OB Quiz 4: Part 1

When does cold stress occur?

it occurs when there is a: decrease in environmental temperatures -> a decrease in the neonate's body temperature -> an increase in respiratory rate, heart rate -> an increase in oxygen consumption, a depletion in glucose, and a decrease in surfactant -> respiratory distress can delay the transition from fetal to neonatal transition

What are the three major fetal circulatory structures that undergo changes?

ductus venosus, foramen ovale, ductus arteriosus

What is the most immediate and critical physiological change that occurs from transition to fetus to neonate?

establishment of extrauterine respirations

Cold stress

excessive heat loss that leads to hypothermia and results in the utilization of compensatory mechanisms to maintain the neonate's body temperature

Describe the initiation of respiration on the effect of pulmonary circulation:

first breath -> increase in alveolar oxygen tension and decrease in arterial pH -> dilation of pulmonary arteries -> decrease in pulmonary vascular resistance -> increase blood floe through pulmonary vessels -> increase oxygen and carbon dioxide change within the lungs

Example of artificial passive immunity

gamma globulin, which provides immediate protection for a short time

When does the transition to extrauterine life begin?

when umbilical cord is clamped and neonate takes their first breath - which initiates various changes within the neonates physiological systems

When ductus arteriosus close?

within 15 hours post birth occurs when the pulmonary vascular resistance becomes less than system vascular resistance -> left to right shunt -> closure of ductus arteriosus it will remain open if lungs fail to expand or PaO2 levels drop

Transitional Stool

-begins around the 3rd day and can continue for 3 or 4 days -stool transitions from black to greenish black, to greenish brown, to greenish yellow -occurs both in breastfed and forumla fed

Preventative Nursing Actions for Cold Stress

-dry the neonate thoroughly immediately after birth to decrease heat loss due to evaporation -remove wet blankets from the neonate's direct environment to decrease heat loss due to radiation, evaporation, and conduction -place a stocking cap on the neonate's head to decrease heat loss due to radiation and convection -use pre-warmed blankest and clothing to decrease heat loss due to conduction

Functions of the liver

-Carbohydrate metabolism: liver regulates the blood glucose levels by: converting excess glucose to glycogen, converting glycogen to glucose when glucose levels are low -Amino acid metabolism -Lipid metabolism -Synthesis of plasma proteins -Blood coagulation -Conjugation Bilirubin -Detoxification

Importance of Vitamin K in neonate

-Coagulation factors 2, 7, 9, & 10 are synthesized in the liver -Vitamin K influences the activation of these factors -During intrauterine life, the fetus receives vitamin K from their mother, after birth the neonate experiences a decrease in vitamin K and is at risk for delayed clotting and for hemorrhage -Vitamin K is synthesized in the intestinal flora, which is absent in the newborn. The intestinal flora develops after the introduction of microorganisms, which usually occurs with the first feedings -Vitamin K injection is given as a prophylaxis to decrease the risk of bleeding related to Vitamin K deficiency

Signs of respiratory distress

-Cyanosis -Abnormal respiratory pattern such as apnea and tachypnea -Retractions of the chest wall -Grunting -Flaring of nostrils -Hypotonia

How does a neonate respond to the cold?

-Increasing metabolic rate - increase muscle activity - peripheral vascular constriction - metabolism of brown fat

Critical Component: Signs and Symptoms of Hypoglycemia

-Jitterness -hypotonia -irritability -apnea -lethargy -temperature instability

Nursing Actions for hypoglycemia

-Monitor for signs and symptoms of hypoglycemia -assess the blood glucose level with the use of glucose monitor -Assist the woman with breast feeding -Feed the neonate either formula or dextrose water when the glucose level is <40 mg/dL as per institutional protocol -Maintain NTE to decrease risk of cold stress

Phytonadione

-Vitamin K (AquaMEPHYTON) -Indication: required for the hepatic synthesis of blood coagulation factors 2, 7, 9, & 10 -SE: erythema, pain, and swelling at injection site -Route and dose: IM ; 0.5 to 1 mg within 1 hour of birth

Signs and symptoms of cold stress

-axillary temperature at or below 97.7F or 36.5C -cool skin -lethargy -pallor -tachypnea -grunting -hypoglycemia -hypotonia -jitterness -weak suck

Methods of Reducing Heat Loss

-ensure that the room is warm and free of air drafts -place the infant under a warming unit to help maintain a NTE or assess the neonate in the mother's arms -skin to skin contact between the mother and neonate can decrease the amount of heat loss -when doing assessments in an open crib or in a parent's arms, keep the neonate wrapped and expose only the body area that is being assessed

Meconium Stool

-formed during the 4th gestational month and the first stool eliminated by the neonate -passed within the first 24-48 hours -sticky, thick, black, and odorless

Neonates are at higher risk for thermoregulatory problems related to

-higher body surface-to-area-to-body-mass ratio -higher metabolic rate -limited and immature thermoregulatory abilities

Neonates are at risk for infection related to:

-immature defense mechanism -lack of experience with and exposure to organisms, which leads to a delayed response to antigens

Describe immune system of neonate

-in intrauterine life, the fetus lives in the sterile environment of the maternal uterus and relies on the maternal immune system to protect them from pathogenic organisms

Conjugation of Bilirubin

-increase in the neonate's RBC turnover and an increased RBC count at birth

Describe metabolic system of neonate

-large quantities of glycogen are stored by the fetus during pregnancy in preparation for meeting energy requirements when transitioning from intrauterine to extrauterine life -immediately after birth, the neonate becomes independent of the mother's metabolism and must balance the amount of insulin production with glucose availability

Critical Component: Risks for Hypoglycemia

-neonates of diabetic mothers -neonates weighing > 4,000 grams or large for GA -post-term neonates -pre-term neonates -small for gestational age neonates -hypothermia -neonatal infection -respiratory distress -neonatal resuscitation -birth trauma

Passive immunity

-not permanent, acquired either naturally or artificially

Risks that can occur due to immature neonate kidney's

-over-hydration -dehydration -electrolyte disorders such as hyponatremia and hypernatremia

Actions when the neonate displays signs/symptoms of cold stress:

-place a stocking cap on the neonate's head -skin to skin contact with the mother with a warm blanket over them both when there is a mild decrease in temperature; reassess temperature as per institutional protocol - every 30 mins until stable -place neonate under a preheated radiant warmer

Example of natural passive immunity

-placental transmission of antibiotics from the mother to the fetus. Provides protection for the neonate during the first few months of life from the pathogens to which the mother has been exposed

Risk factors for cold stress:

-prematurity -small for gestational age -hypoglycemia -prolonged resuscitation efforts -sepsis -neurological, endocrine, or cardiorespiratory problems

Active immunity

-process in which B cells detect antigens and produce antibodies against them

Critical Component: Methods of Reducing Heat Loss

-thermoregulatory systems neonates respond more slowly to external temperature changes that those of adults -prevention of heat loss is critical when doing assessments

Where do the most critical and dynamic changes occur?

Respiratory and cardiovascular systems

Factors that negatively affect thermoregulation

Decreased subcutaneous fat Decreased brown fat in preterm infants Large body surface Loss of heat from convection, radiation, conduction, and/or evaporation

Formula-fed stool

Drier and more formed that breastfed stools. It is a paler yellow or brownish yellow and has an unpleasant odor.

Why are neonates of diabetic mothers at higher risk for hypoglycemia?

During intrauterine life, neonates of diabetic mothers produce high levels of insulin in response to the high levels circulating maternal glucose during the first few hours of extrauterine life, the neonate's insulin level remains higher than normal, leading to hypogylcemia

How did fetus maintain body temperature in sac?

In the sac, the fetus is surrounded in amniotic fluid that maintains a fairly constant environmental temperature based on the maternal body temperature

Nursing care in neonatal period?

Maintain body heat Maintain respiratory function Decrease risk of infection Assist parents in providing appropriate nutrition and hydration Assisting parents in learning to care for their newborn

BAT promotes

an increase in metabolism, heat production, heat transfer to the peripheral system

What is the focus of nursing care during the neonatal period?

PROTECT and SUPPORT as they undergo physiological changes and adapts to extrauterine life

Breastfed Stool

Yellow and semi formed. Later it becomes golden yellow with a pasty consistency and has a sour odor.

Function of surfactant in alveoli

a pospholipid, assists in the establishment of functional residual capacity - residual capacity assists in kepping the alveolar sacs partially open at the end of exhalation, which decreases the amount of pressure and energy required on inspiration

Active humoral immunity is further classified as:

acquired immunity: from vaccinations natural immunity: develops from exposure to antigens, after which the individual produces antibodies

Neonatal period

birth to first 28 days of life neonate transitions from intrauterine to extrauterine life and adapts to a new environment

BAT

brown adipose tissue aka brown fat or nonshivering thermogenesis highly dense and vascular adipose tissue neonates possess large amounts of NAT

Chemical stimuli transition to extrauterine pulmonary function:

cessation of placental blood flow-> -> decreased O2 -> mild hypoxia -> -> increase in carbon dioxide -> decrease of pH (acidosis) -> stimulation of respiratory center in medulla -> stimulation of respirations

When does ductus venosus close?

closes by day 3 of life and becomes a ligament, blood flow through the umbilical vein stops once it is clamped

When does the foramen ovale close?

closes when the left atrial pressure is higher than the right atrial pressure increased PaO2 -> decreased pulmonary pressure -> increased pulmonary blood flow -> increased pressure in left atrium -> closure of foramen ovale Significant neonatal hypoxia can cause a reopening of the foramen ovale

The physiological change of extrauterine respirations is initiated by:

compression of the thorax, lung expansion, increase in alveolar oxygen concentration, and vasodilatation of the pulmonary vessels

Hyperbilirubinemia

condition in which there is a high level of UNconjugated bilirubin in the neonate's blood related to the immature liver function, high RBC that is common in neonates, and an increased hemolysis caused by the shorter life span of fetal RBC

Direct bilirubin

conjugated, water soluble substance by liver enzymes is in a form that can be excreted in the urine and stool

Ductus arteriosus

connects the pulmonary artery with the descending aorta

Ductus venosus

connects umbilical vein to the inferior vena cava

2 Major functions of the kidneys

control of fluid and electrolyte balance and excretion of metabolic waste, once cord is clamped, the neonate's kidneys must take on these functions

Two factors that negatively affect the transition to extrauterine respirations:

decreased surfactant levels related to immature lungs persistent hypoxemia and acidosis that leads to constriction of the pulmonary artiers

Mechanical stimuli of transition to extrauterine pulmonary function:

delivery of face -> loss of variable amounts of amniotic fluid from lungs delivery of chest -> expansion of chest to predelivery proportions -> negative pressure -> passive inspiration of air -> first breath Both result in: entry of air into alveoli replacing the expelled amniotic fluid Leading to: lung fluid is reabsorbed via lymphatic system neonate crying -> intrathoracic pressure Resulting in: Alveoli remain open

What are the two forms of bilirubin:

indirect (unconjugated) and direct (conjugated)

Diarrheal stool

loose and green

Convection

loss of heat from the neonate's warm body surface to cooler air currents, such as air conditioners or oxygen masks

Evaporation

loss of heat that occurs when water on the neonates skin is converted to vapors: such as during bathing or directly after birth

What two stimuli are the primary factors that initiate extra uterine respirations?

mechanical and chemical stimuli

Location of BAT

neck, thorax, axillary area, instrascapular areas, and around the adrenal glands and kidneys

NTE

neutral thermal environment; is an environment that maintains body temperature with minimal metabolic changes and or oxygen consumption decreases possible complications related to the delayed response to environmental changes

Foramen ovale

opening between the right and left atrium

How is heat produced by BAT?

produced by intense lipid metabolic metabolism by BAT BAT reserves are rapidly depleted during periods of cold stress Preterm neonates have limited BAT

The transition to neonatal circulation is strongly influenced by:

the changes within the respiratory system because... the decrease in pulmonary vascular resistance causes an increase in pulmonary blood flow, and the increase in systemic vascular resistance influences the cardiovascular changes

Risk of cold stress

the neonate's responses to extrauterine temperature changes during the first few weeks are delayed and place the neonate at risk for cold stress

Radiation

transfer of heat from the neonate to cooler objects that are not in direct contact with the neonate, such as cold walls of the isolette or cold equipment near the neonate

Conduction

transfer of heat to cooler surface by direct skin contact, such as cold hands of caregivers or cold equipment

Indirect bilirubin

unconjugated, fat soluble and is produced from the breakdown of RBC -it is converted to direct bilirubin

Hypoglycemia level

under 40 mg/dL -common during transitional time, especially in neonates of diabetic mothers