ATI Ch 24 Nursing care of newborns

Vitamin K (phytonadione)

- Administered to prevent hemorrhagic disorders. Vitamin K is not produced in the gastrointestinal tract of the newborn until around day 7. - Vitamin K is produced in the colon by bacteria that forms once formula or breast milk is introduced into the gut of the newborn. NURSING CONSIDERATIONS: - Administer 0.5 to 1 mg intramuscularly into the vastus lateralis (where muscle development is adequate) within 1 hr after birth.

Hypoglycemia

- Frequently occurs in the first few hours of life secondary to the use of energy to establish respirations and maintain body heat. - Newborns of mothers who have diabetes mellitus, are small or large for gestational age, are less than 37 weeks of gestation, or are greater than 42 weeks of gestation, are at risk for hypoglycemia and should have blood glucose monitored within the first 2 hr of life. - Follow facility protocols regarding frequency of assessing blood glucose levels. NURSING ACTIONS ● Monitor for jitteriness; twitching; a weak, high-pitched cry; irregular respiratory effort; cyanosis; lethargy; eye rolling; seizures; and a blood glucose level less than 40 mg/dL by heel stick. ● Have the mother breastfeed immediately or give donor breast milk or formula to elevate blood glucose levels. Brain damage can result if brain cells are depleted of glucose.

Umbilical cord care

- Goal of cord care is to prevent or decrease risk for infection and hemorrhage. NURSING CONSIDERATIONS ● Cord clamp stays in place for 24 to 48 hr. ● The Association of Women's Health, Obstetric and Neonatal Nurses (2013) recommendations for cord care include cleaning the cord with water (using cleanser sparingly if needed to remove debris) during the initial bath of the newborn. ● Assess stump and base of cord for erythema, edema, and drainage with each diaper change. ● The newborn's diaper should be folded down and away from the umbilical stump. ● Bathing infant by submerging in water should not occur until the cord has fallen off. ● Most cords fall off within the 10 to 14 days.

Cold stress

- Ineffective thermoregulation can lead to hypoxia, acidosis, and hypoglycemia. Newborns who have respiratory distress are at a higher risk for hypothermia. NURSING ACTIONS ● Monitor for manifestations of cold stress (cyanotic trunk, depressed respirations). ● The newborn should be warmed slowly over a period of 2 to 4 hr. Correct hypoxia by administering oxygen. Correct acidosis and hypoglycemia.

Diagnostic procedures

- NB hearing screening is required in most states. NB are screened so that hearing impairment can be detected and treated early

Erythromycin

- Prophylactic eye care is the mandatory instillation of antibiotic ointment into the eyes to prevent ophthalmia neonatorum. - Infections can be transmitted during descent through the birth canal. Ophthalmia neonatorum is caused by Neisseria gonorrhoeae or Chlamydia trachomatis and can cause blindness. NURSING CONSIDERATIONS ● Use a single-dose unit to avoid cross-contamination. ● Apply a 1 to 2 cm ribbon of ointment to the lower conjunctival sac of each eye, starting from the inner canthus and moving outward. ● A possible side effect is chemical conjunctivitis, causing redness, swelling, drainage, and temporarily blurred vision for 24 to 48 hr. Reassure the parents that this will resolve on its own. ● Application can be delayed for 1 hr after birth to facilitate baby-friendly activities during the first period of newborn reactivity.

Hepatitis B immunization

- Provides protection against hepatitis B NURSING CONSIDERATIONS ● Recommended to be administered to all newborns. ● Informed consent must be obtained. ● For newborns born to healthy women, recommended dosage schedule is at birth, 1 month, and 6 months. ● For others infected with hep B, hep B immunoglobulin and the hep B vaccine is given within 12 hr of birth. The hep B vaccine is given alone at 1 month, 2 months, and 12 months * It's important NOT to give the vitamin K and the hep B injections in the same thigh. Sites should be alternated

Physical assessment of newborn (NB)

- VS should be checked on admission/birth and every 30 mins (x2), every 1 hr (x2) then eery 8hrs - Weight: checked daily a the same time, suing the same scale - Umbilical cord inspection: observe for any bleeding and ensure that the cord is clamped securely to prevent hemorrhage - In the first 6-8 hr of life as body systems stabilize and pass through periods of adjustment, observe for periods of reactivity - Conduct a pain assessment on the NB every 8-12hrs using the facility's preferred pain assessment tool

Newborn (NB) care

- consists of stabilization and/or resuscitation including establishing a pent airway, maintaining adequate oxygenation and thermoregulation for the maintenance of body temperature

Complications

1) Cold stress 2) Hypoglycemia 3) Hemorrhage

4 mechanisms that facilitate heat loss

1) Conduction: heat loss due to direct contact with a cooler surface - Preheat a radian warmer - Warm a stethoscope and other instruments - Put a pad on a scale before weighing the NB - The NB should be placed directly on the mom's chest and covered with a warm blanket 2) Convection: heat loss due to the flow of heat from the body surface to cooler environmental air - Place the bassinet out of the direct line of a fan or air conditioning vent - Swaddle the NB in a blanket and keep the head covered with a hat - Any procedure done with the NB uncovered should be performed under a radian heat source - Keep ambient temp of the nurser or mother's room at 22-26 C (72 to 78 F) 3) Evanporation: heat loss as surface liquid is converted to vapor - Gently rub the NB dry with a warm sterile blanket (adhering to standard precautions) immediately after delivery - If thermoregulation is unstable, postpone the initial bath until the NB's skin temp is 36.5 C (97.7 F) - When bathing, expose only one body part at a time, washing and drying thoroughly 4) Radiation: heat loss from the body surface to a cooler solid surface that is close to, but not in direct contact - Keep the NB and examining tables away from window and air conditioner

Medications for NB

1) Erythromycin 2) Vitamin K (phytonadione) 3) Hepatitis B immunization

Periods of reactivity

1) First period of reactivity - The newborn is alert, exhibits exploring activity, makes sucking sounds and has a rapid HR and RR - HR can be as high as 160-180/min but will stabilize at a baseline of 100-120/min during a period that lasts 30 ins after birth 2) Period of relative inactivity (decreased responsiveness) - The newborn will become quiet and begin to rest and sleep - HR and RR will decrease - This period will last from 60-100 min after birth 3) Second period of reactivity - The newborn reawakens, becomes responsive again - often gags and chokes on mucus that has accumulated in his mouth - This period usually occurs 2-8 hr after birth and can last 10 minutes to several hours

Labs for NB

1) Hgb and Hct (if prescribed) 2) Blood glucose for hypoglycemia (per facility policy or as prescribed) 3) Metabolic screening: - NB genetic screening is mandated in all states. A capillary heel stick should be done 24hr following birth. For results to be accurate, the NB must have received formula or breast milk for at least 24 hr. If the NB is discharged before 24 hr of age, the rest should be repeated in 1-2 weeks - All states require testing for phenylketonuria (PKU). PKU is a defect in protein metabolism in which the accumulation of the amino acid phenylalanine can result in mental retardation (treatment in the first 2 months of life can prevent mental retardation) 4) Other genetic testing: that can be done include for galactosemia, cystic fibrosis, maple syrup urine disease, hypothyroidism, and sickle cell disease 5) Serum bilirubin: on all NB prior to discharge 6) Collecting blood samples: - Heel stick blood samples done by the nurse using dons clean gloves - Warm the NB's heel first to increase circulation - Cleanse the area with an appropriate antiseptic and allow for drying - A spring-activated lancet is used so that the skin incision is made quickly and painlessly - The outer aspect of the heel should be sued, and the lancet should go no deeper than 2.4mm to prevent necrotizing osteochondritis resulting from penetration of bone with the lancet - Follow facility protocol for specimen collection, equipment to be sued and labeling of specimens - Apply pressure with dry gauze (don't use alcohol because it will cause bleeding to continue) until bleeding stops, and cover with an adhesive bandage - Cuddle and comfort the NB when the procedure is completed to reassure the NB and promote feelings of safety

Identification

1) Identification (using two identifiers) is applied to the NB immediately after birth by the nurse. It's an important safety measure to prevent the NB from being give not the wrong parents, switched, or abducted - The NB, mother and mother's partner are identified by plastic identification wristbands with permanent locks that must be cut to be removed. Identification bands should include the NB's name, sex, date and time of birth and mother's health record number. The NB should have one band placed on the ankle and one on he wrist. In addition, the Nb's footprints and mother's thumb prints are taken. The above information is also included with the footprint sheet - Each time the NB is given to the parents, the identification band should be verified against the mother's identification band - All facility staff who assist in caring for the NB are require to wear photo identification badges - The NB is not to be given to anyone who doesn't have a photo identification badge that distinguishes that person as a staff member of the facility maternal-newborn unit - Many facility have locked maternal-newborn units that require staff to permit entrance or exit. Some facilities have a sensor device on the ID band or umbilical cord clamp that sounds an alarm if the newborn is removed from the facility

Elimination

1) Monitor elimination habits. - Newborns should void once within 24 hr of birth. They should void 6 to 8 times per 24 hr after day 4. - Meconium should be passed within the first 24 hr to 48 hr after birth. The newborn will then continue to pass stool 3 to 4 times a day depending on whether he is being breast- or bottle-fed. - The stools of newborns who are breastfed can appear yellow and seedy. They should have at least 3 stools per day for the first month. These stools are lighter in color and looser than the stools of newborns who are formula-fed 2) Monitor and document output. - Keep the perineal area clean and dry. The ammonia in urine is irritating to the skin and can cause diaper rash. - After each diaper change, cleanse the perineal area with clear water or water with a mild soap. Diaper wipes with alcohol should be avoided. Pat dry, and apply triple antibiotic ointment, petroleum jelly, or zinc oxide, depending on facility protocol.

Respiratory complications

1) Monitor for clinical finding of RR complications - Bradycardia: RR < 30 min - Tachypnea: RR >= 60 min - Abnormal breath sounds: expiratory grinning, crackles and wheezes - RR distress: nasal flaring, retractions, grunting, gasping and labored breathing 2) Interventions for stabilization and resuscitation of airway - The new born is able to clear most secretions in air passages by the cough reflex. Routine suctioning of the mouth, then the nasal passages with a bulb syringe, is done to remove excess mucus in the RR tract - NB delivered by cesarean birth are more susceptible to fluid remaining in the lungs than NB who were delivered vaginally - If bulb suctioning is unsuccessful, mechanical suction and/or back blows and chest thrusts can be used, as well as the institution of emergency procedure - The bulb syringe should be kept with the NB, and the NB's family should be instructed on its use. Family members should be asked to perform a demonstration to show that they understand bulb syringe techniques *Compress bulb before insertion into one side of the mouth * Avoid center of the mouth to prevent stimulating gag reflex * Aspirate mouth first, one nostril, then second nostril

Thermoregulation

1) Thermoregulation provides a neutral thermal environment that helps a NB maintain a normal core temp with minimal O2 consumption and caloric expenditure. A NB has a relatively large surface-to-weight ratio, reduced metabolism per unit area, blood vessels close to the surface and small amounts of insulation - The NB keeps warm by metabolizing brown fat which is unique to NB, but only within a very narrow temp range. Becoming chilled (cold stress) can increase the NB's O2 demands and rapidly use up brown fat reserves. Therefore, monitoring temperature regulation is important - Monitor for hypothermia in the NB (axillary temp < 36.5C (97.7F); increased RR; cyanosis) - Core temp varies within NB, but it should be kept at approximately 36.5 to 37 C (97.7 to 98.6 F) - Temp stabilizes at 37 C (98.6 F) within 4 hr after birth if chilling is prevented

1. A nurse is preparing to administer prophylactic eye ointment to a newborn to prevent ophthalmia neonatorum. Which of the following medications should the nurse anticipate administering? A. Ofloxacin B. Nystatin C. Erythromycin D. Ceftriaxone

1. A. Ofloxacin is an antibiotic, but it is not used for ophthalmia neonatorum. B. Nystatin is used to treat Candida albicans, an oral yeast infection. C. CORRECT: One medication of choice for ophthalmia neonatorum is erythromycin ophthalmic ointment 0.5%. This antibiotic provides prophylaxis against Neisseria gonorrhoeae and Chlamydia trachomatis. D. Ceftriaxone is an antibiotic, but it is not used for ophthalmia neonatorum.

2. A newborn was not dried completely after birth. Which of the following mechanisms should the nurse understand causes heat loss? A. Conduction B. Convection C. Evaporation D. Radiation

2. A. Conduction is the loss of heat from the body surface area to cooler surfaces that the newborn can be in contact with. B. Convection is the flow of heat from the body surface area to cooler air. C. CORRECT: Evaporation is the loss of heat that occurs when a liquid is converted to a vapor. In a newborn, heat loss by evaporation occurs as a result of vaporization of the moisture from the skin. D. Radiation is the loss of heat to a cooler surface that is not in direct contact with the newborn.

3. A nurse is caring for a newborn immediately following birth. Which of the following nursing interventions is the highest priority? A. Initiating breastfeeding B. Performing the initial bath C. Giving a vitamin K injection D. Covering the newborn's head with a cap

3. A. Initiating breastfeeding is important following birth, but it is not the priority action. B. Initial baths are not given until the newborn's temperature is stable. It is not the priority action. C. Vitamin K can be given immediately after birth, but it is not the priority action. D. CORRECT: The greatest risk to the newborn is cold stress. Therefore the highest priority intervention is to prevent heat loss. Covering the newborn's head with a cap prevents cold stress due to excessive evaporative heat loss.

5. A nurse is taking a newborn to a mother following a circumcision. Which of the following actions should the nurse take for security purposes? A. Ask the mother to state her full name. B. Look at the name on the newborn's bassinet. C. Match the mother's identification band with the newborn's band. D. Compare name on the bassinet and room number.

5. A. Asking the mother to state her full name is not appropriate verification because two identifiers should be used. B. Looking at the name on the bassinet is not appropriate verification because two identifiers should be used. C. CORRECT: Each time the newborn is taken to the mother, the mother's identification band should be verified against the newborn's identification band. D. Comparing the name on the bassinet with the room number is not appropriate verification because it does not include two identifiers involving the mother and newborn.

4. A nurse is preparing to administer a vitamin K (phytonadione)injection to a newborn. Which of the following responses should the nurse make to the newborn's mother regarding why this medication is given? A. "It assists with blood clotting." B. "It promotes maturation of the bowel." C."It is a preventative vaccine." D."It provides immunity."

4. A. CORRECT: Vitamin K is deficient in a newborn because the colon is sterile. Until bacteria are present to stimulate vitamin K production, the newborn is at risk for hemorrhagic disease. B. Vitamin K does not assist the bowel to mature. C. Vitamin K is not part of the vaccines that are administered. D. Vitamin K does not provide immunity.

Hemorrhage

Due to improper cord care or placement of clamp NURSING ACTIONS ● Ensure that the clamp is tight. If seepage of blood is noted, a second clamp should be applied. ● Notify the provider if bleeding continues.

Feeding

Feedings can be started immediately following birth. ● Breastfeeding is initiated as soon as possible after birth as part of baby-friendly initiatives. ● Formula feeding usually is started at about 2 to 4 hr of age. A few sips of sterile water can be given to assess sucking and swallowing reflexes and ensure that there are no anomalies, such as a tracheoesophageal fistula, prior to initiating formula. ◯ The newborn is fed on demand, which is normally every 3 to 4 hr for bottle-fed newborns and more frequently for breastfed newborns. ◯ Monitor and document feedings per facility protocol.

Infection control

Infection control is essential in preventing cross-contamination from newborn to newborn and between newborns and staff. Newborns are at risk for infection during the first few months of life because of immature immune systems. - Provide individual bassinets equipped with a thermometer, diapers, T-shirts, and bathing supplies. - All personnel who care for a newborn should scrub with antimicrobial soap from elbows to finger tips before entering the nursery. In between care of the newborn, the nurse should follow facility hygiene protocols. Cover gowns or special uniforms are used to avoid direct contact with clothes.

Family education

Provide family education and promote family-newborn attachment. - Provide family education while performing all nursing care. Encourage family involvement, allowing the mother and family to perform newborn care with direct supervision and support by the nurse. - Encourage mothers and family to hold the newborn so that they can experience eye-to-eye contact and interaction. - Foster sibling interaction in newborn care.

A nurse is conducting a class for parents on care of the newborn. What should the nurse include in this class? Use the ATI Active Learning Template: Basic Concept to complete this item. UNDERLYING PRINCIPLES: Describe three mechanisms that promote airway clearance. NURSING INTERVENTIONS: Describe appropriate bulb syringe technique.

UNDERLYING PRINCIPLES: Mechanisms that promote airway clearance ● Infant's cough reflex ● Mechanical suctioning, back blows/chest thrusts ● Use of the bulb syringe for suctioning NURSING INTERVENTIONS: Bulb syringe technique ● Depress the bulb. ● Insert syringe into side of mouth, avoiding center of the mouth. ● Suction mouth first, then one nostril, then second nostril. NCLEX® Connection: Safety and Infection Control, Home Safety

Bathing

● Bathing can begin once the newborn's temperature has stabilized to at least 36.5° C (97.7° F). A complete sponge bath should be given within the first 1 to 2 hr after birth under a radiant heat source to prevent heat loss. If necessary, the first bath will be postponed until thermoregulation stabilizes. ● Gloves should be worn until the newborn's first bath to avoid exposure to body secretions.

Sleep

● Sleep-wake states are variations of consciousness in the newborn consisting of six states along a continuum comprised of deep sleep, light sleep, drowsy, quiet alert, active alert, and crying. ● Newborns sleep approximately 16 to 19 hr/day with periods of wakefulness gradually increasing. Newborns are positioned supine, "safe sleep," to decrease the incidence of sudden infant death syndrome (SIDS). ◯ No bumper pads, loose linens, or toys should be placed in the bassinet. ◯ Mothers should sleep in close proximity but not in a shared space. Higher incidence rates are noted for SIDS and suffocation with bed sharing/co-sleeping. ◯ Educate parents about the need for immunizations as a measure to prevent SIDS.