NUR 318 Ch. 23: Nursing Management of the Newborn
LATCH Score
-A system that provides a systematic method for gathering information about individual breast-feeding sessions L: How well infant latches onto the breast A: Amount of audible swallowing T: Nipple type C: Level of comfort H: Amount of help mother needs -Each component of the system tool is scored with a 0,1 or 2 --> the higher the score, then the less nursing interventions and teaching are needed
Assessment of Preconception, Prenatal, and Intrapartum Risk Factors: Preconception
-Age -Preexisting medical conditions: diabetes, hypertension, cardiac disease, anemia, thyroid disorder, renal disease, obesity -Genetic factors: family history -Obstetric history: gravidity, parity, number of living children and their ages, history of stillbirth, previous infant with congenital anomalies, habitual abortion, use of assisted reproductive technology, interpregnancy spacing -Blood type and Rh status
Sudden Infant Death Syndrome (SIDS): Take Note!
-All newborns develop their own sleep patterns and cycles, but it may take several months before the newborn sleeps through the night -Frequently, newborns have their day and night hours reversed and tend to sleep more during the daytime and less during the night
Initial Newborn Assessments in First 2 Hours of Life: Take note!
-Always keep a bulb syringe near the newborn in case he or she develops sudden choking or a blockage in the nose -It may be lifesaving
Nursing Interventions: Immediate Newborn Period: Take note!
-Always keep a bulb syringe near the newborn in case he or she develops sudden choking or a blockage in the nose. It may be lifesaving -Ophthalmia neonatorum is a severe form of conjunctivitis caused by chlamydia and/or gonococcal infections that is potentially a blinding condition in newborns
Physiologic jaundice
-An unconjugated hyperbilirubinemia that occurs after the first postnatal day and can last up to 1 week -Total serum bilirubin concentrations peak in the first 3 to 5 postnatal days and decline to adult values over the next several weeks
Formula Feeding: Take note!
-Any formula left in the bottle after feeding should also be discarded, because the infant's saliva has been mixed with it
Initial Newborn Assessments in First 2 Hours of Life
-Apgar scoring -Remember the ABC's -Maintain thermoregulation -Length and weight, vital signs -Gestational age assessment -Neonate's safety -New Ballard Score: Physical maturity (skin texture, lanugo, plantar creases, breast tissue, eyes and ears, genitals) Neuromuscular maturity (posture, square window, arm recoil, popliteal angle, scarf sign, heel to ear)
Immediately after circumcision, the tip of the penis is usually covered with petroleum jelly-coated gauze to keep the wound from sticking to the diaper. Continued care of this site includes
-Assess for bleeding every 30 minutes for at least 2 hours -Document the first voiding to evaluate for urinary obstruction or edema -Squeeze soapy water over the area daily and then rinse with warm water -Pat dry -Apply a small amount of petroleum jelly with every diaper change if the Plastibell was used; clean with mild soap and water if other techniques were used -Fasten the diaper loosely over the penis and avoiding placing the newborn on his abdomen to prevent friction
Infant Safety
-Car seats -Sunprotection -Non-nutritive sucking -Bathing & Umbilical cord care -Recognizing signs of illness
Breastfeeding
-Composition -Assistance -Positioning -Education -Storage and expression -Concerns: Sore nipples Engorgement Mastitis
Hypocalcemia
-Defined as serum calcium <7mg/dl -Risk factors: maternal DM, perinatal asphyxia, trauma, LBW infants, preterm infants, maternal anticonvulsant meds -Early onset within 24-72 hours --> gen. asymptomatic but may have jitteriness and twitching; is self limiting and resolves with feedings -Late onset within 5-7 days of life --> jitteriness and twitching --> seizures, apnea; treatment according to underlying cause with IV calcium prn
Sudden Infant Death Syndrome (SIDS)
-Defined as sudden unexplained death of a child of less than one year of age; usually occurring during sleep -Teach parents about safety -The Safe to Sleep Campaign (NICHD, 2014) recommends the following to reduce the risk of SIDS: Always place baby on his or her back to sleep for all sleep times, including naps Room share: keep baby's sleep area in the same room next to where you sleep Use a firm sleep surface, free from soft objects, toys, blankets, and crib bumpers -Also known as cot death or crib death -Diagnosis requires that the death remain unexplained even after a thorough autopsy and detailed death scene investigation
Circumcision
-Defined as the surgical removal of the foreskin of the male patient -Uncircumcised: If the newborn is uncircumcised, wash the penis with mild soap and water after each diaper change and do not force the foreskin back; it will retract normally over time
Caput succedaneum
-Describes localized edema on the scalp that occurs from the pressure of the birth process -It is commonly observed after prolonged labor -Clinically, it appears as a poorly demarcated soft tissue swelling that crosses suture lines -Pitting edema and overlying petechiae and ecchymosis are noted -The swelling will gradually dissipate in about 3 days without any treatment -Newborns who were delivered via vacuum extraction usually have a caput in the area where the cup was used
Administering Prescribed Medications
-During the immediate newborn period, three medications are commonly ordered: vitamin K and eye prophylaxis with either erythromycin or tetracycline ophthalmic ointment -Take Note: Ophthalmia neonatorum is a severe form of conjunctivitis caused by chlamydia and/or gonococcal infections that is potentially a blinding condition in newborns
Gestational Age: Take note!
-Gestational age assessment is important because it allows the nurse to plot growth parameters and to anticipate problems related to prematurity, postmaturity, and growth abnormalities
Hypoglycemia
-Glucose is the main source of energy for the first several hours after birth -One of the most frequent problems encountered, and maintaining glucose homeostasis is one of the important physiologic events during the fetal-to-newborn transition -During the first 24 to 48 hours of life, as normal neonates transition from intrauterine to extrauterine life, their plasma glucose levels are usually lower than later in life -Hypoglycemia is defined as glucose <45 mg/dl -Generally due to the demand for glucose outweighs the supply -Signs= jitteriness, lethargy, poor feeding, respiratory distress, apnea, seizures -Glucose is the main source of energy for the first several hours after birth -With the newborn's increased energy needs after birth, the liver releases glucose from glycogen stores for the first 24 hours -Initiating early breast- or bottle-feedings helps to stabilize the newborn's blood glucose levels -No evidence supports universal invasive routine measurement of glucose in healthy term newborns -Selective screening of at-risk newborns is more appropriate
Hepatitis B (HBV)
-Hepatitis B (HBV) is transmitted through saliva, blood serum, semen, menstrual blood, and vaginal secretions. The incubation period from the time of exposure to onset of symptoms is 6 weeks to 6 months (CDC, 2015h). In the early 2000s, transmission among heterosexual partners accounted for 40% of infections, and transmission among men who have sex with men accounted for 20% of infections -The World Health Organization (WHO) estimates that the prevalence of hepatitis B worldwide is 2 billion people, with about 240 million chronically infected with it. Worldwide, hepatitis B has the highest death rate of any STI except HIV (WHO, 2015b) -Risk factors for infection include having multiple sex partners, engaging in unprotected receptive anal intercourse, and having a history of other STIs (CDC, 2015h) -The most effective means to prevent the transmission of hepatitis A or B is pre-exposure immunization -Vaccines are available for the prevention of HAV and HBV, both of which can be transmitted sexually -Every person seeking treatment for an STI should be considered a candidate for hepatitis B vaccination, and some individuals (e.g., men who have sex with men, and injection-drug users) should be considered for hepatitis A vaccination -After completing the full 3 to 4-dose hepatitis B vaccine series, 98 percent of healthy infants achieve full immunity to the virus
Hyperbilirubinemia --> Jaundice
-Imbalance in rate of bilirubin production and elimination; total increase of serum bilirubin level >5 mg/dL -Physiologic jaundice (third to fourth day of life): Early-onset breast-feeding jaundice Late-onset breast-feeding jaundice -Pathologic jaundice (within first 24 hours of life): Kernicterus Rh isoimmunization ABO incompatibility
Preoperative circumcision preparation should include confirmation of the following
-Infant is at least 12 hours old or older -Infant has received standard vitamin K prophylaxis -Infant has voided normally at least once since birth -Infant has not eaten for at least an hour prior to the procedure -Written parental consent has been obtained -Correct identification of the infant brought to procedure room
How much do infants sleep?
-Infants sleep for 2 to 4 hours at a time but do not sleep through the night because their stomach capacity is too small to go long periods without nourishment
Cephalhematoma
-Is a localized subperiosteal collection of blood of the skull which is always confined by one cranial bone -This condition is due to pressure on the head and disruption of the vessels during birth -It occurs after prolonged labor and use of obstetric interventions such as low forceps or vacuum extraction -The clinical features include a well-demarcated, often fluctuant swelling with no overlying skin discoloration -The swelling does not cross suture lines and is firmer to the touch than an edematous area -Aspiration is not required for resolution and is likely to increase the risk of infection -Hyperbilirubinemia occurs following the breakdown of the red blood cells within the hematoma -This type of hyperbilirubinemia occurs later than classic physiologic hyperbilirubinemia -Cephalhematoma usually appears on the second or third day after birth and disappears within weeks or months -Large cephalhematomas can lead to increased bilirubin levels and subsequent jaundice
Pathologic jaundice
-Is manifested within the first 24 hours of life when total bilirubin levels increase by more than 5 mg/dL/day and the total serum bilirubin level is higher than 17 mg/dL in a full-term infant -This condition requires intervention -[A commonly used rule of thumb in the NICU is to start phototherapy when the total serum bilirubin level is greater than 5 times the birth weight -Thus, in a 1-kg infant, phototherapy is started at a bilirubin level of 5 mg/dL; in a 2-kg infant, phototherapy is started at a bilirubin level of 10mg/dL and so on.]
Molding
-Is the elongated shaping of the fetal head to accommodate passage through the birth canal -It occurs with a vaginal birth from a vertex position in which elongation of the fetal head occurs with prominence of the occiput and overriding sagittal suture line -It typically resolves within a week after birth without intervention
The best way to judge successful breast-feeding
-Is to monitor infant urine output, stool output, and weight -Newborns should have four to six wet diapers and three to four yellow, seedy stools per day by the fourth day after birth -Breast-feeding-associated jaundice is usually preventable through appropriate breast-feeding practices
Assessment of Preconception, Prenatal, and Intrapartum Risk Factors: Intrapartum
-Length of gestation: preterm, late preterm, early term, term, or postterm -First stage of labor: length, electronic fetal monitoring—internal or external, rupture of membranes (time, presence of meconium), signs of fetal distress (decelerations) -Group B streptococcus status: treatment during labor -Second stage of labor: length, vaginal or cesarean, instrument assisted—forceps or vacuum extractor, complications (shoulder dystocia, bleeding [abruptio placentae or placenta previa]), cord prolapse, maternal analgesia and/or anesthesia -TORCH is the collective name for toxoplasmosis, other infections (e.g., hepatitis), rubella virus, cytomegalovirus (CMV), and herpes simplex virus
Nursing Interventions: Immediate Newborn Period
-Maintaining airway patency Bulb syringe proper technique? -APGAR scoring -Ensuring proper identification -Administering prescribed medications: Vitamin K Eye prophylaxis -Maintaining thermoregulation
Neonatal abstinence syndrome (NAS)
-NAS compromises a constellation of drug-withdrawal symptoms that result from chronic intrauterine exposure to a variety of substances, including opioids, barbiturates, SSRIs, alcohol, benzodiazepines, caffeine, and nicotine. -Newborns of women who abuse tobacco, illicit substances, caffeine, and alcohol can exhibit withdrawal behavior. Withdrawal symptoms occur in 60% of all newborns exposed to drugs (March of Dimes, 2015a). Drug dependency acquired in utero is manifested by a constellation of neurologic and physical behaviors and is known as NAS. Although often treated as a single entity, NAS is not a single pathologic condition. -The manifestations of withdrawal are a function of the drug's half-life, the specific drug or combination of drugs used, dosage, route of administration, timing of drug exposure, and length of drug exposure (Hamdan, 2016). Typical newborn behaviors include CNS hypersensitivity, autonomic dysfunction, respiratory distress, temperature instability, hypoglycemia, tremors, seizures, abnormal cry patterns, feeding difficulties, and gastrointestinal disturbances (Gardner et al., 2016). NAS has both medical and developmental consequences for the newborn.
Initial Newborn Assessments
-Nasal flaring, chest retractions -Grunting on exhalation, labored breathing -Generalized cyanosis, flaccid body posture -Abnormal breath sounds, abnormal respiratory rates -Abnormal heart rates, abnormal newborn size
Assessment for Jaundice: Nursing Management requires a comprehensive approach
-Neonatal gestational age will determine course of management -Continue breastfeeding -Reduction of bilirubin levels: early feeding, phototherapy, exchange transfusions -Phototherapy w/ elevated indirect hyperbilirubinemia -Using phototherapy --> neonate must have eyes covered and as much skin exposed as possible -Education and support; home phototherapy
Selected Screening for Newborns
-PKU -Congenital hypothyroidism -Galactosemia -Sickle cell anemia -Hearing tests
Newborn Nutrition
-Physiologic changes -Nutritional needs Calories= 110-120 cal/kg of body weight daily [Breastmilk & formula contain approx. 20 cal/ounce] -Fluid requirements -Feeding method choice Feeding the newborn Frequency Measures to decrease air swallowing
New Ballard Scale: Neuromuscular Maturity
-Posture -Square window -Arm recoil -Popliteal angle -Scarf sign -Heel to ear
Maneuvers Used in Assessing Gestational Age
-Posture: With infant quiet and in supine position, observe degree of flexion in arms and legs. Muscle tone and degree of flexion increase with maturity. Full flexion of the arms and legs = score 4.* -Square Window: With thumb supporting back of arm below wrist, apply gentle pressure with index and third fingers on dorsum of hand without rotating infant's wrist. Measure angle between base of thumb and forearm. Full flexion (hand lies flat on ventral surface of forearm) = score 4.* -Arm Recoil: With infant supine, fully flex both forearms on upper arms and hold for 5 seconds; pull down on hands to extend fully, and rapidly release arms. Observe rapidity and intensity of recoil to a state of flexion. A brisk return to full flexion = score 4.* -Popliteal Angle: With infant supine and pelvis flat on a firm surface, flex lower leg on thigh and then flex thigh on abdomen. While holding knee with thumb and index finger, extend lower leg with index finger of other hand. Measure degree of angle behind knee (popliteal angle). An angle of less than 90 degrees = score 5.* -Scarf Sign: With infant supine, support head in midline with one hand; use other hand to pull infant's arm across the shoulder so that infant's hand touches shoulder. Determine location of elbow in relation to midline. Elbow does not reach midline = score 4.* -Heel to Ear: With infant supine and pelvis flat on a firm surface, pull foot as far as possible (without using force) up toward ear on same side. Measure distance of foot from ear and degree of knee flexion (same as popliteal angle). Knees flexed with a popliteal angle of less than 10 degrees = score 4.*
Assessment of Preconception, Prenatal, and Intrapartum Risk Factors: Prenatal
-Prenatal care: when started -Nutrition: weight gain, diet, obesity, eating disorders -Health-compromising behaviors: smoking, alcohol use, substance abuse -Blood group or Rh sensitization -Medications: prescription, over-the-counter, and complementary and alternative medications -History of infection: sexually transmitted infections, TORCH* infections, group B streptococcus status
Gestational Age
-Preterm or premature: prior to 37 weeks' gestation -Term: 38 to 42 weeks' gestation -Postterm or postdates: after week 42 gestation -Postmature: after week 42 gestation/placental aging -Small for gestational age (SGA) -Appropriate for gestational age (AGA) -Large for gestational age (LGA)
Variations in Head Size and Appearance
-REMEMBER: The newborn has two fontanels at the juncture of the cranial bones -The anterior fontanel is diamond shaped and closes by 18 to 24 months -Typically, it measures 4 to 6 cm at the largest diameter (bone to bone) -The posterior one is triangular, smaller than the anterior fontanel (usually fingertip size or 0.5 to 1 cm) and closes by 6 to 12 weeks -Palpate both fontanels, which should be soft, flat, and open
Anthropometric Measurements and Vital Signs: Safety Alert!
-Rectal temperatures should not routinely be performed on a newborn because of the risk for perforation and vagal stimulation
Breastfeeding: Take Note!
-Remember that the supply of milk is equal to the demand—the more sucking, the more milk
New Ballard Scale: Physical Maturity
-Skin texture -Lanugo -Plantar creases -Breast tissue -Eyes and ears -Genitals
Apgar Scoring for Newborns
-TAKE NOTE!: Although Apgar scoring is done at 1 and 5 minutes, it can also be used as a guide during the immediate newborn period to evaluate the newborn's status for any changes because it focuses on critical parameters that must be assessed throughout the early transition period
Assessment for Jaundice: Diagnostic tests
-TcB (transcutaneous bilirubin) -TSB level (total serum bilirubin) for infants w/: 70% of -TSB recommended for phototherapy; TcB above 75th percentile on Bhutani nomogram; TcB <13 mg/dl at hospital follow-up; actively receiving phototherapy -ABO, Rh, Blood type , isoimmune antibodies of mother (from maternal testing during pregnancy) -H/H, reticulocyte count -Increased reticulocyte count with anemia indicates hemolysis secondary to conditions with isoimmunization
Circumcision: Take note!
-The decision to circumcise the male newborn is often a social one, with the strongest factor being whether the newborn's father is himself circumcised
Anthropometric Measurements and Vital Signs: Take note!
-The head and chest circumferences are usually equal by about 1 year of age -Head circumference may need to be remeasured at a later time if the shape of the head is altered from birth
A few conditions that contribute to red blood cell breakdown and thus higher bilirubin levels include polycythemia, blood incompatibilities, and systemic acidosis
-These altered conditions can lead to high levels of unconjugated bilirubin, possibly reaching toxic levels and resulting in a severe condition called kernicterus or bilirubin encephalopathy -It can be acute or chronic -Jaundice occurs in most newborn infants -Most jaundice is benign, but because of the potential toxicity of bilirubin, newborn infants must be monitored to identify those who might develop severe hyperbilirubinemia and, in rare cases, acute bilirubin encephalopathy or kernicterus -The focus of good nursing assessment is to reduce the incidence of severe hyperbilirubinemia and bilirubin encephalopathy while minimizing the risks of unintended harm such as maternal anxiety, decreased breastfeeding, and unnecessary costs or treatment. -Although kernicterus should almost always be preventable, cases continue to occur
Assessment for Jaundice: Physical exam
-This is key to successful dx. and treatment of jaundice in the neonate -Assess in first 24 hrs. and throughout neonatal period -Usually starts on face and forehead spreading downward across body and retreats from feet to head -Identification is aided by pressure on the skin, since blanching reveals the underlying color -Jaundice then gradually becomes visible on the trunk and extremities -This cephalocaudal progression is well described. Jaundice disappears in the opposite direction -Nurses play an important role in early detection and identification of jaundice in the newborn -Keen observation skills are essential -Petechiae, bruising, signs of infection, hepatosplenomegaly -Lethargy, poor feeding, hypotonia, loss of Moro reflex = signs of bilirubin toxicity to the brain -Kernicterus (later signs) w/ diminished DTRs, respiratory distress, failure to sick, bulging fontanelle, facial or limb twitching, seizures, shrill, high pitched cry
Assessment for Jaundice: Clinical findings/Risk factors
-This is key to successful dx. and treatment of jaundice in the neonate -Hemolytic disease --> anemia -Inborn errors of metabolism -Prematurity -Bruising/cephalohematoma -Exclusive breastfeeding w/ difficulties &/or poor weight gain -Jaundice in first 24 hrs. -Total bilirubin increase>5mg/dl in 24 hours; >12.5 mg/dl before 48 hrs.; African or Mediterranean descent -Hepatobiliary disease -Previous sibling needing phototherapy
Common Concerns During Transition
-Transient tachypnea of the newborn (discuss next week) -Physiologic jaundice/Hyperbilirubinemia -Hypoglycemia
Formula Feeding
-Types of formula: The general recommendation is for all infants to receive iron-fortified formula until the age of 1 year -Assistance -Positioning: NEVER prop a bottle of formula -Education -Weaning and introduction of solid foods
Weaning
-Weaning can be done because the mother is returning to work and cannot keep breast-feeding, or because the infant is losing interest in breast-feeding and showing signs of independence -There is no "right" time to wean; it depends on the desires of the mother and infant -Weaning represents a significant change in the way the mother and infant interact, and each mother must decide for herself when she and her infant are ready to take that step -Either one can start the weaning process, but usually it occurs between 6 months and 1 year of age -To begin weaning from the breast, instruct mothers to substitute breast-feeding with a cup or bottle -Often the midday feeding is the easiest feeding to replace -A trainer cup with two handles and a snap-on lid with a spout is appropriate and minimizes spilling -Because weaning is a gradual process, it may take months -Instruct parents to proceed slowly and let the infant's willingness and interest guide them -Weaning from the bottle to the cup also needs to be timed appropriately for mother and infant -Typically, the night bottle is the last to be given up, with cup drinking substituted throughout the day -Slowly diluting the formula with water over a week can help in this process; the final result is an all-water bottle -To prevent the baby from sucking on the bottle during the night, remove it from the crib after the infant falls asleep
Introduction of Solid Foods
-When infants double their birth weight and weigh at least 13 lb, it is time to consider introducing solid foods. Readiness cues include: Consumption of 32 oz of formula or breast milk daily (estimated) Ability to sit up with minimal support and turn head away to indicate fullness Reduction of protrusion reflex so cereal can be propelled to back of throat Demonstration of interest in food others around them are eating Ability to open mouth automatically when food approaches it When introducing solid foods, certain principles apply: New foods should be introduced one at a time and a week apart so that if a problem develops, the responsible item can be identified. Infants should be allowed to set the pace regarding how much they wish to eat. New foods should not be introduced more frequently than every 3 to 5 days. Fruits are added after cereals; then vegetables and meats are introduced; eggs are introduced last. A relaxed, unhurried, calm atmosphere for meals is important. A variety of foods are provided to ensure a balanced diet. Infants should never be force-fed (Schlenker & Gilbert, 2015).
Initial Newborn Assessments in First 2 Hours of Life: Safety Alert!
-With the possibility of transmission of viruses such as hepatitis B virus (HBV) and human immunodeficiency virus (HIV) through maternal blood and blood-stained amniotic fluid, the newborn must be considered a potential contamination source until proved otherwise -As part of Standard Precautions, nurses wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing
In every infant, we recommend that clinicians
1) promote and support successful breastfeeding 2) perform a systematic assessment before discharge for the risk of severe hyperbilirubinemia 3) provide early and focused follow-up based on the risk assessment 4) when indicated, treat newborns with phototherapy or exchange transfusion to prevent the development of severe hyperbilirubinemia and, possibly, bilirubin encephalopathy (kernicterus)
