OB week 4
Metabolic System
-glucose values normally decrease about 1 hour post-birth and then values rise and stabilize by 2 to 3 hours post-birth -optimal range for plasma glucose is 70-100 -hypoglycemia (blood glucose level under 40) is common during this transitional time, especially in neonates with diabetic mothers Risk Factors: - gestational and diabetic mom S/S: -jittery -hypotonia -irritability -apnea -lethargy -Temp instability nursing action: -monitor s/s -assess blood glucose -breastfeed or formula feed infant -IV infusion of dextrose solution -Maintain NTE -dec. risk of cold stress
Skin Care
-normal to have sensitive skin -smooth and soft -assess cephalahematoma - drying and flaking of skin = normal - apply barrier protection
Erythromycin ophthalmic ointment
. 5% •Prophylaxis treatment for gonococcal or chlamydial eye infections •Prevents bacterial growth by inhibiting folic acid synthesis •Route and dose: Apply a 1/4-inch lower eyelid of each eye.
Pulse / Heart Rate
- 110- 160 bpm -auscultate for full minute - stethoscope or palpate w/ umbilical stump -Absent (0 pts) - < than 100 bpm (1 pt) - > than 100 bpm (2 pts)
Respirations
- 30 -60 rr - No r effort (0pts) - Slow, Weak Cry (1 pt) -Strong/Good cry (2 pts)
Gastrointestinal System ( GI )
- 5 to 10 ml - day 7 = 16 ml -gastric emptying every 2-4 hrs STOOL : - meconium : thick, tarry , odorless, past 24- 48 hrs, hard to get off skin - transitional : black to greenish 3rd day continues 3-4 days ; breastfed and formula fed -breastfed : yellow semi formed - formula : brown more formed -diarrhea (NOT normal): loose and watery and green -blood stool :NOT normal allergy or gastric irritation -taking iron : greenish brown
Respiratory System ( Mechanical )
- C-section babies have higher risk for respiratory distress -monitor them and deep suction -hypoxia
Signs of respiratory distress
- Cyanosis -Abnormal Respiratory pattern ( tachypnea (hard breathing) and apnea(longer than 30 seconds) - Grunting or singing -Flaring of nostrils -Hypotonia
Activity or Muscle Tone
- No tone : Limp / Flaccid (0 pts) -Poor tone: some flexion (1 pt) -Good tone : flexed and active (2 pts)
Circulatory System ( Ductus Arteriosus )
- Pulmonary artery to descending aorta -close within 15 hours of birth - occurs when Pulmonary resistance LESS than Systemic Resistance -If does not close within 15 hours: Systolic Murmur
Surfactant ( Respiratory System)
- at the end of exhale -decreases pressure - phospholipid (Lubricant) within the alveoli that assists in the functional of the residual capacity - residual capacity: keeps alveolar sacs partially open @ end of exhale ( decreases amount of pressure and energy required on inspiration )
Lab test
- blood test and hearing test - heel stick : -warm neonates foot for 10 minutes by wrapping warm moist washcloth - OAE otoacoustic emissions : -clicking sounds - AABR auditory brain stem response: painless tes when neonate is asleep
Thermoregulatory System (heat loss )
- from warm amniotic fluid to ac room -maintain NTE neutral thermal environment
Brown Fat (BAT)
- highly dense and vascular adipose tissue -Preterm neonate = less brown fat -closer to term = more brown fat - Factors that negatively affect thermoregulation: - dec. subcu fat - dec. brown fat -large body surface -loss of heat from convection, radiation, conduction, and evaporation -dry baby and remove anything that is wet
Circulatory System
- immediate/seconds after chord has been cut -Decreased Pulmonary resistance > increases pulmonary blood flow > increases sys, vascular resistance Effects: -Ductus venosus -Formen Ovale -Ductus Arteriosus
Appearance (color)
- inspect mucus membrane -BLUE or generalized pallor (0 pts) -BLUE extremities, acrocyanosis PINK core (1 pt) - Completely PINK (2 pts) - face may be bruised - acrocyanosis common in most infants
Respiratory System ( Chemical )
- loss of placenta perfusion -clamping and cutting of umbilical chord
Grimace or Reflex Irritability
- newborn response to irritating stimuli - ex. suctioning, rubbing back, slapping/ flicking feet - None (0 pts) - Grimace and not aggressive (1 pt) -Rigorous cry, Cough, sneeze (2 pts)
Circulatory System ( Foram Ovale )
- opening between atria - closes when LEFT atrial pressure higher than the RIGHT - can reopen if significant Hypoxia
Respirator System (Sensory Stimuli )
- sounds, lights, touch
Vitamin K
- vastus lateralis •Prevention of hemorrhagic disease •Action: Vitamin K is required for the hepatic synthesis of blood coagulation factors II, VII, IX, and X. •Route and dose: IM; 0.5-1 mg within 1 hour of birth
Circulatory system ( Ductus Venosus )
- vein into inferior vena cava - closed by day 3 and eventually become a ligament
Immune System
-Active humoral Immunity: -vaccine or natural exposure - Passive Immunity (first 12 weeks of life from mom): -through breastfeeding -natural but dont last long -Lymphocytes: risk for infection -immunoglobulins Risk Factors: -breakdown of skin -screen for STI
Neonatal Period (Neonate)
-Birth - 28 days -maintain body heat: - head covered, blankets maintain rr: - patent airway -decrease risk of infection : -hand washing -limit visitors during flu season - immune system is very low during this time
Hepatic System
-bilirubin conjugation: -indirect : breakdown of RBC -direct: voiding or stooling - encourage early feeding/breastfeeding -hyperbilirubinemia: Blood Coagulation: -vitamin K injection to prevent hemorrhage
Transition to Extrauterine Life
-clamp umbilical cord -goes from low pressure to high pressure -reducing PVR -Pao2 increase causes vasodilation in thoracic cavity -this causes shunts to close
Renal System
At risk for : -Overhydration -Dehydration -Electrolyte disorder (hypo or hyper natremia) -monitor urinary output -neonate lose up to %5 to %10 of birth weight during FIRST week of life
A nurse is caring for a preterm newborn who is in an incubator to maintain a neutral thermal environment. The father of the newborn asks the nurse why this is necessary. Which of the following responses should the nurse make?
C. "Preterm newborns lack adequate temperature control mechanisms." Rationale:Preterm newborns have poor body control of temperature and need support to avoid losing heat. They require an external heat source, such as an incubator.
A nurse is assessing a newborn the day after delivery. The nurse notes a raised, bruised area on the left side of the scalp that does not cross the suture line. How should the nurse document this finding?
Cephalhematoma
.A nurse is caring for a client who just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn?
Clear the respiratory tract. Rationale: Clearing the airway of the infant is the first action the nurse should take immediately following delivery.
Reflexes 1
Moro, Startle, Tonic, Rooting, Sucking
Neonatal Assessment Part 3
Musculoskeletal: - polydactyly = extra digits - syndactyly = webbed digits - ortolani maneuver = hip dislocation Neurological : - hypertonia = tightly flexed - hypotonia = limp or without tone
Pain Assessment
NIPS =
Neonatal Assessment part 2
Neck : - absent of webbing -can turn head side to side Eyes: -position -open and close eyelids -blink reflex intact -color of sclera Ears: - no discharge -pinna without deformeties (well formed and flexible) Nose: -patent nares - neonates breathe from nose -down syndrome = flat nasal bridge Mouth: -lips, gums, palate, intact pink and moist -epstien pearls are present Chest: -barrel shape -auscultate lungs Cardiac: -murmur normal -full 1 minute auscultation - PMI at 3rd and 4th intercostal space -palpate peripheral pulses Abdomen: - soft, round, protuberant, symmetrical, -chord = opaque - or whitish blue with 2 arteries and 1 vein -whartons jelly Rectum: -anus patent -passage of stool within 24 hrs Genitourinary: -female: -labia and gently seperate male: -check meatus and not off to the side NOT NORMAL: -Epispadias: dorsal or top -hypospadias: bottom -undescended testis : not palpated in scrotum -hydrocele: enlarged scrotum
A nurse is completing the admission assessment of a newborn. Which of the following anatomical landmarks should the nurse use when measuring the newborn's chest circumference?
Nipple line Rationale: The nurse should measure the newborn's chest circumference at the nipple line.
Cold Stress
Occurs when : -dec. environmental temp -dec. body temp -inc. HR and RR -inc. O2 consumption -depletion of glucose -dec surfactant -RR distress -baby cannot shiver Risk Factors: -hypoxemia -hypoglycemia - inc. indirect bilirirubin -Sepsis -Neurologic Resp problems, endocrine, and cardio S/S: - < 97.7 F - cool skin -lethargy -pallor -tachypnea -grunting -hypotonia -jittery -weak suck -rr distress Nursing Actions: - skin to skin - warm hands/ warmer -delay bath till temp is stable -place neonate away from air vents -educate to parents -warm blankets -monitor RR, hypoglycemia -place stocking cap -swaddle
A nurse is caring for a newborn who is small for gestational age (SGA). Which of the following findings is associated with this condition?
Wide skull sutures
PKU ( phenylketonuria )
a condition that makes it impossible for babies to metabolize certain proteins
Types of heat loss
conduction, convection, radiation, evaporation
Behavioral Characteristics
initial period: -15- 30 min -alert and active -grunting, flaring, retractions -brief apnea -inc. HR -inc acrocyanosis Relative inactivity: -30 min after birth and last 2 hrs -unresponsive to external stimuli -RR and HR can slightly dec -Sleep state Second Period of Reactivity: -2-8 hrs -inc bowel activity and neonate may pass meconium
reflex 2
plantar grasp, palmar grasp, babinski, stepping or dancing
Circumcision
surgical removal of the foreskin contraindication: -GU defects hypospadeus -refuse of vitakin k -hypoglycemia -infant hasnt voided benefits: - dec UTI Procedure: obtain written consent - dont eat 203 hrs before procedure
Ballard score
test used to estimate gestational age, Most accurate at 12-20 hrs and is based on sum of neuromuscular and physical maturity score the higher the number the more mature.
A nurse is caring for a newborn delivered by vaginal birth with a vacuum assist. The newborn's mother asks about the swollen area on her son's head. After palpation to identify that the swelling crosses the suture line, which of the following is an appropriate response by the nurse?
"A caput succedaneum occurs due to compression of blood vessels."
.A nurse is caring for a client who delivered a healthy term newborn via cesarean birth. The client asks the nurse, "Is there a chance that I could deliver my next baby without having a cesarean section?" Which of the following responses should the nurse provide?
"The primary consideration is what type of incision was performed this time." Rationale: The most common type of incision during a cesarean birth is transverse, which is made across the lower, thinner part of the uterus. It is the primary criteria that permits a vaginal birth after a cesarean (VBAC). Other types of incisions increase the risk of uterine rupture. Additional criteria for VBAC include an adequate maternal pelvis, no uterine scars or history of rupture, the availability of a provider to monitor labor, and personnel to perform a cesarean birth if needed.
A nurse in the ambulatory surgery center is providing discharge teaching to a client who had a dilation and curettage (D&C) following a spontaneous miscarriage. Which of the following should be included in the teaching?
A. Vaginal intercourse can be resumed after 2 weeks. Rationale: The client should avoid vaginal intercourse and the use of tampons for 2 weeks following discharge.
APGAR scoring
A= appearance (color all pink, pink and blue, blue [pale]) P= pulse (>100, < 100, absent) G= grimace (cough, grimace, no response) A= activity (flexed, flaccid, limp) R= respirations (strong cry, weak cry, absent) - given @ 1 min and 5 min of life - if score < than 7 @ 5 min : assign 10 min APGAR - if score < 7 @ 10 min : taken to NICCU until get a score > than 7 for continued monitoring (no need for resuscitated measures)
A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action?
Administer vitamin K. Rationale:Administration of vitamin K is important, but it can be delayed until the newborn is held by the mother and is breastfed. There is another, more important nursing action.
Gestational Age Assessment
Ballard Maturational Score: -physical and neuromuscular maturity Dubowitz Neurological Examination : -response to repetitive motion AGA : average LGA: large ( at risk for hypoglycemia SGA: small (both at risk for hypoglycemia) -LGA and SGA initiate blood glucose screenings
Brazelton Neonatal Behavioral Assessment Scale (NBAS)
Habituation , Orientation, Motor Maturity, Self Quieting ability, Social behaviors
immunization
Hepatitis B: 1st of series of 3 HBig for hep positive mothers or unknown
Neonatal Assessment
Posture -flexion vs extension Head Circumference: -landmark above ears and across forehead -Microcephaly: below 10th percentile (congetinal, drug use, fetal infection) -Macrocephaly: aboce 90th percentile Chest Circumference: -Nipple line Length: top of head to heel Weight: -2500- 4000 g (5 lb/8oz - 8 lb/ 13oz) is normal Temperature: -ONLY axillary - 35.5 C/ 97.7 F - 37.2 C/99 F Respiratory : - 30 - 60 rr -slightly irregular -apnea < 15 seconds -resp > 30 = maternal analgesia or anesthesia Pulse: -full minute - 110-160 bpm - murmurs are normal Blood Pressure: - NOT routine and part of NICU -50-75/30-45 mmhg Integumentary Skin: -color, intact, dry, rashes, bruising, mongolian spots, -Pilonidal dimple : (NOT normal) s small pit or sinus in sacral area -Acrocyanosis and skin warm Head: -note shape -soft -slightly depressed NOT remain (sign of dehydration) -Molding- (cone shape) -Fontanels- soft anterior diamond shape posterior =triangle - Caput succedaneum: prolong pressure ; DOES cross suture line - cephalohematoma : DOES NOT cross suture line and is collection of blood
.A nurse is assessing a newborn immediately following a scheduled cesarean delivery. Which of the following assessments is the nurse's priority?
Respiratory distress Rationale:Shortly before labor, there is a decreased production of fetal lung fluid and a catecholamine surge that promotes fluid clearance from the lungs. Newborns born by cesarean, in which labor did not occur, can experience lung fluid retention, which leads to respiratory distress. The priority assessment when using the airway, breathing, circulation (ABC) approach to client care is to monitor the newborn for respiratory distress.
A nurse is observing a new mother bathing her newborn son for the first time. For which of the following actions should the nurse intervene?
The mother plans to use a cotton-tipped swab to clean the nares