O.B. test 2 Chapter 15 notes

The transition from fetal circulation to neonatal circulation begins -

rapidly within seconds of the clamping of the umbilical cord and the initiation of the first breath.

The establishment of extrauterine _______________ is the most critical and immediate physiological change that occurs in the transition from fetus to neonate.

respiration's

Dehydration can occur due to the neonate's kidneys' limited ability to -

concentrate urine.

Social behaviors:

The ability of the neonate to respond to cuddling and holding. These behaviors are diminished or absent in neonates with neurological injuries or in neonates exposed to drugs in utero.

Bottle fed stool is

drier and more formed than breastfeed stools. It is a paler yellow or brownish yellow and has an unpleasant odor.

The three major fetal circulatory structures that undergo changes are the -

ductus venosus, foramen ovale, and the ductus arteriosus.

Passive immunity, which is not permanent, is acquired -

either naturally or artificially

Cold stress is a term that describes -

excessive heat loss that leads to hypothermia and results in the utilization of compensatory mechanisms to maintain the neonate's body temperature

An example of artificial passive immunity is

gamma globulin, which provides immediate protection for a short time

Neonates are first exposed to organisms from the maternal __________ ________ during the birthing process.

genital tract

The scores from these exams provide a gestational age that is graphed based on

weight, length, and head circumference to determine if the neonate is average for gestational age

The ductus arteriosus -

which connects the pulmonary artery with the descending aorta, usually closes within 15 hours post-birth. ■ This closure occurs when the pulmonary vascular resistance becomes less than system vascular resistance →left to right shunt →closure of ductus arteriosus. ■ It will remain open if lungs fail to expand or PaO2 levels drop.

The ductus venosus -

which connects the umbilical vein to the inferior vena cava, closes by day 3 of life and becomes a ligament. Blood flow through the umbilical vein stops once the cord is clamped.

The foramen ovale -

which is an opening between the right atrium and the left atrium, closes when the left Clamping atrial pressure is higher than the right atrial pressure. ■ Increased PaO2 →decreased pulmonary pressure → increased pulmonary blood flow →increased pressure in left atrium → closure of foramen ovale ■ Significant neonatal hypoxia can cause a reopening of the foramen ovale

However, whenever a neonate has a reduced number of SER

will have a →decreased ability to detoxify medication and an ↑risk of toxic effects from medications.

Breastfed stool is

yellow and semiformed. Later it becomes a golden yellow with a pasty consistency and has a sour odor.

During the first 6-8 hours of extrauterine life, the neonate transitions between periods of activity and inactivity. This is often referred to __________ of _______________ Each of the periods has predictable neonatal behaviors.

"periods of reactivity."

CULTURAL AWARENESS: Cultural and Ethical Variations in Infants

*African American: Mongolian spots and other birthmarks are more prevalent than in other ethnic groups. Amish: Babies are seen as gifts from God. Have high birth rates, large families. *Appalachian: Newborns wear bands around the abdomen to prevent umbilical hernias and asafetida bags around the neck to prevent contagious diseases. *Arab American: Children are "dearly loved." *Chinese American: Male circumcision is a religious requirement; children are highly valued; *Mongolian spots occur in about 80% of infants; bilirubin levels are higher in Chinese newborns than in others, with the highest levels seen on post-birth day 5 or 6. *Cuban American: Childbirth is a celebration; the family takes care of both the mother and infant for the first 4 weeks; tend to bottle feed rather than breastfeed; if breastfeeding, weaning is early, around 3 months; if bottle feeding, weaning is late, around 4 years. *Egyptian American: Children are very important. *Filipino American: Eyes are almond shaped, low to flat nose bridge with mildly flared nostrils; Mongolian spots common. *French Canadian: Five mutations account for 90% of phenylketonuria (PKU); high incidence of cystic fibrosis and muscular dystrophy. *Greek American: High incidence of two genetic conditions: thalassemia and glucose-6-phosphate dehydrogenase (G6PD) deficiency. *Iranian American: Believe in hot/cold influences, with baby boys "hotter" than baby girls; infants may be confined to the home for the first 40 days; ritual bath between the 10th and 40th post-birth day. *Jewish American: Children are seen as valued treasures; high incidence of Tay-Sachs disease; male circumcision is a religious ritual. *Mexican American: Wear stomach belt (ombliguero) to prevent umbilicus from popping out when the infant cries. *Navajo Native American: Infants are kept in cradle boards until they can walk; Mongolian spots are common. *Vietnamese American: Mongolian spots are common.

In utero, the lungs are filled with -

amniotic fluid. Approximately 30 mL of amniotic fluid is forced out of the lungs during the delivery process.

Glucose values normally decrease about __ hour post-birth, and then values rise and stabilize by __ to __ hours post-birth

1, 2 to 3

the procedure -

1. Provide parents with information on the test that has been ordered for their child. 2. Obtain required consents. 3. Warm the neonate's foot for 10 minutes by wrapping in a warm, moist washcloth. This will help facilitate circulation to the peripheral area. 4. Don gloves. 5. With the nondominant hand, hold the neonate's foot in a dorsiflexed position. The nurse or technician should have a firm grasp of the foot, but the foot should not be squeezed. 6. Clean the heel with alcohol. 7. Puncture the skin in the lateral or medial aspect of the heel to decrease the risk of nerve damage.

Full-term neonates excrete __ - __ mL/kg of urine per day for the first few days of life

15-60

A neonatal assessment should be done within __ hours after birth.

2

Stomach emptying time is __ - __ hours. Neonates should feed every -

2-4

Urinary output increases to _____ - _____ mL by end of the first month of life

250-400

The neonatal periodis from birth through the first __ days of life.

28

Hypoglycemia (blood glucose level under ___ mg/dL in the neonate) is common during this transitional time, especially in neonates of diabetic mothers

40

Gastric capacity for the first few days is approximately __ - __ mL and increases to 60 mL by day 7.

5-10

Cold stress occurs when there is:

A decrease in environmental temperatures →a decrease in the neonate's body temperature →an increase in respiratory rate, heart rate →an increase in oxygen consumption, a depletion of glucose, and a decrease in surfactant →respiratory distress

Major components of the immune system:

Active humoral immunity is the process in which B cells detect antigens and produce antibodies against them.

Three common circumcision devices used are

Gomco clamp, Mogen clamp, and Plastibell

Orientation:

The ability of the neonate to focus on visual and/or auditory stimuli. The neonate will turn his or her head in the direction of sound or will follow a visual stimulus. This response is diminished in premature neonates.

Convection:

Loss of heat from the neonate's warm body surface to cooler air currents, such as air conditioners or oxygen masks

Evaporation:

Loss of heat that occurs when water on the neonate's skin is converted to vapors, such as during bathing or directly after birth

________________ and ______________ stimuli are the primary factors that initiate extrauterine respirations

Mechanical, chemical

Self-quieting ability:

The ability of the neonate to quiet and comfort self. It is accomplished by sucking on the fist/hand or attending to external stimuli. The ability is diminished in neonates with neurological injuries or in neonates exposed to drugs in utero.

Motor maturity:

The ability of the neonate to control and coordinate motor activity. Normal findings are smooth, free movement with occasional tremors. Movement is jerky in premature neonates and/or in neonates with CNS abnormalities or injuries.

Habituation:

The development of decreased sensitivity to a repeated stimulus such as light, sound, or heel stick. It is a protective mechanism against overstimulation. Habituation may not be fully developed in premature neonates or in neonates with CNS abnormalities or injuries.

Nursing care of the neonate during hospitalization is divided into two time frames. List these time frames -

The first is the 4th stage of labor, which is from birth through the first 4 hours of extrauterine life. The second is from 4 hours of age to discharge.

Detoxification in neonates is performed by -

The smooth endoplasmic reticulum (SER) of the liver produces enzymes that detoxify harmful substances such as medications

Conjugation of bilirubin -

There is an increase in the neonate's RBC turnover (shorter RBC life span) and an increased RBC count at birth. These factors contribute to a proportionally greater amount of bilirubin production.

Sleep/awake states:

These are also referred to as infant states or behavior states.

Radiation:

Transfer of heat from the neonate to cooler objects that are not in direct contact with the neonate, such as cold walls of the isolette or cold equipment near the neonate

Conduction:

Transfer of heat to cooler surface by direct skin contact, such as cold hands of caregivers or cold equipment

Hyperbilirubinemiais

a condition in which there is a high level of unconjugated bilirubin in the neonate's blood related to the immature liver function, high RBC count that is common in neonates, and an increased hemolysis caused by the shorter life span of fetal RBCs

Brown adipose tissue (BAT) -

also referred to as brown fat or nonshivering thermogenesis, is a highly dense and vascular adipose tissue. Neonates possess large amounts of BAT, while children and adults have smaller amounts

Transitional stool begins -

around the 3rd day and can continue for 3 or 4 days. The stool transitions from black to greenish black, to greenish brown, to greenish yellow. This phase of stool characteristics occurs in both breastfed and formula-fed neonates.

This initial assessment provides the ______________ data for the neonate and assists in determining the course of nursing and medical care.

baseline

BAT reserves are rapidly depleted during periods of _______ ________

cold stress

This change is initiated by -

compression of the thorax, lung expansion, increase in alveolar oxygen concentration, and vasodilatation of the pulmonary vessels.

List the 4 ways in which there is a Loss of body heat -

convection, radiation, conduction, and/or evaporation

During intrauterine life, neonates of ____________ mothers produce high levels of insulin in response to the high levels of circulating maternal glucose. During the first few hours of extrauterine life, the neonate's insulin level remains higher than normal, leading to hypoglycemia.

diabetic

Because intact and healthy skin is a first-line defense against infection, the neonate's skin needs to be assessed at each shift and with each __________ __________ and care must be provided to maintain healthy skin.

diaper change

Indirect bilirubin(unconjugated bilirubin), a fat-soluble substance, is produced from the breakdown of red blood cells (RBCs). It is converted to ____________ _____________ a water-soluble substance, by liver enzymes. Direct bilirubin is in a form that can be excreted in the urine and stool.

direct bilirubin(conjugated bilirubin),

The surgical procedure is performed by the physician before

discharge or at a well-child check-up.

Neonates usually lose 5%-10% of birth weight during the first week of life due to -

diuresis.

The maternal genital tract may contain

group B Streptococcus and E. coli, which can result in neonatal sepsis

Phenylketonuria (PKU) is an

inborn error of metabolism. Neonates with PKU are unable to metabolize phenylalanine, which is an amino acid commonly found in many foods such as breast milk and formula. This leads to a buildup of phenylpyruvic and phenylacetic acids, which are abnormal metabolites of phenylalanine. The buildup of abnormal metabolites can cause permanent brain damage

There are two forms of bilirubin:

indirect and direct

Newborn screening

is a blood test that screens for infections, genetic diseases, and inherited and metabolic disorders and is performed on all babies born in the United States

Neutral thermal environment (NTE)

is an environment that maintains body temperature with minimal metabolic changes and/or oxygen consumption. ■ A neutral thermal environment (NTE) decreases possible complications related to the delayed response to environmental temperature changes.

Diarrhea stool is

loose and green

A delay or decrease in urinary output can occur in neonates whose mothers received ____________ ______________ during labor.

magnesium sulfate. Magnesium sulfate blocks neuromuscular transmissions and can cause urinary retention

Sensory stimuli such as exposure to temperature changes, sounds, lights, and touch also influence respirations by stimulating the respiratory center of the ___________

medulla.

Gestational age assessment of the newborn is based on the mother's -.

menstrual history, prenatal ultrasonography, and/or neonatal maturational examination

BAT is located in the -

neck, thorax, axillary area, intrascapular areas, and around the adrenal glands and kidneys.

Routine newborn screening began in the 1960s when all babies were screened for _________________________, and over the years technologies advanced and can now screen for approximately 30 disorders

phenylketonuria (PKU)

An example of natural passive immunity is the

placental transmission of antibiotics from the mother to the fetus. This provides protection for the neonate during the first few months of life from the pathogens to which the mother has been exposed.

The Ballard Maturational Score (BMS) is calculated by assessing the physical and neuromuscular maturity of the neonate. It can be completed in less time than the Dubowitz neurological exam. It consists of six evaluation areas for neuromuscular maturity and six items of observed physical maturity The examination determines weeks of gestation and classifies the neonate as

preterm (<37 weeks), term (37-42 weeks), or post-term (>42 weeks).

The calculation of gestational age by instruments such as Dubowitz neurological exam or Ballard scale of physical and neuromuscular maturity assists in predicting potential

problems and establishing plan of care based on gestational age.

The limited abilities of the kidneys can affect the excretion of drugs from the neonate's systems and increase the risk of-

side effects and toxicity

What is the major metabolic change in neonates immediately after birth -

the neonate becomes independent of the mother's metabolism and must balance the amount of insulin production with glucose availability.

Meconium stool begins -

to form during the 4th gestational month and is the first stool eliminated by the neonate. It is sticky, thick, black, and odorless. It is first passed within 24-48 hours.

Cold stress can delay the -

transition from fetal to neonatal circulation.

Active humoral immunity is further classified as:

■ Acquired immunity that develops from vaccination ■ Natural immunity that develops from exposure to antigens, after which the individual produces antibodies

"The American Society for Pain Management Nursing (ASPMN) holds the position that nurses and other healthcare professionals must provide optimal pain management throughout the circumcision process for male infants. Parents must be prepared for the procedure and educated about the infant's pain assessment. They must also be informed of pharmacologic and integrative pain management therapies." Nursing actions include:

■ Administering acetaminophen 1 hour prior to procedure ■ Applying topical anesthetic cream prior to procedure ■ Positioning newborn in a semi-recumbent position on a padded surface with arms swaddled ■ Administering 24% sucrose or breast milk orally 2 minutes before penile manipulation or offering pacifier for nonnutritive sucking if sucrose or breast milk contraindicated ■ Administrating oral acetaminophen for at least 24 hours post procedure ■ Instructing parents in infant pain assessment and management, and in care of circumcision

The neonate responds to cold by:

■ An increase in metabolic rate, ■ An increase of muscle activity, ■ Peripheral vascular constriction, ■ Metabolism of brown fat.

BAT promotes:

■ An increase in metabolism ■ Heat production ■ Heat transfer to the peripheral system

Nursing Actions from 4 Hours of Age to Discharge - The second stage of neonatal care focuses on monitoring the neonate's adaptation to extrauterine life and assisting parents in learning about their newborn and how to care for her (see Critical Component: Promoting Parent-Infant Attachment). The nursing actions listed are for neonates who do not exhibit signs of distress or potential complications.

■ Assess vital signs as per hospital policy. ■ Vital signs for stable neonates are assessed at a minimum of once a shift. ■ The neonate may continue to have difficulty in regulating her body temperature. ■ Notify the physician or nurse practitioner if temperature decrease persists. ■ Complete neonatal assessment once per shift. The type of assessment varies based on institutional policies. ■ Promote parent-infant attachment by providing uninterrupted times with the infant. ■ Promote sibling attachment by providing opportunities for interactions with the newborn, such as having older siblings assist with newborn care or listen to the newborn's heart. ■ Prevent infant abduction from the hospital. Each hospital has policies and procedures addressing methods to prevent infant abduction. Common steps that are taken are: ■ Footprints and photo of infant for identification purposes ■ Arm bands on the mother, father, and neonate that contain the same identification number. The bands of the neonate should be checked with the bands of the parents at the beginning of each shift and when taking or returning the neonate from or to the mother's room. ■ Personnel working in the maternal-newborn units should have name tags that are specific to that unit. Name tags should have a photo and name of the person. ■ Instruct parents and family members to not allow a person to take their newborn if the person does not possess the appropriate identification that is specific to the maternity unit. ■ Encourage parents to accompany any person who removes their infant from the mother's room. ■ Place the neonate's crib on the far side of the room away from the door leading to the hallway. ■ Instruct parents not to leave their newborn in the mother's room unattended. This includes when she is taking a shower. ■ The maternal-newborn units should be secure and only visitors with identification allowed to enter. ■ Assist parents with infant feeding ■ Provide information to parents on newborn care (see Chapter 16). ■ Teach parents about normal newborn characteristics (see Table 15-4). ■ Instruct parents to place their newborn on his back or side to decrease the risk of sudden infant death syndrome

Signs and Symptoms of cold stress -

■ Axillary temperature at or below 36.5°C (97.7°F) ■ Cool skin ■ Lethargy ■ Pallor ■ Tachypnea ■ Grunting ■ Hypoglycemia ■ Hypotonia ■ Jitteriness ■ Weak suck

Period of Relative Inactivity

■ Begins approximately 30 minutes after birth and lasts 2 hours ■ Sleep state The neonate is unresponsive to external stimuli ■ The respiratory rate decreases and can fall slightly below normal range. ■ The heart rate decreases and is within normal limits. ■ Oral mucus production decreases.

Constipation in bottle fed neonates in comparison to breastfed neonates -

■ Constipation usually does not occur in breastfed neonates. ■ Constipation can occur in bottle-fed infants when formula is not properly diluted.

Signs of Respiratory Distress -

■ Cyanosis ■ Abnormal respiratory pattern such as apnea and tachypnea ■ Retractions of the chest wall ■ Grunting ■ Flaring of nostrils ■ Hypotonia

Benefits related to circumcision:

■ Decreased incidence of urinary tract infections ■ Decreased incidence of sexually transmitted infections

Factors that negatively affect thermoregulation are:

■ Decreased subcutaneous fat ■ Decreased BAT in preterm neonates ■ Large body surface

Two factors that negatively affect the transition to extrauterine respiration's are:

■ Decreased surfactant levels related to immature lungs ■ Persistent hypoxemia and acidosis that leads to constriction of the pulmonary arteries

There are two sleep states and four awake states.

■ Deep sleep: During this state, there is no body movement except for an occasional startle reflex. The startle reflex is delayed in response to external stimuli. External stimuli are less likely to cause a change in state. The eyes are closed and there are no eye movements. Breathing is smooth and even. ■ Light sleep: During this state, there is random body movement. Rapid eye movement (REM) is present. The neonate responds to external stimuli with a startle reflex and with a possible change of state. Breathing is irregular. ■ Drowsy: During this state, there is intermittent body movement. Eyes open and close, and have a dull and heavy-lidded appearance. Breathing is irregular. Response to sensory stimuli is delayed. External stimuli will most likely cause a change in state. Breathing is irregular. ■ Alert: During this state the neonate's eyes are wide open with a bright look and focus on the sources of stimuli. There is a delay in response to stimuli and minimal body movement. Respirations are regular. ■ Eyes open: During this state, there is a considerable body movement with periods of fussiness. The eyes are open. The neonate responds to external stimuli with increased startle reflexes and motor activity. Breathing is irregular. ■ Crying: During this state, there is high motor activity and intense crying. It is difficult to calm the neonate. The eyes are opened or tightly closed. Breathing is irregular

During the transitional period, the neonate's immune system begins to:

■ Develop normal microbial flora of the skin, respiratory tract, and gastrointestinal tract ■ Respond to bacterial colonization of potential pathogens

Most hospital nurseries have written policies on which neonates should routinely be assessed for gestational age. Gestational age assessment is commonly completed on:

■ Neonates who, based on the maternal menstrual history, are preterm,born before 37 weeks; or post-term,born after 42 weeks by dates ■ Neonates who weigh less than 2,500 grams or more than 4,000 grams ■ Neonates of diabetic mothers ■ Neonates whose condition requires admission to a neonatal intensive care unit (NICU).

Nursing Preventative actions -

■ Dry the neonate thoroughly immediately after birth to decrease heat loss due to evaporation. ■ Remove wet blankets from the neonate's direct environment to decrease heat loss due to radiation, evaporation, and conduction. ■ Place a stocking cap on the neonate's head to decrease heat loss due to radiation and convection (Fig. 15-7). ■ Skin-to-skin contact with the mother with a warm blanket over the mother and neonate decreases heat loss due to radiation and conduction. ■ Use pre-warmed blankets and clothing to decrease heat loss due to conduction. ■ Swaddle in warm blankets to decrease heat loss due to convection and radiation. ■ Pre-warm radiant warmers and heat shields to decrease heat loss due to conduction. ■ Delay initial bath until the neonate's temperature is stable to decrease heat loss due to evaporation. ■ Place the neonate away from air vents to decrease heat loss due to convection. ■ Place the neonate away from outside walls and windows to decrease heat loss due to convection radiation. ■ Maintain a NTE to decrease heat loss due to convection and radiation.

Methods of Reducing Heat Loss The thermoregulatory systems of neonates respond more slowly to external temperature changes than those of adults. Prevention of heat loss is critical when doing assessments. Methods to reduce heat loss during assessments are:

■ Ensure that the room is warm and free of air drafts. ■ Place the infant under a warming unit to help maintain a NTE or assess the neonate in the mother's arms. Skin-to-skin contact between the mother and neonate can decrease the amount of heat loss. ■ When doing assessments in an open crib or in a parent's arms, keep the neonate wrapped and expose only the body area that is being assessed

The thermoregulatory systems of neonates respond more slowly to external temperature changes than those of adults. Prevention of heat loss is critical when doing assessments. Methods to reduce heat loss during assessments are:

■ Ensure that the room is warm and free of air drafts. ■ Place the infant under a warming unit to help maintain a NTE or assess the neonate in the mother's arms. Skin-to-skin contact between the mother and neonate can decrease the amount of heat loss. ■ When doing assessments in an open crib or in a parent's arms, keep the neonate wrapped and expose only the body area that is being assessed.

Second Period of Reactivity

■ Follows the period of relative inactivity and lasts 2-8 hours ■ Varies between active alert and quiet alert state ■ Periods of rapid respiration in response to stimuli and activity ■ Heart rate varies related to activity level and response to stimuli. ■ Increased bowel activity and may pass meconium stool ■ The neonate responds to external stimuli.

The Brazelton Neonatal Behavioral Assessment Scale is composed of 28 behavior items and 18 reflex items. These behaviors/reflex items are divided into six categories:

■ Habituation ■ Orientation ■ Motor maturity ■ Self-quieting ability ■ Social behaviors ■ Sleep/awake states

The Dubowitz neurological exam is a standardized tool that assesses 33 responses in four areas:

■ Habituation(the response to repetitive light and sound stimuli) ■ Movement and muscle tone ■ Reflexes ■ Neurobehavioral items

AWHONN recommends that Newborn Screening programs include the following:

■ Health care provider education ■ Parent education ■ Parental notification and consent, even if tests are mandatory ■ Timely screening tests prior to hospital or birthing facility discharge ■ Post discharge follow-up for additional screening tests or other services, when appropriate ■ Resources for appropriate referrals ■ Accurate and consistent systems for data collection ■ Access to interventions and treatments indicated by the diagnosis

Risks related to circumcisions -

■ Hemorrhage ■ Infection ■ Adhesion's ■ Pain

Neonates are at higher risk for thermoregulatory problems related to:

■ Higher body surface-area-to-body-mass ratio ■ Higher metabolic rate ■ Limited and immature thermoregulatory abilities

Neonates are at risk for infection related to:

■ Immature defense mechanism ■ Lack of experience with and exposure to organisms, which leads to a delayed response to antigens ■ Breakdown of skin and mucous membranes that provides a portal of entry for bacteria

Phytonadione (Vitamin K, AquaMEPHYTON)

■ Indication: Prevention of hemorrhagic disease in neonate ■ Action: Vitamin K is required for the hepatic synthesis of blood coagulation factors II, VII, IX, and X. ■ Common side effects: Erythema, pain, and swelling at injection site ■ Route and dose: IM; 0.5-1 mg within 1 hour of birth

Hypoglycemia Signs and Symptoms

■ Jitteriness ■ Hypotonia ■ Irritability ■ Apnea ■ Lethargy ■ Temperature instability

The focus of nursing care during this time is to protect and support the neonate as he undergoes numerous physiological changes and adapts to extrauterine life. This is accomplished by:

■ Maintaining body heat ■ Maintaining respiratory function ■ Decreasing risk for infection ■ Assisting parents in providing appropriate nutrition and hydration ■ Assisting parents in learning to care for their newborn

Review the prenatal record and birth record for factors that could place the neonate at risk for complications. Examples of risk factors are:

■ Maternal malnutrition prior to and/or during pregnancy ■ Maternal age younger than 16 and older than 35 years ■ Chronic maternal illnesses such as diabetes and hypertension ■ Hypertensive disorders of pregnancy ■ Labor and birth before 38 weeks of gestation ■ Long labor: Greater than 24 hours ■ Operative delivery: Use of forceps or vacuum extractor ■ Medications during labor that have an effect on the central nervous system (CNS; e.g., magnesium sulfate and analgesia/anesthesia) ■ Prolonged rupture of membranes (longer than 24 hours) ■ Meconium-stained amniotic fluid ■ Placental abnormalities ■ Apgar score 7 or below at 5 minutes

Nursing Actions

■ Monitor for signs and symptoms of hypoglycemia. ■ Assess blood glucose level with use of glucose monitor. ■ Assist the woman with breastfeeding. ■ Feed the neonate either formula or dextrose water when the glucose level is <40 mg/dL as per institutional protocol, generally 5 mL/kg. ■ Maintain NTE to decrease risk of cold stress.

Risks for Hypoglycemia

■ Neonates of diabetic mothers ■ Neonates weighing >4,000 grams or large for gestational age ■ Post-term neonates ■ Preterm neonates ■ Small for gestational age neonates ■ Hypothermia ■ Neonatal infection ■ Respiratory distress ■ Neonatal resuscitation ■ Birth trauma

Complete a general survey of the neonate before the head-to-toe assessment.

■ Observe the respiratory pattern and assess respiration's and breath sounds. ■ It will become more difficult to assess respiratory rate once the neonate responds (cries) to being handled during the assessment. ■ Observe posture. ■ Assess the skin for color, birth trauma, and birthmarks. ■ Observe the level of alertness/activity. ■ Assess muscle tone and posture.

Initial Period of Reactivity

■ Occurs in the first 15-30 minutes post-birth ■ The neonate is alert and active. ■ The neonate vigorously responds to external stimuli. ■ Respirations are irregular and rapid (can be as high as 90 breaths per minute). ■ The neonate may exhibit momentary grunting, flaring, and retractions. ■ Brief periods of apnea may occur. ■ The heart rate is rapid and can be as high as 180 beats per minute. ■ Brief period of cyanosis can occur. ■ The amount of oral mucus increases.

Initially the neonate's kidneys are immature and place the neonate at risk for:

■ Over-hydration ■ Dehydration ■ Electrolyte disorders such as hyponatremia and hypernatremia

Actions when the neonate displays signs/symptoms of cold stress -

■ Place a stocking cap on the neonate's head. ■ Skin-to-skin contact with the mother with a warm blanket over both the mother and neonate when there is a mild decrease in temperature; reassess temperature as per institutional protocol. ■ Swaddle in warm blankets; reassess temperature as per institutional protocol, which is generally every 30 minutes until stable. ■ Place the naked neonate under a preheated radiant warmer. ■ Attach the servo-controlled probe on the neonate's abdomen or other body surface that is closest to the radiant source. ■ It is recommended not to place probe over BAT areas, but there are too few research studies to view this as evidenced-based practice (Blackburn, 2012). ■ Set the control to 36.5°C. ■ Monitor the neonate's temperature, respiratory rate, and heart rate every 5 minutes when rewarming. ■ Assess and adjust the neonate's fluid requirement; fluids may need to be increased to compensate for insatiable water loss. ■ Monitor temperature as per institutional protocol. ■ Obtain a heel stick to assess for hypoglycemia (glucose <40 mg/dL). ■ Treat hypoglycemia.

Risk Factors -

■ Prematurity ■ Small for gestational age ■ Hypoglycemia ■ Prolonged resuscitation efforts ■ Sepsis ■ Neurological, endocrine, or cardiorespiratory problems

Causes of potential threats to skin integrity are:

■ Pressure exerted on the presenting part of the fetus during the labor and birthing process from maternal structures such as the pelvis, causing edema and hematomas ■ Abrasions, bruising, and edema of the skin related to use of vacuum extractors, forceps, and internal fetal monitoring ■ Exposure to bacteria from the maternal genital tract ■ Use of adhesives ■ Use stretchy wraps vs adhesives for securing probes and electrodes ■ Drying out and flacking of skin during the first few weeks of life ■ This is a natural process in the skin's transition from intrauterine to extrauterine life. ■ Diaper dermatitis ■ Actions to decreases risk of diaper dermatitis: ■ Change diapers with each feeding. ■ Use superabsorbent diapers that contain gelling materials which keep moisture away from skin. ■ Apply barrier products containing petrolatum and/or zinc oxide. ■ Apply antifungal creams when fungal infection is present

Circumcision Contraindications for circumcision include:

■ Preterm neonates ■ Neonates with a genitourinary defect ■ Neonates at risk for bleeding problems ■ Neonates with compromising disorders such as respiratory distress syndrome

Nursing Actions During the 4th Stage of Labor The changes that occur in the neonate's body during the transition to extrauterine life require frequent assessments and monitoring to identify early signs of physiological compromise (see Critical Component: Danger Signs and Critical Component: Hypothermia). Early identification of complications or difficulty with transition allows for earlier initiation of nursing and medical actions to support the neonate in a healthy transition. The following nursing actions occur in the labor/delivery/recovery room and/or nursery depending on hospital policies and health state of the neonate.

■ Review prenatal and intrapartal records for factors that place the neonate at risk, such as prolonged rupture of membranes (risk of infection), meconium-stained fluid (risk of respiratory distress), and gestational diabetes (risk of hypoglycemia). ■ Decrease risk of cold stress by: ■ Drying the neonate immediately after birth to prevent excessive heat loss through evaporation. ■ Discarding wet blankets and placing the neonate on dry, warm blankets or sheets. ■ Placing a stocking cap on the neonate's head to decrease the risk of heat loss through convection. ■ Placing the neonate in the mother's arms with skinto-skin contact and a warm blanket over mother and baby or placing the neonate under a preheated radiant warmer. ■ Support respirations by clearing the mouth and nose of excessive mucus with a bulb syringe when indicated. ■ Use universal precautions and wear gloves until after the neonate has been bathed to decrease exposure to blood-borne pathogens from amniotic fluid and maternal blood. ■ Obtain the Apgar score at 1 and 5 minutes and initiate appropriate actions based on the score (see Chapter 8). ■ Assess vital signs. ■ This is usually done within 30 minutes of birth, 1 hour after birth, and then every hour for the remainder of the recovery period. ■ The frequency of assessments may vary based on institutional policies and the health of the neonate. ■ Vital signs are assessed every 5-15 minutes for neonates with signs of distress. ■ Administer O2per institutional protocol, if the heart rate is below 100 beats per minute, cyanosis is present, and/or apnea occurs. Before administration of O2 the nurse should: ■ Check the airway and apply suction if indicated. ■ Stimulate the neonate by rubbing his back. ■ Inspect the clamped cord for number of vessels and for bleeding. ■ Complete and place identifying bands on the neonate and parents before the neonate is separated from parents (e.g., taken to the nursery or NICU). ■ Weigh and measure the neonate. ■ Complete a neonatal assessment within 2 hours of birth. ■ Explain to the parents the assessments and procedures performed on their newborn. ■ Complete a gestational age assessment as per hospital policies. ■ Obtain blood glucose levels by using a glucose monitor. ■ This is done on all neonates who exhibit symptoms of hypoglycemia as well as neonates who are at risk for hypoglycemia. ■ Administer erythromycin ophthalmic ointment to each eye. ■ The American Academy of Pediatrics (AAP) and Centers for Disease Control and Prevention (CDC) recommend that ophthalmic neonatorum prophylaxis be administered to all newborns within a few hours of birth. ■ Refer to institutional policies for timing of the application of ointment. ■ Administer phytonadione IM. ■ Support breastfeeding by providing a relaxing environment for the woman and her newborn (Fig. 15-9). ■ Bathe the neonate with neutral pH soap. The initial bath is delayed until the neonate's temperature is stable and within normal limits. ■ Promote parent-infant attachment by creating a relaxing environment: ■ Cluster nursing activities to allow for periods of uninterrupted time for new parents to spend time with their newborn. ■ Dim lights and close room door. ■ Notify the neonate's physician or nurse practitioner of the neonate's date and time of birth, and assessment findings.

The promotion of parent-infant attachment is a critical component of nursing care, and needs to occur as soon as possible after birth. Often nurses allow other nursing actions to take priority over parent-infant attachment or find it is easier to do assessments under the warming unit. Assessments and monitoring of vital signs can be performed in the parent's arms when the neonate is full term, the Apgar score is 8 or higher, and there were no signs of fetal distress during labor or at the time of birth. Nursing actions -

■ Skin-to-skin contact with a warm blanket over the neonate and parent. ■ Point out and explain expected neonatal characteristics such as molding, milia, and lanugo. ■ Provide alone time for the couple and their newborn by organizing care that allows for uninterrupted time. ■ Delay administration of eye ointment until parents have had an opportunity to hold the baby. Once ointment is administered, the neonate is less likely to open his or her eyes and make eye contact with parents.

Danger Signs The following signs may be an indication of an abnormality or complication. Document these signs in the neonatal record and report them to the physician or nurse practitioner:

■ Tachypnea (>60 breaths per minute) ■ Retractions of chest wall ■ Grunting ■ Nasal flaring ■ Abdominal distention ■ Failure to pass meconium stool within 48 hours of birth ■ Failure to void within 24 hours of birth ■ Convulsions ■ Lethargy ■ Jaundice within first 24 hours of birth ■ Abnormal temperature, either abnormally high or low ■ Jitteriness ■ Persistent hypoglycemia ■ Persistent temperature instability

Hepatitis B is a disease that is spread through contact with blood of an infected person or by sexual contact with an infected person, and it causes inflammation of the liver.

■ The CDC recommends that all neonates be vaccinated for hepatitis B before hospital discharge (see Critical Component: Intramuscular Injections). ■ CDC also recommends that neonates who have been or possibly have been exposed to hepatitis B during birth be given both hepatitis B vaccine and hepatitis B immune globulin (HBIg) within 12 hours of birth. ■ The second dose of hepatitis B vaccine is given at 1-2 months of age. The third dose is given at 6-18 months of age.

Heel Stick

■ The heel stick is a common procedure performed on neonates. ■ Blood is collected to assess blood glucose and hematocrit and for newborn screening.