Newborn Nursing Care

Sleep-wake states

Variations in the state of consciousness of infants are called sleep-wake states. The six states form a continuum from deep sleep to extreme irritability: two sleep states (deep sleep and light sleep) and four wake states (drowsy, quiet alert, active alert, and crying)

Erythromycin

erythromycin 0.5% ophthalmic ointment is the recommended prophylactic medication ...to prevent ophthalmia neonatorum or neonatal conjunctivitis

Desquamation of the skin

Desquamation (peeling) [cracking] of the skin of the term infant does not occur until a few days after birth. Large, generalized areas of skin desquamation present at birth can be an indication of post maturity.

Psudomenstruation

female newborns to have mucoid vaginal discharge and even some slight bloody spotting (pseudomenstruation)

Digits

Digits may be missing (oligodactyly); Extra digits (polydactyly) are sometimes found on the hands or feet. Fingers or toes may be fused (syndactyly).

Milia

Distended, small, white sebaceous glands noticeable on the newborn face are known as milia.

Length

In the term neonate, head-to-heel length ranges from 45 to 55 cm (same as ATI)

Apgar five signs

- heart rate, based on auscultation with a stethoscope or palpation of the umbilical cord - respiratory effort, based on observed movement of the chest wall - muscle tone, based on degree of flexion and movement of the extremities - reflex irritability, based on response to suctioning of the nares or nasopharynx -generalized skin color, described as pallid, cyanotic, or pink

Most important risk factors to know immediately after birth

-Length of gestation: preterm, late preterm, early term, term, or postterm - rupture of membranes (time, presence of meconium) - signs of fetal distress (decelerations) - vaginal or cesarean, instrument assisted - complications (shoulder dystocia, bleeding [abruptio placentae or placentae previa]) - cord prolapses -maternal analgesia and/or anesthesia

Signs of respiratory distress

Signs of respiratory distress can include nasal flaring, intercostal or subcostal retractions (in-drawing of tissue between the ribs or below the rib cage) or grunting with respirations. A respiratory rate of less than 30 or greater than 60 breaths/minute with the infant at rest must be evaluated.

Ideal method of promoting warmth

ideal method for promoting warmth and maintaining neonatal body temperature is early skin-to-skin contact (SSC) with the mother

Abnormal temperature

A body temperature greater than 37.5° C (99.5° F) is considered to be abnormally high The newborn who is hyperthermic because of sepsis appears stressed: vessels in the skin are constricted, color is pale, and hands and feet are cool.

Fractured clavicle

A fractured clavicle often occurs in macrosomic infants and in those who had a difficult birth (e.g., shoulder dystocia). Unequal movement of the upper extremities or crepitus over the clavicular area can indicate fracture.

Ballard score

A gestational age assessment is completed within the first hours of birth (Ballard score) A frequently used method of determining gestational age is the New Ballard Score. It assesses six external physical and six neuromuscular signs.

Transcutaneous bilirubinometry

A more accurate noninvasive assessment of hyperbilirubinemia is accomplished using transcutaneous bilirubinometry

Nevus flammeus

A port-wine stain, or nevus flammeus, usually visible at birth, usually pink and flat at birth. True port-wine stains do not blanch on pressure or disappear.

Vitamin K IM

Administering vitamin K intramuscularly is routine in the newborn period in the United States... to prevent vitamin K deficiency bleeding

Vernix caseosa

After 35 weeks of gestation, the skin is covered by vernix caseosa (a cheese like, whitish substance) that is fused with the epidermis and serves as a protective covering. Removal of the vernix (via bathing) is followed by desquamation (skin peeling) of the epidermis in most infants.

Bulb syringe

Airway: If the infant has excess mucus in the respiratory tract, the mouth and nasal passages can be gently suctioned with a bulb syringe

Immune system

All newborns, and preterm newborns especially, are at high risk for infection during the first several months of life.

Babinski (plantar)

All toes hyperextend, with dorsiflexion of big toe—recorded as a positive sign.

Hyperthermia

Although occurring less frequently than hypothermia, hyperthermia can occur Hyperthermia can result from the inappropriate use of external heat sources such as radiant warmers, phototherapy, sunlight, increased environmental temperature, and the use of excessive clothing or blankets

AGA

Appropriate for gestational age (AGA) (between the 10th and 90th percentiles)

Identification

As soon as possible after birth, the nurse places identically numbered bands on the infant's wrist and ankle, on the mother, and in some birth settings, on the father or significant other.

Skin assessment

Assess for: signs of birth injuries such as forceps marks and lesions related to fetal monitoring; Bruises or petechiae can be present on the head, neck, and face of an infant born with a nuchal cord (cord around the neck) or who had a face presentation at birth; Petechiae can be present if increased pressure was applied to an area. (such as buttocks for a newborn who was breech)

Hypoglycemia after birth

At birth, the newborn is removed from the maternal glucose supply resulting in an initial drop in blood glucose Glucose levels are not routinely assessed in newborns unless there are risk factors or symptoms of hypoglycemia. Risk factors include small or large for gestational age, preterm, and infant of a diabetic mother. The hypoglycemic infant can be asymptomatic or can display the classic symptoms of jitteriness, lethargy, apnea, feeding problems, or seizures. Hypoglycemia in the initial newborn period is most often transient and easily corrected through feeding. The necessity for glucose requires careful assessment of neonates who are at risk for hypoglycemia (e.g., infants of mothers who have diabetes; infants who are macrosomic or small for gestational age; and newborns who experienced prolonged birth, hypoxia, or preterm birth) Transient tremors are normal and can be observed in nearly every newborn. These tremors should not be present when the infant is quiet Tremors or jitteriness are easily elicited by motions or voice and cease with gentle restraint of the body part, whereas seizure activity continues. The hypotonic neonate shows little resistance and can feel like a "rag doll." Glucose levels should be measured in all newborns with risk factors for hypoglycemia and in any newborn with clinical manifestations of hypoglycemia.

Convection

Convection is the flow of heat from the body surface to cooler ambient air.

Breast

Breast tissue and areola size increase with gestation. By 36 weeks, a breast bud of 1 to 2 mm is palpable; this increases to 12 mm by 42 weeks.

Cranial size and shape

Cranial size and shape can be distorted by molding (the shaping of the fetal head by overlapping of the cranial bones to facilitate movement through the birth canal during labor

Crying

Crying is the language an infant uses most often to communicate needs. It can signal hunger, discomfort, pain, desire for attention, or fussiness. Infants may cry in response to environmental stimuli such as cold, being overstimulated, or being held by multiple persons. Responsiveness of the caregiver to the crying creates trust as the infant learns to associate the caregiver with comfort.

Breath sounds

Breath sounds should be clear and equal bilaterally, although fine rales for the first few hours are not unusual.

Caput succedaneum

Caput succedaneum is a generalized, easily identifiable edematous area of the scalp, most often on the occiput. This edematous area, present at birth, extends across suture lines of the skull and usually disappears spontaneously within 3 to 4 days.

Cephalohematoma

Cephalhematoma is a collection of blood between a skull bone and its periosteum. Therefore, a cephalhematoma does not cross a cranial suture line As the hematoma resolves, hemolysis of RBCs occurs, and hyperbilirubinemia can result

SGA

small for gestational age (SGA) infant (less than the 10th percentile)

Erythema toxicum

Erythema toxicum: a transient rash, also called newborn rash, it has lesions in different stages: erythematous macules, papules, and small vesicles. The lesions can appear suddenly anywhere on the body. Although the appearance is alarming, the rash has no clinical significance and requires no treatment.

Causes of Neonatal Unconjugated (Indirect) Hyperbilirubinemia

Fetomaternal blood group incompatibility (Rh, ABO) Enclosed hemorrhage (cephalhematoma, bruising) Sepsis Polycythemia Delayed passage of meconium Fasting or delayed initiation of feeding Immaturity Asphyxia, hypoxia, hypothermia, hypoglycemia Breastfeeding infants are at greater risk for hyperbilirubinemia Physiologic or nonpathologic jaundice (unconjugated hyperbilirubinemia) occurs in approximately 60% of term newborns. It appears after 24 hours of age and usually resolves without treatment. In normal full-term newborns, TSB levels... average peak of 5 to 6 mg/dL by 72 to 96 hours of life. From that point, TSB levels gradually decrease Bruising can increase the risk for hyperbilirubinemia. It peaks at about 3 to 5 days in term infants and resolves after 1 to 2 weeks.

Lanugo

Fine lanugo hair may be noted over the face, shoulders, and back.

Hydrocele

Hydrocele, caused by an accumulation of fluid around the testes, usually resolve without treatment Circumcision is contraindicated in the presence of hypospadias because the foreskin is used in repair of this anomaly.

Hypothermia

Hypothermia from excessive heat loss is a common and potentially serious problem. (for newborns) Hypothermia: The infant can appear pale and mottled; the skin feels cool, especially on the extremities. If the hypothermia is not corrected, it will progress to cold stress Newborns produce heat through no shivering thermogenesis. This is accomplished primarily by metabolism of brown fat

Pilonidal dimple

If a pilonidal dimple (sacral dimple) is noted, further inspection is required to determine whether a sinus is present. A pilonidal dimple, especially with a sinus and nevus pilosis (hairy nevus), can be associated with spina bifida.

Normal reproductive signs

In term neonates, the labia majora and minora cover the vestibule The position of the urethra should be at the tip of the penis. With hypospadias, the urethral opening is located in an abnormal position, at any point on the ventral surface of the penile surface from the glans to the perineum. At 36 to 40 weeks of gestation, the testes are palpable in the upper scrotum, and rugae appear on the anterior portion. If the urethral opening is located on the dorsal surface of the penis, it is known as epispadias After 40 weeks, the testes can be palpated in the scrotum, and rugae cover the scrotal sac.

Signs of adequate hydration

In the adequately hydrated infant, the mucous membrane of the mouth is moist and pink

Stepping or "walking"

Infant will simulate walking, alternating flexion and extension of feet

Palmar or Plantar Grasp

Infant's fingers curl around examiner's fingers or toes curls downward.

Infantile hemangiomas

Infantile hemangiomas: typical lesion is a raised, sharply demarcated, bright or dark red rough-surfaced swelling that may be present at birth or may appear during the early weeks after birth,

Telangiectatic nevi

telangiectatic nevi: They are usually small, flat, and pink and are easily blanched They have no clinical significance and require no treatment.

Jaundice

Jaundice is generally noticeable first in the head, especially in the sclera and mucous membranes, and progresses gradually to the thorax, abdomen, and extremities. Traditionally newborn jaundice has been categorized as either physiologic or pathologic (nonphysiologic), depending primarily on the time it appears and on serum bilirubin levels. Jaundice is usually considered pathologic or nonphysiologic if it appears within 24 hours after birth (or otherwise bilirubin levels are higher than they should be for age of newborn, rising faster than they should be, or lasting longer than it should be) If increased levels of unconjugated bilirubin are left untreated, neurotoxicity can result as bilirubin is transferred into the brain cells. Acute bilirubin encephalopathy... This can include a range of symptoms such as lethargy, hypotonia, irritability, seizures, coma, and death. Kernicterus refers to the irreversible, long-term consequences of bilirubin toxicity (which causes brain damage) Visual assessment of jaundice alone does not provide an accurate assessment of hyperbilirubinemia, especially in dark-skinned newborns

Meconium

Meconium is greenish black and viscous and contains occult blood. Most healthy term infants pass meconium within the first 12 to 24 hours of life, and almost all do so by 48 hours.

Mongolian spots

Mongolian spots, bluish black areas of pigmentation, can appear over any part of the exterior surface of the body, including the extremities. They are most common on the back and buttocks The presence of Mongolian spots on the newborn should be documented carefully in the medical record. These normal skin pigmentations can be mistaken for bruises once the infant is discharged, and this can raise suspicion of physical abuse.

Infection in newborn

Newborns are susceptible to infection.

Respirations

Once respirations are established, breaths are shallow and irregular, ranging from 30 to 60 breaths/minute NOTE: ATI says that apnea less than 15 seconds is normal. The textbook states less than 20 seconds. We will use ATI information for testing. Newborn infants are by preference nose breathers. The reflex response to nasal obstruction is to open the mouth to maintain an airway. This response is not present in most infants until 3 weeks after birth; therefore, cyanosis or asphyxia can occur with nasal blockage. The newborn should be breathing spontaneously. The trunk and lips should be pink; acrocyanosis is a normal finding

Pathologic jaundice

Pathologic or nonphysiologic jaundice is either pathologic in origin or severe enough to warrant further evaluation and treatment.

Abnormal skin signs

Petechiae scattered over the infant's body should be reported to the health care provider

Radiation

Radiation is the loss of heat from the body surface to a cooler solid surface not in direct contact but in relative proximity.

Hearing screening

Routine hearing screening is recommended for all newborns before hospital discharge. Term newborns can hear and differentiate among various sounds. They will turn toward a sound and attempt to locate the source.

Sensory stimulation

Sensory stimulation occurs in a variety of ways with birth. Some of these include handling by the obstetric health care provider, suctioning the mouth and nose, and drying by the nurses. The initiation of respirations in the neonate is the result of a combination of chemical, mechanical, thermal, and sensory factors

Signs of DDH

Signs of DDH are asymmetric gluteal and thigh skinfolds, uneven knee levels, a positive Ortolani test, and a positive Barlow test.

Skin-to-skin

Skin-to-skin contact with the mother is an effective means of reducing conductive and radiant heat loss and enhancing newborn temperature control and maternal-infant interaction. Conduction is the loss of heat from the body surface to cooler surfaces in direct contact. If the infant does not remain skin-to-skin with the mother during the first 1 to 2 hours after birth, the nurse places the thoroughly dried infant under a radiant warmer or in a warm incubator until the body temperature stabilizes. The infant's skin temperature is used as the point of control

Epstein pearls

Small whitish areas (Epstein pearls) may be found on the gum margins and at the juncture of the hard and soft palates. The neonate is unable to move food from the lips to the pharynx; therefore, placing the nipple (breast or bottle) well inside the baby's mouth is necessary.

Sucking and rooting

Sucking and rooting: Infant turns head toward stimulus and opens mouth.

Swallowing

Swallowing is usually coordinated with sucking and breathing and usually occurs without gagging, coughing, apnea, or vomiting.

Swelling of the breasts

Swelling of the breast tissue in term infants of both sexes. This finding has no clinical significance, requires no treatment, and subsides within a few days

Moro

Symmetric abduction and extension of arms are seen; fingers fan out and form a C with thumb and forefinger; slight tremor may be noted; arms are adducted in embracing motion and return to relaxed flexion and movement. A cry may accompany or follow motor movement. (a picture explains this response much better than words)

Transient Tachypnea of the Newborn (TTN)

Tachypnea with rates up to 100 breaths/minute can be present along with intermittent grunting, nasal flaring, and mild retractions.

Signs of infection

Temperature instability or hypothermia can be symptomatic of serious infection; newborns do not typically exhibit fever, although hyperthermia can occur (temperature greater than 38° C [100.4° F]). Lethargy, irritability, poor feeding, vomiting or diarrhea, decreased reflexes, and pale or mottled skin color are some of the clinical signs that suggest infection. Respiratory symptoms such as apnea, tachypnea, grunting, or retracting can be associated with infection such as pneumonia The greatest risk factor for neonatal infection is prematurity because of immaturity of the immune system. Other risk factors include premature rupture of membranes, chorioamnionitis, maternal fever, antenatal or intraportal asphyxia, invasive procedures, stress

We will use gestational age categories from ATI

Term (37 to 42 weeks), Preterm or Premature (born before 37 weeks), Postterm/postdate (born after 42 weeks), or Postmature(after 42 weeks AND placental insufficiency) Postmature: show characteristics of progressive placental insufficiency. These infants are labeled as postmature and are likely to have little if any vernix caseosa, absence of lanugo, abundant scalp hair, and long fingernails. The skin is often cracked, parchment-like, and peeling. A common finding in postmature infants is a wasted physical appearance that reflects placental insufficiency. Depletion of subcutaneous fat gives them a thin, elongated appearance (we rarely see this in the US because induction of labor or cesarean are typically done when mother reaches 41 weeks, because of risk of increased newborn mortality)

Surfactant

The alveoli of the term infant's lungs are lined with surfactant Retention of lung fluid can interfere with the infant's ability to maintain adequate oxygenation

Document regurgitation

The amount and frequency of regurgitation, "spitting," or vomiting after feedings should be documented.

Transitional stools

Usually appear by third day after initiation of feeding

Colostrum

The colostrum consumed by breastfed neonates during the first 2 to 3 days after birth promotes stooling. Colostrum, a natural laxative, facilitates the passage of meconium in breastfed infants

First priority after birth

The first priority for the newborn is to establish effective respirations.

Voiding frequency

The frequency of voiding varies from 2 to 6 times per day during the first and second days of life (but minimum of 1 time the first day) and increases during the subsequent 24 hours. After day 4, approximately 6 to 8 voidings per day of pale straw-colored urine indicate adequate fluid intake.

Measure head

The head is measured at the widest part, which is the occipitofrontal diameter... just above the infant's eyebrows ATI says length ranges from 32 to 36.8 centimeters.

Heart rate

The heart rate for a term newborn ranges from 120 to 160 beats/minute. NOTE: ATI uses a range of 110-160 --> we will use this range for exams! The infant's first breaths...causes a functional closure of the foramen ovale. During the first few days of life, crying can temporarily reverse the flow through the foramen ovale and lead to mild cyanosis. A heart rate that is either high (more than 160 beats/minute) or low (fewer than 100 beats/minute) should be reevaluated within 30 minutes to 1 hour or when the activity of the infant changes.

Assess heart rate

The heart rate is quickly assessed by grasping the base of the cord or by auscultating the chest with a stethoscope. The nurse counts for 6 seconds and multiplies by 10 to calculate the heart rate. It should be greater than 100 beats/minute.

Initial assessment after birth

The initial (brief) assessment of the neonate is performed immediately after birth. This is followed by Apgar scoring at 1 and 5 minutes

Postpone bath

The initial bath is postponed until the newborn's skin temperature is stable

Distinguish taste

The newborn can distinguish among tastes and has a preference for sweet solutions

Reproductive signs in postterm infants

The postterm neonate has deep rugae and a pendulous scrotum.

Cold stress

The respiratory rate increases in response to the increased need for oxygen...these changes can prompt a transient respiratory distress or aggravate existing RDS Reserves of brown fat, usually present for several weeks after birth, are rapidly depleted with cold stress Excessive fatty acids... exacerbate hyperbilirubinemia Hypoglycemia is another metabolic consequence of cold stress

Second period of reactivity

The second period of reactivity occurs roughly between 2 and 8 hours after birth and lasts from 10 minutes to several hours. Brief periods of tachycardia and tachypnea occur, associated with increased muscle tone, changes in skin color, and mucus production.

Sole creases

The soles of the feet should be inspected for the number of creases during the first few hours after birth; as the skin dries, more creases appear. More creases correlate with a greater maturity rating

Blood pressure

The term newborn infant's average systolic BP is 60 to 80 mm Hg, and average diastolic BP is 40 to 50 mm Hg. (This is the same as ATI)

Weigh infants

The totally unclothed neonate is placed in the center of the scale, which is usually covered with a disposable pad or cloth to prevent heat loss via conduction and to prevent cross-infection. The nurse should place one hand over (but not touching) the neonate to be prepared to prevent the infant from falling off the scales.

Dry infants

This heat loss is intensified by failing to completely dry the newborn after birth or with bathing. Evaporation is the loss of heat that occurs when a liquid is converted to a vapor. In the newborn, heat loss by evaporation occurs as a result of moisture vaporization from the skin. Vigorously drying the infant provides tactile stimulation to stimulate respiratory effort and removes moisture to prevent evaporative heat loss.

Tonic neck or "fencing"

With infant facing left side, arm and leg on that side extend; opposite arm and leg flex (turn head to right, and extremities assume opposite postures)

Abdominal breathing

abdominal breathing is characteristic of newborns Irregular respirations with periodic breathing; risk for apnea; inability to rapidly alter depth of respirations

Follow up jaundice

all newborns should be followed after discharge from the birthing facility for the development of unexpected jaundice and that parents should be given printed and oral information about newborn jaundice

Hyperbilirubinemia treatment

all newborns should be followed after discharge from the birthing facility for the development of unexpected jaundice and that parents should be given printed and oral information about newborn jaundice There are two ways to reduce unconjugated bilirubin levels: phototherapy and exchange blood transfusion. During phototherapy using a lamp, the neonate, wearing only a diaper, is placed under a bank of lights

Central cyanosis

central cyanosis is abnormal and signifies hypoxemia. With central cyanosis, the lips and mucous membranes are bluish (circumoral cyanosis) Because central cyanosis is a late sign of distress, newborns usually have significant hypoxemia when cyanosis appears.

LGA

large for gestational age (LGA) (more than the 90th percentile)

First period of reactivity

lasts up to 30 minutes after birth, the infant is alert Respirations are irregular, with a rate between 60 and 80 breaths/minute. Fine crackles can be present on auscultation. Audible grunting, nasal flaring, and retractions of the chest also can be present, but these should cease within the first hour of birth (otherwise this is abnormal, need evaluation for respiratory distress) Lungs: Fine crackles may be auscultated for several hours after birth

Limited fluid intake

limited fluid intake can result in a 5% to 10% loss of the birth weight over the first 3 to 5 days The neonate should regain the birth weight within 10 to 14 days Normal urine during early infancy is usually straw colored and almost odorless. Sometimes pink-tinged uric acid crystals or "brick dust" appear on the diaper. Uric acid crystals are normal during the first week, but thereafter can be a sign of inadequate intake

Serious respiratory problems

more serious respiratory problems...tend to last beyond the first 2 hours after birth (or start after the first 2 hours) The respiratory symptoms (TTN) can be accompanied by hypotension, temperature instability, hypoglycemia, acidosis, and signs of cardiac problems.

Transition of extrauterine life

most critical of these is the establishment of effective respirations Most newborns breathe spontaneously after birth and are able to maintain adequate oxygenation. The positive pressure created by crying helps keep the alveoli open.

Period of decreased responsiveness

period of decreased responsiveness lasts from 60 to 100 minutes.

Acrocyanosis

the bluish discoloration of hands and feet, is a normal finding in the first 24 hours after birth. The hands and feet appear slightly cyanotic (acrocyanosis) Acrocyanosis is normal and appears intermittently over the first 7 to 10 days (not constantly, like 1st 24 hours), especially with exposure to cold

Abnormal cardiac signs

the presence of a murmur AND accompanying signs such as poor feeding, apnea, cyanosis, or pallor is considered abnormal and should be investigated Most heart murmurs heard during the neonatal period have no pathologic significance, and more than one-half of the murmurs disappear by 6 months of age.

Transient blood coagulation deficiency

transient blood coagulation deficiency between the second and fifth days of life. (related to lack of vitamin k) The administration of intramuscular vitamin K shortly after birth helps prevent vitamin deficiency bleeding (VKDB) which can occur suddenly and can be catastrophic

Abnormal Newborn Breathing

• Bradypnea (<30 respirations/min) • Tachypnea (>60 respirations/min) • Abnormal breath sounds: coarse or fine crackles, wheezes • Audible expiratory grunt • Respiratory distress: nasal flaring, retractions • Skin color: central cyanosis, mottling