Mom/Baby Exam 3 Sherpaths

Which two factors trigger cardiovascular adaptation after birth?

-Umbilical cord clamping -Initiation of respiration umbilical cord clamping -Umbilical cord clamping functionally closes the umbilical arteries, umbilical vein, and ductus venosus. initiation of respiration -Initiation of respiration inflates the lungs, decreases pulmonary vascular resistance, and stimulates increased pulmonary blood flow, leading to closure of the ductus arteriosus and foramen ovale.

Which assessment finding would the nurse document as a normal variation that does not require immediate attention of the health care provider?

-Vaginal bleeding -Breast engorgement with nipple discharge -Reducible umbilical hernia vaginal bleeding -Vaginal bleeding (pseudomenstruation) in a female newborn is a normal variant and results from changes in hormone levels after birth. breast engorgement with nipple discharge -Breast engorgement with nipple discharge is a normal variant and results from changes in the hormone levels after delivery. reducible umbilical hernia -A reducible umbilical hernia is a normal variant. Most umbilical hernias resolve without intervention. A nonreducible hernia, however, may require surgical correction.

Which findings are consistent with subinvolution for a woman 24 hours postpartum?

-excessive blood loss -foul odor from lochia -a fundus 2U above the umbilicus

Match the gestational classifications with their definition.

34 0/7 through 36 6/7 weeks - Late preterm 37 0/7 through 38 6/7 weeks - Early term 39 0/7 through 40 6/7 weeks - Full term 41 0/7 through 41 6/7 weeks - Late term

Infants born prior to completion of which gestational week are considered premature?

37

Episiotomy

Episiotomy, or incision of the perineum just before delivery, was once routine for vaginal deliveries. The use of episiotomy has steadily declined as a result of a lack of positive research to support the purported benefits. Patients who deliver vaginally over an intact perineum experience less pain, have less blood loss, and resume comfortable intercourse sooner than patients who have an episiotomy or lacerations. Whenever possible, the best outcome for the woman occurs when she gives birth over an intact perineum, which results in less blood loss, a lower risk for infection, and less postpartum discomfort. An episiotomy may be indicated when fetal heart rate (FHR) abnormalities necessitate a hastened birth.

Lacerations: Classification and Types

First-Degree -Extends through the skin and tissue, superficial to muscular system Second-Degree -Extends through perineal muscles Third-Degree -Continues through anal sphincter muscle Fourth-Degree -Involves anterior rectal wall Vaginal Lacerations -Vaginal lacerations can occur with a perineal laceration and are usually up the lateral walls (sulci) and can involve the levator ani muscle. Vaginal vault lacerations are circular and can occur with a precipitous birth with a rapid fetal descent. Cervical Injuries -Cervical injuries are likely to occur as the lateral edges of the external part of the cervix retract over the advancing fetal head. Most cervical lacerations are small with minimal bleeding; however, they can extend to the vaginal vault or lower uterine segment. Cervical injuries can result when delivery happens before the cervix is fully dilated.

Supporting Nutritional Status: Enteral Nutrition

For those receiving enteral feedings, fortified breast milk is preferred over preterm formula. Fortification increases caloric density, often to 24 kcal/oz (versus 20 kcal/oz), and meets other nutritional requirements of premature newborns. There is evidence to support the use of donor breast milk if parental breast milk is not available, given numerous health benefits associated with breast milk including immunity and protection against necrotizing enterocolitis. Enteral feedings are advanced from passive (gavage) to active (bottle and/or breastfeeding). Enteral feedings are often begun within the first few days of life, most often via gavage feeding. Minimal enteral feedings (trophic feedings) generally begin with only a few milliliters of milk to promote maturation of the intestinal tract, intestinal motility, and gastric hormone production. Nurses are responsible for overseeing enteral feedings and progression. Interventions related to enteral feeding include the following: Gavage Feeding -Placing feeding catheter via the oral (preferred) or nasal route. -Administering gavage (tube) feedings per health care provider prescription, either continuous or intermittent (bolus) over 30 to 60 minutes. -Offering a pacifier during gavage feedings for oral stimulation and association of sucking and feeling of fullness. Bottle Feeding -The first oral feedings are often small volumes followed by administration of the rest of the feeding via gavage. -Monitor infant feeding cues such as rooting, hand-to-mouth movements, and sucking on a pacifier; crying is a late hunger sign. -Provide period of rest before and after feedings. -Offer a pacifier before feeding to promote alert state prior to feeding gradually increases the amount and frequency as tolerated. -For infants with stable thermoregulation, wrap in warm blankets, place a hat on infant's head, and hold for feedings. -Position infant at a 45- to 60-degree angle and support head and neck in neutral position. -Use a bottle on which each milliliter is marked to ensure accurate feeding volume measurement. -Feed slowly and allow periods of rest if/when infant stops sucking; remove nipple from mouth if the infant has long sucking bursts without pausing to breathe and rest. -Burp frequently. -Stop feeding for any signs of intolerance (coughing, gagging, and change in respiratory rate) or fatigue, such as falling asleep. -Remaining feeding volume not taken orally may be given by gavage. Breastfeeding -Given the health benefits of breast milk, nurses should encourage parents of preterm infants to express breast milk. -Support lactation through instruction on the use of a breast pump and by providing sterile storage containers, labels, and storage instructions. -When the infant is stable and ready, breastfeeding may be introduced. -Often pre- and post-breastfeeding weights are prescribed to measure exact volume of milk consumed during a feeding. -Support the mother in initiating breastfeeding, including support in holding the infant and handling of any attached equipment. -Consider lactation consultation if needed to promote breastfeeding success.

Which intervention is most important for preventing infection in premature newborns?

Hand hygiene

Other Methods to Support Thermoregulation

Skin-to-Skin (Kangaroo Care) -Usually offered when preterm infant is stable. -Infant (wearing diaper only) is placed vertically on parent's bare chest. -Maintains body temperature while also promoting interaction and bonding. Polyethylene Bag -Infants less than 29 weeks' gestation may be placed in a polyethylene bag or wrap that covers them from the shoulder down. -Bag prevents heat loss by evaporation and decreases insensible water loss. -May be used until infant is stabilized. Head Coverings -Head coverings are effective in preventing heat loss and may be used inside or outside of an incubator. -Fabric-insulated or wool hats are more effective than stockinette hats.

Other Interventions to Support Respiration

Surfactant -Surfactant may be administered via endotracheal tube as an adjunct to oxygen and ventilation therapy -Surfactant is associated with reduced length of ventilator support and oxygen therapy as well as increased survival Nitric Oxide -Inhaled nitric oxide (INO) promotes pulmonary vasodilation in the pulmonary circulation -INO is administered through the ventilator circuit and blended with oxygen Extracorporeal Membrane Oxygenation (ECMO) -ECMO is a highly complex and costly treatment used to support life and allow treatment of severe hypoxemia related to cardiac and/or respiratory failure -ECMO is a modified "heart-lung machine" where the heart is not stopped and blood does not entirely bypass the lungs -ECMO provides oxygen to circulation, allowing the lungs to rest, and decreases pulmonary hypertension and hypoxemia

Complications

Despite technological advances in care, premature newborns often develop complications. Complications are more common among newborns with lower gestational age and birth weight. Some common complications of prematurity include respiratory distress syndrome, bronchopulmonary dysplasia, intraventricular hemorrhage, and necrotizing enterocolitis. Nurses must recognize the clinical signs of these complications to ensure timely and appropriate interventions are implemented. Respiratory Distress Syndrome (RDS) -Caused by insufficient production of surfactant, which is usually produced beginning at 34 to 36 weeks of gestation. -Surfactant reduces alveolar surface tension, allowing alveoli to remain open during exhalation. -Insufficient surfactant production results in alveolar collapse on exhalation. -Widespread atelectasis occurs because infants are unable to keep lungs inflated. CLINICAL SIGNS -Tachypnea (≥60 breaths/min) -Dyspnea -Pronounced intercostal or substernal retractions -Fine inspiratory crackles -Audible expiratory grunt -Flaring of the external nares -Cyanosis or pallor -Apnea -With progression of condition, deteriorating vital signs including blood pressure, apnea, and body temperature instability Bronchopulmonary Dysplasia (BPD) -Also known as chronic lung disease -Most common in infants born at 28 weeks' gestation or less, weighing less than 1000 g (2.2 lb) -Result of acute lung injury among infants who received supplemental oxygen and mechanical ventilation -Pathologic process related to alveolar damage from lung disease, prolonged exposure to mechanical ventilation, high peak inspiratory pressures and oxygen, and immature alveoli and respiratory tract CLINICAL SIGNS -Dyspnea, increased work of breathing, retractions -Barrel chest -Inability to wean from oxygen or mechanical ventilation after course of RDS (surfactant deficiency) -Wheezing -Tachycardia, tachypnea -Weight loss, poor weight gain, poor feeding -Irritability, restlessness Intraventricular Hemorrhage (IVH) -Bleeding around and into ventricles of the brain -30% of preterm infants <1500 g (3.3 lb) develop IVH -Occurs most often in first few days of life -Hemorrhage graded 1 to 3 ---Grade 1 is small bleed with few clinical changes ---Grade 2 extends to lateral ventricles ---Grade 3 causes distention of ventricles CLINICAL SIGNS -Signs dependent on severity of hemorrhage, with some showing subtle or no clinical signs -Lethargy -Poor muscle tone -Respiratory deterioration, cyanosis, apnea -Decreased hematocrit -Acidosis -Hyperglycemia -Decreased reflexes -Tense fontanel -Seizures Necrotizing Enterocolitis (NEC) -Acute inflammatory condition of the intestinal tract that may lead to necrosis -Cause unknown -More common in infants whose GI tracts experience vascular compromise -Intestinal ischemia, immature GI host defenses, bacterial proliferation, and feeding substrate CLINICAL SIGNS -Feeding intolerance -Abdominal distention, tenderness -Decreased bowel sounds -Visible loops of bowel -Erythema of intestinal wall -Bloody stools -Signs of infection -Apnea, bradycardia, temperature instability, lethargy, hypotension, and shock also may be present -Thrombocytopenia, increased or decreased leukocytes, and metabolic acidosis may occur

Which interventions would the nurse implement for a premature newborn with evaporative losses?

-Adjust incubator temperature. -Provide high humidity. -Assess blood glucose.

Which assessments would the nurse include during the initial assessment of a newborn after birth?

-Airway patency -Heart sounds -Color airway patency -The nurse would assess the airway patency of the newborn; if the airway is not patent, resuscitation or immediate intervention is needed. heart sounds -The nurse would assess the heart sounds of the newborn (heart rate, rhythm, and whether murmur is present) to determine whether resuscitation or immediate intervention is needed. color -The nurse would assess the color of the infant. If not pink, the infant may require resuscitation or immediate intervention.

Which assessment findings are expected in a premature newborn?

-Axillary temperature range of 36.3°C to 36.9°C (97.3°F to 98.4°F) -Weight gain of 15 to 20 g/kg/day -Loss of 15% birth weight during first week of life Axillary temperature range of 36.3°C to 36.9°C (97.3°F to 98.4°F) -Axillary temperature range in premature newborns is slightly lower than normal newborns due to lower fat stores and limited capability to generate heat. Axillary temperature range of 36.3°C to 36.9°C (97.3°F to 98.4°F) is considered normal. Weight gain of 15 to 20 g/kg/day -Premature newborns are expected to gain between 15 and 20 g/kg/day, which is slightly less than normal newborns who typically gain around 30 g per day. Loss of 15% birth weight during first week of life -Loss of 15% birth weight during the first week of life is expected in premature newborns. This is higher than normal newborns, who are expected to lose up to 10% of their birth weight during the first week of life.

Which effects can a full bladder have on the uterus in the postpartum period?

-Displaces the uterus -Promotes a boggy uterus -Inhibits uterine involution

Which clinical signs are associated with respiratory distress syndrome?

-Dyspnea -Inspiratory crackles -Apnea

Which findings are concerning when assessing a third-degree laceration of a postpartum woman?

-Edema -Stitches that are not well approximated

Which signs are included in the Apgar assessment completed at 1 and 5 minutes after birth?

-Heart rate -Respiratory effort -Muscle tone -Response to catheter -Color heart rate -Heart rate is assessed by auscultation or palpation of the umbilical cord. respiratory effort -Respiratory effort is assessed by chest wall movement. muscle tone -Muscle tone is assessed by degree of flexion and movement of extremities. response to catheter -Reflex irritability is assessed by response to suctioning of nares or nasopharynx. color -Color is described as blue or pale, pink body with blue extremities, or completely pink.

Which assessment findings suggest excessive blood loss requiring immediate intervention for a postpartum patient who had a cesarean delivery?

-Heart rate of 120 beats/min -Blood pressure of 80/40 mm Hg -Urinary output of 20 mL/hour -Abdominal distension and severe pain

Which characteristics predispose the newborn to heat loss?

-Large body surface to mass ratio -Thin subcutaneous fat layer -Superficial blood vessels large body surface to mass ratio -Newborns have a large skin surface in proportion to their size, increasing the risk for heat loss. thin subcutaneous fat layer -Newborns have inadequate stores of brown fat and are at a higher risk for heat loss due to thin layers of subcutaneous fat. superficial blood vessels -Because of the lack of subcutaneous tissue, newborn blood vessels are closer to the surface, leading to increased insensible heat loss.

Which factors contribute to compromised physiologic functioning in premature newborns?

-Limited brown fat stores -Capillary fragility -Minimal maternal immunoglobulin storage -Weak or absent gag reflex

Which observations would the nurse document as normal findings of an inspection of the newborn head?

-Molding -Separation of sutures molding -Molding is the shaping of the fetal head by overlapping of the cranial bones to facilitate movement through the birth canal during labor. This is a normal finding in newborns born during a vaginal delivery. separation of sutures -Separation of sutures is a normal finding. Sutures should be palpable with a small separation between each.

Which nursing findings are concerning when assessing the breasts and nipples of a postpartum woman?

-Nipples are pink with a blister line. -Breasts are red and firm.

Which nonpharmacologic interventions are recommended for premature newborns experiencing pain?

-Nonnutritive sucking -Containment -Skin-to-skin contact nonnutritive sucking -Nonnutritive sucking is a recommended comfort measure; evidence shows diminished pain in premature newborns who are offered a pacifier for nonnutritive sucking. containment -Containment (or facilitated tucking) is an evidence-based comfort measure for premature newborns experiencing pain. skin-to-skin contact -Skin-to-skin contact is an evidence-based comfort measure for premature infants experiencing pain. Evidence shows lower pain and decreased stress.

Which factors put a patient at risk for postpartum complications?

-Prolonged rupture of membranes -30-hour long labor -Third-degree perineal laceration and moderate edema

Which teaching elements are appropriate to include in the plan of care for the postpartum patient with a third-degree laceration?

-Recommend a high-fiber diet. -Apply cold to the area for the first 12 hours as needed. -Recommend stool softeners.

Which characteristics would the nurse expect to observe when caring for a premature newborn?

-Scrawny extremities -Smooth, translucent skin -Vernix caseosa scrawny extremities -Premature infants appear scrawny due to limited subcutaneous fat. smooth, translucent skin -Premature infants have skin that is bright pink or red, shiny, smooth, and often translucent. vernix caseosa -Vernix caseosa and fine lanugo hair may be present on the body of premature infants.

Which interventions would the nurse implement to facilitate parent-infant bond?

-Teach containment techniques. -Encourage skin-to-skin contact. -Include parents in infant care.

Which factors stimulate the initiation of respirations after birth?

-Thermal -Sensory -Chemical -Mechanical Thermal -Abrupt temperature change from intrauterine to extrauterine environment stimulates skin sensors that send impulses to stimulate the respiratory center in the brain. Sensory -Tactile stimulation from health care providers during and after birth stimulate skin sensors and initiate respiration. Chemical -Fetal hypoxia related to decreased uterine blood flow during labor activates chemoreceptors that stimulate the respiratory center. Mechanical -Mechanical factors, such as closure of cardiac shunts and changes in pressure in the heart and lungs, force fluid out of the lungs and stimulate respiration.

Which reflex is elicited by pressing a finger against the base of the newborn's fingers?

Palmar grasp reflex -The palmar grasp reflex is tested by pressing a finger against the base of the newborn's fingers. The expected response is for the fingers to curl tightly.

Which statements explain how plasma volume returns to baseline after delivery?

-Profuse sweating aids in decreasing plasma volume levels. -Increased urinary output promotes the excretion of excess plasma volume. -Decreased aldosterone hormone levels promote diuresis of excess plasma volume.

Which statements by the patient indicate a need for additional teaching regarding the need for contraception postdelivery?

-"Because I am breastfeeding, I don't need to worry about contraception." -"I can wait for my period to resume before using contraception."

Which nursing questions are appropriate for a patient 9 days postpartum who feels tired and still has vaginal discharge?

-"What color is your lochia?" -"Is there an odor to your lochia?" -"How often are you changing your peripads?"

Which statements regarding the assessment of newborn vital signs are accurate?

-A heart rate of 146 beats/min is normal. -A blood pressure of 70/48 is normal. -Respiratory rate and heart rate are assessed for a full minute.

Which characteristic of newborns necessitates the administration of vitamin K at birth?

Absence of intestinal flora -Intestinal flora needed to produce vitamin K are absent in the first week after birth. Vitamin K is administered at birth to activate clotting factors and decrease the risk for hemorrhagic disease.

Which intervention is associated with reduced length of ventilator support and oxygen therapy in premature newborns?

Administration of surfactant -Surfactant administered via endotracheal tube has been shown to reduce the length of ventilator support and oxygen therapy and increase survival of premature newborns.

Summary

After birth, the newborn undergoes numerous physiologic adaptations necessary for extrauterine life. These adaptations include changes to the respiratory, cardiovascular, thermoregulatory, and other body systems. Chemical, mechanical, thermal, and sensory factors contribute to respiratory adaptation as the lungs are established as the site of gas exchange. Cardiovascular adaptation involves transitioning from fetal to neonatal circulation in response to umbilical cord clamping and initiation of respiration. Newborns are predisposed to heat loss; therefore thermoregulation is an important adaptation to extrauterine life. Numerous other body systems undergo adaptation, including the hematologic, gastrointestinal, hepatic, renal, and immune systems. Understanding these adaptations is essential for nurses caring for newborns during this transitional period. Newborn assessment includes preliminary assessments immediately after birth followed by a comprehensive head-to-toe assessment. The preliminary assessment immediately after birth prioritizes respiratory and cardiac function as well as Apgar scoring at 1 and 5 minutes. Assessment of gestational age may identify newborns at risk for complications. The nurse performs a comprehensive head-to-toe assessment and identifies expected findings, normal variants, and abnormal findings that may require intervention. Primitive reflexes are assessed as an indicator of central nervous system function.

Episiotomy and Lacerations: Assessment and Nursing care

Assessment and nursing care for patients with episiotomies and lacerations largely focus on prevention, and nursing care differs depending on the grade of laceration. For third- and fourth-degree lacerations especially, care must be provided to increase the probability that the mother will maintain fecal continence. In addition, preventing infection is an important nursing consideration because a laceration or episiotomy increases the risk for an infection caused by an interruption in skin integrity. The nurse assists with and teaches women proper perineal care and how to maintain a clean environment. Prevention before birth -Gradual stretching of the perineum is the key to reducing the need for episiotomy. Daily perineal massage and stretching by the patient from 36 weeks of gestation until delivery has been shown to reduce the risk for perineal trauma during birth. Women older than 30 years who were pregnant for the first time and adhered to the practice of a daily 10-minute perineal massage showed the greatest benefit. Prevention during labor -An upright position while pushing promotes gradual stretching of the patient's perineum. Laboring down, or delaying pushing until the urge is felt, also gradually distends the soft tissues of the pelvic floor. When the patient pushes, use of an open-glottis technique rather than prolonged breath-holding also promotes gradual perineal stretching. Recovery and postpartum care -Nursing interventions during the recovery and postpartum periods are similar for all types of perineal trauma. Assess and observe the perineum for hematoma and edema. Perineal cold applications are done for the first 12 hours, followed by intermittent perineal heat applications after at least 12 hours, if needed. Assess the perineum, episiotomy, or laceration repair using REEDA. -Measures such as increased activity, increased intake of oral fluids and dietary fiber, and use of stool softeners can be implemented to facilitate the patient's comfort during the healing process. For patients with third- and fourth-degree lacerations, enemas and suppositories are contraindicated. In some cases, antibiotic therapy may be initiated.

Which newborn assessment finding is considered a normal variant?

Caput succedaneum -Caput succedaneum is an area of edema to the newborn's head as a result of labor; it is considered a normal variant.

Supporting Thermoregulation: Overview

Interventions to support thermoregulation are another critical action of nurses caring for premature newborns. Prevention of heat loss and cold stress is essential for infant survival; therefore interventions aim to provide a neutral thermal environment. A neutral thermal environment is one in which oxygen consumption is minimal but adequate to maintain body temperature. Although prevention of hypothermia and cold stress are emphasized, care must also be taken to prevent overheating.

Reflexes

BABINSKI -Method ---Stroke lateral sole of foot from heel to across base of toes. -Expected Response ---Toes flare with dorsiflexion of the big toe. GALLANT -Method ---With newborn prone, lightly stroke along the side of the vertebral column. -Expected Response ---Entire trunk flexes toward side stimulated. PALMAR AND PLANTAR GRASP -Method ---Press finger against base of newborn's fingers or toes. Expected Response ---Fingers curl tightly; toes curl forward. MORO ("Startle") -Method ---Let newborn's head drop back approximately 30 degrees. Alternatively, infant may demonstrate the Moro reflex in response to a loud noise. -Expected Response ---Sharp extension and abduction of arms and fanned fingers followed by flexion and adduction to "embrace" position. ROOTING -Method ---Touch or stroke from side of mouth toward cheek. -Expected Response ---Newborn turns head to side touched. Difficult to elicit if newborn is sleeping or just fed. STEPPING or WALKING -Method ---Hold newborn so feet touch solid surface. -Expected Response ---Newborn lifts alternate feet as if walking. SUCKING -Method ---Place nipple or gloved finger in mouth, rub against palate. -Expected Response ---Newborn begins to suck, but may be weak if recently fed. SWALLOWING -Method ---Observe the infant while feeding (breast or bottle). -Expected Response ---Swallowing coordinated with sucking and breathing without coughing, gagging, or vomiting. TONIC NECK REFLEX -Method ---Gently turn head to one side while newborn is supine. -Expected Response ---Newborn extends extremities on side to which head is turned, with flexion on opposite side.

Cardiovascular Adaptation

Cardiovascular adaptation after birth involves a transition from fetal to neonatal circulation. Fetal Circulation -Three shunts, the ductus venosus, foramen ovale, and ductus arteriosus, are essential to fetal circulation. ---In utero, the placenta is the site for gas exchange. Oxygenated blood enters fetal circulation through the umbilical vein and approximately half is shunted through the ductus venosus to the inferior vena cava (Kliegman et al., 2020). ---Within the heart, oxygenated blood is preferentially shunted from the right to left atrium through the foramen ovale. Blood in the left atrium flows to the left ventricle and is pumped through the ascending aorta to the heart, brain, head, and upper body (Horeczko & Inaba, 2018). ---Deoxygenated blood from the superior vena cava preferentially flows from the right atrium to the right ventricle and is pumped through the pulmonary artery. Due to pulmonary vascular resistance in the fluid-filled lungs, the majority of this blood bypasses the lungs and is shunted through the ductus arteriosus to the descending aorta to return to the placenta for oxygenation through the two umbilical arteries (Horeczko & Inaba, 2018). Neonatal Circulation -Cardiovascular adaptation after birth occurs in response to umbilical cord clamping and initiation of respiration (Horeczko & Inaba, 2018; Kliegman et al., 2020). ---Umbilical cord clamping functionally closes the umbilical arteries, umbilical vein, and ductus venosus; all convert to ligaments within 2 to 3 months. ---Initiation of respiration inflates the lungs, decreases pulmonary vascular resistance, and stimulates increased pulmonary blood flow. ---Increased oxygen levels cause the ductus arteriosus to functionally close within 24 hours; it converts to a ligament within 3 to 4 weeks. ---Increased pulmonary blood flow to the left atrium promotes closure of the foramen ovale, with complete closure occurring around 3 months of age.

Which statement explains how intrathoracic pressure contributes to newborn respiratory adaptation?

It forces fetal lung fluid out of the alveoli and into interstitial spaces. -Pressure changes in the lungs force fetal lung fluid out of the alveoli to allow air into the lungs.

Which nursing finding requires intervention when assessing a postpartum woman who delivered by cesarean birth?

Distended abdomen with no bowel sounds auscultated -Abdominal distention and the absence of bowel sounds would concern the nurse. This may indicate the presence of bowel obstruction.

Lacerations: Overview

During childbirth, there is a risk for acute injury and lacerations of the perineum, vagina, uterus, and supporting structures during the birthing process. The probability of sustaining a laceration varies and is more pronounced in nulliparous women because tissues are firmer and more resistant. Additional factors that can increase the likelihood of a laceration include: -Nutritional status -Birth position -Pelvic anatomy -Fetal malpresentation/position -Use of vacuum or forceps for delivery -A prolonged second stage of labor -Rapid delivery Acute lacerations to the vagina, perineum, uterus, and the surrounding tissues can occur during delivery. Small cervical lacerations occur frequently and generally do not require repair. Lacerations of the vagina, perineum, and periurethral area primarily occur during the second stage of labor, when the fetal head descends rapidly, such as during a precipitous birth or when assistive devices such as a vacuum extractor or forceps are used during delivery. Lacerations to this highly vascular area usually result in profuse bleeding and must be repaired with absorbable sutures. Blood from a laceration will be bright red in contrast to dark-red lochia. Bleeding may be frank and copious, but a slow, steady trickle is just as dangerous.

Initial Postpartum Assessment and Chart Review

During the early postpartum period, components of nursing care include: -Assisting the mother with rest and recovery from labor and birth -Assessing physiologic and psychologic adaptation after birth -Preventing complications -Educating the mother regarding self-management and infant care -Supporting the mother and her partner during the initial transition to parenthood After the initial postpartum assessment, the nurse needs to review the woman's chart thoroughly to identify postpartum risk factors. The nurse can act upon the identified risk factors in assessing the patient for potential postpartum complications and normal recovery. Gravida/para status -After delivery, multigravidas are at increased risk for excessive bleeding and afterpains. Prenatal laboratory tests/immunization status -Rh-negative women will need to receive Rho(D) immune globulin within 48 hours after delivery (prevents sensitization in the Rh-negative woman if the infant is Rh-positive). -Rubella-nonimmune women should receive a rubella vaccination before discharge. -Tdap should be offered to postpartum women if they did not receive it prenatally. ---Rho(D) immune globulin suppresses the immune response. Therefore the woman who receives both Rho(D) immune globulin and a live virus immunization such as rubella must be tested in 3 months to see if she has developed rubella immunity. If not, she will need another dose of the vaccine. Medical history/complications during pregnancy -The woman's medical history should be reviewed for chronic illnesses such as hypertension and diabetes. -Complications during pregnancy should be addressed. Women with preeclampsia are at risk for eclampsia for 24 to 48 hours after birth. -Women with gestational diabetes will need to have their blood glucose monitored. Labor and delivery summary -Women with prolonged labor and pushing time are at risk for uterine atony and postpartum hemorrhage. -Women with prolonged rupture of membranes and labor are at risk for postpartum infection. -Medications received during labor should be examined. Women who received oxytocin for a prolonged period of time are at risk for uterine atony. Women who received magnesium sulfate are also at risk for uterine atony and postpartum hemorrhage. -Women who received epidural anesthesia are at risk for incomplete bladder emptying as a result of decreased sensation. -Women with repaired lacerations or episiotomies may have perineal edema and decreased ability to void postpartum, and there is potential for additional blood loss. General newborn information/feeding preference -The status and sex of the newborn should be reviewed. -The feeding preference should be addressed to guide postpartum teaching and interventions. -Mothers should be taught about the benefits of breastfeeding.

Match the method of neonatal heat loss with its description.

Heat loss from moisture leaving skin -Evaporation Heat loss from direct contact with cool surfaces -Conduction Heat loss from body surface exposure to cooler ambient air -Convection Heat loss to a cooler surface nearby but not in direct contact -Radiation

Adaptation of Other Body Systems

Hematopoietic System -The immature hematopoietic system undergoes numerous changes during the transition to extrauterine life. ---Red blood cell (RBC), hemoglobin, and hematocrit levels are elevated at birth and normalize during first month of life. ---White blood cell count is elevated at birth, but normalizes in 4 to 5 days. ---Intestinal flora needed to produce vitamin K are absent in the first week after birth; vitamin K is administered at birth to decrease the risk for hemorrhagic disease. Gastrointestinal System -The gastrointestinal tract is sterile at birth. Intestinal flora are established during the first few days of life. ---Stomach capacity is 6 mL/kg at birth and becomes increasingly capable of larger volumes. ---Cardiac sphincter is relaxed, leading to regurgitation after feedings. ---Intestines are long in proportion to size; this allows for more absorption, but it makes newborns more prone to water loss from diarrhea. ---Most enzymes are functional at birth except for pancreatic amylase and lipase, which are responsible for carbohydrate and lipid metabolism. ---Stools progress from thick, greenish-black meconium to loose, greenish-brown transitional stools to milk stools. Hepatic System -Changes to the liver are necessary in the newborn period to maintain blood glucose levels and for clotting. Blood Glucose Maintenance -Glucose levels are lowest between 30 and 90 minutes after birth, then rise. -Glycogen stores are converted to glucose until feedings are adequate to meet energy needs. -Hypoglycemia is a risk due to rapid glucose use. -Newborns at highest risk for hypoglycemia include preterm or late preterm newborns, small- or large-for-gestational-age newborns, newborns born to mothers with maternal diabetes, and newborns exposed to stressors (asphyxia, infection, cold stress). Conjugation of Bilirubin -Hemolysis of RBCs leads to elevated bilirubin levels, requiring conjugation by the immature liver. -Jaundice may result if bilirubin levels exceed capacity of the liver to conjugate. -Elevated bilirubin in the blood (hyperbilirubinemia) may require treatment. Renal System -The urinary system must adapt to help with excretion of waste products and for balance of fluid and electrolytes. Kidney Function -Kidney perfusion dramatically increases after birth, contributing to improved kidney function in the first days of life. -Newborns have limited capacity to concentrate urine, gradually increasing during the first month of life. -Kidney function is immature, with limited ability to filter, reabsorb, and maintain fluid and electrolyte balance compared with adults. Fluid Balance -Body weight is 75% water at birth (extracellular and intracellular). -Diuresis of extracellular fluid occurs during first few days of life, leading to weight loss of 5% to 10% in most newborns. Immune System -The immature immune system of a newborn places it at high risk for infection. ---Maternal immunoglobulin G (IgG) crosses the placenta in utero and provides a newborn with passive immunity; passive immunity wanes around 6 months of age, at which time the infant's production increases. ---Immunoglobulin M (IgM) is produced rapidly after birth and reaches adult levels around 1 year of age.

Managing Pain and Environmental Stress

Increasingly, evidence has shown the negative consequences of infant pain and environmental stress. Nurses have the primary responsibility to implement interventions to prevent and manage pain and environmental stress. Interventions for Pain -If preparing for a procedure, wake the infant slowly and gently. -Allow infant to rest before and after procedures. -Nonpharmacologic comfort measures include the following: ---Containment (sometimes called facilitated tucking): position the extremities flexed and midline by swaddling, holding, or by using positioning devices. Leave at least one hand near the mouth for sucking. ---Pacifier for nonnutritive sucking ---Soft rocking, holding, or prone positioning ---Skin-to-skin contact ---Breastfeeding -Pharmacologic pain treatments (as prescribed by the health care provider) to be administered before painful procedures and when infant shows signs of pain: ---Topical anesthesia for pain during some procedures ---Nonnarcotics such as acetaminophen may be administered ---Opioids, such as morphine and fentanyl, may be tolerated by preterm infants -Monitor infant's response to pain interventions frequently and adjust treatment as needed. Interventions for Environmental Stress -Cluster care (perform several tasks at same time, such as vital signs and diaper changes) -Schedule care for newborn's awake periods as much as possible -Coordinate diagnostic testing and other care to minimize stress Reduce Stimuli -Minimize noise exposure, including monitor, alarms, ambient talking, and traffic -Decrease light exposure, use dimmers at night, place blankets over incubators, or cover infant's eye with a mask Promote Rest -Schedule naps to promote sleep-wake cycle -Contain infant's arms and legs to promote joint flexion -Provide boundaries with rolled blankets or positioning devices Consistent Individualized Care -Consistent nursing care promotes similar handling and care techniques -Nurses are able to learn infant responses

Which equipment is most commonly used to promote a neutral thermal environment in premature newborns?

Incubator -Incubators are used for the majority of premature newborns to provide a neutral thermal environment and minimize heat loss.

Supporting Thermoregulation: Incubators and Radiant Warmers

Incubators and radiant warmers are used until the infant is able to maintain normal body temperature, considered to be between 36.5°C and 37.2°C (97.9°F and 99°F). Often incubators or radiant warmers are servo-controlled, meaning they regulate the heat output based on a thermal sensor that is attached to the newborn's abdomen; the device automatically warms when the infant's temperature drops. Incubator -Incubators are used for the majority of premature infants. -Incubators have double walls to minimize radiant heat loss; warmed air circulates inside the incubator. -Incubators should be prewarmed before infants are placed inside them. -The incubator port holes are kept closed as much as possible to maintain heat. -Nurses must carefully monitor infant temperature. Radiant Warmer -Radiant warmers are often used when infants need procedures because they are open and make visualization and access easier. -Air currents may promote heat loss by convection. -To decrease convective heat loss, doors near the warmer should be closed and nearby traffic minimized.

Respiratory Adaptation

Initiation of respiration is the first newborn adaptation to extrauterine life. In utero, fetal alveoli are fluid-filled, and oxygenation occurs through transplacental gas exchange (Lowdermilk et al., 2019). To initiate respiration after birth, the fetal lung fluid is forced from the alveoli to interstitial spaces for air to enter the lungs (McKinney et al., 2017). Chemical, mechanical, thermal, and sensory factors contribute to the process of initiating respiration and establishing the lungs as the site for gas exchange (McKinney et al., 2017). Chemical Factors -Labor contractions cause transient fetal hypoxia through temporary decreases in uterine blood flow. -Fetal hypoxia activates chemoreceptors in the carotid arteries and aorta. -Decreased oxygen and increased carbon dioxide levels stimulate the respiratory center in the medulla. -Prostaglandin, which inhibits respiration, levels drop as a result of clamping the umbilical cord. -Surfactant reduces alveolar surface tension and prevents alveolar collapse as the infant exhales. Mechanical Factors -Fetal chest compression during birth forces fluid from the lungs to the upper airway (note, this factor is reduced in delivery by cesarean section). -Chest recoil after birth leads to negative intrathoracic pressure that draws air into the lungs (note, this factor is reduced in delivery by cesarean section). -Crying distributes the air throughout the lungs and promotes alveolar expansion. Thermal Factors -Abrupt temperature change from the intrauterine to extrauterine environment stimulates skin sensors that send impulses to stimulate the respiratory center in the brain. Sensory Factors -Tactile stimulation from health care providers during and after birth stimulate skin sensors and initiate respiration. Light, sound, smells, and pain at delivery may also stimulate skin sensors and initiate respiration.

Supporting Respiration: Overview

Interventions to support respiration are one of the primary foci of nursing care of premature newborns. Respiratory interventions are determined by the clinical status of the premature newborn and response to therapy. Common nursing interventions include positioning, hydration, suctioning, oxygen therapy, and assisted ventilation. All interventions are administered in collaboration with the interdisciplinary health care team.

Focused Postpartum Assessment: Vaginal Delivery

It is important for the nurse to conduct thorough, focused assessments of postpartum women. Women with vaginal births will have unique assessment needs centered on the vaginal and perineal areas. Vital signs and a physical assessment should be performed according to hospital guidelines. It is common for women to have elevated temperatures in the first 24 hours after birth as a result of dehydration during labor. Temperatures above 100.4°F should be reported to the health care provider. Low blood pressure and elevated heart rate should also be investigated and reported to the health care provider, as these may indicate hypovolemia and/or shock. The respiratory rate should be between 12 and 20 breaths/min. Pain is considered the fifth vital sign. The location and severity should be assessed, and the nurse should assist with comfort measures. The nurse can use the acronym BUBBLEHE to complete the rest of the focused assessment: B (BREASTS) -The breasts should be inspected for size, symmetry, and color. Asymmetry could indicate unilateral engorgement. Redness could indicate mastitis. The nipples should also be assessed for lacerations or blisters, as these conditions can lead to mastitis. -The breasts should be palpated as well. They should be soft and nontender the first 24 to 48 hours after birth. As the milk comes in, they should feel full. Tenderness may be related to mastitis or engorgement. U (UTERUS) -The fundus should be palpated for consistency and location. The fundus should be firm and midline. If the fundus is displaced to the right, the bladder should be emptied. The fundus should be at the level of the umbilicus within 12 hours after birth. It should descend one fingertip per day. -If the uterus is boggy, the nurse should gently massage until it firms up. The nurse should also press gently to expel clots. The lochia, vital signs, and urinary output should also be assessed and reported to the health care provider. -Assessing the fundus can be an anxiety-provoking experience for any postpartum woman. Remember to time fundal examinations with pain medication administration. Performing a fundal examination on a postoperative woman 30 to 45 minutes after you give a pain med makes it more comfortable and may help alleviate anxiety. Pain is considered the fifth vital sign. The location and severity of pain should be assessed, and the nurse should assist with comfort measures. B (BOWELS) and B (BLADDER) -The abdomen should be inspected, and bowel sounds should be auscultated. The bowel sounds should be active in all quadrants. -The perineal area should be inspected for edema and hemorrhoids. Women with hemorrhoids or episiotomy/laceration incisions will need stool softeners to prevent straining from hard stools. -The bladder will need to be assessed for distention. A full bladder can lead to uterine atony, excessive bleeding, and infection. It will need to be emptied by catheterization if the woman is unable to void. -Women with urethral lacerations may have difficulty voiding as a result of edema and pain. L (LOCHIA) -The lochia needs to be assessed for color, odor, and amount. -The lochia will have a fleshy odor, but it should not have a foul odor. A foul odor is associated with infection. -If a pad is saturated within an hour, this is considered heavy. -If a pad is saturated within 15 minutes, this is considered excessive. -Heavy and excessive lochia require further investigation and intervention. E (EPISIOTOMY OR LACERATION INCISION) -Episiotomy and lacerations should be assessed thoroughly. -REEDA is an acronym that may be used for assessment criteria (redness, edema, ecchymosis, drainage, and approximation). -Redness and purulent drainage may indicate infection. -Edema may inhibit urinary elimination. -Approximation refers to the intactness of the sutures. These should be intact, with edges of the wound completely closed. H (HOMANS SIGNS) and E (EMOTIONAL STATUS) -The lower extremities should be inspected and palpated. Warmth, tenderness, and unilateral enlargement may indicate the presence of a blood clot. -Emotional status should be assessed for signs/symptoms of postpartum depression such as decreased bonding, decreased sleep, and prolonged periods of crying. -The reversal of maternal adaptation to pregnancy and associated birth trauma are noted in the puerperium period (6 weeks after delivery). -The deep tendon reflexes should also be assessed. Hyperreflexia could be a sign of worsening preeclampsia.

Which criterion is used to classify an infant as small-for-gestational-age (SGA)?

Less than 10th percentile for weight

Prematurity Classification Based on Infant Size

Low-birth-weight (LBW) infant -An infant whose birth weight is less than 2500 g (5.5 lb), regardless of gestational age Very low-birth-weight (VLBW) infant -An infant whose birth weight is less than 1500 g (3.3 lb) Extremely low-birth-weight (ELBW) infant -An infant whose birth weight is less than 1000 g (2.2 lb) Appropriate for gestational age (AGA) infant -An infant whose birth weight falls between the 10th and 90th percentiles on intrauterine growth curves Small for date (SFD) or small for gestational age (SGA) infant -An infant whose rate of intrauterine growth was restricted and whose birth weight falls below the 10th percentile on intrauterine growth curves Large for gestational age (LGA) infant -An infant whose birth weight falls above the 90th percentile on intrauterine growth curves Intrauterine growth restriction (IUGR) -Found in infants whose intrauterine growth is restricted (sometimes used as a more descriptive term for the SGA infant) Symmetric IUGR -Growth restriction in which the weight, length, and head circumference are all affected Asymmetric IUGR -Growth restriction in which the head circumference remains within normal parameters while the birth weight falls below the 10th percentile

Supporting Nutritional Status: Parenteral Nutrition

Nurses have an important role in monitoring and promoting nutritional status of premature newborns. Primarily, interventions to support nutrition relate to parenteral and enteral feedings. Preterm infants often need specialized nutrition to meet their unique nutritional needs. For infants unable to tolerate all enteral feedings, TPN is prescribed to meet their individualized nutritional needs. Parenteral Nutrition -Interventions related to TPN primarily involve infusing the TPN per the health care provider's prescription and monitoring for IV infiltration. -Scrupulous hand hygiene is needed before handling TPN tubing or IV sites. -Frequent repositioning is needed to maintain body alignment and protect the IV site.

Supporting Respiration: Oxygen Therapy and Assisted Ventilation

Many infants will require supplemental oxygen and assisted ventilation. The need for oxygen therapy is largely determined by clinical criteria, such as respiratory effort; respiratory distress, including apnea, tachycardia, bradycardia, and central cyanosis; and abnormal oxygen saturation and/or blood gas measurement. Mechanical ventilation, or ventilator support, is indicated for severe hypoxemia or severe hypercapnia. Oxygen Therapy -Oxygen is administered by the least invasive method that is effective. -Administration may be by nasal cannula, oxygen hood, or via ventilatory assistive devices. -Oxygen is often warmed and humidified to minimize insensible water loss and drying of mucous membranes. -The nurse continually monitors infant oxygen level and titrates as clinically indicated. Ventilatory Support -Ventilatory support methods are determined by infant clinical status and response to therapy. -Nurses often work with respiratory therapists to care for infants receiving ventilatory support. -Ventilatory support is weaned slowly as the infant's status improves; typically infants will be extubated, then placed on continuous positive airway pressure (CPAP), and then weaned to oxygen alone via cannula or hood. Continuous Positive Airway Pressure (CPAP) -May be delivered via nasal prongs, mask, or endotracheal tube -Provides constant distending pressure to promote lung expansion and prevents alveolar collapse Conventional Mechanical Ventilation -Often needed when respiratory failure, severe apnea or bradycardia, or other conditions present High-Frequency Oscillation (HFO) -Delivers fast, frequent respirations with less pressure and volume, which decreases lung injury from pressure (barotrauma) and volume (volutrauma)

Measurements

Measurements are important indicators of health and are tracked throughout infancy and childhood. The nurse must know appropriate technique in measuring newborn weight, length, and head and chest circumference. Weight -weighed naked -2500-4000 g Length -measure from top of head to heel with leg extended -48-53 cm Head circumference -measured around largest part of head, usually just above the ears -32-38 cm Chest circumference -Measured at the nipple line -30-36 cm (12-14 in) -2 cm less than head circumference

Through which mechanism does nonshivering thermogenesis generate heat in a newborn?

Metabolism of brown fat -Nonshivering thermogenesis increases the newborn's body temperature by metabolizing brown fat.

Which physiologic process in the postpartum period is associated with the hormone prolactin?

Milk production -Milk production is associated with increased prolactin hormone levels after birth.

Facilitating Parent-Infant Bond

Nurses play an important role in facilitating the parent-infant bond. Having a premature newborn can be a traumatic experience. Nursing interventions to promote parental attachment include preparing and supporting parents, providing information, encouraging interaction, and involving parents in care and decision making. Prepare parents for neonatal intensive care unit -Describe the environment, staff activity, number of infants, and alarm noise -Describe the infant's equipment, including ventilators, IV lines, feeding tubes, and monitors -Describe how the infant will look -Describe the infant, including size, breathing, and weak cry -Emphasize thorough handwashing every visit -Stay with parents during the visit -Explain some of the care being provided -Give parents written information as appropriate -Encourage visits as much as possible -Offer realistic encouragement on the infant's condition -Provide opportunities to express concerns and feelings and ask questions Support parental visits -Emphasize thorough handwashing every visit -Early on, stay with parents during the visit, then gradually provide more privacy -Introduce self and explain some of the care being provided -Encourage visits as much as possible -Offer realistic encouragement on infant's condition -Provide opportunities to express concerns and feelings and ask questions -Provide information about support groups, educational offerings, and/or counseling services available -Incorporate cultural practices as appropriate -Encourage parents to engage in self-care, and take breaks periodically Provide information -Encourage questions about the infant's care and condition -Explain the equipment used to care for the infant -Interpret information from monitors and the meaning of alarms -Discuss all nursing care, its purpose, and expected response -Offer realistic reassurance, emphasizing positive aspects -Use interpreter as needed -Offer written information as appropriate -Help parents to understand any setbacks or complications; offer support and resources Encourage interaction with infant -Encourage early and frequent interaction -Explain that preterm infants may have little facial expression or eye contact -Point out signs of improvement and individual traits of the infant -Help parents "see" the infant rather than focus on the equipment -Encourage quiet holding and gentle touch -Teach soothing techniques, such as containment -Skin-to-skin (kangaroo care) has been shown to promote attachment as well as numerous health benefits: ---Lower infant stress and pain ---More stable vital signs ---Increased weight gain ---Shorter length of stay ---Quiet sleep and less crying Involve parents in care and decision making -Involve parents in the care of the infant as soon as possible -Change linens when parents are holding infant; bathe infants when parents are present to promote participation -Progress care involvement to include changing diapers, feeding, and bathing -Encourage visitation by other family members -Give parents information and encourage active participation in care decisions -Offer praise, and point out positive infant response to parental touch and caregiving

Overview

Nursing interventions for the premature newborn are individualized for each infant and aim to promote health and prevent complications. Common nursing interventions in the care of premature newborns relate to promoting the health and function of body processes, preventing infection, managing pain and environmental stress, and facilitating parent-infant bond.

Skin Care and Infection Prevention

Nursing interventions related to skin and infection primarily focus on prevention. Such actions include minimizing adhesives, use of gentle cleansers, positioning, and hand hygiene. Adhesives -Minimize adhesive tape or bandages; pectin barriers and hydrocolloid adhesives, semipermeable dressing, hydrogel, silicone-based adhesive products, and barrier films are appropriate alternatives. -Commercial devices are available for securing tubes and catheters. -If adhesive tape is used, back tape with cotton, skin barrier, or hydrocolloid dressing. -Delay adhesive removal until adherence is reduced. -If skin breakdown occurs, hydrogel and hydrocolloid dressings may be used. Cleansing -Disinfectants pose risks to infants; povidone-iodine may injure the skin and have toxic effects. -Alcohol should not be used. -Bathing should not be more often than every other day. -Infants less than 32 weeks' gestational age should have warm water baths without soap for the first week after birth. -Swaddle bathing is preferred; keep the infant loosely wrapped while submerged, then unwrap, bathe, and rewrap limbs individually. -Gentle cleansers with pH of 5.5 to 7 may be used for bathing. -Stable infants without umbilical lines may be immersed in water. -Emollients may be recommended to promote skin integrity and prevent dry, cracked, and peeling skin. Positioning -Infants should be repositioned every 2 to 3 hours or when other care activities occur. -Repositioning is necessary to reduce pressure on the skin and from equipment. -Body containment with blanket rolls, swaddling, and boundaries may be soothing. -Side-lying and prone positioning are preferred to supine (only in nursery). -Monitor the infant's response and ability to tolerate position. Hand Hygiene and Infection Prevention -Hand hygiene is the most important intervention to prevent infection. -Encourage parents and staff to thoroughly wash hands and arms before handling infants. -Prevent exposure to individuals with contagious illnesses. -Identify and report possible infections early; monitor response to treatment.

Maintaining Fluid and Electrolyte Balance

Nursing interventions to maintain fluid and electrolyte balance primarily relate to monitoring and managing fluid balance and minimizing insensible fluid loss. -Use IV infusion control devices that administer fluid with a precision of 0.1 mL/hr. -IV medication dilution should be the minimal amount needed for safe administration of the drug. -Promote IV patency by assessing often; use of restraint may be needed to prevent infiltration. -Frequent laboratory testing may necessitate blood transfusion. -Interventions for infants with increased stooling or voiding, evaporative losses, and/or inadequate fluid administration may include the following: ---Adjusting incubator temperature ---Providing high humidity under cover in radiant warm (known as swamping) ---Adjusting volume of fluid administered ---Assessing blood glucose if hyperglycemia is suspected, which may cause diuresis -If concerned about weight gain, the nurse considers overfeeding, fluid retention. Interventions may include the following: ---Careful assessment of fluid status and urinary output ---Blood glucose assessment ---Individualized interventions prescribed by the health care provider

Head to Toe Assessment

POSTURE TECHNIQUE AND EXPECTED FINDINGS ---Inspect prior to disturbing with other assessment components ---Flexed extremities that move freely, resist extension, return quickly to flexed state ---Hands usually clenched ---Movements symmetric ---Slight tremors on crying ---"Molds" body to caretaker's body when held, responds by quieting when needs met NORMAL VARIATIONS -If newborn was born in breech position, expect extended, stiff legs -May have temporary facial asymmetry or resist extension of extremities due to prenatal pressure on limb or shoulder ABNORMAL FINDINGS -Hypotonia -Hypertonia -Limited or unequal movement -Seizure SKIN TECHNIQUES AND EXPECTED FINDINGS -Inspect semi-naked in well-lit room, observing for color, jaundice, birthmarks, or bruising -Assess skin turgor by gently pinching inner thigh -Generally pink (erythematous immediately after birth), though varies with race and ethnicity -Peripheral acrocyanosis (bluish or purple coloring of the hands or feet) -Small amounts of lanugo over shoulders, sides of face, forehead, upper back -Skin turgor is normal with quick recoil -Some cracking and peeling of skin NORMAL VARIATIONS -Mottling (may be normal) -Telangiectases ("stork bites," infantile hemangiomas) -Milia -Erythema toxicum ("newborn rash") -Petechiae to presenting area -Ecchymoses from forceps -Slate gray nevus (Mongolian spot) -Nevus vascularis (strawberry hemangioma) ABNORMAL FINDINGS -Cyanosis of mouth (hypoxia) -Pallor (anemia, hypoxia) -Facial bruising (nuchal cord) -Ruddy (polycythemia) -Mottling (cold stress, hypovolemia, sepsis) -Gray (hypoxia, hypotension) -Jaundice noted to skin or sclera, especially within first 24 hours -Generalized petechiae or ecchymoses -Nevus flammeus -Hemangioma -Edema to hands, feet, tibia, periorbital -Skin tag, webbing -Lack of subcutaneous fat HEAD TECHNIQUE AND EXPECTED FINDINGS -Inspect size, shape, symmetry -Inspect pattern and distribution of hair -Palpate head, sutures, fontanels -Molding -Anterior fontanel diamond-shaped, approximately 5 cm, soft, and flat; may bulge slightly with crying -Posterior fontanel triangular, 0.5-1 cm -Sutures palpable with small separation between each -Hair silky and soft with individual hair strands NORMAL VARIATIONS -Overriding sutures -Slight asymmetry -Caput succedaneum ABNORMAL FINDINGS -Cephalohematoma -Macrocephaly, microcephaly -Severe molding (birth trauma) -Indentation (fracture) -Bulging or full fontanel; depressed fontanel -Widely spaced sutures -Abnormal hair growth patterns that may indicate genetic abnormalities -Hard, ridged area not resulting from molding may be caused by premature closure of the sutures, called craniosynostosis -Facial asymmetry EYES TECHNIQUE AND EXPECTED FINDINGS -Inspect for appearance, symmetry, movement -Assess pupillary response, red reflex -Eyes symmetric in size, shape, and movement -Pupils equal and reactive to light -Doll's eyes sign, red reflex present -Minimal tearing NORMAL VARIATIONS -May have subconjunctival hemorrhage or edema of eyelids from pressure during birth -Transient strabismus or nystagmus ABNORMAL FINDINGS -Inflammation or drainage -Persistent tearing -Lens opacity or absent red reflex -Jaundiced sclera, blue sclera -Agenesis -Unequal, constricted, or fixed pupils -Persistent strabismus -Doll's eyes sign; sunsetting EARS TECHNIQUE AND EXPECTED FINDINGS -Observe size, location, symmetry -Assess hearing -Note, most newborns will have a hearing screen performed before they leave the hospital, to identify congenital hearing loss -Well-formed and complete -Area where upper ear meets head even with outer canthus of eye -Startle response to loud noises, voices ABNORMAL FINDINGS -Agenesis -Low-set ears -Skin tag, preauricular sinus, dimples -Lack of response to sound NOSE TECHNIQUE AND EXPECTED FINDINGS -Observe shape, placement, patency, configuration -Midline and symmetric -Minimal drainage -Nostrils patent bilaterally NORMAL VARIATIONS -Slightly flat or deviated after birth ABNORMAL FINDINGS -Copious drainage -Malformation or asymmetry -Flaring of nares -Blockage of one or both nasal passages MOUTH (INCLUDING FEEDING) TECHNIQUE AND EXPECTED FINDINGS -Inspect lips, gums, tongue, uvula, and palate -Assess sucking, rooting, swelling, gag reflexes -Assess feeding -Observe for signs of hypoglycemia -Lips, gums, tongue pink and moist -Soft and hard palate intact -Uvula midline -Symmetric size and movement -Sucking, rooting, swallowing, gag reflexes present -Feeding: good suck, swallow, breath coordination NORMAL VARIATIONS -Precocious teeth -Epstein pearls -Ankyloglossia (short lingual frenulum) ABNORMAL FINDINGS -Gross anomalies in placement, size, or shape -Cyanosis, circumoral pallor -Asymmetry of movement of lips -Suck reflex weaker in preterm newborn -Choking, coughing, and cyanosis during feedings -Macroglossia, micrognathia -Thrush -Cleft hard or soft palate -Signs of hypoglycemia may include jitteriness, poor muscle tone, diaphoresis, tachycardia, tachypnea or dyspnea, high-pitched cry, lethargy, irritability NECK/CLAVICLES TECHNIQUE AND EXPECTED FINDINGS -Inspect neck and assess range of motion, symmetry -Inspect and palpate clavicles -Short neck, full range of motion -Head held midline -Newborn raises head when prone -Clavicles intact NORMAL VARIATIONS -Transient positional deformity but passive movement of head possible ABNORMAL FINDINGS -Webbing (unusually large fat pad between the occiput and the shoulders) -Restricted range of motion -Mass present -Crepitus, lump, or crying with clavicle palpation CHEST TECHNIQUE AND EXPECTED FINDINGS -Inspect and palpate chest -Assess respiration and work of breathing -Auscultate heart sounds including rate, rhythm, and presence of murmur -Chest is barrel shaped and symmetric; nipples present and located appropriately -Symmetric chest expansion; synchronized with abdominal movements -Breath sounds clear -Heart sounds S1S2 without murmur NORMAL VARIATIONS -Xiphoid process may be prominent -Breast modules may be present (approx. 6 mm) -Breast engorgement with white nipple discharge ABNORMAL FINDINGS -A lump, swelling, or tenderness to ribs -Crepitus (grating of the bone) or movement of the bone, which may be palpated if a fracture is present -Malformation or bulging of chest, unequal movement -Retractions or respiratory distress -Supernumerary nipples, nipples widely spaced -Murmur indicates abnormal blood flow through heart, though most are temporary ABDOMEN TECHNIQUE AND EXPECTED FINDINGS -Inspect and palpate abdomen, umbilical cord -Auscultate bowel sounds -Rounded, prominent -Liver palpable 1-2 cm below right costal margin -Two arteries and one vein in umbilical cord -Umbilical cord clamp tight and drying -Bowel sounds present NORMAL VARIATIONS -Reducible umbilical hernia ABNORMAL FINDINGS -Umbilical cord abnormality - one artery, meconium stain, bleeding, redness or drainage, herniation -Gastroschisis -Sunken or scaphoid appearance of the abdomen and bowel sounds in the chest (diaphragmatic hernia) -Enlarged liver -Abdominal mass -Absent bowel tones GENITALIA TECHNIQUE AND EXPECTED FINDINGS -Female: inspect labia majora and minora, clitoris, vagina, urinary meatus -Clitoris and labia majora edematous -Labia minora may protrude over labia majora -Urinary meatus and vagina present -Urine passed within 12-24 hours -Male: inspect penis, urinary meatus, scrotum, and testes -Palpate testes -Assess cremasteric reflex -Prepuce nonretractable -Meatus at tip of penis -Rugae on scrotum -Testes within scrotal sac bilaterally -Urine passed within 12-24 hours NORMAL VARIATIONS -Vaginal bleeding (pseudomenstruation) -Hymenal tags -"Brick dust" staining of diaper (uric acid crystals) -Scrotal edema and ecchymosis (breech birth) -Hydrocele, small, noncommunicating -Testes palpable in inguinal canal -"Brick dust" staining of diaper (uric acid crystals) ABNORMAL FINDINGS -Decreased urine output may indicate renal impairment or dehydration -Ambiguous genitalia -Stenosed meatus -Bladder exstrophy -Virilization -Fecal discharge -Absence of vaginal orifice -Hydrocele, epispadias, chordee -Inguinal hernia -Undescended testes -Cryptorchidism ANUS TECHNIQUE AND EXPECTED FINDINGS -Inspect anus and assess sphincter tone -Anus present, patent -Sphincter tone normal -Meconium stool passes within 24-48 hours ABNORMAL FINDINGS -Imperforate anus without fistula -Rectal atresia and stenosis -Absent anal opening -Absent stool EXTREMITIES TECHNIQUE AND EXPECTED FINDINGS -Inspect and palpate all extremities, noting symmetry and muscle tone -Assess flexion, range of motion, symmetry of all joints -Inspect digits on hands and feet -Assess peripheral pulses and capillary refill -Extremities symmetric with normal muscle tone -Joints with full range of motion, symmetric contour, spontaneous and symmetric movement -Correct number and formation of fingers and toes -Peripheral pulses strong and equal bilaterally, capillary refill brisk NORMAL VARIATIONS -Transient positional deformities -Slight tremors may be apparent -Acrocyanosis ABNORMAL FINDINGS -Limited range of motion or asymmetry -Hypotonia or hypertonia -Femoral pulses that are weaker than the brachial pulses -Delayed capillary refill may indicate cardiac abnormalities -Signs of fracture: ---Crepitus ---Redness ---Lumps ---Swelling -Polydactyly, syndactyly, fused or absent digits -Single transverse palmar crease at the base of the fingers (simian crease) -Club foot HIPS AND SPINE TECHNIQUE AND EXPECTED FINDINGS -Inspect and assess gluteal fold, thigh folds, leg length, and range of motion of hips -Inspect and palpate spine, shoulders, scapulae, iliac crests -Gluteal and thigh folds symmetric; hips with full, symmetric range of motion -Spine straight and easily flexed -Infant momentarily raises and supports head -Shoulders, scapulae, and iliac crests symmetric ABNORMAL FINDINGS -Hip dysplasia: unequal thigh folds, gluteal folds or leg length; reduced or unequal range of motion -Limited spinal movement -Meningocele, myelomeningocele -Pigmented nevus with hair tuft along spine -Pilonidal dimple or sinus NEUROLOGIC TECHNIQUE AND EXPECTED FINDINGS -Assess presence and strength of reflexes (next screen) -Observe for tremors, jitteriness -Assess cry and if consolable -Reflexes present -Tremors, jitteriness absent -Lusty cry, consoles easily, molding when held ABNORMAL FINDINGS -Shrill, high-pitched, hoarse, catlike cry -Stiffens and pulls away or arches when held -Excessive irritability

Overview

PPH is a life-threatening event that can occur in a postpartum woman with little to no warning. PPH can occur immediately after birth (early PPH) or up to 6 weeks after birth (late PPH). It is defined as blood loss of more than 500 mL after a vaginal birth and blood loss of more than 1000 mL after a cesarean birth. Because blood loss is subjective and grossly underestimated, it is the role of the nurse and health care provider to recognize the symptoms of a PPH before the blood loss is profound.

Which respiratory assessment finding is expected in a premature newborn?

Periodic breathing -Periodic breathing, cessation of breathing for 5 to 10 seconds followed by rapid respirations for 10 to 15 seconds, is an expected finding in premature newborns.

Newborn Adaptation and Assessment - Overview

Physiologic adaptations are necessary for a newborn to transition to extrauterine life. These adaptations include changes in the respiratory, cardiovascular, thermoregulatory, and other body systems. Understanding these adaptations is essential for nurses caring for newborns during this transitional period.

Supporting Respiration: Positioning, Hydration, and Suctioning

Positioning -Side-lying and prone positioning of the infant promote respiratory secretion drainage and prevention of aspiration of regurgitated feedings. -Prone positioning also increases oxygenation, enhances respiratory control, improves lung mechanics and volume, and reduces energy expenditure. -Note, prone positioning is NOT safe at home given the increased incidence of sudden infant death syndrome (SIDS). Hydration -Adequate hydration is necessary to maintain thin secretions that drain easily. Suctioning -Infants are suctioned only when needed. -Suctioning duration should be 5 to 10 seconds. -Suctioning decreases oxygenation; therefore infants are often hyperoxygenated before and after suctioning. -Suctioning risks trauma to mucous membranes; this may result in edema, narrowed air passages, and entry for organisms.

Physiologic Function

Premature infants are considered high risk due to their immature organ systems and inadequate nutrient reserves. The physiologic function of premature newborns is largely dependent on gestational age; lower gestational age is predictive of lower physiologic function. Similarly, lower birth weights are associated with worsened functioning. Common factors that contribute to compromised physiologic functioning of preterm newborns are as follows: Nutrition and Feeding -Weak or absent suck, swallow, and gag reflex -Difficulty coordinating sucking, swallowing, and breathing -Small stomach capacity -Weak abdominal muscles -Limited store of nutrients -Decreased ability to digest proteins or absorb nutrients -Immature enzyme systems Renal Function -Inadequate excretion of metabolites and drugs -Impaired ability to concentrate urine -Inability to maintain acid-base, fluid, and electrolyte balance Hematologic Status -Increased capillary fragility -Increased tendency to bleed (prolonged prothrombin time and partial thromboplastin time) -Slowed production of red blood cells resulting from rapid decrease in erythropoiesis after birth -Loss of blood due to frequent blood sampling for laboratory tests -Decreased red blood cell survival related to the relatively larger size of the red blood cell and its increased permeability to sodium and potassium Immune Function -Shortage of stored maternal immunoglobulins -Impaired ability to produce antibodies -Compromised integumentary system (thin skin and fragile capillaries) Respiratory Function -Decreased number of functional alveoli -Deficient surfactant levels -Smaller lumen in the respiratory system -Greater collapsibility or obstruction of respiratory passages -Insufficient calcification of the bony thorax -Weak or absent gag reflex -Immature and friable capillaries in the lungs -Greater distance between functional alveoli and the capillary bed Thermoregulation -Minimal insulating subcutaneous fat -Limited stores of brown fat (an internal source for the generation of heat present in normal term infants) -Fragile capillaries -Decreased or absent reflex control of skin capillaries (shiver response) -Inadequate muscle mass activity (rendering the preterm infant unable to produce his or her own heat) -Poor muscle tone, resulting in more body surface area being exposed to the cooling effects of the environment -Immature temperature regulation center in the brain Central Nervous System Function -Birth trauma with damage to immature structures -Bleeding from fragile capillaries -An impaired coagulation process, including prolonged prothrombin time -Recurrent hypoxic and hyperoxic episodes -Predisposition to hypoglycemia -Fluctuating systemic blood pressure with concomitant variation in cerebral blood flow and pressure

Premature Newborn - Introduction

Premature infants are high risk due their physiologic immaturity and inadequate nutritional reserves. However, the health status of premature newborns varies considerably. Nurses play a critical role in the care of premature newborns by performing continual assessments, distinguishing between normal and abnormal findings, and implementing interventions to promote health and prevent complications.

Feeding Assessment

Premature newborns are born with an immature digestive system and inadequate nutrient stores. The amount and method of feeding are determined based on the infant's gestational age, size, and health status. Very immature infants or infants with significant health complications may receive total parenteral nutrition (TPN) via IV infusion. TPN solutions contain the major nutrients needed for metabolism and growth including calories, amino acids, fatty acids, vitamins, and minerals. It is continued, in decreasing amounts, until the infant is able to tolerate full enteral feedings necessary for growth. Enteral feeding may be delivered by enteral tube or nipple feeding. Evidence has shown that early introduction of small amounts of enteral feedings is beneficial for stable preterm infants; such feedings (termed trophic feedings) have been shown to stimulate the GI tract. Coordination of sucking and swallowing typically does not begin until 32 to 34 weeks' gestation, with full synchronization usually around 36 to 37 weeks. As such, premature newborns are prone to aspiration and often require enteral tube feeding. It is important for nurses to perform feeding assessments often for infants receiving enteral feedings. Feeding Tolerance Assessment -Document the amount of breast milk or formula and compare with prior feeding and amount needed for infant's age and weight. -Vomiting or frequent regurgitation may indicate that the feedings are too large. -Diarrhea may be a sign of formula/breast milk intolerance and/or too rapid advancement of the feeding. -Bilious vomitus may be a sign of an intestinal obstruction. -Recent evidence has shown that checking gastric residuals should often be avoided because doing so may damage the gastric mucosa. Gastric residuals were common practice to determine whether the stomach was emptying. However, the nurse should follow health care provider prescriptions and agency policies; gastric residuals are assessed by aspirating stomach contents to measure the residual amount of feedings. -Stools may be tested for reducing substances (which indicate malabsorption of carbohydrates) or occult blood if feeding intolerance is suspected. Readiness for nipple feeding -Newborns must have an intact gag reflex. If they do not, they are more likely to aspirate nipple feedings. -Signs of nipple feeding readiness during gavage feedings include the following: ---Rooting ---Respiratory rate <60 breaths/min ---An increasing ability to tolerate holding and handling ---Sucking on the gavage tube, a finger, or a pacifier -Signs of nonreadiness include the following: ---Respiratory rate >60 breaths/min ---No rooting or sucking ---Absent gag reflex ---Excessive gastric residuals Assessment of Nipple Feeding -Assess coordination of suck, swallow, and breathing. -Observe for aspiration. -Assess the respiratory rate before and during feedings. When the respiratory rate is more than 60 breaths/min before feedings, gavage feed to prevent aspiration. -Observe for signs that the effort of feeding with an artificial nipple requires too much energy and oxygen for the infant. -Observe for other adverse signs of nipple feedings, including the following: ---Increased or decreased heart rate ---Increased or decreased respiratory rate ---Markedly decreased oxygen saturation level ---Apnea ---Cyanosis, pallor ---Coughing, choking ---Gagging, spitting up ---Drooling, gulping ---Falling asleep early in the feeding ---Feeding time more than 20 to 30 minutes -As the infant matures, less energy is expended during feeding sessions; feedings go more quickly and the infant shows fewer signs of fatigue.

Prematurity Classification Based on Gestational Age

Preterm (premature) -An infant born before completion of 37 weeks of gestation Late Preterm -An infant born from 34 0/7 through 36 6/7 weeks of gestation Early Preterm -An infant born from 37 0/7 through 38 6/7 weeks of gestation Full Term -An infant born from 39 0/7 weeks through 40 6/7 weeks of gestation Late Term -An infant born from 41 0/7 through 41 6/7 weeks of gestation Postterm (postmature) -An infant born after 42 weeks of gestation

Which assessment finding indicates readiness for nipple feeding in premature newborns?

Rooting -Rooting and sucking on a finger or pacifier are signs of readiness for nipple feeding.

Assessment Techniques, Expected Findings, and Abnormal Findings

Preterm newborns are prone to problems that affect all body systems and processes. Common problems that arise include those related to respiration, thermoregulation, fluid and electrolyte balance, skin, infection, pain, stress, and parent-infant bond. Although many assessment techniques and findings are similar to those in normal newborns, below is a summary of important assessment techniques and findings when caring for premature newborns. Respiration TECHNIQUES -Assess respiratory rate, breath sounds, and work of breathing frequently EXPECTED FINDINGS -Lungs clear to auscultation -Respiratory rate of 30-60 breaths/min -Periodic breathing is common - cessation of breathing for 5-10 seconds followed by rapid respirations for 10-15 seconds ABNORMAL FINDINGS -Adventitious (crackles), diminished, or absent breath sounds -Apnea - cessation of breathing for ≥20 seconds -Work of breathing, including grunting, nasal flaring, or retractions -Central cyanosis, pallor, bradycardia, hypotonia Thermoregulation TECHNIQUES -Most premature infants will have continuous temperature monitoring by skin probe attached to heat control mechanism of radiant warmer or incubator -Axillary measurement may be used, particularly in stable late premature infants EXPECTED FINDINGS -Abdominal skin temperature range: 36°C to 36.5°C (96.8°F to 97.7°F) -Axillary temperature range: 36.3°C to 36.9°C (97.3°F to 98.4°F) ABNORMAL FINDINGS -Axillary temperature <36.3°C to >36.9°C (<97.3°F to >98.4°F) -Abdominal skin temperature <36°C to >36.5°C (<96.8°F to >97.7°F) -Poor feeding or feeding intolerance -Irritability followed by lethargy -Weak cry or suck -Decreased muscle tone -Skin pale, cool to touch, mottled, or cyanotic -Hypoglycemia -Respiratory distress -Poor weight gain if chronic Fluid and Electrolyte Balance TECHNIQUES -Monitor intake and output to determine fluid balance ---Intake includes parental feeding, medications, and oral fluids ---Output includes regurgitation, drainage tubes, stools, and urine -Daily weights using same scale at same time each day; rate of gain or loss calculated EXPECTED FINDINGS -Daily weight gain of approximately 15-20 g/kg/day is typical -Premature infants may lose up to 15% of birth weight during first week of extrauterine life (in contrast to 10% in normal newborns) ABNORMAL FINDINGS -Signs of dehydration ---Urine output <2 mL/kg/hr ---Urine specific gravity >1.01 ---Weight loss greater than expected ---Dry skin and mucous membranes ---Sunken anterior fontanel ---Poor tissue turgor ---Blood: elevated sodium, protein, and hematocrit levels -Signs of overhydration ---Urine output >5 mL/kg/hr ---Urine specific gravity <1.002 ---Edema ---Weight gain greater than expected ---Bulging fontanels ---Moist breath sounds ---Difficulty breathing ---Blood: decreased sodium, protein, and hematocrit levels Skin TECHNIQUES -Frequent skin assessments -Consider skin assessment tool, such as Neonatal Skin Condition Score ABNORMAL FINDINGS -Adhesives often damage premature newborn skin, particularly removal -Disinfectants used before procedures may damage skin and/or be absorbed -Erythema or other signs of pressure injury, particularly from equipment such as endotracheal tubes, intravenous (IV) lines, and electrodes Infection TECHNIQES -Assess for signs of infection, particularly following invasive procedures ABNORMAL FINDINGS -Temperature instability: hypothermia, hyperthermia -Central nervous system changes: lethargy, irritability -Changes in color: cyanosis, pallor, jaundice -Cardiovascular instability: poor perfusion, hypotension, bradycardia/tachycardia -Respiratory distress: tachypnea, apnea, retractions, nasal flaring, grunting -Gastrointestinal (GI) problems: feeding intolerance, vomiting, diarrhea, glucose instability -Metabolic acidosis Pain TECHNIQUES -Pain is assessed whenever vital signs are taken -Assess infant's response to painful stimuli and pain interventions, including pharmacologic and nonpharmacologic interventions -Consider assessment tool, such as Premature Infant Pain Profile (PIPP) ABNORMAL FINDINGS -Increased or decreased heart rate and respirations, apnea -Decreased oxygen saturation -Increased blood pressure -High-pitched, intense, harsh cry -Whimpering, moaning -"Cry face" -Eyes squeezed shut -Grimacing -Bulging or furrowing of the brow -Tense, rigid muscles or flaccid muscle tone -Rigidity or flailing of extremities -Sleep-wake pattern changes Stress and Overstimulation TECHNIQUES -Assess noise exposure and infant's ability to tolerate activity and noise -Monitor frequency of interruptions, newborn responses to care EXPECTED FINDINGS -Infant tolerates care, routine activity, and handling -Infant has periods of relaxed behavior or sleep ABNORMAL FINDINGS -Oxygenation Changes ---Blood pressure, pulse, and respiratory instability ---Cyanosis, pallor, or mottling ---Flaring nares ---Decreased oxygen saturation levels ---Sneezing, coughing -Behavior Changes ---Stiff, extended arms and legs ---Fisting of the hands or splaying (spreading wide apart) of the fingers ---Arching ---Alert, worried expression ---Turning away from eye contact (gaze aversion) ---Regurgitation, gagging, and hiccupping ---Yawning ---Fatigue sign Parent-Infant Bond TECHNIQUES -Observe parental interactions and behaviors toward the infant -Encourage parent involvement in infant care (to extent possible) EXPECTED FINDINGS -Talking about infant using positive terms -Making eye contact, pointing out characteristics -Naming the infant, using name -Smiling, talking to infant -Holding and participating in care -Visiting, calling to check on infant ABNORMAL FINDINGS -Using negative terms to describe the infant -Discussing the infant in impersonal or technical terms -Failing to give the infant a name or to use the name -Visiting or calling infrequently or not at all -Decreasing the number and length of visits -Showing interest in other infants equal to that in their own infant -Refusing offers to hold and learn to care for the infant -Showing a decrease in or lack of eye contact -Spending less time talking to or smiling at the infant

Match the method of ventilation with its description.

Provides constant distending pressure and promotes lung expansion -continuous positive airway pressure Indicated for respiratory failure, severe apnea, or bradycardia -conventional mechanical ventilation Decreases lung barotrauma and volutrauma -high frequency oscillation

Initial Assessment: Apgar Score

The Apgar score is derived from a rapid assessment of the newborn's transition to extrauterine life at 1 and 5 minutes after birth. Five signs are evaluated and given a score of 0, 1, or 2 -Heart rate is assessed by auscultation or palpation of the umbilical cord. -Respiratory effort is assessed by chest wall movement. -Muscle tone is assessed by degree of flexion and movement of extremities. -Reflex irritability is assessed by response to suctioning of nares or nasopharynx. -Color is described as blue or pale, pink body with blue extremities, or completely pink. Heart Rate -0: absent -1: below 100 -2: over 100 Respiratory Effort -0: absent -1: slow, irregular -2: good, crying Muscle Tone -0: limp -1: some flexion of extremities -2: active motion Response to catheter in nostril (tested after oropharynx is clear) -0: no response -1: grimace -2: cough or sneeze Color -0: blue, pale -1: body pink, extremities blue -2: completely pink Scores from each sign are summed, with 10 being the highest possible score. Scores from 0 to 3 indicate severe distress, 4 to 6 indicate moderate difficulty, and 7 to 10 indicate minimal to no difficulty adjusting to extrauterine life (Lowdermilk et al., 2019). If the 5-minute Apgar score is less than 7, ongoing scoring should continue every 5 minutes for up to 20 minutes (Goyal, 2020).

Appearance

The appearance of premature newborns will vary considerably based on gestational age. Some common characteristics include the following: -Small size -Head appears large related to size of body (due to cephalocaudal growth) -Scrawny due to limited subcutaneous fat -Low muscle tone (hypotonicity) ---Low activity level, related to low muscle tone ---Extremities limp and in extended position -Skin appears bright pink or red, shiny, smooth, and is often translucent (blood vessels may be visible) -Vernix caseosa and fine lanugo hair may be present on body -Ear cartilage is soft and pliable -Minimal creases to soles and palms; appear smooth -Male infants may have undescended testes and few scrotal rugae -Female infants may have prominent labia minora and clitoris

Gestational Age

The gestational age of a newborn is an important assessment that may identify newborns at risk for complications. The two preferred methods of estimating gestational age are classification based on gestation and use of the New Ballard Score. Assessments are also made relating the birth weight with gestational age. Gestation Classification -Gestation classifications are based on the number of gestational weeks, calculated from the last menstrual period of the mother (Lowdermilk et al., 2019). ---Preterm, or premature: born before 37 0/7 weeks of gestation, regardless of birth weight ---Late preterm: 34 0/7 through 36 6/7 weeks ---Early term: 37 0/7 through 38 6/7 weeks ---Full term: 39 0/7 through 40 6/7 weeks ---Late term: 41 0/7 through 41 6/7 weeks ---Postterm: 42 0/7 weeks and beyond ---Postmature: born after completion of week 42 of gestation and showing the effects of progressive placental insufficiency New Ballard Score -The New Ballard Score (NBS) is an assessment tool used to evaluate gestational age postnatally in infants as early as 20 weeks' gestation. The NBS assesses six physical and six neuromuscular characteristics, with a total score indicating the gestational age of the newborn. Birth Weight and Gestational Age -The birth weight is plotted on a growth grid to reflect the growth percentile. Appropriate-for-gestational-age (AGA) infants fall within the 10th and 90th percentiles. Small-for-gestational-age (SGA) infants are less than the 10th percentile for weight. Large-for-gestational-age (LGA) infants are greater than the 90th percentile for weight. SGA and LGA are at higher risk for morbidity and mortality compared with AGA infants.

Initial Assessment: Abbreviated Examination

The initial assessment of the newborn occurs immediately after birth. This initial assessment includes an abbreviated examination and the Apgar score at 1 and 5 minutes. The purpose of this brief examination is to identify the need for resuscitation or obvious anomalies requiring immediate intervention. A more thorough head-to-toe examination occurs later. General appearance -color pink -acrocyanosis present -flexed posture -alert -active Respiratory system -airway patent -no upper airway congestion -no retractions or nasal flaring -respiratory rate 30-60 -lungs clear to auscultation bilaterally -chest expansion symmetric Cardiovascular system -heart rate > 100, strong and regular -no murmurs heard -pulses strong and equal bilaterally Neurologic system -moves extremities -noromotonic -symmetric features, movement -reflexes present: ---sucking ---rooting ---moro ---grasp -anterior fontanel soft and flat Gastrointestinal system -abdomen soft, no distention -cord attached and clamped -anus appears patent Eyes, nose, mouth -eyes clear -palate intact -nares patent Skin -no signs of birth traumna -no lesions or abrasions Genitourinary system -normal genitalia

Overview

The nurse performs numerous assessments of the newborn during the critical transition to extrauterine life. During such assessments, the nurse determines whether findings are normal, a normal variant (atypical finding of no clinical significance), or abnormal. The nurse must understand normal newborn assessment findings and variants to determine whether intervention is necessary.

Summary

The physiologic immaturity of premature newborns places them at high risk for numerous problems with body systems and processes. Any infant born before completion of 37 weeks of gestation is considered preterm (premature), though infants born from 34 0/7 through 36 6/7 weeks of gestation are classified as late preterm. Although prematurity classification is based on gestational age, there are additional classifications that are used based on the infant size. The physiologic function of premature newborns is largely dependent on gestational age; lower gestational age is predictive of lower physiologic function. The appearance of premature newborns will vary considerably based on gestational age, to include small size, head appearing disproportionately larger than the body, scrawny, with shiny pink and translucent skin. Common problems that arise include those related to respiration, thermoregulation, fluid and electrolyte balance, skin, infection, pain, stress, and parent-infant bond. The amount and method of feeding are determined based on the infant's gestational age, size, and health status. Despite technological advances in care, premature newborns often develop complications. Complications are more common among newborns with lower gestational age and birth weight. Some common complications of prematurity include respiratory distress syndrome, bronchopulmonary dysplasia, intraventricular hemorrhage, and necrotizing enterocolitis. Nursing interventions for the premature newborn are individualized for each infant and aim to promote health and prevent complications. Common nursing interventions to support respiration include positioning, hydration, suctioning, oxygen therapy, and assisted ventilation. All interventions are administered in collaboration with the interdisciplinary health care team. Prevention of heat loss and cold stress is essential for infant survival; therefore interventions to support thermoregulation aim to provide a neutral thermal environment. Nursing interventions to maintain fluid and electrolyte balance include monitoring and managing fluid balance and minimizing insensible fluid loss. Interventions for skin care and infection prevention include minimizing adhesives, use of gentle cleansers, positioning, and hand hygiene. Increasingly, evidence has shown the negative consequences of infant pain and environmental stress. Important nursing interventions include the prevention and management of pain and environmental stress. Nurses have an important role in monitoring and promoting nutritional status of premature newborns. This includes administering parenteral and enteral feedings as well as progressing infants from gavage to nipple feedings. Nursing interventions to promote parent-infant bond include supporting parents, providing information, encouraging interaction, and involving parents in care and decision making.

Overview

The physiologic immaturity of premature newborns places them at high risk for numerous problems with body systems and processes. One of the essential roles of nurses on the interdisciplinary care team is to perform continual assessment and analysis of the infant's physiologic status. Nursing assessments focus on identifying normal versus abnormal findings to determine whether intervention is necessary.

Physiologic Changes and Assessment During the Postpartum Period - Overview

The postpartum period begins after birth and extends until the reproductive organs are returned to a normal nonpregnant state approximately 6 weeks later, but this time frame varies among women. This transitional period is also referred to as the puerperium or the fourth trimester of pregnancy. The physiologic changes that occur to reverse the changes that accompanied the pregnancy are distinct but are also a healthy transition. The nurse can support the woman's recovery during the postpartum period by applying knowledge of maternal and newborn anatomy and physiology, applying knowledge of newborn developmental and behavioral characteristics, and supporting the family's adaptation after birth.

Postpartum Hemorrhage - Introduction

The postpartum period is a time of many physiologic and psychological changes for the new mother. Nurses have a unique role in being at the bedside of the postpartum woman to observe these changes. Postpartum hemorrhage (PPH) is the leading cause of maternal morbidity and mortality for women across the globe (World Health Organization, 2017). Nurses must be knowledgeable of the signs and symptoms and be prepared to rapidly attend to the woman who is experiencing a PPH.

Summary

The woman's body undergoes many physiologic changes after birth. Most of the changes are related to the birth of the fetus, expulsion of the placenta, and changes in hormone levels. It is important for the nurse to understand these normal physiologic changes. It is also vital for the nurse to be able to conduct a physical assessment on a postpartum woman. The nurse should have knowledge of the normal assessment findings and appropriate interventions for abnormal findings. Initial postpartum assessments should be done frequently, as this is the most critical time period for the early identification of postpartum complications. A thorough chart review can help the nurse to identify postpartum risk factors. Focused postpartum assessments should be done according to hospital guidelines. It is also vital for the nurse to be able to intervene quickly for abnormal findings. For women who have undergone a cesarean birth, the nurse needs to be aware of specific needs and needs to perform careful evaluation of the incision site for signs of infection. Also, the nurse needs to assess for other potential complications related to the respiratory, gastrointestinal, and urinary systems. Nursing care interventions such as regular coughing and deep breathing, early ambulation, and slow advancement of diet can help prevent complications after cesarean delivery.

Physiologic Changes in Other Body Systems

There are anatomic and physiologic changes to the mother's endocrine, cardiovascular, neurologic, and gastrointestinal systems during the postpartum period. ENDOCRINE -After the expulsion of the placenta, estrogen, progesterone, and human placental lactogen rapidly decrease. -Human chorionic gonadotropin (hCG) hormone levels remain elevated for 3 to 4 weeks after birth. -Nonlactating mothers will have a cessation of prolactin secretion within 14 days after birth. CARDIOVASCULAR -Changes in blood volume depend on the blood loss during labor and the amount of extravascular water (physiologic edema). -Average blood loss is less than 500 mL for vaginal births and less than 1000 mL for cesarean delivery. -Cardiac output returns to pre-pregnant values within 6 to 8 weeks after delivery. -Excess plasma volume decreases rapidly after birth by diuresis and diaphoresis. -Diuresis refers to increased urinary output. This is caused by decreased aldosterone, decreased oxytocin, and decreased sodium retention. -Diaphoresis refers to profuse perspiration. This is also related to hormonal changes. -Fibrinolysis returns to the pre-pregnant state 4 to 6 weeks after delivery. Postpartum women are at risk for thrombus formation during this time period. NEUROLOGIC -Women who received spinal anesthesia are at risk for spinal headaches postpartum. -Women may develop preeclampsia or eclampsia within the first 24 to 48 hours after delivery or up to 6 weeks postpartum. Women should be aware of neurologic changes and notify their health care provider if they experience headaches, dizziness, blurred vision, etc. GASTROINTESTINAL -Increased hunger and thirst are common after delivery as a result of dehydration and energy expenditure in labor and diaphoresis postpartum. -Women who have undergone cesarean births are at increased risk for bowel obstruction. They are also at increased risk for discomfort from gas. -Hemorrhoids may occur from pushing during labor. -Constipation is common postpartum, but women should resume regular bowel activity within 8 to 14 days after delivery. Women should receive teaching on how to prevent constipation postpartum, such as dietary changes to increase fiber (bran, fresh fruits, and vegetables) and fluid intake (drink 8 to 10 cups of fluids per day). -Bowel elimination may be impaired if the woman has a perineal laceration, episiotomy, and/or perineal edema.

Physiologic Changes of the Reproductive System

There are numerous changes to the reproductive system during the postpartum period. These include changes to the uterus, breasts, vagina, cervix, and perineum, and menstrual and ovulatory changes. UTERUS -Involution is the return of the uterus to a nonpregnant state after birth. -Expulsion of the placenta is caused by smooth muscle contractions. ---Afterpains are intermittent contractions of the uterus. ---Decreases within 3 days. ---May increase with breastfeeding or multiparity. -By the end of the third stage of labor, the uterus is 2 cm below the umbilicus; it rises to 1 cm above within 12 hours and descends 1 to 2 cm every 24 hours. ---By the sixth postpartum day, the uterus is between the umbilicus and symphysis pubis. ---The uterus is not palpable by 6 weeks postpartum. -Document location of the uterus in relationship to the umbilicus; with one fingertip below the umbilicus, record U-1. ---Subinvolution is the failure of the uterus to return to a nonpregnant state. Common causes are retained placental fragments and infection, with excessive blood loss, foul odor, and fundus above the umbilicus. LOCHIA -Lochia is associated with uterine involution and changes in the endometrium and is described according to color and amount. -Lochia characteristics: ---Lochia rubra: red; postpartum days 1 to 3 ---Lochia serosa: pink or brown tinged; postpartum days 4 to 10 ---Lochia alba: white, cream, or light yellow; postpartum days 11 to 14 but can last 3 to 6 weeks postpartum -Lochia should not have an offensive odor but should smell like normal menstrual flow. BREASTS AND LACTATION -After the expulsion of the placenta, decreased estrogen and progesterone levels help initiate the lactation process. -Initially, colostrum is produced and secreted. Colostrum is a thin clear or light-yellow substance that is antibody-rich and meets newborns' nutritional requirements. -Increased prolactin hormones are responsible for milk production that occurs 3 to 5 days after birth. -Increased oxytocin levels are responsible for milk ejection or letdown (lactogenesis stage II). VAGINA, CERVIX, AND PERINEUM -Edema related to pushing and delivery may occur but will resolve. -The vagina may have lacerations and edema. It takes 6 weeks for complete healing. Lactating mothers may have vaginal dryness and painful intercourse, also known as dyspareunia, as a result of decreased estrogen levels. -The perineum may have edema and bruising. It may also have a repaired laceration or an episiotomy incision. These take weeks or months for complete healing, depending on the degree. -If vacuums or forceps were used for the birth, the woman may have experienced vaginal or cervical lacerations or hematomas of the pelvic soft tissues. -Hemorrhoids (anal varicosities) may be present as a result of pushing efforts. Hemorrhoids decrease in size within 6 weeks postdelivery and ultimately recede. -A woman should be counseled to practice good hygiene during the first 2 weeks after birth. OVULATION AND MENSTRUATION -Ovulation may occur before menses postpartum. -For nonlactating mothers, ovulation may occur as soon as 3 weeks after delivery, and menses may resume within 6 to 8 weeks. -For lactating mothers, it will take longer for Diaphoresis and menses to occur, as a result of decreased estrogen levels.

Thermoregulatory Adaptation

Thermoregulation, the maintenance of body temperature, is an important adaptation to extrauterine life. Characteristics that predispose the newborn to heat loss include thin skin, superficial blood vessels, thin subcutaneous fat layer, and large body surface to mass ratio (Lowdermilk et al., 2019; McKinney et al., 2017). Excessive heat loss may cause hypothermia, which may progress to cold stress. In a neutral thermal environment, a newborn is able to maintain his or her body temperature with minimal heat production. Environmental temperatures necessary for a neutral thermal environment will vary depending on gestational age, size, postnatal age, and whether clothed or not (McKinney et al., 2017). Factors related to thermoregulation in the neonate are as follows: Heat loss -The four methods of heat loss include the following: ---Evaporation: heat loss due to moisture evaporating from skin ---Conduction: heat loss from direct contact with cool surfaces ---Convection: heat loss from body surface exposure to cooler ambient air -Radiation: heat loss to a cooler surface nearby but not in direct contact Heat Production (Thermogenesis) -Methods to generate heat may include the following: ---Increased muscle activity, crying, and restlessness ---Vasoconstriction ---Increased metabolic activity ---Flexion to limit surface area exposure and conserve heat ---Nonshivering thermogenesis (the metabolism of brown fat to generate heat) Cold Stress -Hypothermia may lead to cold stress. Consequences of cold stress may include the following: ---Increased oxygen need ---Decreased surfactant production ---Respiratory distress ---Hypoglycemia ---Metabolic acidosis ---Jaundice

Which nursing intervention promotes maturation of the intestinal tract and intestinal motility in premature newborns?

Trophic feedings -Trophic feedings (minimal enteral feedings) are just a few milliliters of milk initiated within a few days of life. Evidence shows that early trophic feedings promote maturation of the intestinal tract and intestinal mobility.

Physiologic Changes in Other Body Systems, cont'd

URINARY -Postpartum diuresis increases the filling of the bladder postpartum. -Women may have lacerations and/or edema near the urethral meatus from pushing or delivery that can inhibit bladder elimination. -Epidural/spinal anesthesia also decreases sensation in the bladder, and it may take several hours after delivery for anesthesia to wear off. -Stress incontinence should disappear within 3 months after birth. INTEGUMENTARY -Hyperpigmentation of the skin disappears with the rapid decline in estrogen hormone levels after delivery. -Striae gravidarum (stretch marks) will change in color from red to white or silver. They do not disappear. -Hair loss is common as a result of hormonal changes after birth. MUSCULOSKELETAL -Reversal of the adaptations of the mother's musculoskeletal system during pregnancy occurs in the puerperium period. -Muscle soreness is common as a result of use in labor. -Hip and joint discomfort are common for the first few days after delivery as a result of decreased relaxin hormone secretion. -Joints stabilize by 6 to 8 weeks postpartum, and most return to the pre-pregnancy state. However, changes to the feet are permanent (mothers may notice an increase in shoe size).

Match the fetal cardiac shunts with the description of their adaptation after birth.

Umbilical cord clamping leads to functional closure -Ductus venosus Increased pulmoney blood flow promotes closure -Foramen ovale Increased oxygen levels lead to functional closure -Ductus arteriosus

Uterine Atony

Uterine atony is a serious condition that can occur after childbirth. After childbirth and the birth of the placenta, the uterus will typically undergo an intense contraction of the smooth muscle due to either the natural release of oxytocin, the administration of synthetic oxytocin, or both. If the uterus fails to contract after the birth, it is known as uterine atony. Uterine atony is the leading cause of early PPH—a hemorrhage that occurs in the first 24 hours after the birth. Uterine atony that occurs immediately after birth is often related to the retention of placental segments, not allowing the uterus to completely contract and therefore bleed. In addition to retained placenta, uterine atony can also be the result of an overstretched, overworked, or infected uterus. Uterine atony not related to retained placenta is associated with several risk factors. Multiple Gestation -Multiple gestation describes a pregnancy where there are two or more growing fetuses, which can cause an overstretched uterus. Prolonged Labor -A prolonged labor (greater than 24 hours) can lead to an overworked and tired uterus. Labor Induction or Augmentation with Synthetic Oxytocin -A labor that is either induced or augmented with synthetic oxytocin can lead to an overworked and tired uterus due to the length and/or strength of the contractions. Chorioamnionitis -Chorioamnionitis is an infection of the fetal membranes and can lead to prolonged labor and an infected uterus (both of which are associated with uterine atony). High Parity -A woman who has had more than five pregnancies to 20 weeks' gestation or greater is more likely to have an overstretched uterus. Polyhydramnios -A medical condition describing an excessive amount of amniotic fluid (greater than 2 L of amniotic fluid), which can cause an overstretched uterus. Macrosomia -Fetal macrosomia describes a newborn who has a birth weight of more than 4000 g regardless of his or her gestational age, which can cause an overstretched uterus.

Vital Signs

Vital signs and measurements are important indicators of health. The nurse must know normal newborn vital signs because they vary considerably from adult vital signs. Heart rate, respiratory rate, and temperature are routinely assessed. Blood pressure is assessed only if cardiovascular concerns arise (Lowdermilk et al., 2019). Heart rate and respiratory rate should be assessed for a full minute because variability is common. Axillary temperature assessment is preferred, safe, and accurate. -Heart rate: 120-160 -Respiratory rate: 30-60 -Temperature: 36.5-37.5C (97.7-99.5F) (axillary) -Blood pressure: ---systolic: 65-95 ---diastolic: 30-60 After birth, newborns progress through periods of reactivity that may cause variability in vital signs. The first period of reactivity follows birth and is marked by alertness and interest in surroundings. Temperature may be decreased, and pulse and respirations elevated. This is followed by a period of sleep or decreased activity during which time the pulse and respirations decrease. The second period of reactivity follows, with increased interest in feeding. Pulse and respiration may increase again.

Thermoregulation: Weaning to Open Crib

Weaning is individualized, but it may be considered when the infant is stable, 1500 g (3.3 lb), gaining weight, and tolerating enteral feedings. Transfer to open crib is supported by wrapping in warm blankets and dressing in hats and clothing because clothing conserves heat and helps maintain temperature. -Nurses will follow agency protocols for weaning, but typically the incubator temperature is decreased gradually and continues if the infant's temperature remains stable. -Infant may be dressed in a light layer of clothing and hat while in incubator. -When transferring to crib, wrapping in warm blankets helps insulate body heat. -Temperature is monitored closely.

Retained Placenta

When the placenta has not been delivered within 30 minutes after delivery it is said to be "retained." A retained placenta can occur for several reasons or for reasons unknown; however, some reasons for a retained placenta might include: -Scarring at the placenta site (from a previous pregnancy or uterine surgery) -Placenta accreta: slight penetration of the myometrium (uterine wall) -Placenta increta: deep penetration of the myometrium (uterine wall) -Placenta percreta: perforation of the uterus A retained placenta must be either manually or surgically removed to prevent uterine atony and PPH. Manual removal involves the health care provider (physician or midwife) inserting his or her hand into the uterus and gently separating the placenta from the uterine wall. This procedure can be very uncomfortable for a woman without anesthesia; therefore the woman should be made comfortable before this procedure. After the manual removal of the placenta, it is important for the health care provider to explore for any remaining placental parts through manual exploration or ultrasound. If the placenta is not able to be removed manually or if remaining parts are seen on ultrasound, the health care provider may opt for either a dilatation and curettage (D&C) or a surgical opening of the uterus to remove the placenta.

Etiology of PPH

When there is excessive bleeding immediately after birth or during the postpartum period, it is important to note both the color and the consistency of the blood. Because excessive bleeding can occur up to 6 weeks after the birth, the nurse must educate the woman on signs, symptoms, and risk factors for PPH. The reason for a PPH may not always be clear; however, there are several reasons why a PPH may occur. Some of the most common reasons are: -Uterine atony -Retained placenta -Lacerations of the genital tract that were not repaired following the birth -Hematomas -Uterine inversion -Subinvolution of the uterus Estimation of blood loss is very inaccurate. Nurses tend to underestimate bleeding in the postpartum mother. For accurate assessment of postpartum bleeding all pads, underpads, drapes, packs, and sponges (cesarean delivery) need to be weighed for amount. One mL of blood is equivalent to 1 g. Tachycardia is an early sign of PPH, with a decreased blood pressure presenting later.

Focused Postpartum Assessment: Cesarean Delivery

Women who have undergone cesarean births will have unique assessment needs centered on the abdominal surgery and incision site. The acronym BUBBLEHE may be used for assessment of a woman who has undergone a cesarean delivery as well. The nurse will also have some additional areas to assess and for which to develop nursing care and interventions. Respiratory -Women who receive patient-controlled pump (PCA) narcotics for pain relief will need close monitoring of both respiratory rate and continuous pulse oximeter measurements, as they are at risk for respiratory depression. -Women who received general anesthesia for surgery are at risk for respiratory complications such as pneumonia. Women should perform deep-breathing and coughing exercises and use an incentive spirometer for prophylactic measures. Gastrointestinal -Cesarean delivery is considered a major abdominal surgery, and women are at risk for bowel obstruction. Decreased or absent bowel sounds should be reported to the health care provider and require intervention. -It is common for women to have gas-related discomfort. Increased fluid intake and antigas medications can help relieve discomfort. -Women who received general anesthesia may have nausea and vomiting postoperatively. Antiemetic medications should be administered to assist with this discomfort. The diet should also be advanced slowly. Ice chips and clear liquids should be initiated in this time period. -One of the most uncomfortable things for a postoperative mother who has undergone a cesarean delivery is gas pain. A great way to get rid of this is to encourage early and frequent ambulation. Encourage her to walk the newborn in the bassinet through the halls, and she'll find that she's passing gas in no time. Urinary -Women will have an indwelling catheter for the first 24 hours after surgery. -Women are also at increased risk for bladder infections. Cloudy urine, foul odor, elevated temperature, and dysuria should be reported to the health care provider. Abdominal dressing/incision -The abdominal dressing should be assessed for drainage and bleeding. -If excessive drainage or bleeding is noted, the health care provider should be notified. Once the dressing is removed, the incision site should be assessed using REEDA.