Physiological and Behavioral Responses of the Neonate
Actions for when the neonate displays signs/symptoms of cold stress include...
- Place a stocking cap on the neonate's head - Skin-skin contact with the mother with a warm blanket over both the mother and neonate when there is a mild decrease in temperature; reassess temperature as per institutional protocol - Swaddle in warm blankets; reassess temperature as per institutional protocol, which is generally every 30 minutes until stable. - Place the naked neonate under a preheated radiant warmer - Monitor temperature as per institutional protocol - Obtain a heel stick to assess for hypoglycemia (glucose below 40 mg/dL) and treat for hypoglycemia based on glucose level
Risk factors for cold stress
- Prematurity - Small for gestational age - Hypoglycemia - Prolonged resuscitation efforts - Sepsis - Neurological, endocrine, or cardiorespiratory problems
Signs and symptoms of cold stress
- Axillary temperature at or below 36.5 C (97.7 F) - Cool skin - Lethargy - Pallor - Tachypnea - Grunting - Hypoglycemia - Hypotonia - Jitteriness - Weak suck
The neonate responds to cold by...
- An increase in metabolic rate - An increase of muscle activity - Peripheral vascular constriction - Metabolism of brown fat
Signs of Fetal Respiratory Distress
- Cyanosis - Abnormal respiratory pattern such as apnea and tachypnea - Retractions of the chest wall - Grunting - Flaring nostrils - Hypotonia
Factors that negatively affect thermoregulation are...
- Decreased subcutaneous fat - Decreased BAT in preterm neonates - Loss of body heat from evaporation, conduction, convection, and/or radiation
Two factors that negatively affect the transition to extrauterine respirations are?
- Decreased surfactant levels related to immature lungs - Persistent hypoxemia and acidosis that leads to constriction of the pulmonary arteries
Nursing actions for cold stress of the neonate
- 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. - Use prewarmed blankets to decrease heat loss due to convection and radiation - Prewarm radiant warmers and heat shields to decrease heat loss due to conduction - Place a stocking cap on the neonate's head to decrease heat loss due to radiation and convection -Skin-to-skin contact with the mother with a warm blanket over the mother and neonate decreases heat loss due to radiation and conduction - Swaddle in warm blankets to decrease heat loss due to convection and radiation - Delay initial bath until the neonate's temperature is stable to decrease heat loss due to evaporation. - Place the neonate away from air vents to decrease heat loss due to convection - Place the neonate away from outside walls and windows to decrease heat loss due to convection radiation - Maintain an NTE to decrease heat loss due to convection and radiation
Neonates are at higher risk for thermoregulatory problems related to...
- Higher body-surface-area-to-body-mass ratio - Higher metabolic rate - Limited and immature thermoregulatory abilities
Possible consequences of cold stress are...
- Hypoglycemia - Metabolic acidosis - Decreased surfactant production - Respiratory distress that can lead to neonatal death - Hypoxemia - Increased indirect bilirubin - Delayed transition from fetal to neonatal circulation - Weight loss
Neonates are at risk for infections related to...
- Immature defense mechanism - Lack of experience with and exposure to organisms, which leads to delayed response to antigens - Breakdown of skin and mucous membranes, which provides a portal of entry for bacteria
Erythromycin Ophthalmic Ointment (0.5%)
- Indication: Prophylaxis for gonococcal or chlamydial eye infections - Action: Prevents bacterial growth by inhibiting folic acid synthesis - Common side effects: Edema and inflammation of eyelids - Route and Dose: Apply a 1/4 inch bead of ointment to lower eyelid of each eye. - Precaution: Prevent the applicator tip from directly touching the eye by holding the application tube 1/2 inch from the eye.
Signs and symptoms of hypoglycemia in neonates
- Jitteriness - Hypotonia - Irritability - Apnea - Lethargy - Temperature instability
The focus of nursing care during this time (fetus transitioning to neonate) is to protect and support neonates as they undergo numerous physiological changes and adapt to extrauterine life. This is accomplished by...
- Maintaining body heat - Maintaining respiratory function - Decreasing risk for infection - Assisting parents in providing appropriate nutrition and hydration - Assisting parents in learning to care for their newborn
Nursing actions for hypoglycemia in neonate
- Monitor for signs and symptoms of hypoglycemia - Assess blood glucose with use of glucose monitor - Assist the woman to either breastfeed or formula feed her infant. IV infusion of a dextrose solution or buccal 40% dextrose gel is used when hypoglycemia persists - Maintain NTE to decrease risk of cold stress
Risks for hypoglycemia in neonates
- Neonates of diabetic mothers - Neonates weighing more than 4,000 g or large for gestational age - Post-term neonates - Small-for-gestational-age neonates - Hypothermia -Neonatal infection - Respiratory distress - Neonatal resuscitation - Birth trauma
What are the two primary factors that initiate extrauterine respirations?
The primary factors that initiate extrauterine respirations are mechanical and chemical stimuli.
What is the optimal plasma glucose range for neonates?
70-100 mg/dL
Transitional stool
Begins around the third day and can continue for 3 to 4 days. The stool transitions from black to greenish black, to greenish brown, to greenish yellow. This phase of stool characteristics occurs in both breastfed and formula-fed neonates.
Meconium stool
Begins to form during the fourth gestational month and is the first stool eliminated by the neonate. It is sticky, thick, black, and odorless. It is first passed within 24 to 48 hours.
When does closure of the ductus arteriosus occur?
Closure occurs when the pulmonary vascular resistance become less than the system vascular resistance which causes a left to right shunt and thus causes the closure of the ductus arteriosus.
Hypotonia
Commonly known as floppy baby syndrome, is a state of low muscle tone, often involving reduced muscle strength.
Formula fed stool
Drier and more formed than breastfed stools. It is a paler yellow or brownish yellow and has a unpleasant odor.
In the transition from fetus to neonate, the most critical and dynamic changes occur in which two systems?
In the transition from fetus to neonate, the most critical and dynamic changes occur in the respiratory and cardiovascular systems.
Self-quieting ability
The ability of the neonate to quiet and comfort self. It is accomplished by sucking on the fist/hand or attending to an external stimuli. The ability is diminished in neonates with neurological injuries or in those exposed to drugs in utero.
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 neonate's skin is converted to vapors, such as during bathing or directly after birth.
Social behaviors
The ability of the neonate to respond to cuddling and holding. These behaviors are diminished or absent in neonates with neurological injuries or in neonates exposed to drugs in utero.
Motor maturity
The ability of the neonate to control and coordinate motor activity. Normal findings are smooth, free movement with occasional tremors. Movement is jerky in premature neonates and/or neonates with CNS abnormalities or injuries
Orientation
The ability of the neonate to focus on visual and/or auditory stimuli. The neonate will turn his or her head in the direction of sound or will follow a visual stimulus. This response is diminished in premature neonates.
Habituation
The development of decreased sensitivity to a repeated stimulus such as light, sound, or heel stick, It is a protective mechanism against overstimulation. Habituation may not be fully developed in premature neonates or in neonates with CNS abnormalities or injuries.
The establishment of what is the most critical and immediate physiological change that occurs in the transition from fetus to neonate?
The establishment of extrauterine respirations is the most critical and immediate physiological change that occurs in the transition from fetus to neonate.
Initiation of respiration affects pulmonary circulation and gas exchange in this sequence
The first breath increases the alveolar oxygen tension (PaO2) and decreases the arterial pH which causes the the dilation of the pulmonary arteries which decreases the pulmonary vascular resistance which increases the blood flow through the pulmonary vessels which increases the oxygen and carbon dioxide exchange within the lungs.
Second period of reactivity
The second period of reactivity follows the period of relative inactivity and lasts 2 to 8 hours. Neonates vacillate between active alert and quiet alert states. The neonate is more responsive to external stimuli. There are periods of rapid respirations and increased heart rate in response to stimuli and activity. There is an increase in bowel activity and the neonate may pass meconium stool.
Sleep/awake states
These are also referred to as infant states or behavior states. There are two sleep states and four awake states.
How are extrauterine respirations established?
This change is initiated by compression of the thorax, which forces amniotic fluid from the lungs; lung expansion; increase in alveolar oxygen concentration; and vasodilation of the pulmonary vessels.
Ductus arteriosus
This connects the pulmonary artery with the descending aorta, and usually closes within 15 hours post birth. It will remain open when the lungs fail to expand or when PaO2 levels drop.
Ductus venous
This connects the umbilical vein to the inferior vena cava, closes by day 3 of life and becomes a ligament. Blood flow through the umbilical vein stops once the chord is clamped.
Brown adipose tissue (BAT)/brown fat/nonshivering thermogenesis
This is a highly dense and vascular adipose tissue. Full-term neonates possess large amount of BAT which preterm neonates, children, and adults have smaller amounts. BAT is located in the neck, thorax, axillary area, intrascapular areas, and around the adrenal glands and kidneys.
Cold stress
This is a term that describes excessive heat loss that leads to hypothermia and results in the utilization of compensatory mechanisms to maintain the neonate's body temperature.
The foramen ovale
This is an opening between the right atrium and the left atrium, closes when the left atrial pressure is higher than the right atrial pressure. Significant neonatal hypoxia can cause a reopening of the foramen ovale.
Brazelton Neonatal Behavioral Assessment Scale (BNBAS)
This is used to assess the neonate's neurobehavioral system.This test is not usually performed on healthy neonates. It is composed of 28 behavior items and 18 reflex divided into six categories.
When does cold stress occur?
This occurs when there is a decrease in environmental temperature that causes decrease in the neonate's body temperature which can lead to respiratory distress.
When does closure of the foramen ovale occur?
This occurs when there is increased PaO2 which causes a decreased pulmonary pressure which causes an increased pulmonary blood flow which causes an increased pressure in the left atrium, which causes the foramen ovale to close.
Initial period of activity for a neonate
This period of reactivity occurs in the first 15 to 30 minutes post birth. The neonate is alert and active and vigorously responds to external stimuli. - Respirations are irregular and rapid and can be as high as 90 breaths per minute; the heart rate is rapid and can be as high as 180 beats per minute (bpm) - The neonate may exhibit momentary grunting, flaring, and retractions - The neonate may experience brief periods of apnea and brief periods of cyanosis. - The amount of oral mucus increases.
Period of relative inactivity
This period of relative inactivity begins approximately 30 minutes after birth and lasts 2 hours when the infant enters a sleep state and becomes unresponsive to external stimuli. Respiratory rate and heart rate decrease and can fall slightly below normal range, and oral mucus production decreases.
How soon should a neonatal assessment be performed?
This should be performed within 2 hours after birth.
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.
Breastfed stool
Yellow and semi-formed. Later is becomes a golden yellow with a pasty consistency and has a sour odor.
