have an innie not an outtie

results of cold stress

ACUTE - hypoglycemia - hypoxia - metabolic acidosis - pulmonary vasoconstriction CHRONIC - impaired weight gain due to consumption of calories for heat production - if the degree and duration of cold stress exceed the infant's ability to compensate, a gradual fall in core temperature will occur accompanied by respiratory failure, heart failure, and eventually death can lead to hypoglycemia can lead to poor weight gain seen with kids who have chronic heart disease and they are not doing as well when core temp drops the enzymes in your body do not function like they should so the baby can crash which then leads to recusitation

physical assessment: abdomen

Cylindrical in shape - concave abdomen may indicate diaphragmatic hernia and/or hypoxia Intestines have reduced blood flow inintially - as the bowel begins to fill with air, normal motility and bowel sounds are present within 15 minutes abdomen - umbilical cord should be odorless and exhibit no intestinal structures - abdomen should be round, dome-shaped, and nondistended - bowel sounds should be present 15-20 min following birth

physical assessment: Head

Head is proportionally larger than the body Molding of the skull bones may occur during vaginal birth "Cone Head" typically resolves over first few days Fontanels: Normall soft and flat - anterior: open, diamond shaped 2-4 cm (1-2in) - posterior: small, triangular, 0.5-1 cm (0.25-0.5 in)

transitional care

The process by which RN can initially assess and care for a newborn in a famly centered environment, during the first and second stages of the transitional period - insures triage of the infant to the appropriate setting: rooming-in, transitional care, or NICU - after the first stage of transition during whih 2 nurses are generally present (1 for mom and 1 for baby), ideally 1 nurse will then care for both mom and baby - facilitates attachment and breastfeeding. - they get them into NICU from the emergency room if need be - this is what nurses do - we look at baby to see if they can go with mom, go to transitional nursery, or if they have to go to NICU - we want to contribute to bonding and breastfeeding but have to make sure baby is okay.

Transition and transitional care

The transition period - during the first hours after birth, the neonate progresses through a predicatable sequence of events, recovering from the stress of birth and adapting to extrauterine life - want to see what the baby does

Measurements - weight - head circumference - chest circumference - length

Weight: 2500-400 gm= 5# 8oz- 8# 13 oz Head circumference: 33-35.5 cm= 13-14 in Chest circumference: 30.5-35 cm= 12-13 in Length: 48-53 cm= 19-21 - head and chest should be about the same or similar

neurological assessment

newborn reflexes - rooting - sucking - swallow - palmar and plantar grasps: tells us if baby has intact CNS - Moro or startle reflex: startle is when you take a large noise and scare kid; moro is when hands should wrap around your when holding - babinski

sequelae of severe cold stress

moderate to severe RDS shock DIC pulmonary hemorrhage - moderate to servere respiratory distress

physical assessment: nose and mouth

- Nares present - sneezing - intact palate with midline uvula - normal frenulum of tongue and upper lip - minimal or absnet salivation - sucking, rooting and gag reflexes present nose - should be midline, flat and broad with lakc of a bridge - some mucus should be present, but with no drainage - newborns are obligate nose breathers and do not develop the resonse of opening the mouth with a nasal obstruction until 3 weeks after birth. Therefore, a nasal blockage can result in flaring of teh nares, cyanosis, or asphayxia - newborns sneeze to clear nasal passages mouth - assess for palate closure and strength of sucking - lip movements should be symmetrical - saliva should be scant. Excessive saliva can indicate a traheosophageal fistula - epstein's pears (small white cysts found on the gums and at the junction of the soft and hard palates) are expected findings. they result from accumulation of epithelial cells and disappear a few weeks after birth - tongue should move freely, be symmetrical in shape, and not protrude. (a protruding tongue can be a sign of down syndrome) - soft and hard palate should be intact - gums and tongue should be pink. Gray-white patches on the tongue and gums can indicate thrush, a fungal infection caused by candida albicans, sometiems acaquired from the mothers vaginal secretions.

transition period: normal newborn findings - skin

- acrocyanosis: vasoconstricted peripheral vessels resulting in a mottled appearance - Petechiae of the face and facial bruising (could probably be due to birth process in a newborn; but in a child it could mean an infection) - smooth, pink to reddish - possible flaking in areas of the major creases - vernix caseosa between folds - languano - cutu smarmorata: transient mottling (if it is there for a long time then it could mean infection but in a newborn it is due to change in autnomic nervous system and should be monitored because it should go away) - erythemia toxicum neonatorum: newborn rash (less perfuse than staff) - discolorations: mongolian spots and stork bites skin - skin color should be pink or acrocyanotic with no jaundice present on the first day. Secondary to increased billirubin, jaundice can appear on the third day of life, but then decrease sontaneously. - skin turgor should be present, showing that the newborn is well hydrated. The skin should spring back immediately when pinched - texture should be dry, soft, and smooth, showing good hydration. cracks in the hands and feet can be present. In full term newborns, desquamation (peeling) occurs a few days after birth. - vernix caseosa (protective, thick cheesy covering) amounts vary, with more present in cresaes and skin folds - Lanugo (fine downy hair) varies regarding the amount present. It is usually found on the pinnae of ears, forehead, and shoulders

Physiology of transition

- effective rhythmic respirations initiated within 30-45 seconds after birth -environmental factors: a relatively cool ambient temperature, tactile stimulation assist in initiating respirations - clamping of umbilical cord causes immediate changes in PaO2 and PaCO2 affecting chemoreceptors and aids in the reflexive initiation of respirations . - when baby is born they cry and take in air - clamp the cord which causes changes in PaO2 and PaCO2

reproductive system adaptations

- enlarged genitalia when they are born - swelling of the breast tissue - anus should be present, patent, and not covered by a membrane - meconium should be passed within 24-48 hours after birth - genitalia of a male newborn should inlude rugae on the scrotum - testes should be present in the scrotum - male urinary meatus is located in teh penile tipe - genitalia of a female should include labia majora covering the labia minora and clitoris, and are usuallly edematous. - vaginal blood tinged discharge can occur in female newborns, which is caused by maternal pregnancy hormones. this is an expected finding - a hymenal tage should be present - urine should be passed within 24 hours after birth. uric acid crustals will produce a rust color in the urine the first couple days of life - scrotum could be swollen from coming through the birth canal - girls may have spotting of blood from hormones- estrogen usually does that - preterm babies the clitoris and majora are usually larger - girls can have some drainage (white or clear)

physical assessment: eyes - eyelids - color of iris - cornea can be... - lacrimal gland and tears

- eyelids usually edematous - color of iris: slate grey, dark blue, or brown - cornea may be clear vs hazy - pupillary response to light and red reflex present - absence of tears - scleral hemorrhages are a common finding - may fix on objects and follow to midline eyes - assess eyes for symetry in size and shape - each eye and the space between the eyes should equal one-third the distance from the inner to the outer canthus of both eyes to rule out chromosomal abnormalities, such as downsyndrome - eyes are usually blue or gray following birht - lacrimal glands are immature, with minimal or no tears - subconjuctival hemorrhages can result from pressure during birth - pupillary and red relfex are present - eyeball movement will demonstrate random, jerky movements

hepatic system changes

- iron storage - carbohydrate metabolism - conjunction of bilirubin - coagulation liver and gallbladder liver conjugates billirubin and takes coagulation factors and helps develop them it is not as well working as adult liver so may not be able to conjugate bilirubin as much which can lead to jaundice blood sugars are usually within 50-60 collostrum is higher in glucose than normal milk

other system adaptations - neuromuscular system - skeletal system - immune system

- not completely myelinated (myelin sheaths) at birth - sometimes baby can twitch at birth - take wrists and pull all the way down and they can touch because the joints are not there but as they get olderthat gets harder and harder to do - baby cannot localize infections which makes them at a higher risk for sepsis

targeted SpO2 after birth

1 minute= 60-65% 2 minutes= 65-70% 3 minutes= 70-75% 4 minutes= 75-80% 5 minutes= 80-85% 10 minutes= 85-95%

Gestational age classifications - AGA - SGA - LGA

AGA: appropriate for gestational age about 80% of the neonatal population SGA: small for gestational age <2500 g or 5# 8 oz in the term neonate LGA: Large for gestational age >4000 g or 8# 13 oz in the term neonate - if 36 weeks gestation and LGA then there can be some problems - can see what gestational age and compare it to weight

Newborn vital signs :HRT - heart rate - respirations - temperature

Admission vital signs include - heart rate (auscultate for 1 minute) 120-160 and regular heart rate 80s to 110s may be normal during sleep respiratory rate (observe for 1 minute) 30-60 breaths per minute, may be irregular Axillary preferred method for temperature 97.9 F- 99.7 F is normal axillary range - core temperature is 1 degree higher - axillary temp will drop more than a core temp - when core temp is low you are in pretty bad shape - axillary is less invasive and better at detecting problems sooner

The heart rate - what should it be normally while awake - what could it be while asleep - sinus bradycardia and associated with what - sinus tachycardia and associated with what - supraventricular tachycardia and associated with what

Heart rate (auscultate for 1 minute) - 120-160 and regular - HR 80s-110s may be normal during sleep - sinus bradycardia: <80 bpm may be associated with cardiac anomalies, sepsis, and/or hypoxemia - sinus tachycardia: heart rate greater than normal for gestational age >180-200 bpm is usually related to activity that creates demands on the heart. Removal of stimulus returns heart rate to baseline. Rarely requires treatment. - Supraventricular tachycardia (SVT) rates up to 200+ bpm cannot be tolerated by the newborn, usually causes CHF within 48 hours - if it drops below 80 they will start doing CPR - can put baby's head in a basin of ice water or can press on eyeball to try and get heart rate down but nurses dont usually push on the eye

change in stooling patterns

Meconium Transitional stools Milk stools - with mechonium stool, they can be seen in first stool; usually an ivory colored and could be indicative of cystic fibrosis but doesn't always mean that - breast fed stool is more frequent and doesnt smell as bad; usually doesn't irritate the baby'sskin as bad; its softer - darker in color and smell bad and worse with bottle fed babies; can also lead to diaper rash

The heart: Murmurs - two types of murmurs

Murmurs: caused by turbulent blood flow and often described as prolonged heart sounds 2 types of murmurs: - innocent: not caused by underlying cardiovascular disease - pathologic: caused by underlying cardiovascular disease Nursing assessment should minimally include: - documentation of presence or absence of heart murmur - the pediatrician or pediatric cardiologist may grade the murmur. While this may also be done by experienced nursing staff, most document a description of the murmur's intensity - good murmurs and bad murmurs - occurs when turbulence is occuring - document if a loud murmur or soft murmur - document how loud it is and when you hear it - ductus arteriois (PDA) is anatomically closed but physically open

Initial meds

Neonatal conjunctivitis, also known as ophthalmis neonatorum, is a form of conjunctivitis contracted by newborns during delivery. The baby's eyes are contaminated during passage through the birth canal from a mother infected with either Neisseria gonorrheae or Chlamydia trachomatis. Opthalmic ointment containing 0.5% erythromycin is typically applied to the newborn's eyes within 1 hour of birth as prophylaxis. If left untreated it can cause blindness. erythromycin - prophylactic eye care is the mandatory instillation of antibiotic ointment into the eyes to prevent opthalmia neonatorum - infections can be transmitted during descent through the birth canal. Ophthalmia neonatorum is caused by Neisseria gonorrhoeae or Chlamydia trachomatis and can cause blindnes Vitamin K - administered to prevent hemorrhagic disorders. Vitamin K is not produced in the gastrointestinal tract of the newborn until around day 7. Vitamin K is produced in the colon by bacteria that forms once formula or breast milk is introduced into the gut of the newborn

Respiratory adaptations - what initiates breathing - transient tachypnea and who is it seen more in and why - what is the normal respiratory rate - how long should periods of apnea be and when do they most occur

Squeeze baby's chest the fluid can come out and then when released the baby starts breathing At first you may hear crackles within a baby because all the fluid may not be out yet... usually within an hour that will go away Transient tachypnea- usually in a C section seen more because they dont have the squeezing of the chest respiratory rate varies from 30-60 breaths/minute with short periods of apnea (less than 15 seconds) occurring most frequently during the rapid eye movement sleep cycle. Periods of apnea lasting longer than 15 seconds should be evaluated. crackles and wheezing are manifestations of fluid or infection in the lungs. grunting and nasal flaring are clinical findings of respiratory distress

Newborn physical assessment overview

a brief physical examination should be performed in the delivery room to rule out obvious congenital anomalies, birth injuries, and cardiorespiratory distress - a more complete examination is performed before 2 hours of age - the infant must be kept warm during the examination a systematic, organinzed approach certain components of a physical exam may need modification to match the infant's state documentation is done in appropirate areas abnormalities noted and reported to physician Auscultation best accomplished on quiet infant warm hadns and stethoscope avoid over mannipulation to avoid dsiturbing the infant if ABC is okay then parents can see baby Within 2 hours an assessment should be done -baby does not always cooperate sometiems such as during reflexes so you may have to come back and do it later

infants most susceptible to cold stress

already stressed infants with severe birth asphyxia, hypoglycemia, RDS or sepsis infants with poor glucose stores, decreased amounts of subcutaneous tissue and little or no brown fat stores (Preterm or SGA)

gestational age: neurological characteristics

although neurological characteristics also progress during pregnancy, these signs can be affected by illness, neurological damage, or other conditions leading to depression in the infant (including the effects of labor and birth) neurological examination is best performed when the infant is 18 to 24 hours old - can be affected by things that happen to the baby such as being depressed by birth

Neutral thermal environment

an environment in which heat production and oxygen consumption are minimized infant target temperatures axillary temp: 36.5 C- 37 C (97.7-98.6 F) skin temp (36.00-36.5) dependent on weight, gestational age and chronological age temperature outside the NTE may result in development of either hypothermia or hyperthermia with serious metabolic consequences - its neutral and thermal - point where using least amount of oxygen as possible

cold stress

an infant responds to cold stimulus with physiologic responses that can present even when the core body temperature is normal - increased oxygen consumption - glucose utilization - acid production utilize oxygen and glucose to help keep them warm

signs and symptoms of cold stress and hypothermia

apnea, bradycardia, tachypnea, poor perfusion acrocyanosis increased oxygen requirement seizures, acidosis, dusky color with crying feeding intolerance, lethargy, irritability, jitteriness, hypoglycemia, cyanosis - increased oxygen requirement means know something is wrong if you have to keep increasing oxygen

APGARS and interventions

assesment begins immediately after birth assessments of - respirations, crying - reflexes, irritability - heart rate, pulse - color, body and extremeties -tone (muscle tone) interventions based upon these assessments to begin immediately Do NOT wait for one minute APGAR to begin interventions - gives you a picture at the time how that baby is doing; a low score you cannot make assumptions - looking at airway, breathing, circulation - look at muscle tone - do it at one minute and five minutes - if you need to do resuscitation then you do it at 10 minutes and then maybe 15 minutes Heart rate: 0= absent 1= slow, less than 100/min 2= greater than 100/min Respiratory rate 0= absent 1= slow, weak cry 2= good cry Muscle tone 0= flaccid 1= some flexion of extremeties 2= well-flexed reflex irritability 0= none 1= grimace 2= cry color 0= blue, pale 1= pink body, cyanotic hands and feet (acrocyanosis) 2= completely pink an apgar score is assigned based on a quick review of systems that is completed at 1 and 5 minutes of life. this allows the nurse to rapidly assess extrauterine adaptation and intervene with appropriate nursing actions 0-3 indicates severe distress 4-6 indicates moderate difficulty 7-10 indicates minimal or no difficulty with adjusting to extrauterine life

physical assessment: chest

chest should be round and symmetrical - asymmetry suggests pneumothorax - barrel chest may indicate diaphragmatic hernia breast enlargement and engorgement may be present - on rare occasions there may be small droplets of breast milk present chest - should be barrel shaped - respirations are primarily diaphragmatic - clavicals should be intact - absence of retractions - nipples should be prominent, well formed, and symmetrical - breast nodules can be 3-10 mm

Cephalohematoma

collection of blood between the peristium and the skull, usually the result of birth trauma firm, tense collection of blood that may increase in size after birth typically in the parietal or occipital areas. usually on one side of the head, but multiple cephalohematomae may be present confined to suture lines usually asymptomatic, but may be associated with newborn jaundice. may take weeks or months to resolve - high incidence of hemorrhage with cephalohematoma - usually resolved with body absorbing the blood - does not cross the suture lines Cephalohematoma - collection of blood between the peristeum and the skull bone that it covers. it does not cross the suture line. it results from trauma during birth such as pressure of the fetal head against the maternal pelvis in a prolonged difficult labor or forcepts delivery. It appears in the first 1 to 2 days after birth and resolves in 2 to 3 weeks

Transition period: normal newborn findings - agranulocytosis - central cyanosis - pallor; with bradycardia, with tachycardia - plethora and associated with what - jaundice that appears within the first 24 hours is usually associated with what

color - mucus membranes are the most reliable indicators of central color - acrocyanosis suggests irritability of peripheral circulation and may be a normal finding within the first 24 hours after birth. It can also be the result of cold, stress, shock or polychythemia - central cyanosis indicates low O2 saturation in the blood usually of cardiac or respiratory origin - pallor at birth refelcts poor perfusion and circulatory failure - pallor associated with bradycardia usually results from anoxia - pallow associated with tachycardia usually indicates anemia - plethora (beet red color) assoiated with polycythemia - jaundice (pathologic) that appears within the first 24 hours, usually related to ABO incompatability - mucous membranes is where you look to tell how well baby is oxygenated - should be pink - acrocyanosis can happen because of birth but is normal within the first 24 hours - too many blood cells: they won't carry as much oxygen b/c no where for it to go which can cause acrocyanosis because even though have extra blood cells not enough oxygen being carried with them - can cause hypoglycemia

Methods of heat loss

convection - heat lost to air or fluid around the infant that is cooler than the infant's temperature (air drafts on infant from open delivery room door) (flow of heat from the body surface to cooler environmental air. place bassinet out of the direct line of a fan or air conditioning vent, swaddle the newborn in a blanket, and keep the head covered. any procedure done with the newborn uncovered should be performed under a radiant heat source.) radiation - heat lost to solid objects near the infant that are cooler than infants temperature (windows to the outside not covered by draperies) (loss of heat from the body surface to a cooler solid surface that is close to, but not in direct contact. keep the newborn and examining tables away from windows and air conditioners) conduction - heat lost to cold surfaces or to objects with which infant comes into contact (loss of body heat resulting from direct contact with a cooler surface. preheat a radiant warmer, warm a stethoscope and other instruments, and pad a scale before weighing the newborn. The newborn should be placed directly on the mother's chest and covered with a warm blanket) Evaporation - heat lost when water evaporates from the infant's skin surface or respiratory tract (infant not dried immediately after birth) (loss of heat as surface liquid is converted to vapor. gently rub the newborn dry with a warm sterile blanket immediatley after delivery. when bathing, expose only one body part at a time, washing and drying throughly.)

behavioral characteristics

crying - strong and lusty - sounds vary in same infant based upon level of discomfort sucking - usually noted within first hour of birth - may suck on fingers, fist or thumb between feedings

interventions to prevent hypothermia

delay first bath until temp is stabalized pre warm radiant warmer and isolettes dry infant immediately after birth (follow NRP guidelines) use and change warm blankets under and around infant frequently close doors to delivery room, surgical suite or nursery and place warmer away from traffic patterns and air drafts maintain room temperature between 75 F and 80 F place hat on infant's head to decrease heat loss (covers 12% of body surface area)

the APGAR score

developed by virginia apgar, MD evaluates five variables on a scale of 0-2 total score ranges from 0-10 assigned at 1 and 5 minutes additional scoring if the 5 minute score is <7 limitations - measures a depression of vital signs - dependent upon subjective evaluation there is some subjectivity; a person is different from another person in scoring

hunger cues.. when do I feed my baby?

early - smacking or licking lips - opening and closing mouth - sucking on lips, tongue, hands, fingers, toes, toys, or clothing active - rooting around on the chest of whoever is carrying him - trying to position for nursing, either by lying back or pulling on your clothes - fidgeting or squirming around a lot - hitting you on the arm or chest repedatedly - fussing or breathing fast late - moving head frantically from side to side - crying

Caput Succedaneum

edema occuring in and under the presenting part of the fetal scalp during birth. Generally due to pressure restricting venous and lymph flow most common form of birth trauma to the head not restricted to suture lines benign and usually resolves in a few days - localized swelling of the soft tissues of the scalp caused by pressure on the head during labor - an expected finding that can be palpated as a soft edematous mass and can cross over the suture line - caput succedaneum usually resolves in three to four days and does not require treatment

physical assessment: Genitals

female - labia and clitoris: edematous - hymental tag often present - labia majora larger than minora - urethral meaturs behind - vaginal discharge male - scrotum large, edematous and pendulous - testes palpable - urethral opening at tip of glands - foresin may be tightly adhered to the glans of the penis (phimosis)

Three stages of the transition period

first stage (0-30 minutes): PERIOD OF REACTIVITY - the newborn is alert, exhibits exploring activity, making sucking sounds, and has a rapid heart rate and respiratory rate. Heart rate can be as high as 160-180/min, but will stabiliize at a baseline of 100-120/min during a period that lasts 30 minutes after birth - very reactive; good for baby to go to skin to skin; after this they will fall asleep and rest second stage (30 minutes- 2 hours): PERIOD OF DECREASED RESPONSIVENESS or PERIOD OF RELATIVE INACTIVITY - the newborn will become quiet and begin to rest and sleep. The heart rate and respirations will decrease, and this period will last from 60-100 min after birth third stage (2 hrs-8hrs): SECOND PERIOD OF REACTIVITY - newborn reawakens, becomes responsive again, and often gags and chokes on mucus that has accumulated in his mouth. This period usually occurs 2-8hrs after birth and can last 10 minutes to several hours

newborn vital signs: B/P

in the normal newborn assessment B/P is no longer recommended by the AAP or AACOG B/P is assessed in cases of persistent heart murmur, abnormal pulses, tachycardia, poor perfusion, abnormal precordial activity and hepatomegaly Normal B/P ranges vary depending upon whether the infant is Term or Preterm and postnatal age B/P are assessed on all 4 extremeties - results from the upper extremeties may be slightly lower than those in the lower extremeties, but should be approximate systolic average range 35-80 mmHg diastolic average range 22-25 mmHg pulse ox should be about the same but BP is usually lower

integumentary system - stork bite - milia - Mongolian spot

milia - small raised white spots on the nose, chin, and forehead - these spots disappear spontaneously without treatment - parents should not squeeze the spots Mongolian spots - bluish purple spots of pigmentation - commonly noted on the shoulders, back, and buttocks - frequentlypresent on newborns who have dark skin - be sure the parents are aware of mongolian spots, and document location and presence Telangiectatic nevi (stork bites) - flat pink or red marks that easily blanch and are found on the back of the neck, nose, upper eyelids, and middle of the forehead - usually fade by the second year of life

transition period: normal newborn findings - activity - lack of flexion associated with what - excessive flexion suggests what - asymmetrical movements suggests what

monitor activity: spontaneous flexion and extension of the extremeties - lack of flexion associated with hypotonia: may be seen in preterm infants or a result of CNS trauma - Excessive flexion suggests Hypertonicity- may be result of CNS trauma - asymmetrical movements of arms, legs, or face may indicate birth injuries

Physical assessment: Neck

neck is short and thick "stork bite" marks may be present at the nape of the neck Tonic Neck reflex: an infant's head is turned to one side, the infant should flex the opposite upper extremity and extend the other upper extremity to the same side the head is turned to neck - should be short, thick, surrounded by skin folds, and exhibit no webbing - neck should move freely from side to side and up and down - absence of head control can indicate prematurity or down syndrome

cardiovascular adaptations - normal heart rate - where and how long do you listen - what do you do with murmurs

normla heart rate ranges from 110-160 per minute with brief fluctuations above and below this range depending on activity level (crying, sleeping). Apical pulse rate is assessed for 1 full minute, preferably when the newborn is sleeping. The pediatric stethoscope head is placed on the fourth or fifth intercostal space at the left midclavicular line over the apex of the newborn's heart. Heart murmurs are documented and reported

physical assessment: respirations and breath sounds

observe, auscultate, or palpate for a full minute respiratory rate: 30-60 breaths per minute - may be irregular during transition, coarse rales and moist tubular sounds may be present until clearing of lung fluid is complete infants are obligate nose breathers - obstruction of nares may lead to respiratory distress and cyanosis signs of respiratory distress - retractions: intercostal, substernal, subcostal, supraternal - mild nasal flaring and grunting common immediately after birth - beyond this period, flaring and retrations suggest respiratory problems: TTN, RDS, Pneumonia - suprasternal retractions may indicate airway obstruction Retractions with high RR means baby could be in respiratory distress

Other system adaptations - renal system - gastrointestinal system (digestion, stools)

palpate the abdomen on each side; kidneys pretty large in a baby - baby should pee but baby's can't concentrate urien as much - specific gravity may be 1.005-1.015 - can develop acidosis and electrolyte imbalance - more at risk for dehydration (urine would be more yellow) GI system - baby can suck and swallow - can manage fats - can take in glucose - term baby should know how to suck and swallow well - takes until about 30 weeks gestation before they start learning - stomach is about the size of a marble - cardiac sphincter (top of stomach; keeps things in) is not as well developed in a baby as they are in an adult - Mechonium is thick and sterile from the baby which can be found in the stool - drugs can also be found in the stools - first 24-48 hours they should have a BM elimination - monitor elimination habits -newborns should void 6-8 times per 24 hours after day 4 - meconium should be passed within the first 24 hours to 48 hours after birth. The newborn will then continue to pass stool 3-4 times a day depending on whether he is being breast or bottle fed - the stools of newborns who are breastfed can appear yellow and seedy. They should have at least 3 stools per day for the first month. These stools arelighter in color and looser than the stools of newborns who are formula fed monitor and document output - keep the perineal area clean and dry. the ammonia in urine is irritating to the sin and can cause diaper rash - after each diaper change, cleanse the perineal area with clear water or water with a mild soap. diaper wipes with alcohol should be avoided. pat, dry, and apply triple antibitoic ointment, petroleum jelly, or zinc oxide, depending on facility protocol.

physical assessment: ears

position: top of pinna is horizontal to outer canthus of eye ( in asian infants the pinna is horizontal to the inner canthus of the eye) - pinna is flexible, well formed cartilage - loud noise should elicit startle reflex - hearing screening is mandatory prior to discharge (usually delayed until 12 hrs after birth due to fluid accumulation in the ear canal) ears - when examining the placement of ears, draw an imaginary line through the inner to the outer canthus of the newborns eye. The eye should be even with the upper tip of the pinna of the newborns ear. Ears that are low set can indicate a chromosome abnormality, such as down syndrome or a kidney disorder - cartilage should be firm and well formed. lack of cartilage indicates prematurity - the newborn should respond to voices and other sounds - inspect ears for skin tags

circumcision - what is it - benefits of it - when should it not be given - nurses role

possible benefits - easier hygiene - decreased risk of UTI - decreased risk of STI - decreased risk of cervical cancers for partners might not be an option for blood-clotting disorders does not affect fertility or sexual pleasure Nurse's role - comfort baby - assist doctor with any supplies - swaddle and return baby to parents - educate parents and continue to observe for bleeding and first void - circumcisions is easier to clean and decreases sexually transmitted infections and other infections - if they have bleeding disorder they usually will not do the circumcision circumcision care - surgical removal of the foreskin of the penis - personal choice made by the newborn's family for reasons of health and hygiene, religious conviction (jewish male on eighth day after birth), tradition, culture, or social norms. Parents should make a well informed decision in consultation with the provider - circumcision should not be done immediately following birth because the newborns level of vitamin K is at a low point, and the newborn would be at risk for hemorrhage Health benefits of circumcision - easier hygiene - decreased risk of urinary tract infections - decreased risk of STI's, including HIV - prevention of penile problems, such as phimosis - decreased risk of penile cancer and cervical cancer in female partners contraindications for circumcision - familiar history of bleeding disorders - newborns who are circumcised and whose parents decline vitamin K can be more likely to experience bleeding at the circumcision site, especially if they are breastfed

transition period: normal newborn findings - posture

posture - general flexion - flexion of the extremeties - breech infants exhibit leg extension - frank breech infants exhibit abduction and external leg rotation

assessment of neurological signs - posture 30 weeks? 34 weeks? 35 weeks? 36-38 weeks?

posture 30 weeks: only slight flexion of feet and knees 34 weeks: thighs and hips are flexed (frog position), but usually the arms remain extended 35 weeks: beginning of arm flexion 36-38 weeks: resting position fully flexed flexion angles and joint mobility - flexion angle decreases as gestational age increases denotes increased joint mobility - square window appears after 31 weeks gestation - dorsiflexion is not noted until 34-35 weeks gestation. this angle decreases until it disappears at term - popliteal angle is directly r/t muscle tone in lower extremeties the greater the gestational age, the smaller the angle - reflexes most helpful in determining gestational age rooting and sucking movements occur at about 34 weeks gestation

other neurological characteristics

posture: generally flexed position similar to position in utero tone - extremeties have brisk recoil to flexion - able to hold head erect momentarily while in sitting position tremors or jitteriness: - quivering or tremors may occur as result of immature nervous system - not always result of hypoglycemia - if a baby is upset and you put them back in a bundle then they should relax - if very hypertonic the baby will keep their head flexed upon lifting them up - with jitteriness it is stronger and more prominent- could indicate hypoglycemia but may not always

gestational age assessment

prenatal factors/examination - LMP - Subject to a woman's ability to correctly recall date and regularity of menses - maternal examination: fundal height - fetal examination: ultrasound reliability of ultrasounds varies by trimester Postnatal - most reliable method of determining gestational age - based upon neurological development and physical characteristics Classification of gestational age allows clinician to anticipate clinical problems and apply early diagnostic testing nursing staff should perform a gestational age assessment on every infant gestational age and classification especially important with a history of little or no prenatal care, no maternal history available, or if the infant appears to be small or large for gestation

equipment used to maintain NTE

radiant warmers - pre warm - if remaining in warmer, Skin probe must be used ("baby mode") - generally set at 36-37 - if infants temp is low set the warmer 0.5 C higher dthan the baby's temp check baby's temp frequently (Q15 min) and raise control temp by 0.5 increments after baby's temp reahches normal range, check temps q 30 minutes until stable incubators/isolettes - pre warm - most isolettes will come with an attached card listing weight and gestational age to provide a recommended starting temperature - have to change temp slow b/c babies do not respond as fast to heat changes

sequence of cold stress response

release of norepinephrine---> stimulates lipolysis in brown fat By products of lipolysis (fatty acids and glycerol) are used as fuel by the liver and mucles Peripheral vasoconstriction --> conservation of core body temp chemical thermogenesis--> lipoplysis and fatty acid oxidation in brown fat produce heat that is released to perfusing blood increased oxygen consumption eventually leads to hypoxia and impaired cellular function Anaerobic metabolism ensues with production of lactic acid and metabolic acidosis Decreased surfactant release and pulmonary vasoconstriction reduecd perfusion of the lungs marked increase in consumption of glucose and breakdown of glycogen stores, leading eventually to hypoglycemia

sleep and activity patterns - what are the six major behavioral states

six major behavioral states outlined by Dr. T Brazelton - deep sleep - quiet sleep -drowsy - quiet alert - active alert - crying identifying infant's behavioral state is helpful in determining the infant's abilility to perceive stimuli and interact with others helpful in teaching mothers to identify feeding cues - be aware of these it helps you to know when to interact with them - with deep sleep you could run a vacuum and not wake him up - quiet alert is where they are alert and you can talk to them - active alert is when they are looking around and wondering why things are the way they are - crying is when they are hungry or wet helping mom know these things can help her know when to interact and care for baby

physical assessment: back

spine intact with openings, masses, curves, dimples or hairy tufts patent anal opening even glutel folds trunk incurvation reflex present spine - should be straight, flat, midline, and easily flexed

initial assessment

stimulate and dry infant Assess ABC's - airway, breathing, circulation Encourage skin-to-skin contact Assign APGAR scores Give erythromycin prophylaxis and vitamin K Keep newborn, mother, and partner together whenever possible - monitor ABC's - if baby seems stable we want to do skin to skin contact - usually give shots in the nursery but can be done in the ER - parents may wish for no separation ever but if the baby needs to be transported you have to do what you have to do The nurse performs a quick initial assessment to review the newborn's systems and to observe for any abnormalities - external assessment: skin color, peeling, birthmarks, foot creases, breast tissue, nasal patency, and meconium straining (can indicate fetal hypoxia) - chest: point of maximal impulse location; ease of breathing; auscultation for heart rate and quality of tonesl and repirations for crackles, wheezes, and equality of bilateral breath sounds - abdomen: rounded abdomen and umbilical cord with one vein two arteries - neurologic: muscle tone and reflex reaction (moro refelx); palpation for the presence and size of fontanels and sutures; assessment of fontanels for fullness of bulge - other observations: inspection for gross structural malformations expected reference ranges: - weight= 2500-4000 g (5.5-8.8 lbs) - length = 45-55 cm (18-22 inches) - head circumference: 32-36.8 cm (12.6-13.5 in) chest circumference : 30-33 cm (12 to 13 in)

physical assessment: extremities

symmetrical full range of motion all 10 fingers and toes present without webbing brachial and femoral pulses present and equal pink nail beds or acrocyanosis creases on anterior 2/3 of sole scarf sign present normal hip abduction without clicks extremeties - assess for full range, symmetry of motion, and spontanteous movement - extremeties should be flexed - assess for bowed legs adn flat feet, which should be present because lateral muscles are more developed than the medial muscles - no click should be heard when abducting the hips -gluteal folds should be symmetrical - soles should be well lined over two thirds of the feet - nail beds should be pink, and no extra digits are present - scarf sign is when take the hand around the opposite shoulder and see how far it goes - check to see if hips are dislocated

Jaundice

the manifestation of the pigment bilirubin in the tissues of the body - phototherapy breaks bonds between bilirubin and fat cells

thermoregulation of the newborn

the means by which a balance is maintained between the amount of body heat lost and the amount of body heat produced significant decrease in temp (<35.8/ 96.5 F) increases oxygen consumption methods of heat production and conservation - heat is generated through oxidation of glucose and free fatty acids Brown fat (unique to newborn) metabolism provides non shivering heat production flexed fetal position decreases body surface whcih minimizes heat loss peripheral vasconstriction - babies have more brown fat which has inervations of the nervous system - also higher in mitochondria then regular fat which makes heat in our body Thermoregulation - provides a neutral thermal environment that helps a newborn maintain a normal core temp with minimal oxygen consumption and caloric expenditure. a newborn has a relatively large surface- to- weight ratio, reduced metabolism per unit area, blood vessels close to the surface, and small amount of insulation - the newborn keeps warm by metabolizing brown fat, which is unique to newborns, but only within a very narrow temperature range. Becomeing chilled (cold stress) can increase the newborns oxygen demands and rapidly use up brown fat reserves. therefore, monitoring temp regulation is important. - monitor for hypothermia in the newborn axilarry temp of less than 36.5 cyanosis increased respiratory rate

prevention and interventions for hyperthermia

use temp charts to preset environmental temps on isolettes bathe infant use skin probes and appropriate skin probe covers (reflectant is best)