Lecture 2: Newborn Adaptation, Assessment & Nursing Care (EXAM 1)

#3 The mother of a newborn questions the nurse about the rash on the neck and chest of her 24-hour-old newborn. The lesions are discrete, 2-mm, white papules on a pink base. What term would the nurse use to define this finding?

*A. Erythema toxicum* B. Milia C. Mongolian spots D. Telangeictatic nevus (stork bites)

Skin Care

1.) *Bathing *: Provide when temp stable (usually >98 deg.) - Sponge bath (many different techniques; procedures based on principles) - Tub bath - Mild shampoo • Johnson and Johnson/Baby Magic - Never leave child unattended - Assess skin thoroughly • Cuts • Birthmarks • Nevi • Other 2.) *Cord Care* - Clamped - Ongoing assessment for infection - Keep diaper folded under cord - Per hospital/MD orders: Alcohol, Triple Dye, goldenseal - Air Dry - No submerging tub bath until after cord has fallen off (usually 10-14 days)

*Methods of Heat Loss*

1.) *Evaporation* - Heat loss when water is converted to vapor - Air drying of the skin that results in cooling 2.) *Conduction* - Movement of heat away from the body when infants come in direct contact with objects cooler than their skin 3.) *Convection* - Transfer of heat from the infant to cooler surrounding air 4.) Radiation - Transfer of heat to cooler objects that are not in direct contact with the infant

Brief Overview of Hyperbilirubinemia (Jaundice)

1.) *Excessive accumulation of bilirubin in the blood* - Characterized by a yellowish discoloration of the skin - Rise in the direct and indirect serum bilirubin levels • Uncongugated/Indirect (not soluble in water, must be broken down by liver) • Congugated/Direct (water soluble, excreted in feces and urine) - If bilirubin levels get too high in the newborn, it can cause bilirubin encephalopathy which can cause brain damage to the baby.

Newborn Care Discharge Teaching

1.) *Follow-up MD appt.* - Be sure parents have MD's phone number, and are encouraged to call if any questions/issues 2.) *Breathing:* - Irregularity of respirations - Sneezing normal; doesn't mean baby is ill - Obligatory nose breathers: keep free of mucous 3.) *Use of bulb syringe* - Be sure parents know how to use this and to have it handy!!! 4.) *Temperature* - Use common sense in dressing infant: one layer more than adults have on - Feel trunk: if cold or hot, intervene! - Take temp if baby doesn't seem right: show technique: call MD if <97.7 or >100 5.) *Output* - At least 6 wet diapers/day by 4th day - 1—5 stools. Less with formula fed. 6.) *Bathing* - Sponge bath until cord falls off, then can submerge - Keep warm! 7.) Handling the infant - Head support - Positions - Wrapping - Handwashing!!!

Common Problems: Musculoskeletal

1.) *Hip dysplasia* - Partial or complete - Tests: Hip rotation feeling for "clicking" sound/feel • *Positive* Barlow and/or Ortolani signs • Assessment of symmetry of gluteal folds • Assessment of leg length - Treatment: • Double diaper • 3 -6 months in a harness and/or casting

Overview of Fetal Circulation after Birth

1.) *In Utero:* - The fetus does not breathe air or metabolize substances in the liver, so 3 shunts are needed to divert circulating blood away from lungs and liver: *• Ductus Venosus • ForamenOvale • Ductus Arteriosus* - At birth, clamping of the umbilical cord, increases in blood oxygen, and shifts in pressure within the heart and the pulmonary and systemic circulations cause these shunts to close - These changes are necessary to transition to extra-uterine life, and occur within the first few minutes of life

Newborn Integumentary System

1.) *Integumentary System* - To include hair and nails - Color, texture, distribution, eruptions, birthmarks • Color pink and blanching white over bony prominences to show good capillary refill • Mouth, tongue, and gums 2.) Normal Variations: - Soft and smooth - Leathery, cracking, peeling in post term - Hair distribution - Fingernails and scratches • later date babies have longer nails and can hurt themselves - Milia - Erythema toxicum (AKA: newborn rash) • Cause unknown, suspected maternal hormones - Sucking blister - Mottling - Cradle cap • scaly, crusty 3.) Electrode scalp marks, scalp lacerations, forceps facial marks, vacuum extraction marks on scalp -due to instruments in labor and delivery (can cause trauma)

Genitalia Assessment (Male)

1.) *Male infant genitalia*: - Testicles descended or not • Undescended = cryptorchidism: common with preterm - Scrotum • Rugae (full term) or smooth (earlier baby) • Hydrocele (swollen scrotum) - Urethral opening: • Evaluate is it midline? Hypospadius or epispadias - Red/golden stain in diaper? • Uric acid crystals

Skin Color

1.) *Normal*-pink, warm, and dry 2.) *Acrocyanosis* - cyanosis occurring in hands and feet - Common in first 24 hours - Exasperated by cold stress 3.) *Mottling*: lacy pattern 4.) *Harlequin sign* 5.) *Jaundice* 6.) *Central cyanosis* - Pale blue in thoracic area including extremities - May signal cardiac involvement

Hyperbilirubinemia (Jaundice)

1.) *Physiologic jaundice* - Occurs *after the first 24* hours of life (usually day 2-4) as a result of hemolysis of red blood cells and immaturity of the liver 2.) *Pathologic jaundice* - Begins *in the first 24 hours* and may require treatment with phototherapy - Or persistent jaundice after the first week of life in term infant - Or persistent jaundice after first 2 weeks of life in preterm infant 3.) *Breastfeeding Jaundice* - Often caused by a lack of sufficient in take, self-limiting, peaks at day 3 4.) *Breast milk jaundice* - Onset after 3-5 days, peaks at 2 weeks; related to milk composition

Preemie v. Post-date

1.) *Preemie vs. Post-dates*: Infants of varying gestational age have certain predictable physical characteristics 2.) *Preemie*: - Thin, gelatinous skin - Presence of superficial veins - Absence of some reflexes - "Floppier" muscle tone - Extended body positioning - "Floppy" ears/lack recoil - Absence of plantar creases - Presence of lanugo & vernix - Genitals: Males: Undescended testes Females: "splayed"/open vulva 3.) *Post-dates*: - Opaque skin - Dry skin, cracked, peeling - Long fingernails - Presence of reflexes - Less presence of lanugo and vernix - Body flexion (frog-like) - Presence of plantar creases - Well-formed ears with ready- recoil - Presence of breast buds

Heart Rate/Cardiovascular

1.) *Range: 110-160 -BPM- Count apical & for 1 full minute* (count for a full minute because HR is irregular) - Murmur may be common (in first 24 hours), but still follow-up - PMI often visible through chest

Newborn Measurements

1.) *Weight* - Normal between *2500-4000g (5 lb, 8 oz - 8 lb, 13 oz.)* - Average weight 7 lb, 8 oz. - Expected to lose up to 10% of birth weight during first few days - Normally regain or exceed birth weight by 14 days old. 2.) *Length* - Normally 46 - 56 cm (18 - 22 inches); average 20 inches 3.) *Head Circumference* - Normally 32-37 cm (12.6 - 14.6 inches); 1⁄4 the size of an adult head 4.) *Chest Circumference* - Usually 2 to 3 cm smaller than the head - Normally 35-36 cm (11.8-13.4 inches); average 12.6 inches

Newborn Rash

1.) *erythema toxicum* -comes and goes -not contagious -can be alarming to parents

*Preventing Heat Loss in the Newborn*

1.) *evaporation* - Dry at delivery - Dry after bathing - Keep linens dry - Use K pads - Use saran wrap blankets - Use humidified air 2.) *Convection* - Warm the environment - Avoid drafts - Cover the infant - Use hats 3.) *Conduction* - Pre-warm bedding - Use a warmed scale - Cover x-ray plates - Warm the diapers - Warmwater 4.) *radiation* - Avoid windows -Use incubator door covers - Double walled isolettes

Newborn head: Molding

1.) *molding*: is dependent on how long baby was left in the birth canal

Surfactant

1.) A lipoprotein that reduces the surface tension within the alveoli in the lungs 2.) Without surfactant, the alveoli would collapse as an infant exhales 3.) Sufficient surfactant is usually produced by 34-36 weeks gestation

Jaundice Treatment

1.) Adequate feedings - Infants treated with phototherapy require 25% more fluid intake - Breastfeed at least every 2-3 hours - Bottle feed at least every 3-4 hours - Stimulate voiding and stooling 2.) Avoid water feeds - Does not stimulate stool secretion 3.) Repeat blood bilirubin levels 4.) High levels of bilirubin - *Phototherapy* (protect eyes/genitals, reposition frequently; Q 2 hrs.) - IV fluids - Exchange transfusion

CCHD: Critical Congenital Heart Defect

1.) Affects approx. 18/10,000 babies 2.) Life threatening & requires intervention during infancy 3.) To improve early detection, the AAP recommends all infants screened prior to d/c 4.) Test: - Pulse Ox: • <95% in both RH and foot or >2% difference = abnormal.

Newborn Screening Blood Test

1.) All states require newborn blood screening for PKU (phenylketoneurea) and hypothyroidism 2.) Many states include additional screening tests for conditions such as - Galactosemia - Sickle cell disease and thalassemia - A variety of others that vary from state to state

American Academy of Pediatrics Guidelines for Infant Sleep Safety & SIDS Risk Reduction

1.) Always place baby on his or her back for every sleep time. 2.) Always use a firm sleep surface. Car seats and other sitting devices are not recommended for routine sleep. 3.) The baby should sleep in the same room as the parents, but not in the same bed (room-sharing without bed-sharing). 4.) Keep soft objects or loose bedding out of the crib. This includes pillows, blankets, and bumper pads. 5.) Wedges and positioners should not be used. 6.) Pregnant woman should receive regular prenatal care. 7.) Don't smoke during pregnancy or after birth. 8.) Breastfeeding is recommended. 9.) Offer a pacifier at nap time and bedtime. 10.) Avoid covering the infant's head or overheating. 11.) Do not use home monitors or commercial devices marketed to reduce the risk of SIDS. 12.) Infants should receive all recommended vaccinations. 13.) Supervised, awake tummy time is recommended daily to facilitate development and minimize the occurrence of positional plagiocephaly (flat heads).

American Academy of Pediatrics (AAP) Recommendation

1.) American Academy of Pediatrics found the health benefits of newborn male circumcision outweigh the risks, but the benefits are not great enough to recommend universal newborn circumcision. 2.) The AAP policy statement recently published says the final decision should still be left to parents to make in the context of their religious, ethical and cultural beliefs

Protocols

1.) Assess for hypoglycemia in LGA, SGA, IDM, postterm, and preterm infants (and patients that are symptomatic) - If accucheck glucose levels less than 40 mg/dl • obtain venous blood glucose and feed infant or repeat accucheck to verify (depends on hospital protocol) and breast feed - Repeat accucheck at 1,3, and 6 hours (or per hospital protocol)

Abdomen

1.) Assess in supine position 2.) Visual Inspection first: - Examine cord for vessel number and clamping • 3 vessels, AVA (2 arteries 1 vein) - Is abdomen round, soft - Observe for hernias around umbilicus • (Weak abdominal wall fascia may show a lump or protrusion when infant cries) 2.) Auscultate: bowel sounds in four quadrant 3.) Swollen breast tissue common in full-term infants, may have white secretion from nipples (3 days-2 weeks) -from maternal hormones 4.) Supernumerary nipples -extra nipples

Infant Posterior Assessment

1.) Assess spine for curvature 2.) Assess gluteal folds for symmetry 3.) Assess for spina bifida 4.) Observe for pilonidal dimpal or tuft of hair - May signify spina bifida occulta

Suture Lines

1.) Assess suture lines 2.) May be approximated, overriding or open

Head

1.) Assessment of Fontanels - Soft, flat, full, bulging (increased ICP), depressed (dehydrated) - Soft & flat: normal - Full, bulging: increased intracranial pressure - Depressed: dehydration - Assess fontanels while infant is held in the upright position - 2 Fontanels • Anterior fontanel ✵ Diamond shaped ✵ Closes by 18 months of age • Posterior fontanel ✵ Triangular shaped ✵ Smaller than the anterior fontanel ✵ Closes by 2 to 4 months of age 2.) Palpation of the suture lines - Sutures overriding, approximated, or spread? • All variations of normal 3.) Assessment of head shape: - Molding or not molded 4.) Assessment of head for areas of swelling - Determine if it's caput, hematoma or subgaleal hemorrhage

Causes of Hyperbilirubinemia

1.) Baby's inability to keep up with the rapid breakdown of RBC's 2.) Inability of the immature liver to conjugate bilirubin -fat soluble into water soluble form 3.) Bile duct obstruction 4.) Hemolytic disease of the newborn -you'd see this in the first 24 hours 5.) Traumatic birth injuries 6.) Delayed feeding/Slow meconium excretion

Psychosocial Adaptation

1.) BehavioralStates - Drowsy - Quiet Alert State (best for bonding) - Active Alert State (often fussy, restless) - Crying 2.) Periods of Reactivity - First period of reactivity • 30 min to 2 hrs after birth: bonding/BF - Period of sleep - Second period of reactivity (4-6 hrs after birth; varied in duration)

Cardiac/Circulatory Assessment

1.) Blood Pressure - Not routinely done in normal newborns • Done if appears to be circulation problems ✵ Unequal pulses ✵ Poor perfusion 2.) Pulse assessment - Check brachial & femoral pulses • Should be equal bilaterally ✵ If not, could indicate circulatory problem 3.) Check cap refill - Should be <3 sec - Check blanching for jaundice as well

Cephalhematoma

1.) Blood accumulation between skull and periosteum 2.) Does not cross suture line 3.) Usually seen within 24 hrs & may increase in size for 2-3 days (better to worse) 4.) 2-3 weeks to resolve

Suctioning Secretions

1.) Bulb suction immediately PRN to clear airway - Mouth then nose 2.) May use mechanical suction if needed but not necessary if bulb syringe is successful - Creates vagal stimulation resulting in bradycardia 3.) Always have bulb syringe handy, and teach parents how to use it. -vaginal delivery babies' chests and stomach gets squeezed and they spit up a lot of saliva in their lungs -c/section babies don't go through this and they have more mucus and are "spittier" 4.) Cardiac sphincter (between esophagus and stomach) is relaxed, so newborns regurgitate feedings frequently: Risk for aspiration

Eyes

1.) Check color of iris, sclera - Subconjunctival hemorrhages common - Jaundice assessment 2.) Eye color usually established within 3 month, but may change up to age 1 year 3.) Visual field: 10 -12 inches from face 4.) Assess for edema, drainage - May be a reaction to eye prophylaxis 5.) May have transient strabismus (cross-eyes)

Newborn Stools

1.) Classification of stools - Meconium: • Greenish/black, tarry. Usually passed 12-24 hrs • can cause skin breakdown 2.) Breast milk - Loose, no odor, light yellow- 3.) Transitional: greenish yellow 4.) Formula stools -Foul odor, more formed than breast milk stools -Can be green, brown, light yellow

Birthmarks

1.) Congenital dermal melanocytosis (Mongolian blue spots) -common bruise looking birthmark -require careful documentation since it can be mistake for bruises or child abuse 2.) Telangiectatic nevus (nevi, or stork bite) -nape of neck -flat pink birthmark 3.) Nevus flammeus (port wine stain) - non-elevated, does not grow, fade or blanch 4.) Nevus vasculosus (strawberry mark) - elevated/raised; may grow until 6 mo, then will shrink spontaneously

General Infant Care

1.) Diapering 2.) Assist with feeds 3.) Positioning 4.) Identifying infant in hospital 5.) Security/Infant Abduction band

Immediate Newborn Care at Delivery

1.) Establish and maintain respirations 2.) Prevent hypothermia/cold stress 3.) Frequent assessment of respiration and color 4.) Physical examination, vital signs 5.) Identification

Genitalia Assessment (female)

1.) Gestational age assessment - Full term: labia majora enlarges until clitoris and labia minora are almost completely covered - Pre term: more "splayed" open looking 2.) Vaginal skin tags may be present -note these in chart 3.) Smegma presence normal 4.) Pseudomenses 5.) Importance of cleaning front-to-back -educate patient

Hearing Tests

1.) Hearing screening given to newborns prior to discharge from the hospital. 2.) Auditory brainstem response and otoacoustic emissions testing are used for screening 3.) If baby's don't "pass" they are referred for further testing

Newborn Screening Tests Prior to D/C

1.) Hearing test 2.) State newborn screening blood test 3.) CCHD - Critical Congenital Heart Defect

Initiation of Respirations

1.) In utero, the alveoli are collapsed 2.) Breathing is initiated by - Chemical factors • Decrease in blood O2 levels & increase in CO2 levels stimulate the respiratory center in the infant's brain - Mechanical Factors • Fetal chest compression during vag. Birth - Thermal Factors • Sensors in the skin sense the change in temp. and stimulate the resp. center of the brain

Maturity Growth Charts

1.) Infant measurements (length, weight & head circumference) are plotted along growth grids 2.) *AGA* = appropriate for gestational age = the middle 80% 3.) *LGA*= large for gestational age = top 10% 4.) *SGA* = small for gestational age = bottom 10%

General Assessment of the Newborn

1.) Is done as soon as the baby is stabilized and placed on mom's abdomen or in the open warmer 2.) *Visual inspection* - Body position: flexed vs. floppy tone ✵flexed is good ✵floppy: neurological or medications passed from mom to baby - Skin color: pink with acrocyanosis - Symmetry of ROM (assess for potential injuries; neurological or physical trauma from birth) ✵fx clavicle is very common during birth

Urinary System/Elimination

1.) Kidney function - The ability of the newborn kidneys to filter, reabsorb and maintain fluid and electrolyte balance is less than that of the adult kidney. 2.) The first void should occur within 24 hours. 3.) If no stool in 24-48 hours, may have imperforate anus

Classifications

1.) LGA: Weight >90% 2.) SGA: Weight<10% 3.) AGA: 10-90% 4.) LBW: 2,500g or less 5.) VLBW: 1,500g or less 6.) IUGR: Intrauterine growth restriction 7.) Preterm: prior to 37 weeks gestation 8.) Term: 37-42 weeks gestation 9.) Post dates >42 weeks

*Thermogenesis*

1.) Methods of heat production - Increase activity - Flexion - Metabolism - Vasoconstriction • blue hands and feet - Nonshivering thermogenesis (brown fat) •fat that has mitochondria that can burn and produce heat • can't shiver like we do •if they shivering they are hypoglycemic or have neurological problems 2.) These factors increase oxygen and glucose consumption and may cause respiratory distress, hypoglycemia, and jaundice.

Circumcision

1.) Most common surgical procedure in infants - Involves removal of the foreskin - Controversial 2.) *Reasons to*: - Disease risk reduction - Cultural/religious factors - Parental preference - Lack of knowledge about care of the foreskin - Any others? 3.) *Reasons against*: - Unnecessary surgery - Culture: uncommon in some cultures - Cutting part of a sexual part of the organ - Cleanliness, esp. during diapering period - Anything else? 4.) Risks of Circumcision -Hemorrhage -Infection -Removal of too much or too little -Phimosis (tightening of the foreskin) -Adhesions, necrosis -Unsatisfactory cosmetic effect -Urinary retention -Urethral stenosis or fistula -Injury to the glans -Pain during and after surgery 5.) Most Common Types of Circumcision - *GomcoClamp* • Pressure of clamp for 3-5 minutes, then slit/cut away excess skin • Petroleum gauze strips to site after to prevent sticking to diaper - *Plastibell* • Plastic rim to fall off within 5-8 days • Yellow crust around area normal/do not remove/distinguish from infection 6.) Educate family to... -Keep area clean -Change diaper with every void -Wash penis with warm water -Apply petroleum jelly with each diaper change -Not tub bath until healed -Report any abnormal discharge or redness -Monitor for bleeding • Apply gentle pressure with sterile gauze and call pediatrician

Immune System

1.) Neonates are less effective at fighting off infection than the older child or adult. - IgG crosses the placenta in utero and provides a newborn with passive immunity. - IgM and IgG are produced to protect against infection.

Gestational Age Assessment

1.) Newborn maturity level is rated and classified by nurses to determine the gestational age 2.) This is based on physical as well as neuromuscular maturity 3.) This is important because infants of premature or post-mature gestational age are at risk for certain complications 4.) Neuromuscular characteristics - Posture - Square window - Arm recoil - Popliteal angle - Scar sign - Heel to ear

Nose

1.) Nose breathers for first few months, unless crying - remove obstructions by sneezing 2.) Check each nare for patency *(Choanal Atresia)* by gently obstructing each nostril one at a time, closing the mouth and checking for a rise and fall in chest 3.) Have the ability to smell and turn toward food source -bathing babies isn't best practice ✵washing off microbiome ✵washing off scent that is important in bonding ✵all babies are handled with gloves

Mouth

1.) Observe for cleft lip and palate 2.) Epstein pearls -hard white cysts on palate 3.) Precocious teeth -might refer to pediatric dentist so it doesn't com eout on its own and be a risk for aspiration 4.) Blisters (sucking or possible acquired infection) 5.) Thrush -fungal infection -if it is thrush, it is red and angery underneath the white -if it is normal and pink underneath the white, it is not thrush -check anal area, thrust often goes through GI tract -mom and anyone in contact with baby needs to be treated 6.) tongue-tied? - short frenulum which may impact feeding; causes heart shape at tip of tongue -"fixed" by snipping it 7.) Presence of suck reflex? 8.) Gag reflex - Absence of gag reflex may indicate brain damage

Newborn Face

1.) Observe for symmetry - Cranial nerve VII damage due to traumatic birth, or use of forceps can cause facial asymmetry. - Observe for symmetry when infant cries -asymmetry may extend down their body as well

Nursing Responsiblities

1.) Obtain signed consent 2.) Gather equipment 3.) Monitor for bleeding: a few drops of blood during first few diaper changes is normal 4.) Monitor for void (call if not within 6-8 hours) 5.) Monitor for infection: high or low temp, purulent or foul-smelling drainage 6.) Monitor for displacement of plastibell 7.) Teaching

Physiologic Jaundice

1.) Occurs after 24 hours of life - Baby does not have to be breastfeeding - Most common type - Causes: • Immature liver cannot break down the RBCs that were necessary in utero, but are no longer necessary in such quantity as newborn is now breathing air • Traumatic birth injuries (bruising, hematoma)

Pathologic Jaundice

1.) Occurs within 24 hours of birth - *Causes*: usually caused by pathology such as: • Hemolytic disease of the newborn • Neonatal sepsis • Maternal disease - Usually does not respond to phototherapy alone but will be treated initially with this treatment

Newborn prophylactic medication administration:

1.) Ophthalmic prophylaxis - Prevents gonococcal and chlamydial infections - Erythromycin (most common), silver nitrate, or tetracycline 2.) Vitamin K prophylaxis(Phytonadione) - Dose: 0.5 to 1.0 mg IM in *vastus lateralis* - Vitamin K normally produced by intestinal flora, but newborn GI tract is sterile, so Vitamin K given prophylactically - Assists with blood clotting - If not given within 2-3 days following birth, possible hemorrhages may occur

Infant Safety/Security

1.) Parents should be educated that no one except designated personnel should be allowed to take their baby 2.) Student nurses can't take the baby, but you can return them - Just check bands to make sure they match 3.) Infants should always be transported in a portable crib (not walking in the hallway holding the baby) - Safety issue (could trip) - Infant abduction issue

Factors that may affect parent-infant bonding

1.) Physical abnormalities of the baby - Parents may shy away from infant 2.) Critically ill infant 3.) Pain state of the mother 4.) Family dynamics of the baby's family 5.) Illness in the mother - *Chorioamnionitis* (amniotic fluid infection) • May involve infant ✵ Presents with fever, high heart rate, high respirations

Jaundice Assessment

1.) Physical assessment: yellowish discoloration of skin 2.) Check blanching of skin & color of sclera 3.) Progresses from head to toe 4.) TCB: transcutaneous bilirubin 5.) Blood test: total serum bilirubin (TSB) 6.) CBC, Coomb's test, reticulocyte count 7.) For physiologic jaundice, the bilirubin peaks at 5 to 6 mg/dL between the 2nd & 4th days of life. 8.) It should then begin to fall, so that by 5 to 7 days, the level should be less than 2 mg/dL 9.) Charts help tell what is normal bilirubin level for infants depending on how many days old they are

Immediate Newborn Care

1.) Prevent Cold Stress - warm blankets & heat source present at all deliveries 2.) Think,"Airway,Breathing,Circulation" - An oxygen source must be available at ALL deliveries as must an endotrachial tube and laryngoscope 4.) Suction Airway if Necessary - Bulb syringe, mechanical suction - Mouth before nose • stimulation of nares causes reflex stimulation that could cause aspiration of the fluids in the mouth 5.) *Apgar Scoring* at 1 and 5 minutes (and again at 10 min if either score was less than 7 out of 10) -APGAR: appearance, pulse, grimace, activity, respiration 6.) QuickAssessment - heart, lungs, appearance, cord vessels (stethoscope must be handy) - Full head-to-toe done at a later time, after bonding and breastfeeding • if baby is stable, we want to put on mom for skin-to-skin 7.) Medications (Code drugs/Narcan if needed) 8.) Promote Bonding and Feeding

Preventing Heat Loss

1.) Radiant warmer preparation -if baby is unstable -needing meds -giving baths 2.) Place infant on abdomen of mother immediately after birth 3.) Dry and remove wet linen 4.) Hat 5.) Warm anything that is applied directly to infant's skin 6.) Kangaroo care (skin to skin)

Respiratory Rate

1.) Range: 30 to 60 breaths per minute 2.) *Common variations:* - Irregular, shallow, no distress - Moist breath sounds may be present shortly after birth - Periodic breathing is *normal* when less than 15 -20 seconds ✵considered an apnic episode if its >15 seconds (needs intervention)

Ears

1.) Recoil and pinna formation (gestational age) 2.) Angle of ear related to eye - Low-set ears may be sign of chromosomal disorder 3.) Observe for ear pits & skin tags -report ear pits to doctors (they can be linked with other issues) -skin tags can be in front or behind ears and are associated with kidney problems 4.) Baby's response to noise - May clap a hand or ring a bell to detect startle response in infant 5.) Hearing screen done prior to discharge 6.) shape and recoil of the ear -well formed pinna -good, fast recoil -slow recoil is an earlier gestation baby

Neurological System

1.) Reflexes - Grasp Neurological System • Palmar and plantar (hands & feet) - Rooting - Sucking - Gag - Swallow - Stepping - Moro - Babinski - Tonic neck

Transient Tachypnea of Newborn (TTN)

1.) Respiratory rate greater than 60 2.) Usually resolves within 24 hrs to a few days 3.) Due to retained lung fluid 4.) May be present in full term infant or preemie 5.) Common in which circumstances? -c-sections and precipitous birth (fast vaginal delivery)

Hypospadias

1.) SHOULD NOT circumcise baby in hospital, may need skin for surgical reproduction -may need skin for surgical reproduction 2.) can lead to infertiity issues

Positioning the Infant

1.) Safe sleep (SIDS) - The American Academy of pediatrics recommends all infants be placed supine to sleep. - Avoid overheating. - Not to sleep in a bed or couch with adults 2.) *Plagiocephaly* - Supervised periods of lying prone each day

Newborn Cry

1.) Should be strong and lusty 2.) High-pitched, shrill cry is abnormal - neurologic disorders - drug exposure/withdrawal - hypoglycemia 3.) An important method of communication; indicates a change in baby's condition or needs

Uric Acid

1.) Should resolve to normal urine color in diaper by day 5

Subgaleal Hemorrhage

1.) Subgaleal hemorrhage occurs when the emissary veins which connect the dural sinuses with the veins in the scalp, rupture 2.) This is a serious complication that the infant can develop shortly after birth, and in many cases, it can be fatal. 3.) Presence of fluctuance. Fluctuance is a ripple effect that occur across the scalp. This ripple effect is caused by the fluid buildup in the scalp. 4.) If the infant is on its back and the head is lifted off the bed, the fluid will pool towards the back of the scalp creating this ripple effect in the skin. It looks similar to waves in the ocean.

Caput Succedaneum

1.) Swelling of soft tissues 2.) May cross suture lines 3.) Resolves: goes from worse to better

*Respiratory Distress*

1.) Tachypnea (>60 resp/min) 2.) Cyanosis 3.) Nasal Flaring 4.) Grunting 5.) Retractions - Intercostal - Substernal

Discharge Teaching: S/Sx of Illness

1.) Temperature greater than 38C(100.4) or below 36.6C (97.9) axillary 2.) Continual rise in temperature 3.) Forceful or frequent vomiting 4.) Refusal of two feedings in a row 5.) Difficulty in waking baby 6.) Cyanosis with or without feeding 7.) Absence of breathing longer than 20 seconds 8.) Inconsolable infant or continuous high-pitched cry 9.) Discharge or bleeding from the umbilical cord, circumcision, or any opening 10.) Two consecutive green watery or black stools, or increased frequency of stools 11.) No wet diaper for 18 to 24 hours 12.) Fewer than 6 to 8 wet diapers per day after 4 days 13.) Development of eye drainage

CDC Recommendation

1.) The CDC says there is now strong evidence that male circumcision can: - Cut a man's risk of getting HIV from an infected female partner by 50 to 60 percent. - Reduce their risk of genital herpes and certain strains of human papillomavirus by 30 percent or more. - Lower the risk of urinary tract infections during infancy, and cancer of the penis in adulthood.

Last Minute Details...

1.) assessment frequencies - Based on status of infant whether in NBN or NICU 2.) VS usually with every assessment 3.) Assessment involve all systems but taking VS do not 4.) "Dirty baby" hasn't had it's first bath yet & is covered with maternal secretions. Must be handled by nurses with gloves until after first bath. 5.) Order of Vital Signs 6.) What if VS are outside of normal parameters? 7.) Hand wash!!!!!(and make others do it too!) 8.) Care of infants (diapering, baths) based on concepts, and details of how nurses provide care may vary.

Petechiae

1.) benign if they disappear within 2 days of birth and no new lesions appear -if they don't disappear or new lesions are appearing then its reportable

Cardiovascular System Adaption

1.) blood flow through the lungs: -In the fetus, only 15% of cardiac output goes to lungs via the pulmonary artery. • Within 15-20 minutes after birth, 60% of cardiac output goes to lungs • Within 24-48 hours, 100% of cardiac output goes to lungs. • For this to occur, the Ductus Arteriosus must close. 2.) Increased P02 levels from lung respiration *- Increases systemic vascular resistance - Systemic resistance is greater than pulmonary resistance -Result: ductus arteriosus closes* 3.) Increased PO2 levels from lung respiration - *Decreases pulmonary vascular resistance which allows •Increased pulmonary blood flow •Increased pressure in left atrium •Decreased right atrium pressure -Result: foramen ovale closes* 4.) Increased PO2 from lung respiration: *- Increased systemic vascular resistance - Causes decreased systemic venous return - Cessation of umbilical venous return -Result: ductus venosus closes*

Nevi, or "stork bite"

1.) commonly seen at the nape of the neck, but may also be seen elsewhere

Umbilical Cord

1.) evaluate around umbilical cord -should be pink and health -not read or streak -no tub baths until this falls of 2.) fold diaper under cord

Prevention of Infection in a Newborn

1.) eye prophylaxis -AgNO3 •*Erythromycin ointment

Pilonidal Dimple

1.) indicate a form of spina bifida -spina bifida aculta 2.) look for tuft of hair

Newborn Common Sights

1.) lanugo -typically in earlier gestation babies 2.) Vernix -typically found in folds

The New Ballard Score: to Determine Gestational Age

1.) often used for people with no prenatal care or if the baby does not look like you were expecting their age to be

Normal Newborn Vital Signs

1.) temperature (axillary ONLY) *- Range: 36.5 to 37.5 (97.7F - 99.F) axillary • May differ slightly per facility - be sure you know your site's* ranges • If temp low, skin-to-skin, or radiant warmer • Tell RN, recheck 15 min later • If too warm, note layers on infant & teach & unwrap baby • Increased temperature is not reliable indicator of infection, as in children/adults - A temperature *less than* 36.5(97.7F) could indicate SEPSIS ✵ Brown fat metabolism is the baby's last defense mechanism against hypothermia ✵Babies *UNABLE* to produce heat via shivering thermogenesis

Jaundice

1.) usually signs of jaundice is 3-4 days after birth 2.) clear bilirubin, they need to be eating adequately so bilirubin is excrete through feces

#4 The nurse is teaching new parents how to dress their newborn. Which statement(s) would indicate that teaching has been effective? Select all that apply

A. "We should keep our home air-conditioned so the baby doesn't overheat *B. "It is important that we dry the baby off as soon as we give him a bath or shampoo his hair."* *C. "When we change the baby's diaper, we should change any wet clothing or blankets, too."* D. "If the baby's body temperature gets too low, he will warm himself up without any shivering." *E. "Our baby will have a much faster rate of breathing if he is dressed too warmly."*

#6 The nurse administers vitamin K to the newborn for what reason?

A. Most mothers have a diet deficient in vitamin K, which results in the infant being deficient. B. Vitamin K prevents the synthesis of prothrombin in the liver and must be given by injection. *C. Bacteria that synthesize vitamin K are not present in the newborn's intestinal tract.* D. The supply of vitamin K is inadequate for at least 3- 4 months, and the newborn must be supplemented.

#2 The maternal-newborn nurse formulates which nursing goal for a newborn in transition within the first few hours after birth?

A. To facilitate development of a close parent- infant relationship B. To assist parents in developing healthy attitudes about childrearing practices *C. To identify actual or potential problems that may require immediate or emergency attention* D. To provide the parents of the newborn with information about well-baby programs

#1 A newborn is placed under a radiant heat warmer. The nurse knows that thermoregulation presents a problem for newborns because __________.

A. their renal function is not fully developed, and heat is lost in the urine B. their small body surface area favors more rapid heat loss than does an adult's body surface area *C. they have a relatively thin layer of subcutaneous fat that provides poor insulation* D. their normal flexed posture favors heat loss through perspiration

#5 The parents of a 3-month-old infant report that their infant sleeps supine (face up) but is often prone (face down) while awake. The nurse's response should be based on knowledge that this is __________.

A. unacceptable because of the risk of sudden infant death syndrome (SIDS) B. unacceptable because it does not encourage achievement of developmental milestones C. acceptable because it encourages fine motor development *D. acceptable because it encourages head control and turning over*

Musculoskeletal System

Ongoing Visual Inspection 1.) Movement of arms and legs: - should be symmetrical - Asymmetrical movement may indicate nerve damage from birth trauma or congenital anomalies 2.) Extremity movement and digit count - Polydactyl vs. syndactyl 3.) *Club feet* due to lie of infant or congenital anomalies - Treated with casting -can't be retracted to midline 4.) *Broken clavicles* - Confirmed by x-ray - Palpate clavicles for crepitus 5.) *Abnormal palmer creases* - May indicate Down Syndrome -not 100% reliable 6.) *Plantar crease gestational age assmt.*