IM5- Unit 1- Assessment & Intervention (Infant)

Bottle feeding a preterm infant

• Need suck-swallow breathing coordination • Readiness to feed behaviors include: remain engaged in feeding, able to organize oral-motor function, can maintain physiologic stability • Infant fed in semi-sitting position and burped after each 15ml • Feeding should take no longer than 15 to 20 min • Start with one session a day and increase slowly until infant can tolerate all bottle feedings Soft, yellow single hole nipple is usually used. When infant roots and actively searches for the nipple, they are neurodevelopmentally ready to bottle feed. Nurse should assess infants ability to suck. Sucking may be affected by postconceptual age, asphyxia, chronic lung disease, IVH, or other neurologic insult. Nurse should observe infant for signs of stress or respiratory distress which would increase the risk of aspiration. Demand feeding protocols should be considered if infant can maintain enough caloric intake to sustain growth otherwise they feed every 3-4 hours

Preventing Infection in the Preterm Infant

• Nurse is responsible for minimizing preterm's exposure to pathogenic organisms • Strict hand washing and limited visitors • Use separate equipment for each infant • Most nurseries have adopted the Standard Precautions recommended by CDC of isolating every baby • Most nurseries have adopted the JCAHO requirement that all staff members have short-trimmed nails and no artificial nails • Staff members are required to do a 2 to 3 min scrub using antimicrobial solutions • Maintaining strict aseptic practices when changing IV tubing and solutions (tubing changed every 24 hours) • Strict aseptic technique when administering parenteral fluids and assisting with sterile procedures. Buddy system • Incubators and warmers should be changed weekly • qPosition changes (Q3-4h) and using water-bed or gel mattresses to prevent skin breakdown. These babies can be prone position because they are on a monitor • Chemical skin preps and tape can cause skin trauma-avoid as much as possible

Preventing fatigue during feeding of a preterm new born

• Preterm newborns who are ill or fatigue easily are usually fed by gavage • Infant is passive with these methods • Offer pacifier to meet oral needs • Conserves energy and calories • As baby matures, gavage feeds are replaced with nipple feeds. Signs of readiness: Strong gag reflex, Presence of non-nutritive sucking, Rooting behavior Sucking meets oral and emotional needs. Both the LBW and preterm infants nipple-feed more efficiently in a quiet state. The nurse establishes a gradual nipple-feeding program, such as one nipple feeding per day, then one per shift, then one every other feeding and so on. Daily weights are monitored because often there is a small weight loss when nipple feedings are started. If they are loosing a lot of weight, we could be expending too much energy on feedings. Only give 30 minutes to feed, because after that they will spend more calories than they are gain. Look for signs of stress, expand fingers, closing eyes, and turning from bottle. Each feeding needs to be positive, if negative need to stop feeding. Feedings should be bottle fed the first time to have the best assessment for preterm. After it is deemed safe, they can breastfeed. After feedings, the infant is placed on the left side (with support) or on the abdomen to enhance gastric emptying and decrease the chance of aspiration if regurgitation occurs. Gastroesophageal reflux is not uncommon in preterm infants. Long-term gavage feedings may create a nipple aversion (oral) that will require developmental occupational therapy interventions. Burp around 15mL

A nurse in the newborn nursery has just received report. Which of the following infants should the nurse see first? A. A 2-day-old who is lying quietly alert with a heart rate of 185 B. A 1-day-old who is crying and has a bulging anterior fontanelle C. A 12-hour-old who is being held, with respirations that are 45 breaths per minute and irregular D. A 5-hour-old who is sleeping and whose hands and feet are blue bilaterally

(A) A 2-day-old who is lying quietly alert with a heart rate of 185. Explanation: The infant with a heart rate of 185 is having tachycardia. The normal rate for this age is 120 to 160 beats per minute.

A nurse in the birthing room is assessing a newborn. Which newborn characteristic should be assigned an Apgar value of 2? A.A strong cry B.Legs and arms slightly flexed C.Body pink and extremities blue D.A heart rate of ninety beats per minute

(A) A strong cry. Explanation: A strong cry indicates effective respiratory function and is assigned a value of 2

The nurse is completing a newborn assessment and counting the infant's cord vessels. In a normal newborn umbilical cord there are: A.Two vessels: one vein and one artery B.Three vessels: two veins and one artery C.Three vessels: one vein and two arteries D.Four vessels: two veins and two arteries

(C) Three vessels: one vein and two arteries. Explanation: There are three vessels. There is one vein and two arteries in an infant's umbilical cord. The vein carries oxygenated blood to the fetus and the two arteries return deoxygenated blood back to the placenta.

How does the nurse prevent cold stress in an infant?

-Dry the neonate thoroughly immediately after birth to decrease heat loss due to evaporation -Remove wet blankets from the neonates direct environment to decrease heat loss due to radiation, evaporation and conduction -Place a stocking cap on the neonates head to decrease heat loss due to radiation and convection -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

How does the newborns stool change during the first four days of life?

-Meconium Dark green, black, thick, sticky, shiny, tar-like, without smell Should be present at birth or within 24 hours Would need further assessment if not within 24 hours -Transitional stools Dark green, brown, sticky but getting softer Usually appear by day of life DOL 3 -Milk stools Usually appear by DOL 4 Vary depending on whether breast milk or formula is being fed *Breastfeeding stools Yellow, yellow-green, seedy, soft, and squishy *Formula stools Yellow-brown, green-tan brown, thick and firm

Definitions of Jaundice, Milia, lanugo, Mongolian spots, Vernix

1. Jaundice: Yellow coloring of skin. First appears on the face and extends to the trunk and eventually the entire body. Best assessed in natural lighting. When jaundice is suspected, the nurse can apply gentle pressure to the skin over a firm surface such as nose, fore-head, or sternum. The skin blanches to a yellowish hue. Jaundice within the first 24 hours is pathological; usually related to problem of the liver. (relate to the doctor quickly) Jaundice occurring after 24 hours is referred to as physiological jaundice and is related to increased amount of unconjugated bilirubin in the system 2. Milia: White papules on the face; more frequently seen on the bridge of the nose and chin. Exposed sebaceous glands that resolve without treatment. Parents might mistake these for "whiteheads." Inform parents to leave them alone and let them resolve on own 3. Lanugo: Fine, downy hair that develops after 16 weeks of gestation. Thee amount of lanugo decreases as the fetus ages. Often seen on the neonate's back, shoulders, and forehead. Gradually falls out. The presence and amount of lanugo assist in estimating gestational age. Abundant lanugo may be a sign of prematurity or genetic disorder 4. Mongolian Spot: Flat, bluish discolored area on the lower back and/or buttock. Seen more often in African American, Asian, Hispanic, and Native American infants. Might be mistaken for bruising. Need to document size and location. Resolves on own by school age. Not bruising 5. Vernix: A protective substance secreted from sebaceous glands that covered the fetus during pregnancy It looks like a whitish cheesy substance. May be noted in axiliary areas and genital areas of full-term neonates. The presence and amount of vernix assist in estimating gestational age. Full-term neonates usually have none or small amounts of vernix.

Immunologic System of the Preterm Infant

1. Remember that IgG crosses the placenta to provide passive immunity in utero of the last trimester. A preterm infant is offered less protection and they become depleted earlier than a full term. This may be a contributing factor in the higher incidence of recurrent bacterial infection. 2. Premature infants often do not tolerate feedings well so miss out on benefits of IgA (found in breast milk) 3. Preterm skin is easily excoriated and this, coupled with multiple invasive procedures places the infant at great risk for nosocomial infection. Skin is thin and fragile. Good hand washing is a must!! 4. Invasive procedures such as umbilical catheterization, peripheral venipunctures, and mechanical ventilation and prolonged hospitalization place the infant at greater risk for infection.

How many vessels are in the umbilical cord?

2 arteries and 1 vein 2 vessel cords could indicate cardiac or kidney issues. The cord becomes dry and darker in color within 24 hours post-birth and detaches from the body within 2 weeks. Teach cord care; push skin down around base to clean the base. They will cry from annoyance, not painful. Should not have foul smells.

While preparing to apply the identification bracelets to a newborn, the nurse notices that the spelling of the last name does not match the information on the mother's band. What should the nurse do? A. Refrain from applying the bands because all details do not match the mother's band. B. Apply the bands as long as the medical record information is correct. C. Bundle the newborn and transport him or her to the nursery to obtain new bands. D. Tape the footprint sheet to the newborn because it carries all the accurate information.

A. Identification bands must have all the same information to be valid. The nurse must compare the mother's organization identification band with the newborn's organization identification band and verify that they match.

Immune System Review

Active humoral immunity is the process in which B cells detect antigens and produce antibodies against them. Active humoral immunity is further classified as: Active Acquired immunity that develops from vaccination. Natural immunity that develops from exposure to anti-gens, after which the individual produces antibodies. Passive immunity, which is not permanent, is acquired either naturally or artificially. 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. An example of artificial passive immunity is gamma globulin, which provides immediate protection for a short time. Lymphocytes are white blood cells that are primarily composed of T cells and B cells. The number of T cells within the neonate's system is comparable to that in adults, but their functional abilities are decreased, which delays the response to microorganisms. The functional abilities of B cells are also hyporesponsive Immunoglobulins are classified as IgG, IgA, IgM, IgD,and IgE (Table 15-2). Maternal IgGs are the primary antibodies that cross the placenta and enter the fetal system and provide passive immunity for the neonate The maternal transfer of IgG antibodies protects the neonate from bacterial and viral infections for which the mother has developed antibodies, such as rubella, tetanus, and diphtheria (Blackburn, 2012). 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 provide a portal of entry for bacteria

What cranial nerves have developed in the newborn?

All cranial nerves are myelinated except the optic and olfactory nerves.

What to teach about car seat care?

All infants and toddlers should ride in a rear-facing car seat until they are at least 2 years of age or until they reach the highest weight or height allowed by their car seat's manufacturer. (Check labels on seat for this information.) Secure the chest clip even with your baby's armpits. Fasten harness straps snugly against your baby's body. You should not be able to pinch the slack at the baby's shoulder.

How can the nurse minimize heat loss for a preterm infant?

Allow skin to skin between mother and newborn Warm and humidify oxygen to minimize evaporative heat loss and decrease oxygen consumption Place baby in double-walled incubator; Use Plexiglas heat shield over preemie in single-walled incubator; Use radiant warmer and pipe in humidity Avoid placing infant on cold surfaces. Use warmers during procedures; Pre-warm mattresses; warm hands and stethoscopes Maintain temp of 36.5-37.6 C

What opposes air entry into the lung after delivery?

Alveoli are filled with amniotic fluid and it can cause surface tension. Amniotic fluid is usually removed by the normal force of delivery, as the chest is squeezed through the birth canal. The brisk recoil of the thorax occurs and allowing air entry into the upper airway to replace the fluid. The remaining lung fluid is absorbed by pulmonary capillaries within the first few days of life. Surfactant in the infant's lungs breaks alveolar surface tension. It assists in keeping the alveolar sacs partially open at the end of exhalation, which decreases the amount of pressure and energy required on inspiration. (Establishing function residual capacity) Decreased surfactant levels related to immature lungs negatively affects the transition of extrauterine respirations. About 30mL of amniotic fluid is forced out during delivery. The establishment of extrauterine respirations are the most critical and immediate physiological change that occurs in the transition from fetus to neonate. This change is initiate by compression of the thorax, lung expansion, increase in alveolar O2 concentration, and vasodilation of the pulmonary vessels.

What is the first rapid assessment of the newborn?

Apgar score: rapid assessment of five physiological signs that indicate the physiological status of the newborn and includes: heart rate based on auscultation, Respiratory rate based on the observed movement of the chest, muscle tone based on degree of flexion and movement of extremities, Reflex irritability, Color based on observation Completed at 1 and 5 minutes 0-3 indicates severe distress 4-6 indicates moderate difficulty with transition to extrauterine life 7-10 indicates stable status The APGAR score is not used to determine the need for resuscitation, nor is it predictive of long term outcomes of the neonate. Rather it is a rapid objective, convenient shorthand for reporting the status of the newborn and the response to resuscitation. Factors affecting the Apgar score: Physiologic immaturity, infection, maternal sedation, congenital disorders

What is an important step in ensuring safety with newborn ID?

Apply an arm band with the correct information. Only banded people can take the baby from the nursery. One of the procedures after birth is newborn identification. Nurses must be meticulous when recording the identification band number, and birth and newborn information and applying identification bands to mothers and newborn. Bands will go to adopted parents if that is the scenario. Must match mom and baby or ID baby. NO laziness! HESI: apply ID to the ankle and opposite wrist of the infant The NCMEC has reported that 58% of infant abductions occur in the mother's room. Typical profile: Woman btwn ages of 15-44 who is often overweight and has low self esteem; she may be emotionally disturbed because of the loss of her own child or an inability to conceive and may have a strained relationship with partner. Random visitors that are overly interested in where babies are kept May be seen visiting the newborn nursery.

Assessment of the neonatal lungs

Assess respiratory rate by observing the rise and fall of the chest and abdomen for one full minute. 30-60 b/m. Rate increases and decreases with crying/sleeping Respirations <30; may be related to maternal analgesia and/or anesthesia during labor. Periods of apnea should be less than 15 seconds, no color changes, or pulse ox changes. Assessments every 6-8 hours. Lung assessments are huge. Periods of apnea >20 seconds or tachypnea that may be related to sepsis, hypothermia, hypoglycemia, or respiratory distress syndrome. Crackles are not abnormal after birth from amniotic fluid (up to 6 hours). After should be clear, equal, and bilateral No grunting, stridor, or retractions intercostal/substernal/suprasternal. No see-saw breathing or unequal breath sounds

Assessment of the Preterm Infant

Assessment is similar to all babies Color: Usually pink or ruddy; may be acrocyanotic Will not see as much acrocyanotic, because we know they need more help breathing and have already started basic resuscitation efforts. Skin: Reddened, translucent, blood vessels apparent; lack of sub-Q fat Lanugo: Plentiful, widely distributed Head size: Appears large in relation to the body Skull: Bones pliable, fontanels smooth and flat, sutures approximated or overriding. No bulging Ears: Minimal Cartilage, pliable, folded over Nails: Soft; short Genitals: Males: Nonrugated, small scrotum; testes may or may not be descended. Females: Prominent clitoris and labia minora Posture: Flaccid, froglike position (not flexed), causing thermoregulation to be worse Cry: Weak, feeble Reflexes: Poor suck (before 34 wks), swallow and gag (all reflexes are weaker) Activity: Jerky, generalized movements Determining gestational age in preterm newborns requires knowledge and experience in administering gestational assessment tools.

Newborn sutures and Craniosynostosis

At birth the skull is made up of multiple bones held together by seams called sutures. The sutures should remain open as long as the brain continues to grow, enabling the skull to expand and properly accommodate brain growth. Craniosynostosis is a congenital anomaly caused by early closure of one or more of these sutures, resulting in limited or distorted head grown. Craniosynostosis is also called synostosis or cranial stenosis. About 1 in 2,000 infants are born with craniosynostosis, which in some cases, can cause serious issues with development. It is best to seek evaluation and treatment with a team of experienced specialists from a variety of fields.Surgery is often recommended.

What can a nurse do in the initial steps of resuscitation of a newborn?

At every delivery there should be one person who is solely responsible for assessment of the neonate response to the birth and who has the capacity to initiate resuscitation of the neonate if needed. The initial steps of resuscitation is to provide warmth by placing the infant under a radiant warmer, positioning the head in a sniffing position to open the airway, clearing the airway if needed, drying the baby thus stimulating the baby to breath.

How much blood is an infant born with?

Average 500mL +/- 100mL In full term the blood volume is approximately 80-85mL/kg Infant: Hematopoietic System Blood volume depends on placental transport of blood Long cord clamping is delayed or the cord is milked 100mL can be added to the volume. We must know how much blood we are taking out and keep running total of blood loss. Babies also do not have enough iron to help with blood cell production

The nurse is using a bulb syringe to suction a neonate after delivery. The most appropriate technique for bulb syringe suction is to: A.Compress bulb after insertion B.Clear mouth before nasal passages C.Use two bulb syringes, one for mouth and one for nose D.Use mechanical suctioning it is more efficient

B. Clearing the mouth before the nasal passages will minimize the potential aspiration of amniotic fluid.

Immediately after birth, a newborn's mouth and nose are suctioned with the bulb syringe. The newborn has a weak cry and is hypotonic. What should the nurse do first? A. Repeat suctioning of the oropharyngeal area with an appropriate suction catheter. B. Reposition the airway and assess respirations. C. Perform a rapid gestational age assessment to see whether the newborn is preterm. D. Administer 100% blow-by oxygen.

B. Repositioning the newborn's head creates an airway for effective respirations.

The initiation of breathing in a newborn helps to establish: A.maintaining core temperature B.conversion to neonatal circulation C.opening of fetal shunts D.passage of meconium

B. With the newborn's first breath, pressure changes occur within the circulatory system to promote blood flow through the heart and lung passages. Closing of fetal shunts occur along with an increase in pulmonary blood flow which results in additional pressure changes which lead to neonatal circulation.

What is couplet care?

Baby will stay in the Mom's room, and will only leave for procedures

Continue Gestational Age

Birth weight alone is a poor indicator of gestational and fetal maturity Gestational age reflects fetal maturity Higher the score, higher the gestational age Appropriate for 20 to 44 weeks of gestation 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). 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

What is acrocyanosis?

Body pink; extremities blue (not concerning at 1 minute of life) This would get 1 point on apgar score

The nurse is in a delivery room that has a temperature of 23.9°C (75°F). After delivery of a stable, term newborn, the nurse assesses vital signs and discovers that the newborn's temperature is 37.1°C (98.8°F) How should the nurse respond? A. Turn off the warmer and increase the temperature in the room. B. Recognize that the newborn is septic and immediately contact the neonatologist. C. Place the newborn in skin-to-skin contact with the mother to initiate breastfeeding. D. Call the pediatrician and obtain an order for acetaminophen.

C. Placing the newborn in skin-to-skin contact helps maintain his or her temperature and helps initiate breastfeeding.

What strongly influences neonatal circulation?

Change within the respiratory system The decrease in pulmonary vascular resistance causes an increase in pulmonary blood flow, and the increase in the systemic vascular resistance influences the cardiovascular changes. Pressure changes in the heart, lungs, and vessels after the umbilical cord has been clamped.

What are some contraindications and risks related to circumcision?

Contraindications: Preterm neonates Neonates with a genitourinary defect Neonates at risk for bleeding problems Neonates with compromising disorders such as respiratory distress syndrome Risks related to circumcision: Hemorrhage Infection Adhesions Painful

Which finding on physical assessment of a neonate would indicate the need for further observation and examination? A.Epstein Pearls B.Cyanotic hands and feet C.Babinski reflex D.Low-set ears

D. Ears that are low placed are indicative of several congenital and genetic syndromes, including Down syndrome

Promoting Parent-preterm infant attachment Cont.

Daily participation in care is encouraged Nurse provides opportunities for parents to touch, hold, talk to, and care for their baby Don't stroke or bother them when sleeping because it minimizes their growth. Leave alone during sleep time. Highly encouraged to come at feeding times Skin-to-skin holding (kangaroo care) helps parents feel close to their small infants Parental involvement in difficult decisions is essential Rooming in can provide another opportunity for infant and parents to get acquainted When close to discharge Will have call light and access to dr and nurses

Supportive care of the preterm infant

Developmentally Supportive Interventions Include: Provide opportunities for non-nutritive sucking with a pacifier This improves oxygen saturation; decreases body movement; improves sleep, especially after feedings; and increases weight gain Provide objects for the infant to grasp during care giving Grasping may comfort the baby. Teaching the parents to read behavioral cues will help them move at their infant's pace when providing stimulation. Parents are ideally equipped to meet the baby's need for stimulation. Stroking, rocking, cuddling, firm touch, quiet singing, and talking to the baby can all be an integral part of the baby's care. Visual stimulation in the form of en face interaction with the caregivers and the use of mobiles is also important

What is diaper rash?

Diaper dermatitis •Caused By Prolonged And Repetitive Contact With An Irritant Or Combination Of Irritants -Urine And Feces -Soaps -Detergents -Ointments -Chemicals In Disposable Diapers -Friction Peak age 9-12 months. Higher risk for bottle fed infants. Treat: Keep area clean Use a non-irritating cleanser (Gentle cleanser = not antibacterial soap) Use disposable super absorbent diapers Apply skin barrier Clean with warm water that runs off their bottom and clean with gentle soap. Wipe only moves bacteria and irritants around. Diaper area open to air for a little bit

What eye care must be done 1 hour following birth?

Drugs (ophthalmic ointment or drops) •Erythromycin (0.5%) •Tetracycline (1%) •Silver nitrate (1%) All affective against conjunctivitis Prophylaxis (ophthalmia neonatorum) •Effective against conjunctivitis •Gonococcal conjunctivitis •Could cause blindness if not treated Allow for bonding first, because it will cause a glossy appearance and affect their vision.

Assessment of neonatal ears

Early detection of hearing in the infant is at 3-6 months of age. Lack of blink or startle reflex - early indicator of hearing issues Ears: Inspect the ears for position, shape, and drainage. Hearing test is done before discharge Top of the pinna is aligned with external canthus of the eye. Pinna without deformities, well formed and flexible. The neonate responds to noises with positive startle signs. Hearing becomes more acute as Eustachian tubes clear. Neonates respond more readily to high-pitched vocal sounds. Low-set ears are associated with genetic disorders such as Down's syndrome.

What medications should be given to all infants following birth?

Erythromycin ointment is administered to the eyes as prophylaxis to prevent gonococcal and chlamydia infections Vitamin K is administered via IM injection to prevent hemorrhagic disease cause by vitamin k deficiency Hepatitis B vaccine is recommended for all newborns.

What are the 4 ways infants lose heat?

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 Conduction: Transfer of heat to cooler surface by direct skin contact, such as cold hands of caregivers or cold equipment Convection: Loss of heat from the neonate's warm body surface to cooler air currents, such as air conditioners or oxygen masks 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.

What is cold stress?

Excessive heat loss that leads to hypothermia and results in utilization of compensatory mechanisms to maintain the neonate's body temp. ↓ environmental temperature --> ↓ body temperature --> ↑ heart and respiratory rates --> ↑ O2 consumption, depletion of glucose, and ↓ surfactant --> respiratory distress S/S: Axillary temperature at or below 36.5 C (36.5-37.5 C) Cool skin Lethargy Pallor Tachypnea Grunting Hypoglycemia Hypotonia (decreased muscle tone) Jitteriness Weak Suck

Assessment of the neonatal's eyes

Eyes: Assess the position of the eyes. Open the eyelids and assess color of sclera and pupil size. Assess for blink reflex, red light reflex, and pupil reaction to light. Eye color not typically established until 6-12 months. The iris is blue-gray or brown. The sclera is white or bluish-white. Eyes are equal and symmetrical in size and placement. The neonate is able to follow objects within 8-12 inches of the visual field. Edema or bruising may be present due to pressure during labor and birth and/or reaction to eye prophylaxes. Pupils are equally reactive to light. Positive red light reflex and blink reflex. No tear production (tear production begins at 2 months). Subconjunctival hemorrhages related to birth trauma. Strabismus and nystagmus related to immature muscular control. (Cross eyes)

Assessment of neonatal genitalia

Female: Place thumbs on either side of the labia and gently separate tissue to visually inspect the genitalia. Assess for the presence and position of clitoris, vagina, and urinary meatus. Labia majora covers labia minora and clitoris. Labia majora and minora maybe edematous. Blood-tinged vaginal discharge related to the abrupt decrease of maternal hormones (pseudomenstruation). Whitish vaginal discharge in response to maternal hormones. The neonate urinates within 24 hours. The urinary meatus is midline and an uninterrupted stream is noted on voiding Male: Inspect the penis, noting the position of the urinary meatus. Inspect and palpate the scrotum to assess for testicles. With the thumb and fore finger of one hand, palpate each testis while the other thumb and fore finger are placed over the inguinal canal to prevent the ascent of testes during assessment. Start at the upper aspect of the scrotum and move away from the body. The urinary meatus is at the tip of the penis. The scrotum is large, pendulous, and edematous with rugae (ridges/creases) present. Both testes are palpated in the scrotum. The neonate urinates within 24 hours with an uninterrupted stream. Hypospadias: The urethral opening is on the ventral surface of penis. Epispadias: The urethral opening is on the dorsal side of penis. Undescended testes are testes not palpated in the scrotum. Hydrocele is enlarged scrotum due to excess fluid. Ambiguous genitalia; may require genetic testing to determine sex. No urination in 24 hours may indicate a possible urinary tract obstruction, polycystic disease, or renal failure.

Infant: Immune System

First Line defense: Skin and mucous membranes Second Line defense: cellular elements of the immunologic system (neutrophils, eosinophils, lymphocytes) The immune system protects the body from invasion by foreign materials such as bacteria and viruses. Before rupture of membranes, the fetus lives in the sterile environment of the maternal uterus and relies on the maternal immune system to protect him from pathogenic organisms. During the transition from extrauterine life, the neonate begins the process of developing normal microbial flora and must respond to colonization by potential pathogenic bacteria.

What are the 3 fetal shunts?

Foramen ovale: closure soon after birth as the left atrial pressure is higher than the right. The closure occurs when increased PaO2 causes a decrease in pulmonary pressure thus increasing pulmonary blood flow increasing the pressure in the left atrium. (Opening between the right and left atrium) Ductus arteriosus: closure 15 hours to 4 days as pulmonary vascular resistance becomes less than system vascular resistance- left to right shunt- and closes. It will remain open if lungs fail to expand or PaO2 levels drop. (Connects the pulmonary artery with the descending aorta) Ductus venosus: closes by day 3 of life. It connects the umbilical vein to the inferior vena cava and becomes a ligament. Blood stops with the clamp of the umbilical cord. Failed closure of the above shunts takes blood away from the pulmonary circulation.

What is one word to describe new born skin?

Fragile- Immature integumentary function in the newborn; outer layers are very thin and the newborn is therefore at risk for injury

Infant: Renal System

Functional deficiency in the kidney's ability to concentrate urine Normal newborn urine production is 1 to 2 mL/kg/hr Bladder capacity is approximately 15 to 30 mL, resulting in emptying as many as 20 times per day First void should occur within 24 hours after birth Urine is colorless and odorless. Full-term neonates excrete 15-60 mL/kg of urine per day for the first few days of life. Urinary output increases to 250-400 ml by end of the first month of life Should have 6-8 wet diapers in 24 hrs. (from the time of birth with every feeding) A delay or decrease in urinary output can occur in neonates whose mothers received magnesium sulfate during labor. Magnesium sulfate blocks neuromuscular transmissions and can cause urinary retention Neonates usually lose 5%-10% of birth weight during the first week life due to diuresis.

How to assess the gestational age?

Gestational age assessment of the newborn is based on the mother's menstrual history, prenatal ultrasonography, and/or neonatal maturational examination. Ballard: 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 (Table 15-6). The examination determines weeks of gestation and classifies the neonate as preterm (<37 weeks), term (37-42 weeks), or post-term (>42 weeks). SGA is a term used for neonates whose weight is below the 10th percentile for gestational age. LGA is a term used for neonates whose weight is above the 90th percentile for gestational age. AGA: term for infants who are in between the 10th and 90th percentiles

What is the normal newborn HR, RR, BP, and O2?

HR- 110-160 RR- 30-60 BP- 50/30 to 75/45 O2 sat after 24 hours- 95% HR- can be higher if baby is crying and screaming. 110-160 is resting heart rate Periodic breathing- apnea less than 15 seconds. The baby should not change colors and pulse ox should not change. Babies are abdominal breathers. On admission will do all 4 extremities to find shunting or difference in pressures. Should all be equal and could identify a cardiac issue. Check once every shift, resting= stable & mad= high. Infants after 24 hours with a reading of 94% or lower are referred for cardiac echography to assess for congestive heart disease (CHD).

Infant: Thermoregulators

Heart Liver Brain BAT- Brown Adipose Tissue- highly dense and vascular adipose tissue. Neonates have more BAT than children or adults, but preterm has very little. BAT is located in the neck, thorax, axillary area, intrascapular, and around the adrenal glands and kidneys. BAT increases metabolism- heat production- heat transfers to the peripheral system. Heat is produced by intense lipid metabolism of BAT. Infants cannot shiver for thermoregulation

Infants at high risk for thermoregulation issues

Higher body surface area to body mass ratio Higher metabolic rate Limited and immature thermoregulatory abilities Factors that negatively affect thermoregulation: Decreased subcutaneous fat Decreased BAT in preterm infants Large body surface Other risks: Prematurity Small for gestational age (under 10% percentile for weight) Hypoglycemia Prolonged resuscitation efforts Sepsis Neurologic, endocrine, or cardiorespiratory problems

What is hypotonia and hypertonia?

Hypotonia: Floppy, limp extremities indicate possible nerve injury related to birth, depression of CNS related to maternal medication received during labor or to fetal hypoxia during labor, prematurity, or spinal cord injury. (Down's) Hypertonia: Tightly flexed arms and stiffly extended legs with quivering indicate possible drug withdrawal. Paralysis indicates possible birth trauma or spinal injury. Tremors are possibly due to hypoglycemia, drug withdrawal, cold stress.

Hepatic and Hematologic Physiology of the Preterm Infant

Immaturity of the preterm newborn's liver predisposes the infant to several problems At birth, glycogen stores in liver are rapidly used for energy, so preterm is high risk for hypoglycemia The normal Hg at 34weeks is 16.8g/dl and total blood volume ranges from 80ml/kg to 100ml/ kg so any blood loss is significant to the premie. If subject to hemorrhage, rapid growth, and excess blood sampling, the preterm infant is likely to become iron depleted more quickly than term infant. Many preterm infants require transfusions of packed cells to treat symptomatic anemia. ***What do you think that symptoms might be?*** Many are started on oral iron supplements and erythropoietin to enhance red blood cell production as they begin to grow and tolerate feedings S/S of anemia- fatigue, bradycardia, apnea Will begin oral iron when tolerating full feedings well Bilirubin levels increase more rapidly and to a higher level than in the full term infant. Conjugation of bilirubin is impaired in preterm. Early clinical assessment of jaundice is more difficult in preterm newborns because they lack subcutaneous fat.

What is the most critical adaptation upon delivery of the neonate?

Initiation of respirations Primary Stimuli: Chemical and Thermal Chemical factors that stimulate breathing- hypoxia, hypercarbia, and low pH of the blood. These factors initiate impulses to the medulla to start breathing. Thermal factors that stimulate breathing- the neonate leaves the warm environment of the uterus and enters a cooler one. Skin sensory impulses are transmitted to the respiratory center of the medulla. Other: Tactile Tactile factors that stimulate breathing- decent through the birth canal, tapping the newborns feet, rubbing of the torso, drying off with a blanket, or suctioning secretions. Never slap the back to stimulate breathing, because it can cause bleeding.

Assessment of the neonatal extremeties

Inspect extremities, spine, and gluteal folds. Palpate the clavicles. Perform the Barlow-Ortolani maneuver. Arms are symmetrical in length and equal in strength. Legs are symmetrical in length and equal in strength.10 fingers and 10 toes. Inspect symmetry of extremities and full range of motion. No clicks at joints. Equal gluteal folds. C curve of spine with no dimpling. Startle reflex response will show all muscle movements Only thing that can dx Down syndrome is a chromosomal study. Unequal gluteal folds and/or positive Barlow-Ortolani maneuver are associated with congenital hip dislocation. Decreased range of motion and/or muscle tone indicates possible birth injury, neurological disorder, or prematurity. Swelling, crepitus, and/or neck tenderness indicates possible broken clavicle, which can occur during the birthing process in neonates with large shoulders. Simian creases (palmar), short fingers, wide space between big toe and second toe are common with Down's syndrome.

Assessment of the neonatal abdomen

Inspect size and shape of the abdomen. Inspect the umbilical cord. Auscultate for bowel sounds. (Audible within first 20 minutes after birth) Palpate the abdomen, assessing for tone, hernias, and diastasis recti. Liver: palpable 2-3 cm below right costal margin Spleen tip palpable at end of first week of age Kidneys palpable 1-2 cm above umbilicus Femoral pulses equal bilaterally The abdomen is soft, round, protuberant, and symmetrical. Bowel sounds are present, but may be hypoactive for the first few days. Passage of meconium stool within 24 hours post-birth. The cord is opaque or whitish-blue with two arteries and one vein, and covered with Wharton's jelly (thick white covering). Asymmetrical abdomen indicates a possible abdominal mass. Hernias or diastasis recti are more common in African-American neonates and usually resolve on their own within the first year. Failure to pass meconium stool is often associated with imperforated anus or meconium ileus.

Assessment of newborn skin

Inspect the skin for color (varies), intactness, bruising, birthmarks, dryness, rashes, warmth, texture, and turgor. Inspect nails. Should have smooth texture, puffy areas, vernix, lanugo present, acrocynotic or pink without jaundice on first day of life. Deviations from normal: Pallor occurs with anemia, hypothermia, shock, or sepsis. Greenish/yellowish vernix indicates passage of meconium during pregnancy and/or labor. Persistent ecchymosis or petechiae occurs with thrombocytopenia, sepsis, or congenital infection. Abundant lanugo is often seen in preterm neonates. Thin and translucent skin, and increased amounts of vernix caseosa are common in preterm neonates.

How should we educate the parents about circumcision?

Instruct parents to watch for bleeding and signs of infection, and to note when their child voids. Inform parents that the gauze will fall off on its own and they should not pull it off. Pulling gauze off can interfere with the healing process. Instruct parents to fasten diapers loosely. Loosely fitting diapers promote comfort by decreasing pressure on the surgical site and prevent pulling off the scab Instruct parents to notify the physician when: Bleeding is present (larger than the size of a quarter), signs of infection are present, or the neonate has not voided within 24 hours. HESI: with Plastibell extra petroleum jelly should not be applied, because it can prematurely cause the ring to fall off.

How do nurses respond when an infant is in cold stress?

Least invasive to most -Place a stocking cap on the infants head -Skin to skin contact with mother with a warm blanket over both the mother and neonate when this is a mild decrease in temperature; reassess as per institutional procedure -Swaddle in warm blankets; reassess temp per protocol which is generally every 30 minutes -Place the naked neonate under a preheated radiant warmer. -Attach the servo-controlled probe on the neonates abdomen or other body surface that is closet to the radiant source -It is recommended not to place probe over BAT area, but there are too few research studies to view this as EBP -Set the control to 36.5 -Monitor the neonates temp respiratory rate and heart rate every 5 minutes (Increase HR & RR, Decreasing O2 sat) -Assess and adjust the neonate's fluid requirement. Fluids may need to be increased to compensate for insatiable water loss. -When regulated, monitor temperature per protocol: q3-4hr -Obtain a heel stick to assess for hypoglycemia -Treat hypoglycemia if needed

What are the low classifications according to birth weight?

Low birth weight: less than 2500g Very low birth weight: less than 1500g Extremely low birth weight: less than 1000g

Priority goal in nursing for the neonate

Maintain a patent airway •Supine positioning for sleep •Baby in neutral position. Head not to chest or hyperextended. Drop chin can cause apnea. •Suction the oral and nasal secretions with a bulb syringe •More forceful mechanical suctioning should be done gently, with sufficient time for the infant to recuperate. Could cause more respiratory issues than they started with

What are reasons for circumcision?

Male circumcision is an elective surgery to remove the fore skin of the penis. It is reported that 55% of newborn males born in the United States in 2009 were circumcised. The decision to circumcise the neonate is made by the parents and is based on their cultural, religious, and personal beliefs. Benefits: Decreased incidence of urinary tract infections Decreased incidence of sexually transmitted infections (decreased risk of HPV transmission to the partner)

What are some expected findings of a newborn's head?

Molding present because fontanels are open, soft, intact, and slightly depressed. They may bulge with crying. The anterior fontanel is diamond shaped, approximately 2.5-4 cm (closes by 18 months of age).The posterior fontanel is a triangle shape that is approximately 0.5-1 cm (closes between 2 and 4 months).May be difficult to palpate due to excessive molding. There are overriding sutures when there is increased molding. Molding: Elongation of the fetal head as it adapts to the birth canal. Resolves within a week.

Assessment of the neonatal mouth and throat

Mouth: Inspect lips, gums, tongue, palate, and mucous membranes. Open the mouth by placing gentle pressure on the lower lip. Test for rooting, sucking, swallowing, and gag reflexes Expected: Lips, gums, tongue, palate, and mucous membranes are intact, pink, and moist. Reflexes are positive. Epstein's pearls are present Epsteins: White pearl like epithelial cysts on gum margins and palate. Benign and usually disappears within a few weeks. Natal teeth, which can be benign or related to con-genital abnormality. Immature caps of enamel and dentin with poorly developed roots Usually only one or two teeth are present. They are usually benign but can be associated with congenital defects. Natal teeth are often loose and need to be removed to decrease the risk of aspiration. Look for Clef palate and Thrush (will not wipe off with oral care)

Assessment of the neonatal neck and chest

Neck- short, thick, and several skin folds. Could see lanugo and vernix in these folds, clean this area. Inspect ROM. Look for webbing- could be genetic disorder and will need more studies Chest- evident xyphoid process and breast enlargement, witches milk- from cessation of mom's hormones. Supernumerary nipple- third nipple on chest or abdomen. Look for chest expansion during breathing.

How do we screen for metabolic disorders after neonate is born?

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. Routine newborn screening began in the 1960s when all babies were screened for phenylketonuria (PKU), and over the years technology has advanced and can now screen for approximately 30 disorders. 31 testings for CF, genetic diseases, and metabolic disorders Heel stick is to the outer heel. Do not do it in the middle, it can affect gait and how the walk later in life by causing scar tissue. Provide parents with information regarding the screening test. Some states require the parents' written consent. The blood is obtained from a heel stick and may be collected by nursing or laboratory personnel (see Critical Component: Heel Stick). The ideal time of collection is at 2-5 days of age, which provides time for the neonate to ingest breast milk or formula. Most are done within the first 24-48 hours because of discharges occurring during that time period. Neonates are usually retested later at a routine newborn check-up.

Is the nervous system fully developed at birth?

No •At birth, the nervous system is incompletely integrated, but sufficiently developed to sustain extrauterine life •Primitive reflexes; rooting, moro, grasping •Autonomic nervous system is crucial in the newborn transition to life •Myelination of the nerves follows a cephalocaudal and proximodistal progression, closely related to the observed the mastery of fine and gross motor skills. Myelin is necessary for rapid and efficient transmission of some neuron impulses along the neural pathway. •Neural pathway- accounts for senses and pain preception

Is the endocrine system of a new born mature?

No- Endocrine system is developed in newborns, but its function is immature Pituitary is immature and is limited ability to secrete ADH (risk of dehydration) Effects of maternal sex hormones in newborns are evident for the first few days of life Breasts may be engorged and secrete milk for both sexes for the first few days of life (Witches milk) Pseudo menstruation- usually milky secretion, but can have streaking of blood occasionally. Due to sudden drop of progesterone and estrogen in the baby.

Is the muscular system inactive at birth?

No; the muscular system is almost completely formed at birth

Assessment of the neonatal nose

Nose: Observe the shape of the nose. Inspect the opening of the nares. Assess patency of the nares by inserting a small soft catheter. (This may not be done on all infants. Check hospital policy and procedure manual.) The nose may be flattened or bruised related to the birth process. Nares should be patent. Small amount of mucus (thin, white, transparent). Neonates primarily breathe through their noses. Large amounts of mucus drainage can lead to respiratory distress. A flat nasal bridge is seen with Down's syndrome. Nasal flaring is a sign of respiratory distress.

How to assess the newborn's head

Note the shape of the head. Assess the contour Assess degree of head control and head lag. May be able to lift head for a short period, but we need to be supporting their head. Tummy time is a great way to gain head control. Inspect and palpate fontanels and suture lines. Inspect and palpate the head for caput succedaneum and/or cephalohematoma Deviations: Fontanels that are firm and bulging and not related to crying are a possible indication of increased intracranial pressure. Depressed fontanels are a possible indication of dehydration. Fontanels should be soft Birth Trauma: Caput Succedaneum- a localized soft tissue edema of the scalp. It feels spongy and CAN cross suture lines. Results from prolonged pressure of the head against the maternal cervix during labor. Resolves within a week. Cephalohematoma- Hematoma formation between the periosteum and skull with UNILATERAL swelling. It appears within a few hours of birth and can increase in size over the next few days. It has a well defined outline. It does not cross suture lines. Related trauma to the head due to prolonged labor, forceps delivery or use of vacuum extractor. Can contribute to jaundice due to the large amounts of RBCs hemolysis. Resolves within 3 months Physiological Craniotabes- snapping sensation along lambdoid suture that resembles indentation of ping pong ball

Parent-preterm infant attachment

Nurse should promote positive parental feelings toward infant Involve parents early in care and decisions Nurse can point out infant's patterns of behavior and unique characteristics and responses Nurse can teach parents about their infant's sleep/wake states and optimal times for interacting with infants Teach care giving skills and assist to understand premature infant behavioral characteristics Ways to promote positive feelings: Photographs of the baby are given to parents to have at home or to the mother if she is in a different hospital or too ill to come to the nursery and visit. Infant's first name should be placed on infants bed or station as soon as it is known so parents feel that their infant is unique and special. A weekly card with baby's footprint, weight, and length are sent and can promote attachment. Phone number of the nursery or NICU is given so that parents have access to information about their baby day or night. The nurse encourages visits from grandparents and siblings (not RSV season) to promote attachment. Only banded parents can have information

What is thrush? How to treat?

Oral candidiasis- white patches on the tongue, palate, and inner aspects of the cheeks that do not scrape off. Can spread down to the GI tract or from the diaper area to the mouth and hands. Self Limiting- could take 2 months to resolve Disinfect dottles and pacifiers •Boil Reusable Nipples And Bottles For 20 Minutes After A Thorough Washing (spores are heat resistant) •Pacifiers Should Be Boiled For At Least 20 Minutes Every Day Nystatin (Mycostatin) 4x/day: •Administer After Feeding •Swab Over Surface Of Oral Mucosa And Tongue •Swallow Remainder- help GI tract If breastfed treat the infant and the mother (can get thrush on nipples)

Hearing Screening for Neonates

Otoacoustic emissions(OAE) is a painless test that is conducted when the neonate is asleep or lying still. A tiny, flexible ear probe is inserted into the neonate's ear. It records responses of the outer hairs cells of the cochlea to clicking sounds coming from the probe's microphone. A referral is made to a hearing specialist when there is no recorded response from the cochlear hair cells. Automated auditory brain stem response(AABR) is a painless test conducted when the neonate is asleep or lying still. Disposable electrodes are placed high on the neonate's forehead, on the mastoid, and on the nape of the neck. This screening test assesses electrical activity of the cochlea, auditory nerve, and brain stem in response to sound. A referral to a hearing specialist is recommended for neonates who do not have a positive response to the sound stimuli. Both tests need to be conducted in a quiet room. Vernix, blood, and amniotic fluid in the ear can interfere with accurate screening. Neonates who fail the initial screening test are rescreened in one month. Diagnostic testing is recommended for neonates who fail the second screening.

Sings of attachment focusing on the parents

Parental attachment towards the baby should be a healthy balance Assess for the vertical plane- "ooing" within the babies field of vision Nurses have a tendency to focus on mom more, so get dad involved as much as possible. Dads can be involved as much in care as mom. Skin to skin is important.

What is the best way to check a newborn temp? What is the normal temp range?

Place a clean temp probe in the axillary area Temperature: 36.5-37.6 C or 97.7-99.7 F (will have both on exam) Rectal, tympanic, or skin (consider benefit versus risk) Perforation, small ear canal, results vary with skin Hypothermia is related to infection, environmental extremes and/or neuro disorders.

Assessment of the neonatal heart

Point of maximal impulse (PMI) at the 3rd or 4th inter-costal space. S1 and S2are present. Normal rhythm with variation related to respiratory changes. Murmurs in 30% of neonates which disappear within 2 days of birth (many cardiac changes happening at this point) (Louder when closing). Peripheral pulses are present and equal. The femoral pulse may be difficult to palpate. Assess apical pulse rate by auscultating for one full minute. Assess rate and rhythm. Use of a stethoscope designed for neonates is recommended. 110-160 bpm. Rate increases (to 180 bpm) with crying and decreases (to 100 bpm) when asleep. Murmurs may be heard; most are not pathological and disappear by 6 months. Tachycardia (> 160 bpm without crying) indicates possible sepsis, respiratory distress, congenital heart abnormality. Bradycardia (<100 bpm) indicates possible sepsis, increased intracranial pressure, or hypoxemia. More premature the higher the heart rate. More term lower heart rate. Dextrocardia: Heart on the right side of the chest. Displaced PMI occurs with cardiomegaly. Persistent murmurs indicate persistent fetal circulation or congenital heart defects. Need follow up

What is polydactyly and syndactyly?

Polydactyly: Extra digits may indicate a genetic disorder. Not always joints, can be just cartilage. Syndactyly: Webbed digits may indicate a genetic disorder (Down syndrome).

Nonmodifiable Risk Factors for Newborns to be Delivered Preterm

Previous preterm delivery Multiple abortions (could be nonelective) Race/Ethnic Group Uterine/Cervical Anomaly Multiple Gestation Pregnancy Induced Hypertension Short interval between pregnancies Bleeding in the first trimester Other risk factors: Age at pregnancy <17 or >34 years of age Unplanned pregnancy Domestic violence Low pre-pregnancy weight Obesity Infection Substance abuse/Alcohol abuse Cigarette Smoking Late or no prenatal care Pregnancy can be closely monitored and need treatment: 1.Less likely to have good nutrition and accesses to resources 2.Complications may not be picked up 3.Toxic chemicals or illicit drugs 4.Heart disease, diabetes, hypertension, hypothyroidism, renal disease 5.Older and younger moms are more likely to have complications 6.Gestational diabetes, 7.Abruptio placenta, placenta previa, oligohydramnios, preterm labor, PROM, preeclampsia, uterine rupture Prematurity is the leading cause of admission to the NICU. 2nd leading cause of infant mortality in US. The cause is unknown, but these nonmodifiable factors could be a cause.

Alteration in the thermoregulation of a preterm baby

Primary objective is adequate respirations and then thermoregulation. At higher risk for heat loss from less BAT. Every degree lost increases their mortality rate by 10% The more preterm the infant, the less likely the infant is able to maintain heat balance. 1. The baby's ability to produce heat (based on body weight) is much less than the potential for losing heat (based on surface area). The loss of heat in a preterm infant weighing 1500g is five times greater per unit of body weight than in an adult. 2. Without adequate insulation, heat is easily conducted from the core of the body (warmer temperature) to the surface of the body (cooler temperature). Heat is lost from the body as the blood vessels, which lie close to the skin surface in the preterm infant, transport blood from the body core to the subcutaneous tissues. The preterm baby has a decreased ability to vasoconstrict superficial blood vessels and conserve heat in the body core 3. The increased permeability contributes to a greater insensible water loss as well as heat loss. 4.Decreased flexion in the infant increases heat loss. Gestational age influences the amount of flexion. The more preterm the less likely they can hold that flexed position

What is a common factor in the preterm neonate's genitalia?

Prominent clitoris and small labia minora are often present in preterm neonates. Smaller scrotum in male preterm babies because the testes are underdeveloped.

What is the initial neonatal management?

Provide warmth by drying off, this also provides stimulation. Remove wet linens. Rub or gently flick the soles of the newborn's feet if additional stimulation is required Do not slap the newborn's buttocks, as there is no beneficial effect and slapping can cause cerebral trauma Newborn ID and Medication Administration

How does a neutral thermal environment benefit a preterm infant?

Providing a neutral thermal environment minimizes the oxygen consumption required to maintain a normal core temperature; it also prevents cold stress and facilitates growth by minimizing caloric expenditure to maintain body temperature. The preterm infant's immature CNS, as well as small brown fat stores, provides poor temperature control. An infant less than 1200g can lose 80kcal/kg/day through radiation of body heat. Don't want them to waste all of their energy on thermoregulation

How to measure the height of an infant? What is it called?

Recumbent length (laying down) Measure this way until 2 years •Hold Head In Midline •Gently Grasp Knees Together - Push Until Flat & Fully Extended •Mark Paper At Heels And Top Of Head •Measure Between Marks

What is cradle cap, and how is it managed?

Seborrheic Dermatitis Seborrheic dermatitis is a chronic, recurrent, inflammatory reaction of the skin that occurs most commonly on the scalp (cradle cap) but may involve the eyelids (blepharitis), external ear canal (otitis externa), nasolabial folds, and inguinal region. The cause is unknown, although it is more common in early infancy, when sebum production is increased. The lesions are characteristically thick, adherent, yellowish, scaly, oily patches that may or may not be mildly pruritic. Unlike acute dermatitis, seborrheic dermatitis is not associated with a positive family history for allergy, is common in infants shortly after birth, and is common after puberty. Diagnosis is made primarily by the appearance and the location of the crusts or scales. Nursing Care Management Cradle cap may be prevented with adequate scalp hygiene. Frequently, parents omit shampooing the infant's hair for fear of damaging the "soft spots," or fontanels. The nurse should discuss how to shampoo the infant's hair and emphasize that the fontanel is similar to skin anywhere else on the body; it does not puncture or tear with mild pressure. When seborrheic lesions are present, direct the treatment at removing the scales or crusts. Education may need to include a demonstration. Shampooing should be done daily with a mild soap or commercial baby shampoo; medicated shampoos are not necessary, but an antiseborrheic shampoo containing sulfur and salicylic acid may be used. Shampoo is applied to the scalp and allowed to remain on the scalp until the crusts soften. Then the scalp is thoroughly rinsed. A fine-tooth comb or a soft facial brush helps remove the loosened crusts from the strands of hair after shampooing.

What sensory functions are developed by birth?

Smell Taste Touch (tactile) (face, hands, and soles of feet are the most sensitive)

When does a neonate get a Hepatitis B vaccine?

Soon after birth and before end of stay. 3 total doses We will need consent from parents. 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. 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 immunoglobulin (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. Draw up medication or vaccine in a 1-mL syringe with a 25-gauge 5/8 need.

Promotion of developmentally supportive care of the preterm infant

Specially designed NICUs with the single-room care concept are becoming more prevalent across the country to minimize lighting and noise exposure as well as to provide privacy for the parents of the convalescing neonate. The NICU environment contains many detrimental stimuli. Noise levels can be lowered by replacing alarms with lights or silencing alarms quickly and keeping conversations away from the baby's bedside. More disturbing and stress will stunt growth and sleep. Provide all care (cluster care) during feeding times. Dimmer switches should be used to shield the baby's eyes from bright lights with blankets over the top portion of the incubator. Dimming the lights may encourage infants to open their eyes and be more responsive to the parents. Nursing care should be planned to decrease the number of times the baby is disturbed. Facilitate handling by using containment measures when turning or moving the infant or doing procedures such as suctioning Touch infant gently and avoid sudden postural changes Promote self-consoling or soothing activities to provide "nesting" Place blanket rolls or approved manufactured devices next to the infant's sides and against the feet to provide nesting. Remove these closer to discharge. Swaddle infant to maintain extremities in flexed position while ensuring that the hands can reach the face If stressed place hand on chest to comfort Stimulate the kinesthetic advantages of the intrauterine environment by using soft or fleece-like blankets and Gel beds

Assessment of the neonatal back and anus

Spine: Sacral dimple or tuft could mean spina bifida. Anus: Inspect the anus. The anus is patent. Passage of stool within 24 hours. Imperforated anus requires immediate surgery. Anal fissures or fistulas

What are signs of readiness for replacing gavage feeding to breast feeding?

Strong gag reflex, Presence of non-nutritive sucking, Rooting behavior

What to include in discharge teaching of Mom and baby?

Teach about elimination, voiding, wet diaper every feeding, time for play, car seats, position of sleep, and safety. Look at their color, cord care, new born screening, follow up care, 1-2 week checkup. Must have stable vital signs before 12 hr before discharge. Should not see apnea

How does the infant respond to cold stress?

The neonate responds to the cold by: An increase in metabolic rate An increase of muscle activity Peripheral vascular constriction Metabolism of brown fat They do not have a shivering mechanism BAT is rapidly depleted in periods of cold stress Cold stress can delay the transition of fetal to neonatal circulation

Combining all of the assessments of neonate after delivery.

The nurse will complete a newborn assessment of the child; which will include Apgar scores, vital signs, and measurements of weight, length, and circumference of the head, chest, and abdomen. The nurse will ensure that a patent airway is present (priority of care) by stimulation of the infant and, if necessary, by suctioning the infant. The nurse will dry the infant and provide warmth, either by skin-to-skin contact with the mother, by swaddling, or by radiant warmer. Eye drops will be instilled; vitamin K will be given; and hepatitis B vaccination will be done. Identification of the infant will be completed in the delivery room.

Renal System of the Preterm Infant

The preterm infant's kidneys are limited in their ability to concentrate urine or to excrete excess amounts of fluid Renal immaturity affects ability to excrete drugs 1. The GFR is directly related to lower gestational age, so the more preterm the newborn, the lower the GFR, which steadily increases after 34 weeks post-conceptual age. The GFR is also decreased in the presence of diseases or conditions such as severe RDS, Hypotension, and asphyxia. Anuria or oliguria might be observed. Systolic blood pressure varies with gestational age and post-conceptual age. a. Will not give 10mL flush 2. This is due to a blunted response to ADH. This means that if excess fluid is administered, the infant is at risk for fluid retention and overhydration. If too little is administered, the infant will become dehydrated because of the inability to retain adequate fluid. 3. Glycosuria with hyperglycemia can lead to osmoltic diuresis and polyuria 4. Bicarbonate is excreted at a lower serum level and acid is excreted more slowly. After periods of hypoxia or insult the premie's kidneys require a longer time to excrete the lactic acid that accumulates NaHCO3 is frequently required to treat metabolic acidosis 5. Excretion time is longer, many drugs are given over longer intervals (q 18 or 24 vs q 12). Urine output should be carefully monitored when the infant is receiving nephrotoxic drugs such as Vanc or Gent. In the event of oliguria, drugs can become toxic in the infant much more quickly than the adult.

Perioperative Care of Circumcision

The surgical procedure is performed by the physician before discharge or at a well-child check-up. Three common circumcision devices used are Gomco clamp, Mogen clamp, and Plastibell. Mogen clamp is commonly used by Mohels when performing ceremonial circumcisions. Preoperative: Provide parents with information on the benefits and risks of circumcisions, and the procedure. This is usually done by the neonate's health care provider. Obtain written consent from the parents. Verify that the neonate has voided. A lack of voiding may be related to an anatomical abnormality. Circumcisions are contraindicated when there is an anatomical abnormality. Ensure that the neonate does not eat 2-3 hours before the procedure. This decreases the risk of vomiting and aspiration during the procedure. Administer acetaminophen 1 hour before procedure per the physician's order. Given for pain management Intraoperative: The neonate is positioned and secured on a specially designed plastic board, often referred to as a circumcision board. The board is padded to promote comfort. The upper part of the neonate is swaddled to promote comfort and reduce heat loss. An ear bulb is placed near the neonate to use if there is vomiting or increased mucus. The penis is cleansed and a sterile drape specially designed for circumcision is placed over the trunk. A sucrose-dipped pacifier is offered during the block and procedure for pain management. The physician administers a penile nerve block. The physician applies a Gomco clamp, Mogen clamp, or Plastibell. The physician surgically removes the foreskin with a scalpel. Petroleum-impregnated gauze is wrapped around the end of the penis. This promotes comfort by reducing the amount of irritation caused by friction with the diaper. Postoperative: The penis should be assessed every 15 minutes for the first hour for signs of bleeding, then every 2-3 hours according to hospital policies. The physician is notified when bleeding is present (larger than the size of a quarter). Acetaminophen PO is administered every 4-6 hours. Voidings are assessed and documented. The neonate should void within 24 hours after the procedure.

Describe the bones of a newborn

There is more cartilage than ossified bones. Rapid ossification occurs in the first year of life.

What provides the infant immunity with breastfeeding?

Third line of defense: IgG- Breast milk provides passive immunity (by means of immunoglobulin G [IgG]) against most major childhood diseases Natural immunoglobulin production does not begin until second month of life

Infant: Thermoregulation

This is critical to the newborns survival NTE: neutral thermal environment maintains the body temperature with minimal metabolic changes and/or O2 consumption. This decreases possible complications related to the delayed response.

Review over the Renal System

Two major functions of the kidneys are control of fluid and electrolyte balance and excretion of metabolic waste. The kidneys also secrete hormones and regulate the acid-base balance. During fetal life, these functions are assumed by the placenta. Once the cord is clamped, the neonate's kidneys must take on these functions.

When can a newborn have its first bath?

Up to 24 hours after delivery. Will wait until after the first feed for breastfed infants and until thermoregulation is stable. Will not be completely submerged while cord is intact, keep it dry as possible. Soap and water or alcohol to clean the base of the cord. Fold diaper below the umbilical cord. Opportunity for hygiene, assessment, and anticipatory guidance for parents. Teach parents what to look for.

Feeding an preterm infant with TPN

Used when feeding is contraindicated through GI tract TPN provides complete nutrition for metabolic requirements and growth to the infant intravenously A percutaneous central venous catheter(PCVC/PICC) is often used with LBW infant to deliver higher concentration of glucose Serum glucose levels and chemistries should be carefully monitored during infusion Need metabolic panel TPN includes the use of hyperalimentation and intralipids. Hyperalimentation provides vitamins, minerals, protein in form of amino acids, and glucose. Appropriate amino acid intake (1 to 4 kg/day) is necessary to avoid catabolism and maintain the newborn in a positive-nitrogen balance and can be imitated in the first day of life. Intralipids (1 to 3 g/kg/day) are also administered to provide essential fatty acids for normal growth and development. The IV rate with TPN is monitored hourly to maintain accurate intake. The rate should not be increased to "catch up" if administration lags behind. IV site should be observed hourly for signs of infiltration. Hyperalimentation is extremely caustic and causes severe tissue destruction if infiltration occurs. Intake and output must be closely monitored Prolonged administration of TPN combined with little or no enteral feedings can result in cholestatic jaundice so liver enzymes and fractionated bilirubin levels must be monitored. Potential complications can include increased free bilirubin concentrations, impaired pulmonary functions and interference with platelet function. Serum triglyceride levels should be followed. Gradually wean off TPN. Transition to feedings

Gavage feeding of the preterm infant

Used with preterm infants who lack or have a poorly coordinated suck-swallow-breathing pattern, are ill, or ventilator dependent May be used as an adjunct to nipple feeding as transition Administered by intermittent or continuous drip method Early initiation of MEN(minimal enteral nutrition) via gavage is now advocated in the preterm as a supplement to parenteral nutrition MEN or trophic feeds refers to small volume feedings of formula or human milk (usually less than 24ml/kg/day) which are designed to "prime" the intestinal tract, thereby stimulating many of the hormonal and enzymatic functions. Benefits of early feeding: no increase in incidence of NEC, fewer days on TPN, increased weight gain, increased muscle maturation of the gut as well as muscle growth, increase in gut peristalsis, increased gut hormone levels, possible decrease in number of hospital days. Most are INT fed, q3h schedule. Continuous drip can cause gut issues and they can't tolerate it all at once.

Definition of very premature, premature, and late premature

Very premature- less than 32 wks Premature- 32-34 wks Late premature- 34-37 wks 23 wks is a viable pregnancy Less than 23 wks the NICU does not come for the delivery, because there is nothing to do

What senses are not developed in a newborn?

Vision and Hearing Eyes are structurally incomplete, but they still can accommodate and focus on an object for any length of time. Vision: Pupils react to light; blink and corneal reflexes (minimal stimuli/ light touch) Focus on bright, moving objects 8 inches away in midline of visual field Tear glands have minimal function until 2 to 4 weeks of age Hearing: Is similar to that of adults after amniotic fluid is drained Early sensitivity to human voices (not speech)

Why do we administer Vitamin K in neonates?

Vit K is given shortly after birth to prevent hemorrhagic diseases of the newborn. Vit K is synthesized by the intestinal flora; however they are sterile at birth and breast milk only contains low level of Vit K they don't have adequate supply for 3-4 days. Protects from major bleeding. Given in the vastus lateralis muscle.

How can an infant become water intoxicated or dehydrated?

Water intoxication can occur if formula is not being mixed correctly. Dehydration can occur due to the neonate's kidneys limited ability to concentrate urine and a low production of ADH. Electrolyte disorders such as hyponatremia and hypernatremia. There is higher risk for complications for preterm neonates. The glomerular filtration rate (GFR) is initially low in the neonate but doubles by 2 weeks of age Decreased GFR →↓ability to excrete water →↑risk of over-hydration and water intoxication Make sure mom is mixing formula right to prevent water intoxication Dehydration can occur due to the neonate's kidneys' limited ability to concentrate urine. 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 to teach parents about bottle feeding?

What bottles to use, have them bring theirs. Side lying or cradle hold positions to feed. NO propping Eat every 2-4 hours. Allow the babies to create their own schedule the first few days, without waiting 4 hours. Have parents demonstrate mixing formula before discharge. Behaviors during feedings. If baby is stressed they will turn away from the bottle, sneeze a lot, they are saying stop. If having cyanotic spells, stop the feeding. Teach parents what to look for, what's healthy, good feeding and when to stop Most term babies do really well. Preterm is a different story and need more help feeding these babies.

How to keep the mother's supply of milk up, if the preterm infant is on gavage?

When the baby isn't breast feeding, she should still pump around the clock every 3-4hours. Have that milk supply by keeping the demand.

If an infant has an Apgar score of 8, is the newborn stable and what should be done next?

Yes the newborn is considered stable. Continue to stimulate the infant on mom's chest while starting the next assessment. Reassess Apgar in 5 minutes

Breastfeeding a preterm infant

• Should be put to breast as soon as there is a coordinated suck-swallow-breathe coordination, consistent weight gain, and control body temperature without heat source • Preterm infants tolerate breastfeeding with better transcutaneous oxygen pressures and body temperature maintenance than with bottle feeding • Nurse should coordinate flexible feeding schedule • Mothers can pump and milk be given by gavage • Store breast milk cold 5-7 days and frozen for 6 months Assess bottle feeding first before breast feeding By initiating skin to skin holding of the LBW infants in the early intensive care phase, mothers can significantly increase milk volume, thereby overcoming lactation problems. Many mothers find the football hold to be a convenient position for breastfeeding preterm babies. Feeding time may take up to 45 minutes and babies should be burped as they alternate breasts. Can have donated milk

What % is fluid in the body weight of a newborn?

•73% (in an adult, it is 58% fluid) Infant: Fluid and Electrolytes •The infant has a higher ratio of extracellular fluid than an adult •Rate of fluid exchange in a newborn is much faster than in an adult •Infant has a higher level of metabolism in relation to body weight than an adult •Rate of metabolism in a newborn is twice as great related to body weight •Acid forms quickly, leading to rapid development of acidosis •Immature kidney cannot concentrate urine to conserve body fluid

Other neonatal integumentary facts

•Active sebaceous glands •Eccrine (sweat) glands are functional •Growth phases of hair follicles are not in synchrony with hair loss (bald spots) •Amount of melanin is low at birth; skin is lighter than in later life; higher risk for ultraviolet susceptibility

What is important with multiple births?

•Critical for mother to bond to each newborn •Nurses are instrumental in the promotion of bonding •Rooming-in and breastfeeding are encouraged •Allow early visitation of an ill infant •Identify unique characteristics of each No co-bedding for sleep because of risk for SIDS, but can put them together if awake.

Signs of attachment behaviors of the neonate

•Emotional bonding between the parents and newborn •En face position (significant sign) •"Falling in love" with the newborn •Absence of attachment behaviors •Effect on the newborn •Effect on the relationship with the parents

Who to involve with the neonate?

•Family-centered maternity care •Fathers •Cultural influences on fathering behaviors •Paternal engrossment concept- special attachment behavior •May choose to be in the waiting room during delivery or feedings, but not a sign of resentment •Siblings •Grandparents and extended family •Community Make sure mom is getting enough rest!

What to measure during the newborn assessment?

•Head circumference (right above the eyebrows) •Chest circumference •Abdominal circumference •Length (head to heel) •Body weight Microcephaly or hydrocephaly or hemorrhaging will show with head measurement.

Nursing care for the preterm infant

•Monitor physiological data •Establish and maintain respiration: maintain a patent airway •All will be on a monitor, HR, RR, and O2. Can have a continues BP through arterial line. Can access the umbilical artery to use as arterial line Need support of thermoregulator, before 1800g Apply external warmth •Administer fluids and medications: Vit K, to prevent bleeding. Hep B if consented. Eye ointment too •Enteral feeding (nipple, breast, gavage- before 34wks) •Skin care •Developmental and family-centered care

Infant: GI System

•Newborn has a deficiency of pancreatic lipase for fat absorption, which makes cow's milk indigestible •Stomach capacity is small (5 to 60 mL), with lower esophageal pressure and delayed emptying •Salivary glands do not secrete saliva until about 2 to 3 months of age •Colon has small volume; the intestine is longer in relation to body size, with rapid peristaltic waves •Human milk is the best food for a newborn •Immature liver contributes to physiologic jaundice and edema at birth •Increased risk for hypoglycemia •Small, frequent feedings are required; around every 2 to 4 hours. •Regurgitation is common (with newborns) •Frequent "stooling" (at every feeding) is common

What are signs of stress or fatigue in preterm neonates?

•Physiologic Instability (vitals) •Fluctuating tone •Lack of control over movement •Disorganized •Closed eyes and sleeplike withdrawal

How to weigh an infant? What to use?

•Platform Scale For Infants And Very Young Children •Weigh Infants Nude until age 3 Typical birth weigh is 2700-4000g (6-9lbs) Infants loose 10% of body weight by 3-4 days of age from lose of extracellular fluid shift and meconium. As well as limited food intake, especially breastfed infants. Will need to regain that weight by day 10-14. Can weigh less leaving hospital than at birth. More than 10% we need to look at nutritional habits and may be more concerning •Safety- place your hand above the infant or very young child to prevent falls Do Not turn your back on a pediatric patient on a platform scale - could fall out

The general appearance of the neonate

•Posture- Flexion Extension of extremities is often related to prematurity effects, medications given to mother during labor such as mag sulfate, anesthesia birth injuries, hypothermia or hypoglycemia •Behavior- Easily awakened by a loud noise, easily comforted, satisfied after feeding, level of responsiveness to noxious stimuli, transition of sleep states is evident

Assessment of the neurlogic system

•Reflexes (grasp, Babinski, etc.) •Posture, tone, head control, and body movement •Behavioral response to care •Consolability •Cry (frequency and pitch Could see tremors or quivering, but not extended amounts. Flexed position and rapid recoil of extremities to the flexed position. Positive newborn reflexes

Describe the timeframe of term, preterm, and post term infant.

•Term infant: 37 to 42 completed weeks of gestation •Preterm infant: Less than 37 completed weeks of gestation •Post term infant: More than 42 completed weeks of gestation