OB exam 3

Cord care p595 teaching guidelines 18.2

-observe for bleeding, redness, drainage, or foul odor from cord stump and report it to your newborn's pcp 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 fal off naturally

Care of the LGA (large for gestational age) Newborn 808

A newborn whose weight is above the 90th percentile on growth charts or two standard deviations above the mean weight for gestational age is defined as LGA. 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. Note:: Diabetes is commonly associated with LGA new-borns. However, due to poor placental perfusion, the newborn may experience IUGR and be SGA Nursing assessment: Assessment of the LGA newborn begins with a review of the maternal history, which can provide clues as to whether the woman has an increased risk of giving birth to an LGA newborn. Maternal factors that increase the chance of bearing an LGA newborn include diabetes mellitus or glucose intolerance, multi-parity, prior history of a macrosomic infant, postdates gestation, maternal obesity, male fetus, and genetics. At birth, assess the newborn for common characteristics. The typical LGA newborn has a large body and appears plump and full-faced. The increase in body size is proportional. However, the head circumference and body length are in the upper limits of intrauterine growth. These newborns have poor motor skills and have diffculty in regulating behavioral states. LGA newborns are more diffcult to arouse to a quiet alert state.Thoroughly assess the LGA newborn at birth to identify traumatic birth injuries such as fractured clavicles, brachial palsy, facial paralysis, phrenic nerve palsy, skull fractures, or hematomas. Perform a neurologic examination to identify any nerve palsies, looking for abnormalities such as immobility of the upper arm. Observe and document any injuries discovered to allow for early intervention and improved outcomes. LGA infants are at risk for hypoglycemia related to early depletion of glycogen stores in their liver. Obtain frequent blood glucose levels as ordered to evaluate for hypoglycemia. The clinical signs are often subtle and include lethargy, apathy, drowsiness, irritability, tachypnea, weak cry, temperature instability, jitteriness, seizures, apnea, bradycardia, cyanosis or pallor, feeble suck and poor feeding, hypotonia, and coma. Other disorders, including septicemia, severe respiratory distress, and congenital heart disease, may present with similar findings. In addition, be alert for other common problems, such as polycythemia and hyperbilirubinemia (see Table 23.1). Nursing Management: Hypoglycemia in a neonate is defined as blood glucose value below 40 mg/dL. It is commonly associated with a variety of neonatal conditions like prematurity, intrauterine growth restriction, and maternal diabetes. Screening for hypoglycemia in high-risk LGA infants is essential. Supervised breast-feeding or formula feeding may be initial treatment options in asymptomatic hypoglycemia. However, symptomatic hypoglycemia should always be treated with a continuous infusion of parenteral dextrose. LGA infants needing dextrose infusion rates above 12 mg/kg/min should be investigated for a definite cause of hypoglycemia. Hypoglycemia has been linked to poor neurodevelopmental outcome, and hence aggressive screening and treatment is recommended. Assist in stabilizing the LGA newborn. Monitor blood glucose levels within 30 minutes of birth and repeat the screening every hour. Recheck levels before feedings and also immediately in any infant suspected of having or showing clinical signs of hypoglycemia, regardless of age. To help prevent hypoglycemia, initiate feedings, which can be formula or breast milk, with intravenous glucose supplementation as needed. Monitor and record intake and output and obtain daily weights to aid in evaluating nutritional intake.Observe for signs of polycythemia and hyperbilirubinemia and report any immediately to the health care provider so that early interventions can be taken to prevent poor long-term neurologic development outcomes. Polycythemia and hyperviscosity are associated with fine and gross motor delays, speech delays, and neurologic sequelae. Inreasing fluid volume aids in decreasing blood viscosity. Partial exchange transfusion with plasma or normal saline may be used to lower hematocrit and decrease blood viscosity, but this treatment remains controversial. Hydration, early feedings, and phototherapy are used to treat hyperbilirubinemia. Provide parental guidance about the treatments and procedures being done and about the need for follow up care for any abnormalities identified.

Postterm newborn p809

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.The reason why some pregnancies last longer than others is not completely understood. What is known is that women who experience one postterm pregnancy are at increased risk in subsequent pregnancies. The in-cidence of prolonged pregnancy, beyond 42 weeks, is approximately 5.5% (Sielski, 2012).The ability of the placenta to provide adequate oxy-gen and nutrients to the fetus after 42 weeks' gestation is thought to be compromised, leading to perinatal mortality and morbidity. After 42 weeks, the placenta begins aging. Deposits of brin and calcium, along with hemorrhagic infarcts, occur and the placental blood vessels begin to degenerate. All of these changes affect diffusion of oxy-gen to the fetus. As the placenta loses its ability to nourish the fetus, the fetus uses stored nutrients to stay alive, and wasting occurs. This wasted appearance at birth is sec-ondary to the loss of muscle mass and subcutaneous fat. Nursing Assessment: A thorough assessment of the postterm newborn upon admission to the nursery provides a baseline from which to identify changes in clinical status. Review the maternal history for any risk factors associated with postterm birth. Also be aware of the common physical characteristics and be able to identify any deviation from the expected. 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 Assess the newborn's gestational age and complete a physical examination to identify any abnormalities. Review the medical record to determine the color of the amniotic fluid when membranes ruptured and observe for a meconium-stained umbilical cord and fingernails to assess for possible meconium aspiration. Careful suctioning at the time of birth and afterwards, if the condition dictates it, reduces the incidence of meconium aspiration. Also be alert for other typical complications associated with a postterm newborn, such as perinatal asphyxia (caused by placental aging or oligohydramnios [decreased amniotic fluid]), hypoglycemia (caused by acute episodes of hypoxia related to cord compression 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 (see Table 23.1). Nursing management: The birth of a postterm newborn may create stress for the mother and her family. In most situations, birth of a newborn requiring special care was not anticipated. Postterm newborns are susceptible to several birth challenges secondary to placental dysfunction that place them at risk for asphyxia, hypoglycemia, and respiratory distress. The nurse must be vigilant for complications when managing these newborns.The postterm newborn is at high risk for perinatal asphyxia, which is usually attributed to placental deprivation or oligohydramnios that leads to cord compression, thereby reducing perfusion to the fetus. Anticipating the need for newborn resuscitation is a priority. The newborn resuscitation team needs to be available in the birthing suite for immediate backup. The newborn may require transport to the neonatal intensive care unit (NICU) for continuous assessment, monitoring, and treatment, depending on his or her status after resuscitation.Monitor and maintain the postterm newborn's blood glucose levels once stabilized. Intravenous dextrose 10% and/or early initiation of feedings will help stabilize the blood glucose levels to prevent central nervous system sequelae.Also monitor the postterm newborn's skin temperature, respiration characteristics, results of blood studies, such as arterial blood gases (ABGs) and serum biliru-bin levels, and neurologic status. Institute measures to prevent or reduce the risk of hypothermia by eliminating sources of heat loss: thoroughly dry the newborn at birth, wrap him or her in a warmed blanket, and place a stockinet cap on the newborn's head. Providing environmental warmth via a radiant heat source will help stabilize the newborn's temperature.Closely assess all postterm newborns for polycythemia which contributes to hyperbilirubinemia due to red blood cell destruction. Providing adequate hydration helps to reduce the viscosity of the newborn's blood to prevent thrombosis. Be alert to the early, often subtle signs to promote early identification and prompt treatment to prevent any neurodevelopmental delays

Behavioral Patterns of the newborn p563-564

First period of reactivity: Birth to 30 minutes after birth Newborn is alert, moving, may appear hungry Period of decreased responsiveness 30 minutes to 120 minutes old Period of sleep or decreased activity Second period of reactivity: 2 to 8 hours Newborn awakens and shows an interest in stimuli

Vital Signs p570-571

Temperature 97.7-99.5° F (36.5-37.5° C) Heart rate (pulse) to 180 during crying 120-160 bpm; can increase Respirations 30-60 breaths/minute at rest; will increase with crying Blood pressure 50-75 mm Hg systolic, 30-45 mm Hg diastolic

Iron Fortified Formula p605

he AAP (2010g) recommends that bottle-fed infants be given iron supplementation, because iron levels are low in all types of formula milk. This can be achieved by giving iron-fortified formula from birth. The breast-fed infant draws on iron reserves for the rst 6 months and then needs iron-rich foods or supplementation added at 6 months of age. The AAP (2010g) 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

Intraventricular Hemorrhage p843-844

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 oc-curs 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 in-jury resulting from inadequate perfusion of the white matter adjacent to the ventricles), cerebral palsy, learning disabilities, vision or hearing deficits, and cognitive impairment. Pathophysiology: The preterm newborn is at greatest risk for IVH because cerebral vascular development is immature, making it more vulnerable to injury. The earlier the newborn is, the greater the likelihood for brain damage. While all areas of the brain can be injured, the periventricular area is the most vulnerable .Each ventricular area contains a rich network of capillaries that are very thin, fragile, and easily ruptured. The causes of rupture vary and include fluctuations in systemic and cerebral blood ow, increases in cerebral blood flow from hypertension, IV infusions, seizure activity, increases in cerebral venous pressure due to vaginal delivery, hypoxia, and respiratory distress. With a preterm birth, the fetus is suddenly transported from a well-controlled uterine environment into a highly stimulating one. This tremendous physiologic stress and shock may contribute to the rupture of periventricular capillaries and subsequent hemorrhage. Most hemor-rhages occur in the first 72 hours after birth. 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) Nursing assessment: 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. Nursing management: Prevention of preterm birth is essential in preventing IVH. Identify risk factors that can lead to hemorrhage, and focus care on interventions to decrease the risk of hemorrhage. For example, institute measures to prevent perinatal asphyxia and birth trauma and provide developmental care in the NICU. If a preterm birth is expected, having the mother deliver at a tertiary care facility with a NICU would be most appropriate.Care of the newborn with IVH is primarily supportive. 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. Minimize handling of the newborn by clustering nursing care, and limit stimulation in the newborn's environment to reduce stress. Also reduce the newborn's exposure to noxious stimuli to avoid a fluctuation in blood pressure and energy expenditure. Provide adequate oxygenation to promote tissue perfusion but controlled ventilation to decrease the risk of pneumothorax. Support for the parents to cope with the diagnosis and potential long-term sequelae is essential. The long-term neurodevelopmental outcome is determined by the severity of the bleed. Provide education and emotional support for the parents throughout the newborn's stay. Discuss expectations for short-term and long-term care needs with the parents and assist them in obtaining the necessary support from appropriate community resources.

Transient tachypnea of the newborn p837

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. Lower gestational age, cesarean birth, and male sex are independent risk factors for TTN. Performing elective cesarean sections no earlier than 38 weeks' gestation may decrease the risk of TTN. Labor before a cesarean section is not sufcient to decrease the frequency of TTN, even after 37 weeks of gestation, whereas vaginal birth appears be protective against it. Pathophysiology: Most newborns make the transition from fetal to new-born life without incident. During fetal life, the lungs are filled with a serous fluid because the placenta, not the lungs, is used for nutrient and gas exchange. During and after birth, this fluid must be removed and replaced with air. An infant born by cesarean birth is at risk of having excessive pulmonary fluid as a result of not having experienced all of the stages of labor. Passage through the birth canal during a vaginal birth compresses the thorax, which helps remove the majority of this fluid. Pulmonary circulation and the lymphatic drainage remove the remaining fluid shortly after birth. TTN occurs when the liquid in the lung is removed slowly or incompletely. Nursing assessment: 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. Health history and physical examination: Review the perinatal history for risk factors related to TTN such as absence of labor, cesarean birth, precipitous delivery, macrosomia, male gender, or maternal asthma. Closely assess the newborn for signs of TTN. Within the first few hours of birth, observe for tachypnea, 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. Nursing management: Management of transient tachypnea of the newborn (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.

Respiration p554

After respirations are established in the newborn, they are shallow and irregular, ranging from 30 to 60 breaths per minute, with short periods of apnea (less than 15 seconds). The newborn's respiratory rate varies according to his or her activity; the more active the newborn, the higher the respiratory rate, on average. Signs of respiratory distress to observe for include cyanosis, tachypnea, expiratory grunting, sternal retractions, and nasal flaring. Respirations should not be labored, and the chest movements should be symmetric. 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. Take Note:Apneic periods lasting more than 15 seconds with cyanosis and heart rate changes require further evaluation

Newborn reflexes p588-592

Assess the newborn's reexes to evaluate neurologic function and development. Absent or abnormal reflexes in a newborn, persistence of a reflex past the age when the reflex is normally lost, or return of an infantile reflex in an older child or adult may indicate neurologic pathology (Table 18.4). 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 reflex (anal wink).The sucking reflex is elicited by gently stimulating the newborn's lips by touching them. The newborn will typically open the mouth and begin a sucking motion. Placing a gloved finger in the newborn's mouth will also elicit a sucking motion (Fig. 18.17A).The Moro reflex, also called the embrace reflex, occurs when the neonate is startled. To elicit this reflex, place the newborn on his or her back. Support the upper body weight of the supine newborn by the arms, using a lifting motion, without lifting the new-born off the surface. Then release the arms suddenly. The newborn will throw the arms outward and flex the knees; the arms then return to the chest. The fingers also spread to form a C. The newborn initially appears startled and then relaxes to a normal resting position. Assess the stepping reflex by holding the newborn upright and inclined forward with the soles of the feet touching a at surface. The baby should make a step-ping motion or walking, alternating flexion and exten-sion with the soles of the feet (see Fig. 18.17C).The tonic neck reflex resembles the stance of a fencer and is often called the fencing reflex. Test this reflex by having the newborn lie on the back. Turn the baby's head to one side. The arm toward which the baby is facing should extend straight away from the body with the hand partially open, whereas the arm on the side away from the face is flexed and the first is clenched tightly. Reversing the direction to which the face is turned reverses the position (see Fig. 18.17D) Elicit the rooting reflex by stroking the newborn's cheek. The newborn should turn toward the side that was stroked and should begin to make sucking movements (see Fig. 18.17E).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. The toes should fan out. A diminished response indicates a neurologic problem and needs follow-up (see Fig. 18.17F).The newborn exhibits two grasp reexes: palmar grasp and plantar grasp. Elicit the palmar grasp reflex by placing a finger on the newborn's open palm. The baby's hand will close around the finger. Attempting to remove the finger causes the grip to tighten. Newborns have strong grasps and can almost be lifted from a flat surface if both hands are used. The grasp should be equal bilaterally (see Fig. 18.17G). The plantar grasp is similar to the palmar grasp. Place a finger just below the newborn's toes. The toes typically curl over the finger (see Fig. 18.17H).Blinking, sneezing, gagging, and coughing are all protective reflexes and are elicited when an object or light is brought close to the eye (blinking), something irritating is swallowed or a bulb syringe is used for suctioning (gagging and coughing), or an irritant is brought close to the nose (sneezing).The truncal incurvation reflex (Galant reflex) is present at birth and disappears in a few days to 4 weeks (Fig. 18.18). With the newborn in a prone position or held in ventral suspension, apply firm pressure and run a finger down either side of the spine. This stroking will cause the pelvis to flex toward the stimulated side. This indicates T2-S1 innervation. Lack of response indicates a neurologic or spinal cord problem.The anocutaneous reflex (anal wink) is elicited by stimulating the perianal skin close to the anus. The external sphincter will constrict (wink) immediately with stimulation. This indicates S4-S5 innervations

PKU table p600

Description: Autosomal recessive inherited deficiency in one of the enzymes necessary for the metabolism of phenylalanine to tyrosine—essential amino acids found in most foods Clinical Picture/Effect if not treated: 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 Treatment: Lifetime diet of foods low in phenylalanine (low protein) and monitoring of blood levels; special newborn formulas avail-able: Phenex and Lofenalac Timing of screening: Universally screened for in the United States; testing is done 24-48 hours after protein feeding (PKU)

Respiratory distress syndrome (RDS) p837-840 and lecture notes

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 of synthetic surfactant can be credited with the dramatic improvements in the outcome of newborns with RDS. RDS affects an estimated 20,000 to 30,000 infants born alive in the United States annually. The incidence declines with degree of maturity at birth. It occurs in 50% of preterm newborns born at 26 to 28 weeks' gestation, and in 30% of those born at 30 to 31 weeks. Intensive respiratory care, usually with mechanical ventilation, is necessary. Pathophysiology: Lung immaturity and surfactant deficiency contribute to the development of RDS. Surfactant is a complex mixture of phospholipids and proteins that adheres to the alveolar surface of the lungs. Anatomically, the immature lung cannot support oxygenation and ventilation, because the alveolar sacs are insufficiently developed, causing a deficient surface area for gas exchange. Physiologically, the amount of surfactant is insufficient to prevent collapse of unstable alveoli. Surfactant forms a coating over the inner surface of the alveoli, reducing the surface tension and preventing alveolar collapse at the end of expiration. In the affected newborn, surfactant is deficient or lacking, and this deficit results in stiff lungs and alveoli that tend to collapse, leading to diffuse atelectasis. The work of breathing is increased because increased pressure similar to that required to initiate the first breath is needed to inflate the lungs with each successive breath. Hypoxemia and acidemia result, leading to vasoconstriction of the pulmonary vasculature. Right-to-left shunting occurs and alveolar capillary circulation is limited, further inhibiting surfactant production. As the disease progresses, fluid and fibrin leak from the pulmonary capillaries, causing hyaline membranes to form in the bronchioles, alveolar ducts, and alveoli. These membranes further decrease gas exchange. These factors decrease the total surface area of the gas exchange membrane. The end result is hypoxemia, academia, and a worsening respiratory distress. A vicious cycle is created, compounding the problem. Nursing assessment: 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. History and physical examination: 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 squeezing), male gender, and maternal diabetes. Take Note:: Prolonged rupture of membranes, gestational or chronic maternal hypertension, maternal narcotic addiction, and use of prenatal corticosteroids reduce the new-born's risk for RDS because of the physiologic stress imposed on the fetus. Chronic stress experienced by the fetus in utero accelerates the production of surfactant before 35 weeks' gestation and thus reduces the incidence of RDS at birth. The newborn with RDS usually demonstrates signs at birth or within a few hours of birth. Observe the infant for expiratory grunting, nasal aring, 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).The Silverman-Anderson Index is an assessment scoring system that can be used to evaluate five parameters 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 Laboratory and diagnostic testing: The diagnosis of RDS is based on the clinical picture and x-ray findings. A chest x-ray reveals hypoaeration, underexpansion, and a "ground glass" pattern. Nursing management: f untreated, RDS will worsen. In many infants respiratory symptoms decline after 72 hours, paralleling the production of surfactant in the alveoli. The newborn needs supportive care until surfactant is produced. Effective therapies for established RDS include conventional mechanical ventilation, continuous positive airway pres-sure (CPAP), or positive end-expiratory pressure (PEEP) to prevent volume loss during expiration, and surfactant therapy. The use of exogenous surfactant replacement therapy to stabilize the newborn's lungs until postnatal surfactant synthesis matures has become a standard of care, but not necessarily evidence-based.Despite recent advances in the perinatal management of neonatal respiratory distress syndrome (RDS), controversies still exist. Strong evidence exists for the role of a single course of prenatal steroids in RDS prevention, but the potential benefit and long-term safety of repeated courses are unclear. Many practices involved in preterm neonatal stabilization at birth are not evidence-based, including oxygen administration and positive-pressure lung inflation, and they may at times be harmful. Surfactant replacement therapy is crucial in the management of RDS, but the best preparation, optimal dose and timing of administration at different gestations is not always clear. Respiratory sup-port in the form of mechanical ventilation may also be lifesaving, but can cause lung injury, and protocols should be directed at avoiding mechanical ventilation where possible by using nasal continuous positive air-way pressure or nasal ventilation. For newborns with RDS to have best outcomes, it is essential that they have optimal supportive care, including maintenance of a normal body temperature, proper uid management, good nutritional support, and support of the circulation to maintain adequate tissue perfusio.As recommended, care of the newborn with RDS is primarily supportive and requires a multidisciplinary approach to obtain the best outcomes. Therapy focuses on improving oxygenation and maintaining optimal lung volumes. Expect to transfer the newborn to the neonatal intensive care unit (NICU) soon after birth. Apply the basic principles of newborn care, such as thermoregulation, cardiovascular and nutritional support, normal glucose level maintenance, and infection prevention, to achieve the therapeutic goals of reducing mortality and minimizing lung trauma.Anticipate the administration of surfactant replacement therapy, prophylactically or as a rescue approach. With prophylactic administration, surfactant is given within minutes after birth, thus providing replacement surfactant before severe RDS develops. Rescue treatment is indicated for newborns with established RDS who require mechanical ventilation and supplemental oxygen. The earlier the surfactant is administered, the better the effect on gas exchange. Surfactant therapy in treating RDS has been well studied through random controlled research studies. A recent Cochran meta-analysis review showed in-creased survival rates, improved oxygenation and ventilation, and a decreased incidence of pneumothorax with the administration of surfactant for respiratory distress syndrome. Administer the prescribed oxygen concentration via nasal cannula. Anticipate the need for ventilator therapy, which has greatly improved in the past several years, with significant advances in conventional and high- frequency ventilation therapies (Fig. 24.4). Recent studies show no difference in outcomes for newborns who received early treatment with high-frequency oscillatory ventilation compared with those receiving conventional mechanical ventilation. Although mechanical ventilation has increased survival rates, it is also a contributing factor to bronchopulmonary dysplasia, pulmonary hypertension, and retinopathy of prematurity. In addition, support the newborn with RDS using the following interventions: - Continuously monitor the infant's cardiopulmonary status via invasive or noninvasive means (e.g., arterial lines or auscultation, respectively). - Monitor oxygen saturation levels continuously; assess pulse oximeter values to determine oxygen saturation levels. - Closely monitor vital signs, acid-base status, and arterial blood gases. - Administer broad-spectrum antibiotics if blood cultures are positive. - Administer sodium bicarbonate or acetate as ordered to correct metabolic acidosis. - Provide fluids and vasopressor agents as needed to prevent or treat hypotension. -Test blood glucose levels and administer dextrose as ordered for prevention or treatment of hypoglycemia. -Cluster caretaking activities to avoid overtaxing and compromising the newborn. - Place the newborn in the prone position to optimize respiratory status and reduce stress. -Perform gentle suctioning to remove secretions and maintain a patent airway. - Assess level of consciousness to identify intraventricular hemorrhage. -Provide sufficient calories via gavage and IV feedings. - Maintain adequate hydration and assess for signs of fluid overload. - Provide information to the parents about treatment modalities; give thorough but simple explanations about the rationales for interventions. -Encourage the parents to participate in care Provide ongoing assessment and be alert for complications. These may include air leak syndrome, bronchopulmonary dysplasia (chronic lung disease), patent ductus arteriosus, congestive heart failure, intraventricular hemorrhage, retinopathy of prematurity, necrotizing enterocolitis, complications resulting from intravenous catheter use (infection, thrombus formation), and developmental delay or disability.

Bathing and hygiene p592

-Gloves -Plain water on face and eyes; mild soap for rest of body 1.Begin the newborn bath starting from the cleanest area (the eyes) and proceeding to the most soiled area (the diaper area) to prevent cross- contamination. Use plain warm water on the face and eyes, adding a mild soap (e.g., Dove) to cleanse the remainder of the body. Wash, rinse, and dry each area before proceeding to the next one 2.Wash the hair using running water so that the scalp can be thoroughly rinsed. A mild shampoo or soap can be used. Wash both fontanel areas. Frequently parents avoid these "soft spots" because they fear that they will "hurt the baby's brain" if they rub too hard. Reassure parents that there is a strong membrane providing protection. Urge the parents to clean and rinse these areas well. If the anterior fontanel is not rinsed well after shampooing, cradle cap (dry flakes on the scalp) can develop. 3.Make sure to cleanse all body creases, especially the neck folds to remove any milk that may have dripped into these areas 4.Continue downward washing the trunk and extremities ending up with the diaper area last

Breastfeeding guidelines 18.4 p612

-Set aside a quiet place where you can be relaxed and won't be disturbed. Relaxation promotes milk letdown. - Sit in a comfortable chair or rocking chair or lie on a bed. Try to make each feeding calm, quiet, and leisurely. Avoid distractions. - Listen to soothing music and sip a nutritious drink during feedings. -Initially, nurse the newborn every few hours to stimulate milk production. Remember that the supply of milk is equal to the demand—the more sucking, the more milk. - Watch for signals from the infant to indicate that he or she is hungry, such as:Nuzzling against the mother's breasts, Demonstrating the rooting reflex by making sucking motions,Placing first or hands in mouth to suck on, Crying and squirming, Smacking the lips - Stimulate the rooting reflex by touching the new-born's cheek to initiate sucking. - Look for signs indicating that the newborn has latched on correctly: wide-open mouth with the nipple and much of the areola in the mouth, lips rolled outward, and tongue over lower gum, visible jaw movement drawing milk out, rhythmic sucking with an audible swallowing (soft "ka" or "ah" sound indicates the infant is swallowing milk). -Hold the newborn closely, facing the breast, with the newborn's ear, shoulder, and hip in direct alignment. - Nurse the infant on demand, not on a rigid schedule. Feed every 2 to 3 hours within a 24-hour period for a total of 8 to 12 feedings. -Alternate the breast you offer first; identify with a safety pin on bra. - Vary your position for each feeding to empty breasts and reduce soreness. -Look for signs that the newborn is getting enough milk: At least six wet diapers and two to five loose yellow stools daily, Steady weight gain after the first week of age, Pale-yellow urine, not deep yellow or orange, Sleeping well, yet looks alert and healthy when awake - Wake up the newborn if he or she has nursed less than 5 minutes by unwrapping him or her. - Before removing the baby from the breast, break the infant's suction by inserting a finger. -Burp the infant to release air when changing breasts and at the end of the breast-feeding session. - Avoid supplemental formula-feedings to prevent "nipple confusion." - Do not take drugs or medications unless approved by the health care provider. - Avoid drinking alcohol or caffeinated drinks because they pass through milk. - Do not smoke while breast-feeding; it increases the risk of sudden infant death syndrome. -Always wash your hands before expressing or handling milk to store. - Wear nursing bras and clothes that are easy to undo.

Fetal Alcohol Syndrome p858 box 24-2

- Microcephaly (head circumference <10th percentile)* -Small palpebral (eyelid) fissures* - Abnormally small eyes - Intrauterine growth restriction - Maxillary hypoplasia (attened 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 decits (height, weight, or both <10th percentile) 3. Documentation of CNS abnormalities (structural, neurologic or functional)

Imperforate Anus p875

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 vagina in girls or the urethra in boys) (Fig. 24.11). The malformations occur during early fetal development and may be associated with numerous other congenital anomalies in other body systems. Refer to Box 24.6 for anomalies associated with anorectal malformations.Imperforate anus occurs in about 1 of every 5,000 live births. 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. Surgery 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 newborn, observe for an appropriate anal open-ing. If the anal opening exists, observe for passage of meconium stool within the first 24 hours of life. Assess urine output to identify genitourinary problems. For the newborn with an imperforate anus, inspection of the perineal area would reveal absence of the usual opening. In addition, meconium generally is not passed or present within 24 hours of birth.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.

Circumcision care p596

Circumcision is the surgical removal of all or part of the foreskin (prepuce) of the penis. This has been traditionally done for hygiene and medical reasons and is the oldest known religious rite. In the Jewish faith, circumcision is a ritual that is performed by a mohel (ordained circumciser) on the eighth day after birth if possible. The circumcision is followed by a religious ceremony during which the newborn is named.There are three commonly used methods of circumcision: the Gomco clamp, the Plastibell device, and the Mogen clamp. During the circumcision procedure, part of the foreskin is removed by clamping and cutting with a scalpel (Gomco or Mogen clamp) or by using a Plastibell. The Plastibell is fitted over the glans, and the excess foreskin is pulled over the plastic ring. A suture is tied around the rim to apply pressure to the blood vessels, creating hemostasis. The excess foreskin is cut away. The plastic rim remains in place until healing occurs. The plastic ring typically loosens and falls off in approximately 1 week (Fig. 18.19).The debate over routine newborn circumcision continues in the United States. For many years, the purported benefits and harms of circumcision have been debated in the medical literature and society at large, with no clear consensus to date. Despite the controversy, circumcision is the most common surgical procedure performed on newborns, and almost two thirds (61%) of American male newborns are circumcised.A policy statement by the AAP indicates that new-born circumcision has potential disadvantages and risks as well as medical benefits and advantages. Risks to the newborn include infection, hemorrhage, skin dehiscence, adhesions, urethral fistula, and pain. Benefits to the newborn include the following: - Urinary tract infections are slightly less common in circumcised boys. However, rates are low in both circumcised and uncircumcised boys and are easily treated without long-term sequelae. - Sexually transmitted infections are less common in cir-cumcised males, but the risk is believed to be related more to behavioral factors than to circumcision status. However, circumcised males have a 50% lower risk of acquiring HIV infection. - There appears to be a slightly lower rate of penile cancer in circumcised males. However, penile cancer is rare and risk factors such as genital warts, infection with human papillomavirus, multiple sex partners, and cigarette smoking seem to play a much larger role in causing penile cancer than circumcision status.The new AAP recommendations state that if parents decide to circumcise their newborn, pain relief must be provided. Research has found that newborns circumcised without analgesia experience pain and stress, indicated by changes in heart rate, blood pres-sure, oxygen saturation, and cortisol levels. Analgesic methods may include EMLA cream (a topical mixture of local anesthetics), a dorsal penile nerve block with buffered lidocaine, acetamino-phen, a sucrose pacifier, and swaddling.The AAP (AAP, 2012). recommends that parents be given accurate and unbiased information about the risks and benefits of circumcision. As with other newborn procedures, research continues. Nurses must keep informed about current medical research to allow parents to make informed decisions. The absence of compelling medical evidence in favor of or against newborn circumcision makes informed consent of parents of paramount im-portance. The circumcision discussion involves cultural, religious, medical, and emotional considerations. Nurses may have difficulty remaining unbiased and unemotional as they present the facts to parents. Circumcision is a very personal decision for parents, and the nurse's major responsibility is to inform the parents of the risks and benefits of the procedure and to address concerns so that the parents can reach a fully informed decision. e decision to circumcise the male newborn is often a social one, with the strongest factor being whether the newborn's father is himself circumcised.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 avoid-ing placing the newborn on his abdomen to prevent friction. If a Plastibell has been used, it will fall off by it-self in about a week. Inform parents of this and advise them not to pull it off sooner. Also instruct the parents to check daily for any foul-smelling drainage, bleeding, or unusual swelling.If the newborn is uncircumcised, wash the penis with mild soap and water after each diaper change and do not force the foreskin back; it will retract normally over time.

Nursing assessment of a neonatal infection (sepsis) p870

Diagnosis of neonatal infections is challenging. Most 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 abnormalities .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 observation is that the newborn does not "look right." Assess the newborn for common nonspecific 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 differ-ential to identify anemia, leukocytosis, or leukopenia. Elevated C-reactive protein levels may indicate inflammation. As ordered, obtain x-rays of the chest and ab-domen, 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.

Esophageal Atresia p 872

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 (Fig. 24.9).The incidence of esophageal atresia is 1 per 3,000 to 4,500 live births. Pathophysiology: Several types of esophageal atresia exist, but the most common anomaly is a fistula between the distal esophagus and the trachea, which occurs in 86% of newborns with an esophageal defect. 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. Nursing assessment: Review the maternal history for hydramnios. Often this is the first sign of esophageal atresia because the fetus cannot 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 new-born 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. Prepare the newborn and parents for radiographic evaluation. Diagnosis is made by x-ray or an ultrasound or MRI, which will demonstrate a gastric tube coiled in the upper esophageal pouch, and air in the gastrointestinal tract indicates the presence of a fistula. Once a diagnosis of esophageal atresia is established, begin preparations for surgery if the newborn is stable. Note:: The "three C's" of choking, coughing, and cyanosis in conjunction with feeding are considered the classic signs of tracheoesophageal fistula and atresia.

Body Temperature Regulation p554-556

Factors predisposing to heat loss 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

Birth weight variations p803

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 new-borns 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) (Fig. 23.1) -Very low birthweight: less than 1,500 g (3 lb 5 oz) - Extremely low birthweight: less than 1,000 g (2 lb 3 0z)

Necrotizing Enterocolitis (NEC) p844-846

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. Pathophysiology: The pathophysiology of NEC is not clearly understood and is thought to be multifactorial in nature. Current research points to three major pathologic mechanisms that lead to NEC: bowel hypoxicischemia events, perinatal stressors, an immature intestinal barrier, abnormal bacterial colonization, and formula feeding. During perinatal or postnatal stress, oxygen is shunted away from the gut to more important organs such as the heart and brain. Ischemia and intestinal wall damage occur, allowing bacteria to invade. High-solute feedings allow bacteria to flourish. Mucosal or transmucosal necrosis of part of the intestine occurs. Although any region of the bowel can be affected, the distal ileum and proximal colon are the regions most commonly involved. NEC usually occurs between 3 and 12 days of life, but it can occur weeks later in some newborns. Nursing assessment: NEC can be devastating, and astute assessment is crucial. Assessing the newborn for the development of NEC includes the health history and physical examination as well as laboratory and diagnostic testing. The onset of NEC is heralded by the development of feeding intolerance, abdominal distention, and bloody stools in a preterm infant receiving enteral feedings. As the disease worsens, the infant develops signs and symptoms of septic shock (respiratory distress, temperature instability, lethargy, hypotension, and oliguria). Nurses need to be suspicious of this condition in caring for this preterm infant. Health history and physical examination: Assess the newborn's history for risk factors associated with NEC. In addition to preterm birth, prenatal and postnatal predisposing risk factors are highlighted in Box 24.1.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 Always keep the possibility of NEC in mind when dealing with preterm newborns, especially when enteral feedings are being administered. Note respiratory distress, cyanosis, lethargy, decreased activity level, temperature instability, feeding intolerance, diarrhea, bile-stained emesis, or grossly bloody stools. Assess blood pressure, noting hypotension. Evaluate the neonate's abdomen for distention, tenderness, and visible loops of bowel. Measure the abdominal circumference, noting an increase. Determine residual gastric volume prior to feeding; when it is elevated, be suspicious for NEC Laboratory and diagnostic testing: Common laboratory and diagnostic tests ordered for assessment of NEC include: - Kidney, ureter, and bladder (KUB) of the abdomen x-ray: conrms the presence of pneumatosis intesti-nalis (air in the bowel wall) and persistently dilated loops of bowel - Blood values: may demonstrate metabolic acidosis, increased white blood cells, thrombocytopenia, neu-tropenia, electrolyte imbalance, or disseminated intra-vascular coagulation (DIC) Nursing management: Nursing management of the newborn with NEC focuses on maintaining fluid and nutritional status, providing supportive care, and teaching the family about the condition and prognosis. Therapeutic management initially consists of bowel rest and antibiotic therapy. Serial KUB x-rays and C-reactive protein levels are used to assess the resolution or progression of NEC. If medical treatment fails to stabilize the newborn or if free air is present on a left lateral decubitus film, surgical intervention will be necessary to resect the portion of necrotic bowel while preserving as much of the intestinal length as possible. Surgery for NEC usually requires the placement of a proximal enterostomy until the anastomosis site is ready for reconnection. After surgery, post-op supportive care includes fluids, TPN, antibiotics, and bowel rest for 10 to 14 days. Maintaining fluids and nutritional status: f NEC is suspected, immediately stop enteral feedings until a diagnosis is made. Administer IV fluids initially to restore proper fluid balance. If ordered, administer total parenteral nutrition (TPN) to keep the newborn supported nutritionally. Give prescribed IV antibiotics to prevent sepsis from the necrotic bowel (if surgery is required, antibiotics may be needed for an extended period of time). Institute gastric decompression as ordered with an orogastric tube attached to low intermittent suction. Carefully monitor intake and output. Restart enteral feedings once the disease has resolved (normal abdominal examination and KUB negative for pneumatosis) or as determined postoperatively by the surgeon. Providing supportive care: Manage pain by administering analgesics as ordered. Infection control is important, with an emphasis on careful handwashing. In addition, implement these interventions in an ongoing manner: - Check stools for evidence of blood and report any positive findings. -Measure the abdominal girth. - Palpate the abdomen for tenderness and rigidity. -Auscultate for normal bowel sounds. - Observe the abdomen for redness or shininess, which indicates peritonitis. Teaching the family: The diagnosis of NEC may cause significant family anxiety. Listen to the family's worries and fears. Answer their questions honestly. Inform the family that medically treated NEC is usually limited to a short period and resolves within 48 hours of stopping oral feedings, but surigically treated NEC can be a much lengthier process. The amount of bowel that has necrosed, as determined during the bowel resection, significantly increases the likelihood of long-term medical problems. Short bowel syndrome may result from a large resection (short bowel syndrome is discussed in Chapter 42). Reassure the family that al-though some infants have more involved cases of NEC, the improved parenteral nutrition formulations have improved the outcomes for these infants. Provide education about ostomy care if surgery is required (refer to page 1509 for a discussion of ostomy care). Promote interaction with their newborn. Nursing actions of active engagement with parents and the sick infant (providing NICU orientation and physical care), providing cautious guidance (offering in-formation and instruction on infant care), and their subtle presence (overseeing parent's interaction with their infant) all contribute to fostering a positive, trusting relationship with parents. (((SEE BOX 24.1 P 845)))

Cold stress P558

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. However, preterm newborns are at the greatest risk for cold stress and experience more profound effects than fullterm 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 To minimize the effects of cold stress and maintain an NTE, the following interventions are helpful: -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 humidied 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 (Fig. 17.4) - 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) The interventions listed above allow the newborn to minimize his or her metabolic rate and oxygen consumption, thereby conserving vital energy stores required for optimum growth

Neonatal abstinence syndrome p858-862

Newborns of women who abuse tobacco, illicit sub-stances, 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 abstinence syndrome is not a single pathologic condition. The manifestations of withdrawal are a function of the drug's half-life, the specific drug or combination of drugs used, dosage, route of administration, timing of drug exposure, and length of drug exposure. 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. Nursing assessment: A comprehensive prenatal medical and drug history, especially with respect to polydrug use, is vital. Fear of referral to child welfare agencies or the legal system has prompted women to conceal their drug abuse history. Frequently, the first inkling of drug use appears in the newborn when symptoms of withdrawal begin within 72 hours after birth. Typically the infant has been dis-charged by this time, unless the nurse has a high degree of suspicion that would prompt toxicology testing earlier. Several assessment tools can be used to assess a drug-exposed newborn. Figure 24.6 shows an example. Regardless of the tool used for assessment, address these key areas: Maternal history to identify risk behaviors for sub-stance abuse: -Previous unexplained fetal demise - Lack of prenatal care - Incarceration Prostitution -Mental health disorders -History of intimate partner violence - History of missed prenatal appointments -Severe mood swings - Precipitous labor - Poor nutritional status - Abruptio placentae - Hypertensive episodes -History of drug abuse - Laboratory test results (toxicology) to identify sub-stances in mother and newborn -Signs of neonatal abstinence syndrome (Use the WITHDRAWAL acronym; see Box 24.3.) - Evidence of seizure activity and need for protective environment.The newborn's behavior often prompts the health care provider or nurse to suspect intrauterine drug exposure. The newborn physical examination may also reveal low birthweight for gestational age or drug- or alcohol-related birth defects and dysfunction. Assess the newborn for signs of neonatal abstinence syndrome Note: cocaine-exposed newborns are typically fussy, irritable, and inconsolable at times. Cocaine-exposed infants demonstrate poor coordination of sucking and swallowing, making feeding time frustrating for the newborn and caregiver alike. Assist with obtaining diagnostic studies to identify the severity of withdrawal. Toxicology screening of the newborn's blood, urine, and meconium identifies the substances to which the newborn has been exposed. Urine drug screening identifies only recent substance exposure, whereas meconium samples may reveal exposure from the second trimester to the present. Take care to avoid contamination of meconium with urine, as this may affect the accuracy of the sample. Nursing management: The needs of the substance exposed newborn are multiple, complex, and costly, both to the health care system and to society. Substance abuse takes place among people of all colors, sizes, shapes, incomes, types, and conditions. Most pregnant women are unaware of the adverse impact their substance abuse can have on the newborn.Nurses are in a unique position to help because they interact with high-risk mothers and newborns in many settings, including the community, health care facilities, and family agencies. It is the responsibility of all nurses to identify, educate, counsel, and refer pregnant women with substance-abusing problems. For example, nurses can be instrumental in increasing the number of pregnant women who make a serious attempt to quit smoking by using the "5 A's" approach: Ask: Ask all women if they smoke and would like to quit. Advise: Encourage the use of clinically proven treatment plans. Assess: Provide motivation by discussing the "5 R's": - Relevance of quitting to the woman -Risk of continued smoking to the fetus - Rewards of quitting for both - Roadblocks to quitting -Repeat at every visit Assist: Help the woman to protect her fetus and newborn from the negative effects of smoking. Arrange: Schedule follow-up visits to reinforce the woman's commitment to quit. Although this approach is geared to smoking cessation, nurses can adapt it to focus on cessation for any substance use. Early, supportive, ongoing nursing care is critical to the well-being of the mother and her newborn.Caring for a substance-exposed newborn remains a major challenge to health care professionals. The major goals include providing comfort to the newborn by relieving symptoms, improving feeding and weight gain, preventing seizures, promoting mother-newborn interactions, and reducing the incidence of newborn mortality and abnormal development. Promoting comfort:Keep environmental stimuli to a minimum. For example, decrease stimuli by dimming the lights in the nursery, and swaddle the newborn tightly to decrease irritability behaviors. Other techniques such as gentle rocking, using a flexed position, and offering a pacifier can help manage CNS irritability. A pacifier also helps satisfy the newborn's need for nonnutritive sucking. Swaddling, pacifiers, low lighting, oscillating cribs, and avoidance of abrupt changes in the infant's environment can be helpful. Use a calm, gentle approach when handling the newborn and plan activities to avoid overstimulating the newborn, allowing time for rest periods. Meeting nutritional needs: When feeding the newborn, use small amounts and position the newborn upright to prevent aspiration and to facilitate rhythmic sucking and swallowing. Frequent small feedings are preferable and should provide 150 to 250 kcal/kg per 24 hours for proper growth of the infant undergoing significant withdrawal .Breast-feeding is encouraged unless the mother is still using drugs. Monitor the newborn's weight daily to evaluate the success of food intake. Assess hydration; check skin turgor and fontanels. Assess the frequency and characteristics of bowel movements and monitor the newborn's fluid and electrolyte and acid-base status. Preventing complications: Pharmacologic treatment is warranted if conservative measures, such as swaddling and decreased environmental stimulation, are not adequate. The AAP recom-mends that for newborns with confirmed drug exposure, drug therapy is indicated if the newborn has seizures, diarrhea and vomiting resulting in excessive weight loss and dehydration, poor feeding, inability to sleep, and fever unrelated to infection. Common medications used in the management of newborn withdrawal include an opioid (morphine or methadone) and phenobarbital as a second drug if the opiate does not adequately control symptoms. Administer the prescribed medications and document the newborn's behavioral responses.The newborn is at risk for skin breakdown. Weight loss, diarrhea, dehydration, and irritability can contribute to this risk. Provide meticulous skin care and protect the newborn's elbows and knees against friction and abrasions. Promoting parent-newborn interaction: For a mother who abuses substances, the birth of a drug-exposed newborn is both a crisis and an opportunity. The mother may feel guilty about the newborn's condition. Many of these newborns are unresponsive and have disorganized sleeping and feeding patterns. When awake, they can be easily overstimulated and irritated. Such characteristics make parent-newborn interactions difficult and frustrating, leading to possible detachment and avoidance. Nursing support, which includes a description of symptoms and their management, is vital if maternal-infant attachment is to occur and potential neglect or abuse is avoided. Instruct the mother or caretaker how to care for the newborn, including what to do after the newborn goes home.

Administering oxygen (ROP) p817

Oxygen administration is a common therapy in the neonatal intensive care unit, though the normal oxygen concentration for a preterm infant remains unknown. Use of large concentrations of oxygen and sustained oxygen saturations higher than 95% while on supplemental oxygen have been associated with the development of retinopathy 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 appro-priate 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. Respiratory distress in preterm infants is commonly caused by a deficiency of surfactant, retained fluid in the lungs (wet lung syndrome), meconium aspiration, pneumonia, hypothermia, or anemia. The principles of care are the same regardless of the cause of respiratory distress. First, keep the newborn warm, preferably in a warmed isolette or with an overhead radiant warmer, to conserve the baby's energy and prevent cold stress. Handle the newborn as little as possible, because stimulation often increases the oxygen requirement. Provide energy through calories via intravenous dextrose or gavage or continuous tube feedings to prevent hypoglycemia. Treat cyanosis with an oxygen hood or blow-by oxygen placed near the newborn's face if respiratory distress is mild and short-term therapy is needed. Record the following important observations every hour or more frequently if indicated: - Respiratory rate, quality of respirations, and respira-tory effort - Airway patency, including removal of secretions per facility policy - Skin color, including any changes to duskiness, blue-ness, or pallor - Lung sounds on auscultation to differentiate breath sounds in upper and lower fields - Equipment required for oxygen delivery, such as: Blow-by oxygen delivered via mask or tube for short-term therapy - Oxygen hood (oxygen is delivered via a plastic hood placed over the newborn's head) -Nasal cannula (oxygen is delivered directly through the nares) (Fig. 23.4A) - Continuous positive airway pressure (CPAP), which prevents collapse of unstable alveoli and delivers high levels of inspired oxygen into the lungs - Mechanical ventilation, which delivers consistent as-sisted ventilation and oxygen therapy, reducing the work of breathing for the fatigued infant (Fig. 23.4B) - Correct placement of endotracheal tube (if present) - Oxygen saturation levels via pulse oximetry -Heart rate -Administration of medication, such as exogenous surfactant If the newborn shows worsening cyanosis or if oxy-gen saturation levels fall below 87%, prepare to give additional oxygen as ordered. Evaluate arterial blood gas results periodically as ordered. Document any deterioration or changes in respiratory status. Administer exogenous surfactant as ordered. Throughout care, maintain strict asepsis and meticulous hand hygiene in order to reduce the risk of infection.

Pathological Jaudice p864

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. Conditions that alter the production, transport, uptake, metabolism, excretion, or reabsorption of bilirubin can cause pathologic jaundice in the newborn. 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 pathologic jaundice is hemolytic disease of the newborn secondary to incompatibility of blood groups of the mother and the newborn. The most frequent conditions are Rh factor and ABO incompatibilities. Take Note::Significant jaundice in the newborn less than 24 hours of age should be immediately reported to the physician, as it may indicate a pathologic process.

Persistent pulmonary hypertension p842-843

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, hypothermia, 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. Pathophysiology: 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. Normally, the decrease in pulmonary artery pressure and pulmonary vascular resistance with breathing leads to the closure of the ductus arteriosus and foramen ovale. However, with persistent pulmonary hypertension, pulmonary vascular resistance is elevated to the point that venous blood is diverted to some degree through fetal structures, such as the ductus arteriosus or foramen ovale, causing them to remain open, leading to a right-to-left shunting of blood into the systemic circulation. This diversion of blood bypasses the lungs, resulting in systemic arterial hypoxemia. Nursing assessment: Assess the newborn's status closely. A newborn with persistent 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 insufficiency murmur), and measure 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. Nursing management: 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 bicarbonate, 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 hypertension. Monitor arterial blood gases frequently to evaluate the effectiveness of oxygen therapy. Provide respiratory support, which frequently necessitates the use of mechanical ventilation. Administer prescribed medications, monitor cardiopulmonary status, cluster care to reduce stimulation, and provide ongoing support and education to the parents. Note:: Almost any procedure, such as suctioning, weighing, changing diapers, or positioning, can precipitate severe hypoxemia due to the instability of the pulmonary vasculature. Therefore, minimize the newborn's exposure to stimulation as much as possible.

Phototheraphy p603-604

Phototherapy involves exposing the newborn to ultraviolet light, which converts unconjugated bilirubin into products that can be excreted 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. Take Note:Exposure of newborns to sunlight represents the first documented use of phototherapy in the medical literature. Sister J. Ward, a charge nurse in Essex, England, recognized in 1956 that when jaundiced newborns were exposed to the sun they became less yellow. This observation changed the entire treatment of jaundice in newborns. Phototherapy reduces bilirubin levels in the blood by breaking down unconjugated bilirubin into colorless compounds. These compounds can then be excreted in the bile. Phototherapy aims to curtail the increase in bilirubin blood levels; thereby preventing kernicterus, a condition in which unconjugated bilirubin enters the brain. If not treated, kernicterus can lead to brain dam-age and death.During the past several decades, phototherapy has generally been administered with either banks of fluorescent lights or spotlights. Factors that determine the dosage of phototherapy include spectrum of light emit-ted, irradiance of light source, design of light unit, surface area of newborn exposed to the light, and distance of the newborn from the light source . For phototherapy to be effective, the rays must penetrate as much of the skin as possible. Thus, the newborn must be naked and turned frequently to ensure maximum exposure of the skin. Several side effects of standard phototherapy have been identified: frequent loose stools, increased insensible water loss, transient rash, and potential retinal damage if the newborn's eyes are not covered suffciently.Recently, fiber-optic pads (Biliblanket or Bilivest) have been developed that can be wrapped around the newborn or on which the newborn can lie. The light is delivered from a tungsten-halogen bulb through a fiber-optic cable and is emitted from the sides and ends of the fibers inside a plastic pad. These products work on the premise that phototherapy can be improved by delivering higher-in-tensity therapeutic light to decrease bilirubin levels. The pads do not produce appreciable heat like the banks of lights or spotlights do, so insensible water loss is not increased. Eye patches also are not needed; thus, parents can feed and hold their newborns continuously to promote bonding. When caring for newborns receiving phototherapy for jaundice, nurses must do the following: - Closely monitor body temperature and fluid and electrolyte balance. -Document frequency, character, and consistency of stools. - Monitor hydration status (weight, specific gravity of urine and urine output). - Turn frequently to increase the infant's skin exposure to phototherapy. -Observe skin integrity (as a result of exposure to diarrhea and phototherapy lights). - Provide eye protection to prevent corneal injury re-lated to phototherapy exposure. - Encourage parents to participate in their newborn's care to prevent parent-infant separation.

Physiologic Jaundice p 602

Physiologic jaundice is very common in newborns, with the majority demonstrating yellowish skin, mucous membranes, and sclera within the first 3 days of life. In any given year, approximately 60% of the newborns in the United States will experience clinical jaundice. Jaundice is the visible manifestation of hyperbilirubinemia. It typically results from the deposition of unconjugated bilirubin pigment in the skin and mucous membranes.Physiologic jaundice can be best understood as a imbalance between the production and elimination of bilirubin, with a multitude of factors and conditions affecting each of these processes. When an imbalance results because of an increase in circulating bilirubin (or the bilirubin load) to significantly high levels, it may go on to cause acute neurologic sequelae (acute bilirubin encephalopathy). In most infants, an increase in bilirubin production (e.g., due to hemolysis) is the primary cause of physiologic jaundice, and thus reducing bilirubin production is a rational approach for its management.Factors that contribute to the development of physiologic jaundice in the newborn include an increased billrubin load because of relative polycythemia, a shortened erythrocyte life span (80 days compared with the adult 120 days), and immature hepatic uptake and conjugation processes (Cohen, Wong, & Stevenson, 2010). Normally the liver removes bilirubin from the blood and changes it into a form that can be excreted. As the red blood cell breakdown continues at a fast pace, the newborn's liver cannot keep up with bilirubin removal. Thus, bilirubin accumulates in the blood, causing a yellowish discoloration on the skin.The AAP has recently released guidelines for the prevention and management of hyperbilirubinemia in newborns: - Promote and support successful breast-feeding practices 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 be-cause that will not lower bilirubin levels. - Ensure that all infants are routinely monitored for the development of jaundice and that nurseries have es-tablished 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 en-cephalopathy In newborn infants, jaundice can be detected by blanching the skin with digital pressure on the bridge of the nose, sternum, or forehead, revealing the underlying color of the skin and subcutaneous tissue. If jaundice is present, the blanched area will appear yellow before the capillary recall. The assessment of jaundice must be performed in a well-lit room or, preferably, in daylight at a window. Jaundice is usually seen first in the face and progresses caudally to the trunk and extremities .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 If or when the levels of unconjugated serum bilirubin increase and do not return to normal levels with increased hydration, phototherapy is used. The serum level of bilirubin at which phototherapy is initiated is a matter of clinical judgment by the physician, but it is often begun when bilirubin levels reach 12 to 15 mg/dL in the first 48 hours of life in a term new-born .Phototherapy involves exposing the newborn to ultraviolet light, which converts unconjugated bilirubin into products that can be excreted through feces and urine. Phototherapy is the most common treatment for hyperbilirubinemia and has virtually eliminated the need for exchange transfusions in the newborn now.

New ballard score p572

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Respiratory distress syndrome figure 24.2 p838

Refer to image. Sternal retractions are a sign of respiratory distress requriring immediate intervention, such as mechanial ventilation and other monitoring devices.

Apgar Score p569

The Apgar score, introduced in 1952 by Dr. Virginia Ap-gar, is used to 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. It can be used as a rapid method for assessing the survival of a neonate. Assessment of the newborn at 1 minute provides data about the new-born's initial adaptation to extrauterine life. Assessment at 5 minutes provides a clearer indication of the new-born's overall central nervous system status. Five parameters are assessed with Apgar scoring. A quick way to remember the parameters of Apgar scoring is as follows: A = appearance (color) P = pulse (heart rate) G = grimace (reflex irritability) A = activity (muscle tone) R = respiratory (respiratory effort) Each parameter is assigned a score ranging from 0 to 2 points. A score of 0 points indicates an ab-sent or poor response; a score of 2 points indicates a normal response (Table 18.1). 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. The Apgar score is influenced by the presence of infection, congenital anomalies, physiologic immaturity, maternal sedation via medications, labor management, and neuromuscular disorders.When the newborn experiences physiologic depression, the Apgar score characteristics disappear in a predictable manner: First the pink coloration is lost, next the respiratory effort, and then the tone, followed by reflex irritability and finally heart rate. Although Apgar scoring is done at 1 and 5 minutes, it also can be used as a guide during the immediate new-born period to evaluate the newborn's status for any changes because it focuses on critical parameters that must be assessed throughout the early transition period.

Bowel elimination p560

The frequency, consistency, and type of stool passed by newborns vary widely. The evolution of a stool pattern begins with a newborn's first stool, which is meconium. Meconium is composed of amniotic fliuid, shed mu-cosal 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, but this changes rapidly with ingestion of bacteria through feedings. After feedings are initiated, a transitional stool develops, which is greenish brown to yellowish brown, thinner in consistency, and seedy in appearance. Take Note!Newborns who are fed early pass stools sooner, which helps to reduce bilirubin buildup.The 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.

Gestational Age variations p809

The mean duration of pregnancy, calculated from the first day of the last normal menstrual period, is approximately 280 days, or 40 weeks. 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 new-born. 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 Precise knowledge of a newborn's gestational age is imperative for effective postnatal management. Determination of gestational age by the nurse assists in planning appropriate care for the newborn and provides important information regarding potential problems that need interventions Take Note::Although preterm and posterm newborns may appear to be at opposite ends of the gestational age spectrum and are very different in size and appearance, both are at high risk and need special care.

Stomach and digestion p560

The physiologic capacity of the newborn stomach is considerably less than its anatomic capacity. 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. This explains the experience of countless hospital nurses who have learned the hard way that when newborns are fed an ounce or two by bottle during the first day of life, most of it tends to come right back up. The walls of the newborn stomach stay firm, expelling extra milk rather than stretching to hold it.Small, frequent feedings set up a healthy eating pat-tern right from the start. Experts now advise adults that it is healthier to eat smaller amounts more often and the same is true for babies and children. Coaxing an infant to take more milk leads to overfeeding. If feeling overfull at feedings becomes the norm for a young infant, this may lead to unhealthy eating habits that contribute to child-hood and adult obesity later.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. Most digestive enzymes are available at birth, allowing newborns to digest simple carbohydrates and protein. However, they have limited ability to digest complex carbohydrates 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.Adequate digestion and absorption are essential for newborn growth and development. Normally, term newborns lose 5% to 10% of their birth weight as a result of insuffcient caloric intake within the first week after birth, shifting of intracellular water to extracellular space, and insensible water loss. To gain weight, the term new-born requires an intake of 108 kcal/kg/day from birth to 6 months of age

Tracheoesophageal fistula p872

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.

Newborn skin variations p580-582

While assessing the skin, make note of any rashes, ecchymoses or petechiae, nevi, or dark pigmentation. Skin lesions can be congenital or transient; they may be a result of infection or may result from the mode of birth. If any are present, observe the anatomic location, arrangement, type, and color. Bruising may result from the use of devices such as a vacuum extractor during delivery. 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, stork bites or salmon patches, milia, Mongolian spots, erythema toxicum, harlequin sign, nevus flammeus, and nevus vasculosus (Fig. 18.12) -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 (see Fig. 18.12A). The name comes from the marks on the back of the neck where, as myth goes, a stork may have picked up the baby. They are caused by a concentration of immature blood vessels and are most visible when the newborn is crying. They are considered a normal variant, and most fade and disappear completely within the first year. -Milia are unopened sebaceous glands frequently found on a newborn's nose. They may also appear on the chin and forehead (see Fig. 18.12B). They form from oil glands and disappear on their own within 2 to 4 weeks. 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 hey tend to occur in African American, Asian, and Indian newborns but can occur in dark-skinned newborns of all races. The spots are caused by a concentration of pigmented cells and usually disappear within the first 4 years of life. -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 (see Fig. 18.12D). One of the chief characteristics of this rash is its lack of pattern. It is caused by the new-born's eosinophils reacting to the environment as the immune system matures. Histologically, erythema toxicum shows an abundance of eosinophils. Although it has been recognized and described for centuries, its etiology and pathogenesis remain unclear. It does not require any treatment and disappears in a few days. -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. It gives a distinct midline demarcation, which is described as pale on the nondependent side and red on the opposite, dependent side. It results from immature autoregulation of blood flow and is commonly seen in low-birth-weight newborns when there is a positional change. It is transient, lasting as long as 20 minutes, and no intervention is needed. -Nevus flammeus, also called a port-wine stain, commonly appears on the newborn's face or other body areas (see Fig. 18.12E). It is a capillary angioma located directly below the dermis. It is at with sharp demar-cations and is purple-red. This skin lesion is made up of mature capillaries that are congested and dilated. It ranges in size from a few millimeters to large, occasion-ally involving as much as half the body surface. Although it does not grow in area or size, it is permanent and will not fade. Port-wine stains may be associated with structural malformations, bony or muscular overgrowth, and certain cancers. Recent studies have noted an association between port-wine birthmarks and childhood cancer, so newborns with these lesions should be monitored with periodic eye examinations, neurologic imaging, and extremity measurements. Lasers and intense pulsed light have been used to remove larger lesions with some success. The optimal timing of treatment is before 1 year of age -.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 (see Fig. 18.12F). It is commonly found in the head region within a few weeks after birth and can increase in size or number. This type of hemangioma may be very subtle or even absent in the first few weeks of life, but they proliferate in the first few months of life. Commonly seen in premature infants weighing less than 1,500 g , these hemangiomas tend to resolve by age 3 without any treatment.