OB Exam 3 Study guide:

Assessing the GI system, (application) 1st stool, Meconium -Should pass within 24-48 hours -Transitional 3rd day after feeding -Greenish to yellow, thin and "seedy" Milk stool 4th day -Breast fed= yellow gold, pasty sour smell -Formula fed, pale yellow to light brown, firmer more offensive odor Mucous membrane in a hydrated child: moist ad pink -Hard soft palate intact -Presence of moderate to large amounts of mucous us common in the first few hours after birth -Epstein pearls (Small whitish areas) may be found - Make sure NIPPLE is well inside the baby's mouth

-Increased risk of allergies and infection because mucosal barrier in intestines is not fully mature -Because of immaturity newborns are prone to regurgitation, vomiting and GER. this is common most prevalent in 3 months -Can be dressed by avoiding over feeding, burping the infant and positioning him or her with the head slightly elevated digestion: normal newborn is capable of digesting simple carbohydrates and proteins but has a limited ability to digest fats Stools: Feeding behaviors: -be alert and response to hunger cues Signs of Gastrointestinal problems: -Failure to pass meconium indicates bowel obstruction (Hirchsprungs disease ) - fullness of the abdomen above the umbilicus can be caused by hepatomegaly, duodenal atresia or distention -A scaphoid (Sunken ) abdomen , with bowel sounds heard in the chest and signs of respiratory distress, indicates a diaphragmatic hernia - Fullness below the umbilicus can indicate a distended bladder - If an infant is allergic or unable to digest a formula , the stools can become very soft with a high water content that is signaled by a distant water ring around the stool on the diaper. -forceful ejection of stool and a water ring are signs of diarrhea - Passage of meconium from vagina or urinary meatus is a sign of possible fistulous tract from the rectum -Vomiting in large amounts especially if projectile, an be sign of pyloric stenosis -Bilious emesis is suggestive of intestinal obstruction or malrotation of the bowel.

Interventions re: bathing the baby (application) p. 593 Bathing helps : 1) helps clean the skin 2) observe the infants condition 3) promoting comfort 4) parent child family interaction - to protect the newborns skin it is best use a cleanser with a NEUTRAL PH and without preservatives - NO ANTIMICROBIAL CLEANSERS - use either sponge bathing , immersion or swaddles bathing A. Sponge bathing are usually given until the infants umbilical cord falls off and the umbilicus is healed B. Immersion: found to allow less heat loss and provoke less crying - does not increase the risk of bacterial colonization of the cord C. Swaddled bathing is a type of immersion bathing in which the newborn is swaddled in a blanket or towel and immersed in a tub of warm water - One body part at at time is unwrapped and washed

1. Initially bath is delayed for at least 2 hours after birth until the neonate has reached thermal and cardiorespiratory stability 2. Bath should QUICK (5-10 mins) 3. Tap water and minimal amount of ph neutral or slightly acidic cleanser 4. Following, infant should be immediately DRIED, DIAPERED n WRAPPED in warm blankets, CAP is placed on HEAD 5. Ten min later make sure infant is dressed and wrapped in warm blankets n cap is changed Parent teaching: note: A daily bath is not necessary for achieving cleanliness and can do harm by disrupting the integrity of the newborns skin - cleansing of perineum after a soiled diaper and daily cleansing of the face are usually sufficient. - Infants shoulds not be bathed more than every other day - hair shampood once or twice a week

Care of infant receiving photo therapy (application) p. 572 Tx: using phototherapy is used to reduce serum levels of unconjugated bilirubin How: Phototherapy is uses light energy to change the shape and structure of un-conjugated bilirubin, converting it into a conjugated form that can be excreted through urine and stool. -Severity of the newborns hyperbilirubinemia determines the type of phototherapy Interventions While infant is under lamp: -Infant, wearing only a diaper is placed under a bank of lights 45 to 50 cm from the light source -Measure the irradiance of light using a radiometer note: within 4 to 6 hours after initiation of photo therapy, the bilirubin level should begin to decrease -Phototherapy is used until the infants serum bilirubin level decreases to within an acceptable range Note this additional info: When phototherapy is not effective in reducing serum bilirubin levels or with severe hyperbilirubinemia such as in hemolytic disease , EXCHANGE TRANSFUSION may be needed.

A) the infants eye must be protected by an opaque mask to prevent retinal damage: 1. Eyes should be covered completely but not OCCLUDE the NARES 2. Before the mask is applied, the Infants eyes should be CLOSED gently to prevent EXCORIAITION of the corneas 3. Remove the mask periodically and during infant feedings so that the eyes can be assessed and cleansed with water and the parents can have visual contact with the infant. B)Phototherapy can cause changes in infants temperatures: 1. Assess temperature closely. C) Photo therapy lights can increase the rate of insensible water loss, which contributes to fluid loss and dehydration 1. Make sure infant is adequately hydrated - this is accomplished through breastfeeding or infant formula 2. Closely monitor urine output -this may be decreased or unaltered -Urine may have a dark gold or brown appearance note: FEEDINGS OF GLUCOSE AND PLAIN WATER DO NOT DO : this delays bilirubin excretion 3.Monitor #s of stools and consistency 1. clean buttocks area after each stool to help maintain skin integrity -bilirubin breakdown increases gastric motility, which results in loose stool Saftey alert: No ointments, creams, or lotions should be applied to the newborns skin during phototherapy because they can absorb heat and cause burn D) Infants are under lights maximizing skin exposure 1. Turn infants every 2 to 3 hours E)In instances when bilirubin levels increase rapidly and intensive phototherapy is required: 1.use a combination of conventional lights and fiberoptic blankets to maximize bilirubin reduction D) Esure that a covering pad is placed between the infants skin and the fiber optic device to prevent skin burns, especially in preterm infants

Collection of specimens (application) p. 576 -Screening of a newborn often requires obtaining blood by A) Heel stick - heel sticks are to obtain blood for glucose monitoring, screening etc -If lab tech is doing it, assists as needed to maximize safety and infant comfort 1. Warm heel before sample -application of heat 5-10 mins helps dilate the vessels in the area , if using heal warmers watch for burns 2. Apply gloves 3. Clean area with skin antiseptic, restrain the infants foot with a free hand and then puncture the site. Serious complication: is necrotizing osteochondritis resulting from lancet penetration of the bone. A) to prevent this problem, the puncture is made at the OUTER ASPECT of the heel and penetrates no deeper than 2.4mm -To identify the appropriate puncture site, the nurse draws an imaginary line between the fourth and fifth toes (Refer to picture 4. After puncture, gentle pressure is applied with a dry gauze pad To reduce pain: use non-pharmacological methods - allowing the mother to hold the neonate skin to skin - using non-nutritive sucking with or without oral sucrose or swaddling the neonate -cuddled and comforted

B) Venipuncture -Venous blood samples can be drawn from Antecubital, Saphenous, superficial wrist and rarely scalp veins - Positioing is important: the infant is carefully restrained - Use a 23 or 25 gauge butterfly needle or hypodermic needle with a syringe used -Use patience as blood flow is slow and the small needle must remain in place longer than a larger needle note: if this is performed for BLOOD GAS STUDIES: crying, fear and agitation will affect the values therefore every effort MUST BE KEEP the INFANT QUIET during the procedure -Apply pressure over the arterial or femoral vein puncture with a dry gauze square for 3 to 5 mins to prevent bleeding from site. - Asses n hour after any venipuncture for bleeding or hematoma formation at the puncture site -cuddle the infant and provide comfort C) Collection of a urine sample -The urine sample should be fresh and analyzed within 1 hour of collection -A urine bag is used o obtain the urine specimen

Classiffication of Newborns by gestational age and Birth weight p.553 -AGA (appropriate for gestational age): to have grown at a NORMAL rate regardless of length of gestation: preterm, term, posters - LGA (Large for Gestational age): has grown at an ACCELERATED rate during fetal life -SGA (Small gestational age): grown at a RESTRICTED rate - When gestational age is determined according t the New ballard school, the newborn will fall into either AGA,SGA,LGA with term, preterm, post term - Birthweight influences mortality: the lower the birthweight the higher the mortality - the LOWER the gestational age, the higher the mortality.

B)Ballard Assessment & estimation of gestational age(application) fig24-2 p. 554 - A tool used to determine gestational age, is the NEW BALLARD SCORE, A.Estimation of gestational age by Maturity rating evaluating: Neuro muscular Maturity and Physical Maturity - assess six external physical and six neuromuscular signs, each sign has a numeric score and the cumulative score correlates with a maturity rating (Gestational age) Box 24-3 Manuvers used in Assessing Gestational Age -Posture: With infant quiet n in supine position , observe the degree of FLEXION in arms and legs. muscle tone and degree of flexion increase with maturity . Full flexion of the arms and legs= 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 infants 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 of 4 - Popliteal Angle: With the infant supine and pelvis flat on a firm surface, flex lower leg on thigh and then flex thigh on abdomen. While holding knew 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 midline with one hand; use other hand to pull infants arm across the shoulder so that infants hand touches shoulder. Determine location of elbow in relation to midline. elbow does not reach midline=score 4 - Heal 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 knew flexion (Same as popliteal angle ). Knees flexed with a popliteal angle of less than 10 degrees=score 4 .

Identification of risk factors (knowledge) Deviations from normal Range: Posture: Recognition of risk factors enables the nurse to more likely identify early signs of complications -This allows for earlier intervention and promote positive outcomes. Assess risk factors Maternal factors Prenatal factors Length of gestation Intrapartum factors Safety Alert: With the possibility of transmission of viruses such as hepatitis B Virus (HBV) and HIV through maternal blood and blood stained amniotic fluid, the newborn must be considered a potential contamination source until proved otherwise. As a part of standard precautions, nurses wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing.

Box 24-1 Assessment of Preconception, Prenatal , and Intrapartum Risk Factors A. Preconception: -age -pre-existing medical conditions: diabtetes, hypertension, cardiac disease, anemia, thyroid disorder, renal disease , obesity -Genetic Factors: Family history -Obstetric history: Gravidity, Parity, number of living children and their ages, hx of stillbirth, previous infant with congenital anomalies, habitual abortion, use of assisted reproductive technology, inter pregnancy spacing -Blood type and Rh Status B. Prenatal -Prenatal care: when started -Nutrition: weight gain, diet, obesity, eating disorders -Health-comprosing behaviors: smoking, alcohol use, substance abuse -Blood group or RH sensitization -Medications: presciption, OTC, CAM -History of infection: STI, TORCH infections, group B streptococcus status C. Intrapartum: -Length of gestation: preterm, late etc -First stage of labor: length , EFM, ROM, Signs of fetal distress

Interventions for hyperbilirubinemia (application) - the goal of care for the infant with hyperbilirubinemia is to prevent: A) Acute bilirubin Encephalopathy: Acute central nervous system s/sx that are seen in the first week -no direct s/x but directly related to level. a level of 25 mg/dl is considered the upper limit , beyond which the risk for acute bilirubin encephalopathy increases. -s/sx appear between 2 and 6 days after birth and go through several phases 1. First phase: newborn is hypotonic and lethargic, has poor suck, depresseed or absent moro reflex 2. Second phase: appearance of a high pitched cry, opisthotonos , spasticity, hyperreflexia and fever 3. Third phase: the neonate with demonstrate a Shrill cry, apnea, deep stupor to coma, seizures and hearing and visual disturbances note possible death can occur from cardiovascular collapse B) Kernicterus: used to describe the chronic and permanent results of bilirubin toxicity is irreversible, due to untreated hemolytic disease and hyperbilirubenemia greater than or equal to 25 to 30 mg/dl s/sx: over first year these are demonstrated: -hypotonia -Active deep tendon reflexes -Persistent tonic neck reflex -Upward gaze -Sensorineaual hearing loss -Difficulty meeting developmental milestones Severe cognitive impairment and spastic quadriplegia often occur. Tx is being SUPPORTIVE ! Flip for Care management

Care Management: -Initiate early feedings and feed frequently (breastfeeding at least every 3 hours and formula at least every 3-4 hours -Assess skin and mucous membranes for signs of jaundice, indicative of increasing bilirubin levels; monitor total serum bilirubin levels -Note time of jaundice onset - Assess for signs of hypoxia, hypothermia, hypoglycemia and metabolic acidosis -Initiate photo therapy per physcians order -Provide care consistent with mode of phototherapy -shield infants eyes if under phototherapy light -Keep infant nude except for diaper and change positions frequently -Keep skin clean and avoid use of lotions or creams -Maintain adequate fluid intake -Monitor body temperature -Before Exchange transfusion , keep infant on NPO status for 2-4 hours -Check donor blood for compatibility -Have resucitation equipement at bed side -Assit physician with exchange transfusion procedure -Track amounts of blood withdrawn and transfused -Maintain body temperature -Monitor vital signs and observe Condt -It is important to determine the blood type and RH factor of the pregnant woman prenatally. The nurse must obtain a thorough history to assess for events that could have caused the woman to develop antibodies tp the RH factors Prevention f hyperbilirubinemia is the primary prenatal focus of care. The implementation of interventions focused on the care of the woman who fetus is at risk for hyperbilirubinemia , is essential to preventing problems in the newborn. -prenatal control of diabetes , prevention of maternal infection, avoidance of drugs such as diazepam and salicylate near the time of birth -Prevention of preterm birth reduce the risk

Jaundice assessment and screening(application) p. 570 A)Physiologic jaundice: caused by increased levels of unconjugated bilirubin tx: self limiting, requires no tx peaks 3-5 days and resolves after 1-2 weeks Some tx may need photo therapy note: nurse must differentiate Physiologic jaundice from pathologic jaundice, B) Pathologic Jaundice: higher levels of bilirubin -apears in 1st 24hrs and requires tx: tx: phototherapy -Jaundice also can be associated with breast feeding C) Assessment: -assess all newborns for jaundice at least every 8 to 12 hrs - apply pressure with a finger over a bony area: nose, forehead, sternum for 7secs, the release -if jaundice is present, the blanched area will appear yellowish before the capillaries refill -Asses Conjunctival sacs and buccal mucosa in darker skinned infants -Assess in natural light

D) Interventions: Visual assessment isn't good enough use: Transcutaneous bilirubinometry (TCB) : works on dark skin and light skin infants -decreases the need for serum bilirubin measurements E) Interventions contd: -If an infant appears jaundiced in the first 24 hours of life, a TcB or TSB Total serum bilirubin level should be measured and results interpreted based on the newborns age in hours Repeat testing based on risk level, age , progression of jaundice Screening:p. 571 - In effort to prevent severe hyperbilirubinemia the recommend routine screening of all newborns before hospital discharge using TCB or Serum Bilirubin measurement A) if the TcB level is greater than 12mg/dl, a serum bilirubin check is done and levels are interpreted according to the hour specific nomogram

Identify types of grief (knowledge) Stages of grief: Acute distress - shock, numbness, intense crying, depression, bargaining Intense Grief- loneliness, emptiness, and yearning; guilt, anger, fear and anxiety (about getting pregnant again), disorganization, difficulties with cognitive processing, sadness and depression, physical symptoms Reorganization-search for meaning, reduction of distress, reentering normal life activities with more enthusiasm; can make future plans

Emotional Response to Perinatal Loss Often very intense emotions * Men and women grieve differently, but they both grieve * Grieving may last a few weeks, several months, or more than a year Miles model (p913) Significance of perinatal loss on families Grandparents- have hopes and dreams for a grandchild; these have been shattered. The grief of grandparents is often complicated by the fact that they are experiencing intense emotional pain by witnessing and feeling the immense grief of their own child. Young child-will respond more to the response of his or her parents, picking up on the fact that they are behaving differently and are extremely sad. This can cause clinging, altered eating and sleeping patterns, or acting out behaviors, yet it is a time when parents have limited patience for responding to and meeting the needs of the child. Older child- have a more complete understanding of the loss. School-aged children may be frightened by the entire event, whereas teens may understand fully but feel awkward in responding. Older siblings- need to be included in the grieving rituals to the extent the parents and the child feel comfortable. They may need to see the baby to actualize the loss. Reference: Lowdermilk and Perry (2007)

Renal system (knowledge) p. 529 -Born with approx 40ml in bladder -Should void in first 24 hours after birth -excrete 15 to 60ml/kg/day -Voids 2-6x per day of Pale straw colored urine=good fluid intake -An infant who has to voided by 24 hours should be assessed for adequacy of fluid intake, bladder distention, restlessness and symptoms of pain ...notify HCP - Full Term: limited capacity to concentrate urine, specific gravity is low less than 1.004 -"Brick dust" ( uric acid crystals) Normal 1st week ( after that is a sign of dehydration - if the mother is breast feeding and her milk supply has not come in yet, the neonate is protected from dehydration by its increased extracellular fluid volume. - When the babe looses weight over the first 3-5 days , the neonate should regain the birth weigh with in 10 to 14 days, depending on feeding method

Fluid and Electrolyte Balance - their are mostly 75% water -Most of the weight loss is during the first few days after birth causes by extracellular water loss. Daily fluid requirement: A. Weigh more than 1500g is 60 to 80 ml/kg (first 1-2 ays of life B 3-7 days : 100 to 150 ml/kg/day C. 8 to 30 days it is 120 to 180 ml/kg/day -due to the infants decreased ability to excrete sodium results in a higher concentration of etc - Bicarb and buffering are decreased, this can lead to acidosis and electrolyte imbalance S/Sx of renal problems 1. Lack of steady stream such as hypospadias and extrophy of the bladder -Enlarged or cystic kidneys can be identified as masses during abnormal palpation

Milk ejection or let down: -Tx mother the signs that milk injection has occurred 1. tingling sensation in nipples 2. Babe suck changes from quick to slower more drawing sucking pattern 3. Audbile swalloing is present 4. Early days: Uterine cramping and increased lochia during and after feedings 5. Mom feels relaxed or drowsy during feedings 6. opposite breast may leak

Frequency of feedings: How often should the baby nurse? 1.as soon as possible after birth -Babies have an initial alert phase, taking in phase(This is the best time to introduce it to breast) 2.In the first 24 hours, they may be sleepy and not nurse very often 2nd and 3rd day, 3.Tx parents that the baby should be wakened and nursed every 3 hours during the day and at least every 4 hours at night How do you wake up a baby? -The baby's stomach is only the size of a small marble at birth -Feedings: 8 - 12x/day

Risk factors for hyperbilirubinemia (knowledge) p. 881 1. Gestatioal age less than 37 weeks 2. Exclusive breastfeeding 3. Previous sibling who required phototherapy 4. Pre discharge trancutaneous bilirubin (TCB) or (TSB) Total Serum Bilirubin level in the high risk zone 5. Cephalhematoma or significant other bruising 6. Bllood impossibility with positive direct anti globulin test 7. Hemolytic disease such as glucose 6 phosphate dehydrogenase (G6PD) 8. East Asian Race

Hyperbilirubinemia (overview) - is a condition in which total serum bilirubin level in the blood is INCREASED. s/sx: yellow discoloration of the skin, mucous membranes, sclera and various organs -discoleration: known as Jaundice Jaundice: accumulation in the skin of unconjugated bilirubin, a breakdown product of hemoglobin formed after its release from hemolyzed red blood cells - first appears in Face and Head and then progresses toward toes Challenge is to distinguish physiologic jaundice from a serious clinical pathologic condition

Assessment of skeletal injuries( application) Nurses Assessing should be aware for clinical signs of birth trauma such as bruising; edema, abrasions, or absence, limitation or asymmetry of movement The neonate can experience : - impaired mobility - respiratory distress - acute pain as a result of birth trauma Parents are likely to react with concern and anxiety -The nurse provides explanations about the type of injury and treatment plan. -Parents may need assistance and support from the nurse as they provide care for the newborn Nurse: can demonstrate how to hold the infant to prevent discomfort from the injury two types of fractures are: Linear fractures and depressed fractures a) Linear fractions: most common in the parietal bones -Require no TX ...skull fractures are the common in fans with cephalhematoma b) depressed fractures: or "ping-pong ball" indentations can occur during difficult births from pressure of the fetal head on the bony pelvis. They can also occur as the result and use of forceps -a Ct scan is done to rule out bone fragments or underlying injury of th brain tissue - The clavicel bone is most bone often fractured during birth -difficulty delivery of the shoulders with a vaginal birth or extension of the arms in a breech birth often results in clavicular fracture - Risk factors: vacuum assisted birth and birth weigh greater than 4000g - limited movement of the arm , crepitus over the bone and the absence of the moro reflex on the affected side are diagnostic tx: gental handeling no other tx for fractured clavicle exists Flip

Interventions for skeletal injuires (Application) Nurse: post a sign on the bassinet to alert care providers - DO NOT USE THE FIGURE EIGHT BANDAGE The humerus and femur can be fractured during a difficult birth . note: Fractures in newborns generally heal rapidly. -Immobilization is accomplished with spellings, splints, swaddling and other devids Nurse: tx parents to practice handling, changing and feeding the affected neonate under guidance prior to hospital discharge

Feeding techniques (application) he mother needs to be taught the infant behaviors when the babe is ready to feed : FEEDING READINESS CUES r EARLY SIGNS OF HUNGER - Tx parent do not wait until babe is crying, feed on observance of these Cues 1)Hand-to-mouth or hand-to-hand 2)Sucking motions 3)Rooting reflex: infant moves toward whatever touches the area around the mouth and attempt to suck 4) Mouthing Positioning: -encourage and assist the mother to breastfeed in a SEMI-RECLINING Position with the newborn lying PRONE, SKIN to SKIN on moms bare chest - Four positions: the football, or clutch hold, modified cradle, cross cradle, side lying. -Tx mom to use the position that is most comfortable and facilitate latch -Football or clutch hold is most recommend Nurse: Suggest that she empty her bladder and attend to other needs before starting a feed

Latch: -Tx mother for prep to manually express a few drops of colostrum and spread it over the nipple to lubricate the nipple -If the babe is not opening the mouth , the mother should tickle the babys lips with her nipple stimulating the mouth to open - Tx that if feeding is painful , the babe has not taken enough of the breast into the mouth and the tongue is pinching the nipple Tx mother the signs and symptoms feeding is going well 1. The mother reports a FIRM tugging sensation on her nipple, but feels no pinching or pain 2. The baby sucks with cheeks ROUNDED , not dimpled 3. The baby jaw GLIDES SMOOTHLY with sucking and 4. Swallowing is AUDIBLE - If she does feel pain: Asses the latch and positioning. -Tx to prevent trauma to mother -inserting a finger in the side of the baby mouth between the gums and leaving it there until the nipple is completely out of the mouth -Nurse: Should observe at least one feeding every 8 to 2 hours Use the feeding scoring tool such as the LATCH (Latch, Audible swallowing, Type of nipple, Comfort level of the mother and Hold )

Sids (application) p. 590 -The AAP recommends placing the infant in the SUPINE position for sleep during the first year of life to prevent sudden infant death syndrome (SIDS) - Infants should lie on a firm surface - Firm crib mattress covered by a fitted sheet - No soft materials such as bumper pads , comforters, quilts, pillows sheepskins or stuffed toys should not be placed in the crib - no bed sharing - Infants may be brought into the parents bed for comfort or breast feeding but MUST BE RETURNED to the crib before the parent goes to sleep Flip

Parent teaching: to remind the parents about safe sleep practices - use the Mnemonic ABC " I sleep safest ALONE, on my BACK, in my CRIB -Side lying position is not recommend for sleep because of constant rolling back and forth -When infant is awake "TUMMY TIME" can be provided under parental supervision so the infant can begin to develop appropriate muscle tone for eventual crawling ; placing the infant prone at intervals when awake aids in preventing a misshapen head (Positional plagiocephaly) - Care of infant must be taken to prevent the infant from rolling off flat, unguarded surfaces - if you must turn away you should always keep one hand placed securely on the infant - always held securely with head supported

30. Interpreting bilirubin results (application) Beginning after 24 hours of age,Unconjugtaed bilirubin levels in A)Caucasian and African American Neonates: increase from 2mg/dl to peak levels of 5 to 6 mg/dl - Their is a rapid decline in levels to 3 mg/dl by 5 days after birth B) Asian-American infants - this level can increase to 10 to 14 mg/dl between 72 to 120 hours of age - Decline takes 7 to 10 days Jaundice is more common in preterm infants , with a serum bilirubin level reaching a mean peak of 10 to 12 mg by the fifth or sixth day of life note: its takes longer for maximal concentration to be reached in preterm than in full term because of infants immature liver function and slower metabolic process

Pathologic Jaundice : is the result of increased level of total serum bilirubin , when left untreated can cause: Acute bilirubin encephalopathy or kernicterus A) Acute bilirubin Encephalopathy: Acute central nervous system s/sx that are seen in the first week B) Kernicterus: used to describe the chronic and permanent results of bilirubin toxicity Nurse should be mindful of s/s that indicate pathologic jaundice , that warrant further investigation 1. Serum bilirubin concentrations of greater than 5 mg/dl in cord blood 2. Clinical jaundice evident within 24 hours of birth 3. Total serum bilirubin level in a term newborn that exceeds 12.9 mg/dl at any time 4. A serum bilirubin level in a preterm newborn that exceeds 15mg/dl at any time 5. Any case of visible jaundice that permits for more than 14 days of life in a term infant To screen infants for risk of hyperbilirubin: use "Hour specific serum bilirubin levels" to predict risk - Use a nomogram to help determine which newborns might need further eval after discharge

Pain management (application) p. 583 Goals: 1) minimize the intensity, duration and physiologic cost of the pain 2) maximize the neonate ability to cope with and recover from the pain Non-pharmacologic: 1)Swaddling or snugly wrapping infant in blanket Safety alert: Swaddling an infant tightly with legs extended is associated with increased risk for hip dislocation (DDH) note: the correct way to swaddle an infants with the hips in slight flexion and abducted and allowing freedom of movement of the knees . -do not wrap to tightly can caught overheating and respiratory distress - there should be space for 2 to 3 adult fingers between the infants chest -Swaddling not recommend after2 months 2)Nonnutritive sucking (NNS) on a pacifier 3)Oral sucrose in small amounts: in reducing neonatal pain during painful procedures Oral sucrose and NNS is used before and after 4) Skin to skin contact , also known as kangaroo care 5) breastfeeing or beat milk helps reduce pain during heal lancing and blood collection 6) Distraction with visual, oral tactile stimulation 7) sensorial saturation uses: multiple senses to diminish minor pain 8) Touch, massage, rocking, holding and environmental modification Flip for Pharmacologic

Pharmacologic management: Non-opioid Analgesia (Oral liquid acetaminophen: is effective for mild to moderate pain from inflammatory conditions -Morphine and Fentanyl are the most widely used opioid analgesics for pain management of neonatal pain

Transitioning to extrauterine life (application) - these are changes that includes changes in heart rate , respirations and gastrointestinal function. 3 stages of new born transition A) 1st stage: lasts for 30 mins -Hr 160-180 -Respirations irregular -RR: at 60 to 80 bpm -Fine Crackles -Grunting -Nasal flaring -Retractions of chest -Infant is Alert + moro, startle -Bowel sounds are audible -Possibly Meconium B) After the 1st period -60-100 minutes -Decreased activity/sleepiness -Pink -Respirations are shallow up to 60/min unlabored -BS Audible -Nice color C) 2nd period of reactivity -Occurs 2-8 hours after birth -Lasts 10 min-hours -Briefly tachycardia, & tachypnea -Increased muscle tone, color changes -Mucus production -Passage of mecocium

Physiologic Adjustments: A) Breathing: Initiation of breathing their is no single trigger for newborn respiratory function result of a combination of 4 factors: -Chemical, -mechanical, -thermal and -sensory factors B) Surfactant is essential: Alveoli is lined with this helps with lung expansion C) New borns are NOSE BREATHERS -Diaphragmatic excursion: Abdominal breathing is characteristic of newborns Signs of distress: -Nasal flaring -Intercostal retractions -Grunting with resps. -Stridor -Paradoxical respirations -RR less than 30/min -Could be analgesic effect -Rapid change in body temp -Or greater than 60 -Retained fluid -RDS -Infection -Central cyanosis -Persistant acrocyanosis -Central cyanosis -TTNB usually evident in 1-2 hours past birth Supplemental O2

Sepsis, risk for and prevention of (application) Sepsis is the presence of microorganisms or their toxins in blood or tissue . -Newborns are highly susceptible because of their immature immune system. Risk Factors for Neonatal Sepsis: Maternal: Low socioeconomic status, late or no prenatal care, poor nutrition, substance abuse, recently acquired STI , Untreated focal infection, systemic infection, Fever Intrapartum: Premature rupture of fetal membranes, Maternal fever, Chorioamnionitis, Prolonged labor, Premature labor, use of fetal scalp electrode Neonatal: Multiple gestation, male, birth asphyxia, Meconium aspiration , Congenital anomalies of skin or mucous membranes , metabolic disorders (Galactosemia), Low birth weight , Preterm birth, Malnourishment, Formula Feeding , Prolonged hospitilization, Mechanical ventilation , Umbilical artery cauterization or use of other vascular catheters

Prevention measures: WASHING HANDS has demonstrated effective prevention of HACI in nursery units Nurses: -Play major role - implement standard precautions -carefuly and thorughly cleaning the environment (e.g Changing IV tubing per hospital protocol, cleaning resuscitation and ventilation equipment) -Appropriates disposing of excitement and linens Hand hygiene is the single most important measures in preventing the spread of infection -Nurse should provide appropriate education to ensure that good hand hygiene is used frequently. - Overcrowding should be avoided in nurseries -Specific newborn care procedures are intended to prevent infection. Theses include -Instilling antibiotic ointment in newborns eyes 1 to 2 hours after birth, bathing and cord area

Roles of the RN (application) The Carring theory: by Knowing- attempting to understand the event as it has meaning in the life of the parents Being with- or being emotional present Doing for- as you would want to be done for you Enabling- to facilitate the parent's passage through life transitions and unfamiliar events Maintaining faith- ask for name of clergy to come and assist, imprinting positive memories to sustain them

Recognition and Validation of the Loss Emotional Availability Spiritual and Cultural Accommodation Physical Presence Open Communication Normalization of Grief Reactions Decision-Making Assistance Interdisciplinary Involvement Nonjudgmental Attitude Genuine Caring

Assessing respiratory status ( knowledge) p. 817 -Respiratory Function: the preterm infant is most likely to have difficulty transiting Nursing Assessment: things the nurse needs to be aware of for a preterm infants of the physiologic status A) Types of problems that affect Respiratory systems: -Decreased # 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 B)Respiratory difficulty often follows a pattern 1. Infants normally breathe between 30 and 60 breaths/min relying on Abdominal muscles to accomplish this C) Early signs include -Flarring of the nares -Expiratory grunt -retractions: subcostal, suprasternal or intercostal If they show signs of INCREASING RESPIRATORY EFFORT: - seesaw breathing patterns -Retractions -Flaring of the nares -Expiratory grunting -Apneic spells THIS INDICATES DEEPENING DISTRESS - a compromised infants color progresses from: Pink to Circumoral cyanosis to Generalized cyanosis Nursing alert" Acrocyanosis is a normal finding in the neonate, but central cyanosis indicates an underlying problem that requires immediate evaluation. Periodic breathing: is a respiratory pattern commonly seen in preterm infants. such infants exhibit 5 to 10 second respiratory pauses followed by 10 to 15 seconds of compensatory rapid respirations - this should not be confused with apnea, which is a 20 second or greater cessation of respiration, or a shorter pause accompanied by: - bradycardia -cyanosis -hypotonia

Respiratory care : P. 823 Oxygen therapy: clinical criteria that indicate the need for oxygen administration include: - Increased respiratory effort -Respiratory distress with apnea -Tachycardia -Bradycardia - Central Cyanosis -With or without hypotonia - Oxygen pressure (Pao2) of less than 60 mm hg or and oxygen saturation of less than 92% note: oxygen admin to infant is: Warmed and humidified to prevent cold stress and drying If delivering oxygen of more than a few minutes: you must use (hood, nasal cannula, positive pressure mask or endotracheal tube) - Possible complications of oxygen therapy include ROP and BPD - Nurse must asses respiratory status hourly 1. Continuous pulse ox reading and at least one blood gas measurement 2. Hourly documentation: amount and route n mode Neonatal Resuscitation: a) A rapid assessment of infants can indefinitly who do not require resuscitation: - no evidence of meconium or infection in the amniotic fluid -those who are breathing or crying - good muscle tone note if any of these are absent, the infant should receive : 1. Place baby under a radiant warmer, position the head to open the airway, clear the airway with a bulb syringe or suction catheter, dry the babe, stimulate breathing and reposition the baby 2. Provide Ventilation 3. Chest compressions 4. Administration of epinephrine or volume expansion or both -For infants of Resuscitation of Asphyxiated new borns use 21% (Room air) oxygen rather than 100% - AHA resucitation standards for neonatal resuscitation indicate that if the infants condition does not improve within 90 seconds , supplemental oxygen should be provided. - The mount of oxygen to use should be determined by the infants oxygen saturation level and age in minutes ELBW: oxygen saturation maintained between 88% and 93 % but not exceeding 95% 1)Hood therapy: -Can be used for infants who no not require mechanical pressure support -Oxygen amount is controlled -Nurse assess the oxygen saturation at least every hour , concentration must be adjusted in repose to the infants condition -If hood is removed for holding feeding or suctioning and alternative source of oxygen must be provided. 2)Nasal Cannula: these allow adequate , continuous flow of oxygen while allowing optimal vision, positioning and parental holding. Infants can breast feed or bottle feed while receiving oxygen by this method - Proper fit is essential -Prongs must be inspected and cleaned frequently to make sure they are not obstructed by milk or secretions 3) Counties positive Airway Pressure Therapy (CPAP): Infants who are unable to maintain and adequate Pa02 uses CPAP: infuses oxygen or air under a preset pressure by means of nasal prongs of a face mask Nurse: an orogastric tube should be in place for decompression of the stomach during use of nasal prongs - CPAP can cause shunting which can lead to pulmonary hypertension and severe respiratory distress 4) Mechanical Ventilation: - used when blood gas values demonstrate severe hypoxemia or severe hypercapnia. Weaning from Respiratory Assistance: - Respiratory assistance is weaned slowly as the infants status is improved - once ABGs and Oxygen saturation levels are maintained within normal limits Through out the weaning process, the infants oxygen levels are monitored by pulse oximetry , TCPO2 monitoring and blood gas levels -Infant is assessed for signs and symptoms indicating poor tolerance of the process - Increased pulse, repisratoy distress or cyanosis : if these occur the amount of oxygen being delivered is increased and the weaning proceeds more slowly.

Risk or hyperbilirubinemia(knowledge) - All infants should be considered as being a potential risk for hyperbilirubinemia Even if they were LOW RISK - all newborns should be followed after hospital discharge for the development of unexpected jaundice -Tx parents s/sx and how to prevent: -adequate feeding: breast feed early with 1 to 2 hours after birth and often at least 8 to 12 times/24 hours why: colostrum acts as a laxative to promote stooling , which helps rid the body of bilirubin Formula fed : feed every 3 to 4 hours

Risk factors for Hyperbilirubinemia -GA less than 38 wks, -Exlcusive breast feeding(Especially in association with breast feeding difficulties and excessive weight loss -Significant jaundice in sibling -Isoimmune or hemolytic disease G6PD Defiency -Cephalhematoma -Significant bruising -East indian race -Close follow up on infant Nurse should educate and encourage to follow discharge recommendations Follow up should occur 48 to 72 hours after discharge or sooner

Apgar scoring (application) p. 550 -initial assessment of the neonate is performed immediately after birth using the APGAR SCORE and a brief physical examination - Apgar permits RAPID ASSESSEMENT of newborns transitions to outside life based on Five signs 1) heart rate 2) respiratory effort 3) muscle tone 4) reflex irritability: based on the response to suctioning of the nares or nasopharynx 5) Generalized skin color, described as pallid, cyanotic or pink Assessments are made at 1 and 5 mins after birth can be completed by NURSE or BIRTH ATTENDANT - Score of 0 to 3 indicate severe distress -Score of 4 to 6 indicate MODERATE DIFFICULTY -Score of 7 to 10 indicate that the infant is having minimal or no difficulty adjusting to extrauterine life note: APGAR Scores DO NOT PREDICT FUTURE NEUROLOGIC OUTCOME but are useful for: Describing the newborns transition to the extrauterine environment and the need for Resuscitation

Table 24-1 Agar Score ( Sign) (Score) (a)Heart rate : Absent: 0 Slow (<100/min): 1 >100/min: 2 b) Respiratory Effort: Absent 0 Slow, weak cry 1 Good cry 2 C) Muscle Tone: Flaccid 0 Som Flex of Extremities 1 Well Flexed 2 D)Reflex Irritability : No response: 0 Grimace 1 Cry 2 E) Color: Blue, pale 0 Body pink,blue extremities.: 1 Completely pink: 2

Nursing interventions, Providing care: -Assess the patient experience -Be a good listener -Gather data -Culture -Social network Nursing Interventions: A) Supportive intervention enabling the mother/family to accept the reality of death note: One way of actualizing the loss is to tell the parents the sex of the baby and give them the opportunity to name the baby so that the baby can be remembered in a special way. Seeing the baby also helps to actualize the loss- give them an expectation as to what to expect. b) Try to make the baby look as normal as possible. Dress the baby up in a special outfit. In the memory box place pictures of the infant, a lock of the infants hair if possible, foot or hand prints if possible. Create memories for them to take home. Offer infant baptism or dedicaton. C) -Bereavement counseling -Make referrals to community resources -Follow up phone calls note: Assist the bereaved in communicating with, supporting, and getting support from the family 1. Helping parents with holding their fetus or infant 2. Helping Parents with designs Regarding Autopsies , Organ Donation and Disposition of the body 3. Helping the Bereaved Parents Acknowledge and express their feelings 4. Helping them Understand differing responses to loss 5. Meeting their physical needs of bereaved mother in the postpartum period. 6. Assiting in communicating and establishing support from family members 7. Creating Memorabilia for parents to take home 8. Adressing Cultural and Spiritual Needs of the parents 9. Provising Sensitive Discharge and follow up care 10. Providing post mortem care

Therapuetic Communication: Helpful: A) What to say Some responses to grieving mothers and their partners are helpful and others are hurtful. Let's take a moment to review comments on this slide that are helpful, and those that can be hurtful. -Im sad for you -how are you doing with all of this -This must be hard for you - Im sorry -Im here and I want to listen B)What not to say -God had a purpose for her -Be thankful you have another child -The living must go on -I know how you feel -Its gods Will -You have to keep on going for her sake -your young you can have others -well see your back here next year and you'll be happier -now you have an angle in heaven -This happened for the best -Better for this to have happened now , before you knew the babe - There was something wrong with the babe any way

Immediate care after birth (application) - Primary goal of care is to assist the newly born infant to transition to extrauterine life by ESTABLISHING EFFECTIVE RESPIRATIONS - If the infant is at term, is crying or breathing and has good muscle tone, routine care can begin. - Infant is placed PRONE skin-to skin on mom -Dry infant with vigorous rubbing removes moisture to prevent evaporation heat loss and provides stimulation to stimulate respiratory effort. -if neonate is apnea or has gasping respirations, Positive pressure ventilation is needed

Vital signs & measurements: A) Assess HR & RESP 1st -By grasping the BASE OF THE CORD or by Ausculating the LEFT CHEST with a Stethoscope( Lt sternal boarder (foramen ovale: common to detect brief irregularities in the heart rate) -norm Hr: 110-160 bpm -Periodic respirations in 1st period of reactivity (50-60min) (Can cease for seconds <20) and resume again note: can exceed 60 if very active and breathing -BP 60-80/40-50 @birth (if measured an Ocillometric monitor calibrated for neonatal pressures is preffered B)Axillary temp (3rd) -causes infant to cry and struggle so do this after HR and Respirations -Not temporal or tympanic! Prevent heat loss: evaporation, conduction, convection, radiation -mRisk for hypothermia norm temp: 37C (98.6F), with range from 36.5 (97.7) to 37.5C (99.5) C)Weight, length, head and and circumference 1.weight: neonate is unclothed placed on scale with pad or cloth to Prevent HEAT LOSS via CONDUCTION -2500 to 4000g (5.5lbs to 8.8lbs) 2. Head and circumference: measured at the OCCIPITOFRONTAL DIAMETER -32 to 36.8 (12.6 to 14.5 in) length: extend leg until the Knee is flat against the surface , place head against with obtaining this measurement.

Assessment of complications of macrosomia (application) - infant has: round face, chubby body, flushed complexion -Because insulin does not cross the blood brain barrier, the brain is the only organ that is not enlarged -Infants with mothers with diabetes can be LGA but Physiologically immature. Maternal diabetes results in elevated amino acids, free fatty acids along with hyperglycemia. -Insulin has been proposed as the primary growth hormone for intrauterine development - As nutrients cross the placenta the fetal pancrease responds by producing insulin to match the fuel supply 0Resulting in accelerated everything resulting in the macrosomial infant Flip for complications

the infant is most at risk for for: -hypoglycemia, hypocalcemia, hyperviscosity and hyperbilirubinemia Consequent fetal hyperinsulinism represents the basic pathologic mechanism in diabetic pregnancy -the excessive shoulder size in these infants often leads to dystocia -Can insure birth trauma such as clavicle fracture or brachial plexus injury These infants are at risk for RDS (Respiratory Distress Syndrome) - Respiratory Distress Syndrome maternal hypergylcemia can affect fetal lung maturity -Infants exposed to high levels of Maternal glucose, synthesis of surfactant can be delayed because of the high fetal serum levels of insulin or glucose Infants with poorly controlled maternal diabetes is at higher risk.