Chapter 22: Physiological and Behavioral Adaptations of the Newborn

Hyperbilirubinemia

-A condition in which there is too much bilirubin in the blood. When red blood cells break down in the liver, a substance called bilirubin is formed. Babies are not easily able to get rid of the bilirubin and it can build up in the blood and other tissues and fluids of the baby's body. This is called hyperbilirubinemia. Because bilirubin has a pigment or coloring, it causes a yellowing of the baby's skin, eyes, and other tissues. This is called jaundice. -Has variety of etiologic factors, including maternal-fetal Rh and ABO incompatibility

Most common major congenital anomalies that cause serious problems in neonate are:

-Cleft lip or palate -Clubfoot -Developmental dysplasia of the hips -Congenital heart disease -Neural tube defects

Risks associated with cold stress for the preterm infant:

-DECREASED SUPPLY OF BROWN ADIPOSE TISSUE (BAT) -HYPOTONIA -IMMATURE TEMPERATURE REGULATING CENTER IN THE BRAIN

Metabolic Rate Goes UP=

-Glucose goes down -Hypoglycemia -NONSHIVERING THERMOGENESIS (production of heat) -METABOLISM OF BAT (BROWN ADIPOSE TISSUE (BAT)) -anaerobic glycolysis (the transformation of glucose to lactate when limited amounts of oxygen (O2) are available. Anaerobic glycolysis is only an effective means of energy production during short, intense exercise, providing energy for a period ranging from 10 seconds to 2 minutes) increases and decrease in PO2 and pH=METABOLIC ACIDOSIS

Infection in newborn may be acquired:

-In utero -At birth -In breast milk -Within nursery

HEAT PRODUCTION RESULTS IN:

-NONSHIVERING THERMOGENESIS -MUSCULAR ACTIVITY -INCREASED METABOLIC RATE

Characteristics of the preterm infant that make him/her susceptible to cold stress:

-POOR MUSCLE TONE -DECREASED SUBCUTANEOUS TISSUE -THIN PERMEABLE SKIN -HIGHER RATIO OF BODY SURFACE TO BODY WEIGHT -DECREASED ABILITY TO VASOCONSTRICT

OXYGEN CONSUMPTION Goes Up=

-Respiratory rate goes up and oxygen consumption increases -VASOCONSTRICTION -Hypoxia -PULMONARY PERFUSION goes down -SURFACTANT goes down -RETURN TO FETAL CIRCULATION -RESPIRATORY DISTRESS

Jaundice

-The visible yellowish color of skin and sclera caused by elevated serum levels of unconjugated (indirect) bilirubin. -Physiologic jaundice occurs in 60% of term infants and 80% of preterm infants. -Jaundice is considered pathologic if it appears within the first 24 hours of life, if serum levels increase by more than 6 mg/dl in 24 hours, or if serum bilirubin exceeds 15 mg/dl at anytime.

The nurse assisted with the birth of a newborn. Which nursing action is most effective in preventing heat loss by evaporation? A. Warming the crib pad B. Closing the doors to the room C. Drying the infant with a warm blanket D. Turning on the overhead radiant warmer

Answer: D Rationale-P.389

What is the heart rate for term newborns?

120 to 160 bpm with brief fluctuations above and below these values usually noted during sleep and waking states

Galant reflex, or truncal incurvation reflex

It is elicited by holding the newborn in ventral suspension (face down) and stroking along the one side of the spine. The normal reaction is for the newborn to laterally flex toward the stimulated side. https://www.youtube.com/watch?v=bswn56Qg_XM

A TEMPERATURE WITHIN NORMAL RANGE in neonate is?

36.5 - 37.2 DEGREES CENTIGRADE

In most healthy newborns, blood glucose levels stabilize at __ mg/dL during the first hours after birth:

50 to 60 Rationale: In most healthy term newborns, blood glucose levels stabilize at 50 to 60 mg/dL during the first several hours after birth. A blood sugar level less than 40 mg/dL in the newborn is considered abnormal and warrants intervention. This infant can display classic symptoms of jitteriness, lethargy, apnea, feeding problems, or seizures. By the third day of life, the blood glucose levels should be approximately 60 to 70 mg/dL.

What would be a warning sign of ineffective adaptation to extrauterine life if noted when assessing a 24-hour-old breastfed newborn before discharge? A. Apical heart rate of 90 beats/min, slightly irregular, when awake and active B. Acrocyanosis C. Harlequin color sign D. Weight loss representing 5% of the newborn's birth weight

A. Apical heart rate of 90 beats/min, slightly irregular, when awake and active Rationale: The heart rate of a newborn should range from 120 to 140 beats/min, especially when active. The rate should be regular with sharp, strong sounds. Acrocyanosis is a normal finding in a newborn at 24 hours of age. A harlequin sign is a normal finding related to the immature neurologic system of a newborn. A 5% weight loss is acceptable in the newborn.

A nurse caring for a newborn should be aware that the sensory system least mature at the time of birth is: A. Vision B. Hearing C. Smell D. Taste

A. Vision Rationale: The visual system continues to develop for the first 6 months. As soon as the amniotic fluid drains from the ear (minutes), the infant's hearing is similar to that of an adult. Newborns have a highly developed sense of smell. The newborn can distinguish and react to various tastes.

Central Cyanosis

Abnormal in newborns and signifies hypoxemia

The nurse notes that, when placed on the scale, the newborn immediately abducts and extends the arms, and the fingers fan out with the thumb and forefinger forming a "C." This response is known as a: A. tonic neck reflex. B. Moro reflex. C. cremasteric reflex. D. Babinski reflex.

B. Moro reflex Rationale: Tonic neck reflex refers to the "fencing posture" a newborn assumes when supine and turns the head to the side. These actions show the Moro reflex. The cremasteric reflex refers to retraction of testes when chilled. The Babinski reflex refers to the flaring of the toes when the sole is stroked.

Vitamin K is given to the newborn to: A. reduce bilirubin levels. B. increase the production of red blood cells. C. enhance ability of blood to clot. D. stimulate the formation of surfactant.

C. enhance ability of blood to clot. Rationale: Vitamin K does not reduce bilirubin levels. Vitamin K does not increase the production of red blood cells. Newborns have a deficiency of vitamin K until intestinal bacteria that produce vitamin K are formed. Vitamin K is required for the production of certain clotting factors. Vitamin K does not stimulate the formation of surfactant.

An examiner who discovers unequal movement or uneven gluteal skinfolds during the Ortolani maneuver: A. tells the parents that one leg may be longer than the other, but they will equal out by the time the infant is walking. B. alerts the physician that the infant has a dislocated hip. C. informs the parents and physician that molding has not taken place. D. suggests that if the condition does not change, surgery to correct vision problems might be needed.

B. alerts the physician that the infant has a dislocated hip. Rationale: This is an inappropriate statement that may result in unnecessary anxiety for the new parents. The Ortolani maneuver is a technique for checking hip integrity. Unequal movement suggests that the hip is dislocated. The physician should be notified. Molding refers to movement of the cranial bones and has nothing to do with the infant's hips. The Ortolani maneuver is not a technique used to evaluate visual acuity in the newborn. This maneuver checks hip integrity.

The nurse helps a breastfeeding mother change the diaper of her 16-hour-old newborn after the first bowel movement. The mother expresses concern since the large amount of thick, sticky stool is very dark green, almost black in color. She asks the nurse if something is wrong. The nurse should respond to this mother's concern by: A. telling the mother not to worry since all breastfed babies have this type of stool. B. explaining to the mother that the stool is called meconium and is expected of all newborns for the first few bowel movements. C. asking the mother what she ate at her last meal. D. suggesting that the mother ask her pediatrician to explain newborn stool patterns to her.

B. explaining to the mother that the stool is called meconium and is expected of all newborns for the first few bowel movements. Rationale: This type of stool is the first stool that all newborns, not just breastfed babies, have. At this early age this type of stool (meconium) is typical of both bottle-fed and breastfed newborns. The mother's nutritional intake is not responsible for the appearance of meconium stool. The nurse is fully capable of and responsible for teaching a new mother about the characteristics of her newborn, including expected stool patterns.

When caring for a newborn, the nurse must be alert for signs of cold stress, including: A. decreased activity level. B. increased respiratory rate. C. hyperglycemia. D. shivering.

B. increased respiratory rate. Rationale: Infants experiencing cold stress would have an increased activity level. An increased respiratory rate is a sign of cold stress in the newborn. Hypoglycemia would occur with cold stress. Newborns are unable to shiver as a means of increasing heat production; they increase their activity level instead.

A newborn male, estimated to be 39 weeks of gestation, would exhibit: A. extended posture when at rest. B. testes descended into scrotum. C. abundant lanugo over his entire body. D. ability to move his elbow past his sternum.

B. testes descended into scrotum. Rationale: The newborn's good muscle tone will result in a more flexed posture when at rest. A full-term male infant will have both testes in his scrotum and rugae on his scrotum. The newborn will exhibit only a moderate amount of lanugo, usually on his shoulders and back. The newborn would have the inability to move his elbow past midline.

Neonatal Period

Birth through day 28 of life

Acrocyanosis

Bluish dicoloration of infant's hands and feet; normal finding within first 24 hours after birth

What are the 4 modes heat loss in newborns?

Convection, radiation, evaporation and conduction

When weighing a newborn, the nurse should: A. leave its diaper on for comfort. B. place a sterile scale paper on the scale for infection control. C. keep hand on the newborn's abdomen for safety. D. weigh the newborn at the same time each day for accuracy.

D. weigh the newborn at the same time each day for accuracy. Rationale: The baby should be weighed without a diaper or clothes. Clean scale paper is acceptable; it does not need to be sterile. The nurse's hand should be above, not on, the abdomen for safety. Weighing a newborn at the same time each day allows for accurate weights.

Major adaptations associated with transition from intrauterine to extrauterine life occur when in a newborn?

During the first 6 to 8 hours after birth

Examples of physiological tasks of the newborn are

Establishing and maintaing respirations, adjusting to circulatory changes, regulating temperature, ingesting, maintaing and digesting nutrients, eliminating waste and regulating weight.

Nervus Simplex

Flat pink capillary hemangiomas that are easily blanched.

Hyperthermia

Greater than 99.5 degrees Farenheit

Stepping or "walking" reflex

Hold infant vertically under arms or on trunk, allowing one foot to touch table surface------Infant will simulate walking, alternating flexion & extension of feet https://www.youtube.com/watch?v=BiRtE240yZ4

Rh incompatibility:

If fetus is Rh positive and mother Rh negative, mother forms antibodies against fetal blood cells.

Magnet Reflex

If pressure is applied to the soles of the feet of an infant lying in supine position, she/ he pushes back against the pressure with limbs.

Physical signs of central cyanosis

Lips and mucous membranes are bluish

What is the leading cause of death in neonates?

Major congenital defects

COLD STRESS=

Metabolic Rate and Oxygen Consumption go UP=HYPERBILIRUBINEMIA (an excess of bilirubin in the blood, occurring as a result of liver or biliary tract dysfunction or with excessive destruction of red blood cells.) When an infant is stressed by cold, oxygen consumption increases and pulmonary and peripheral vasoconstriction occur, decreasing oxygen uptake; anaerobic glycolysis increases and a decrease in PO2 and pH, leading to metabolic acidosis

Glabellar (Myerson) reflex

Newborn blinks for first four or five taps on head by nurse.

Extrusion reflex

Newborn forces tongue outward https://www.youtube.com/watch?v=oXiCIGcz8ww

The newborn's nurse should alert the health care provider when which newborn reflex assessment findings are seen? (Select all that apply) Newborn turns head toward stimulus when eliciting rooting reflex. Newborn's fingers fan out when palmar reflex checked. Newborn forces tongue outward when tongue touched. Newborn exhibits symmetric abduction and extension of arms, and fingers form "C" when Moro reflex elicited. Newborn's toes hyperextend with dorsiflexion of big toe when sole of foot stroked upward along lateral aspect.

Newborn turns head toward stimulus when eliciting rooting reflex. Rationale: When eliciting rooting reflex, the characteristic response is for the baby to turn head toward stimulus and open mouth. The baby's fingers should curl around the examiner's fingers when eliciting the palmar reflex. Extrusion is elicited by touching tongue, and newborn's tongue is forced outward. The newborn should elicit symmetric abduction and extension of the arms and fingers form a "C" with the Moro reflex. The Babinski reflex is elicited by stroking upward along the lateral aspect on the sole of the feet. The expected response is hyperextension of the toes with dorsiflexion of the big toe.

Crossed Extension

Opposite leg flexes, adducts (towards body midline) and then extends https://www.youtube.com/watch?v=guPMLrbhfzk

What is the greatest risk factor for neonatal infection?

Prematurity because of the immaturity of the immune system

Examples of behavioral tasks include

Processing, storing and organizing multiple stimuli, establishing a relationship with caregivers and the environment and establishing a regulated behavioral tempo independent of the mother, which involves self-regulating arousal, self-monitoring changes in state, and patterning sleep.

Ineffective Thermoregulation=

RISK FOR INJURY: HYPOGLYCEMIA RESPIRATORY DISTRESS HYPERBILIRUBINEMIA

Deep tendon reflexes

Reflex jerks https://www.youtube.com/watch?v=GyUDa2-zZLI

Hypothermia

Result of excessive heat loss and is a common and dangerous problem.

Sucking Reflex

Rooting helps the baby become ready to suck. When the roof of the baby's mouth is touched, the baby will begin to suck.

Grasp reflex (Palmer and Plantars)

Stroking the palm of a baby's hand or foot causes the baby to close his or her fingers or toes in a grasp

What is the term newborn's average blood pressure?

Systolic=60-80 mm Hg; Diastolic=40-50 mm Hg

Most common maternal infections associated with congenital malformations represented by acronym

TORCH

Moro reflex

The Moro reflex is often called a startle reflex because it usually occurs when a baby is startled by a loud sound or movement. In response to the sound, the baby throws back his or her head, extends out the arms and legs, cries, then pulls the arms and legs back in. Fingers fan out and form c with thumb and forefinger. A baby's own cry can startle him or her and trigger this reflex.

CONVECTION examples

The flow of heat from the body surface to cooler ambient air. Examples: Air conditioner, blanket kicked off

Preterm infants are at risk for problems related to:

The immaturity of organ systems

RADIATION example

The loss of heat from the body surface to a cooler solid surface not in direct contact, but in relative proximity. An example is putting a neonate near a window.

CONDUCTION example

The loss of heat from the body surface to cooler surfaces in direct contact. Example: cold hand on baby

Thermoregulation

The maintenance of balance between heat loss and heat production.

What is the neonate's most critical adaptation to extrauterine life?

The neonate's most critical adaptation to extrauterine life is to establish effective respirations.

Mongolian Spots

They are flat, gray-blue in color (almost looking like a bruise), and can be small or large. They are caused by some pigment that didn't make it to the top layer when baby's skin was being formed. Usually found in darker skinned babies.

Newborn Root reflex

This reflex begins when the corner of the baby's mouth is stroked or touched. The baby will turn his or her head and open his or her mouth to follow and "root" in the direction of the stroking. This helps the baby find the breast or bottle to begin feeding.

THERMOREGULATION IN THE PRETERM INFANT

To maintain a neutral thermal environment (NTE) in which oxygen consumption and metabolic rate are minimal, but adequate to maintain body temperature

EVAPORATION examples

Wet hair, wet diaper, milk on shirt

Newborn Tonic Reflex

When a baby's head is turned to one side, the arm on that side stretches out and the opposite arm bends up at the elbow. This is often called the "fencing" position.

Thermogenesis

When in response to cold, the neonate attempts to generate heat by increasing muscle activity.

Pull to Sit Postural Tone

When pulling infant forward with their wrists, head lags until upright position, head is held in same plane with chest and shoulder momentarily before falling forward; infant attempts to right head.

Babinski reflex

When the sole of the foot is firmly stroked, the big toe bends back toward the top of the foot and the other toes fan out. This is a normal reflex up to about 2 years of age.

TORCH infections

includes Toxoplasmosis, Other (syphilis, varicella-zoster, parvovirus B19, Hepatitis B), Rubella, Cytomegalovirus (CMV), and Herpes infections are some of the most common infections associated with congenital anomalies

Nevus flammeus

is a discoloration of the human skin caused by a vascular anomaly (a capillary malformation in the skin).

Heat loss in the healthy term newborn may exceed the capacity to produce heat, which can cause

metabolic and respiratory complications that threaten the newborn's well-being

Erythema Toxicum

pink rash that appears suddenly anywhere on the body of a term newborn during the first 3 weeks.