OB Final

Vertebral column

-Palpation assessment -Abnormalities: •Spina bifida occulta - no protrusion but there is missing bone. Can only feel this. •Meningocele - protrusion of spinal fluid and meninges •Myelomeningocele - protrusion of spinal fluid, meninges, and spinal cord. Cover with moist sterile saline dressing at birth. •Pilonidal dimple - presence of dimple at base of spine.

Hyperbilirubinemia types

-Physiologic (non-pathologic) jaundice: Caused by transient hyperbilirubinemia - considered normal. Not present during first 24 hours of life. Normally day 2-3. Peaks at 5, and goes back to normal at 5-7. Visible at 5g/dL. -Non-physiologic (pathologic) jaundice: Caused by excessive destruction of RBCs or problems in bilirubin conjugation - such as infection, Rh incompatibility. Occurs within first 24 hours of life. Normal at 5-8 g/dL -Breastfeeding (early onset) jaundice: Often caused by insufficient intake of breastmilk, Greater than 12 g/dL -True breast milk (late onset) jaundice: Actual cause is unknown - breastmilk may interfere with conjugation, Occurs after first 3-5 days of life, lasts 3 wks to 3 months, treat with phototherapy, may discontinue breastfeeding

Blood coagulation

-Prothrombin and coagulation factors produced by the liver(2,7,9,10) are activated by vitamin K -Vitamin K is deficient in the newborn

Iron storage

-Stored in liver during lasts weeks of pregnancy -Full-term infants and breastfeed infants do not require supplementation until 6 months. Then they will get through solid foods. -Iron fortified formula

Continuation of Respirations

-Surfactant keeps alveoli partially open between respirations -Air form first breath becomes residual capacity -Subsequent breaths require less effort -Remaining fluid is absorbed into circulatory and lymphatic systems: crying forces fluid into interstitial spaces

Bilirubin testing

-TSB: total serum bilirubin. Will determine level of newborn jaundice. Combo of unconjugated (indirect) and conjugated (direct) bilirubin -TCB: light test on abdomen/sternum, total cutaneous bilirubin

Signs of respiratory distress

-Tachypnea: Increased RR, normal RR is 30-60 -Retractions: substernal, clavicular -Flaring of nares increases amount of air entering lungs because decreases airway resistance -Cyanosis: differentiate between central/peripheral. Will be prominent around mouth. Acrocyanosis does not fall in same category -Grunting—noise made on expiration -Seesaw respirations: between chest and abdomen -Asymmetry of chest expansion

Hepatitis B

-Transmission: Contact with maternal blood during birth, transplacental and from breast milk -Effects on newborn: Asymptomatic at birth, LBW, prematurity, risk for liver cancer, become chronic carriers, -Nursing considerations: Wash infant well before skin is punctured. Administer HBIG & Hepatitis B vaccine to prevent infection. May breastfeed if infant receives vaccine & HBIG.

Chlamydia

-Transmission: During birth -Effects on newborn: Conjunctivitis 1-2 weeks after birth, pneumonia at 4-11 weeks, otitis media, bronchiolitis. -Nursing considerations: Treated with oral azithromycin or erythromycin. Topical treatment of conjunctivitis is not effective.

Candidiasis

-Transmission: During birth -Effects on newborn: White patches in mouth (thrush) that bleed if removed. Rash on perineum. May be systemic in preterm or LBW -Nursing considerations: Administer nystatin drops or cream and teach parents how to administer them. Assess mother for vaginal or breast infection. IV medications for systemic infection.

Group Beta Strep

-Transmission: During birth or ascending after rupture of membranes -Effects on newborn: Sudden onset of respiratory distress in infant that is usually well at birth, temperature instability, pneumonia, shock, meningitis -Nursing considerations: Early identification essential to prevent death with vaginal and rectal swab. Antibiotic treatment of infected mothers during labor has decreased neonatal infection. IV antibiotics given to infected infants.

Syphilis

-Transmission: Transplacental -Effects on newborn: Asymptomatic or spontaneous abortion, stillbirth, enlarged liver and spleen, jaundice, hepatitis, anemia, rhinitis, pink or copper-colored peeling rash, pneumonitis, osteochondritis, CNS involvement -Nursing considerations: Diagnosed by blood and CSF testing. Treated with penicillin.

Varicella-Zoster Virus (chicken pox)

-Transmission: Transplacental -Effects on newborn:Congenital varicella syndrome (skin scarring, limp hypoplasia, CSN & eye abnormalities, death), rash -Nursing considerations: Varicella immune globulin for pregnant women exposed in pregnancy or infants of mothers injects just before or after delivery. Acyclovir to treat. Strict isolation precautions for mothers and infants with lesions.

HIV

-Transmission: Transplacental, contact with blood & secretions during birth, breastmilk -Effects on newborn: Asymptomatic at birth, usually apparent at 12-24 months, enlarged liver & spleen, pneumonia, persistent Candida and infections, diarrhea, meningitis, lymphadenopathy, failure to thrive -Nursing considerations: Diagnosis may be delayed due to presence of maternal antibodies. Wash infant well before skin is punctured. Treat with antiretroviral drugs. Advise against breastfeeding. Early testing may be available but not reliable.

Cytometaglovirus

-Transmission: Transplacental, during birth, in breast milk -Effects on newborns: Most asymptomatic at birth. SGA, CNS abnormalities, learning impairment, enlarged liver, jaundice, purpura, chorioretinitis, hearing loss, microcephaly, seizures. -Nursing considerations: Supportive treatment. Antiviral drugs may be used but have toxic effects. Virus may be present in salvia & urine for months-years.

Rubella

-Transmission: transplacental -Effects on newborn: Spontaneous abortion, cataracts, cardiac defects, deafness, microcephaly, cognitive impairment -Nursing considerations: Contact precautions. May shed virus for 1 year after birth. Supportive treatment. Diagnosis confirmed with presence of virus and antibody

Gonorrhea

-Transmission: usually during birth -Effects on newborn: Conjunctivitis with red, edematous lids and purulent eye drainage. May results in blindness if untreated. -Nursing considerations: All infants receive prophylactic treatment. Erythromycin eye ointment is most common and typically mandated. Infected infants are treated with IV antibiotics.

Infection issues with preterm infants

•3-10 x greater than term infants: maternal infections, inadequate immune system, long hospital stays. •Inadequate passive immunity from mom •Less mature immune response: Alert for signs of infection, Vigilant scrubbing/hand washing: no hand jewelry

Nursing care for thermoregulation

•Abdominal maintained 36 to 36.5 degrees C (probe) •Axillary preterm 36.3 to 36.9 C •Neutral environment: to prevent excessive heat loss. Can use plastic wrap to help baby hold in their heat. •Same interventions as for term but even more important •Equipment—warmers, incubators. Prewarm them! Criteria for transfer from incubator to open crib: At least 3 lbs with weight gain for 5 days, no complications, tolerating feedings. •Indications of inadequate thermoregulation: Hypoglycemia, respiratory distress, Poor feeding, intolerance to feedings, Lethargy, Irritability, Poor muscle tone, Cool skin temp, Mottled skin.

Large for Gestational Age (LGA)

•Above the 90th percentile on intrauterine growth charts. May be full term (macrosomia) or preterm and can be mistaken for full term. •May weigh more than 8lbs, 14 ounces •Causes: Multiparas, Large parents, mothers who are obese, Certain ethnic groups: Asians, AA, Hispanics, Maternal diabetes •Therapeutic Management: early ID with proper prenatal care, delivery with assistive devices or C section •Common Complications: longer labor, complicated deliveries, shoulder dystocia, clavicle fracture, injury to facial nerve, cephalohematoma, bruising, congenital heart defects, higher mortality rate •Nursing Considerations: Be prepared to assist in difficult deliveries or c-section, Assess for complications after birth - risk for hypoglycemia and polycythemia, Treatment as needed

Administering Vitamin K

•Administer within 1 hour of birth; can be delayed (resuscitation or breastfeeding) •Give intramuscularly. Into vastus lateralis. Mother can do cradle hold while breastfeeding during admin if possible. •One dose prevents bleeding problems: Clotting factors 2,7,9,10 promoted which can allow clotting to happen. Preventing hemorrhagic disease of newborn.

Alcohol

-Maternal effects: SAB, placental abruption -Fetal effects: Mental delays, birth defects, FGR, fetal demise

Tobacco

-Maternal effects: Vasoconstriction, SAB, placental abruption, preterm labor, PROM -Fetal effects: Reduced oxygenation, prematurity, LBW, ↑ SIDS

Amphetamines

-Maternal effects: Vasoconstriction, SAB, preterm labor, placental abruption, hemorrhage -Fetal effects: FGR, prematurity, abnormal sleep patterns, agitations, poor feeding, vomiting

Signs of correct latch

-Nose is free -Lips are flanged outward like fish -Chin is immersed in your breast at the bottom of the areola ring -Areola: most of it is hidden inside his mouth

Cocaine

-Maternal effects: CNS stimulant euphoria, vasoconstriction, preterm labor, placental abruption -Fetal effects: Reduced oxygenation, meconium staining, prematurity, irritability, poor response to comforting, stillbirth

Caffeine during pregnancy

-Maternal effects: CNS stimulant, vasoconstriction -Fetal effects: Stimulate fetus, teratogenic effects are undocumented

Opiates

-Maternal effects: Placental abruption, preterm labor, SAB -Fetal effects: Placental abruption, preterm labor, SAB

Cardiovascular adaptation

-Adaptations: Alterations occur simultaneously within the first few minutes after birth -Ductus Arteriosus: closes due to rise in oxygen concentration, Blood in pulmonary artery is direct to lungs for oxygenation -Pulmonary blood vessels: Decreased pulmonary resistance allows blood to enter lungs freely -Foramen Ovale: Closes when pressure in the left atrium becomes higher than the pressure in the right atrium. So lungs are no longer bypassed, Pressures between the right and left sides of the heart are reversed, May need surgical closure. Can cause murmur sound at birth. -Ductus Venosus: Occlusion of umbilical cord stops flow from placenta causing closure. Prostaglandins from umbilical cord were keeping it open. Once closed blood goes to the liver to be filtered.

Newborn cardiorespiratory status

-Assessment: HR, pulses, respirations, breath sounds -Potential problems: Difficulty clearing excessive secretions. -Interventions: Positioning the infant - so airway isn't compressed, Suctioning - bulb suctioning, mouth first then nose: Can do deep suctioning where catheter inserted into lungs to get fluid out (needed if hear crackles/rales/baby drinks amniotic fluid at birth)

Breastfeeding

-Breast changes: estrogen and progesterone prepare during pregnancy (ducts, lobules), can see colostrum as early as 16 weeks, some components in body are converted to breast milk, -Hormonal changes at birth: loss of placental hormones causes: Prolactin: stimulated when placental hormone levels decrease at birth; suckling stimulates increase. Oxytocin - increases with nipple stimulation, Milk ejection reflex or "let down". Can also occur when thinking or seeing baby. -Continued milk production - supply and demand: the more stimulation the more milk is produced.

Initiation of Respirations

-Chemical factors: receptors in carotid and aorta respond by causing hypoxemia that occurs during normal birth. Changes in blood chemistry stimulate respiratory center: Decrease oxygen and pH, and increased in CO2. -Mechanical factors: Compression of fetal chest in birth canal forces out remaining fluid. When pressure released there is a small amount of air drawn into lungs. -Thermal factors: Change from warm to cooler environment causes impulses to stimulate medulla by skin receptors. Almost a startle to help them draw in breath. -Sensory factors: Startle response from tactile, visual, auditory, and olfactory stimuli. Can cause startle response to draw in first breath.

Removal from breast

-Do: Insert pinky into corner of mouth to break seal and then pull baby away. -Do not: just pull off of the breast as that will cause pain and issues with breast tissue

Methods of heat loss

-Evaporation: wet surfaces are exposed to air -Conduction: contact with objects cooler than the skin -Convection: heat is transferred to air surrounding infant -Radiation: heat is transferred to a cooler object not in contact with skin

Factors in increased bilirubin

-Excess production - bc of normal breakdown of rbc's -Red blood cell life - breakdown faster in newborns -Albumin - less, so less bindings sites for conjugation in the liver -Liver immaturity - may not have adequate UGDPT enzyme -Blood incompatibility - Rh incompatibility can increase amount of RBC breakdown -Gestation - preterm and late term have immature conjugation abilities -Intestinal factors - need intestinal flora to get rid of conjugated bilirubin, but born without flora. -Delayed feeding - delayed est of normal flora and meconium passing, meconium very high in bilirubin. -Trauma - bruising and cephalohematoma increased RBC breakdown -Fatty acids released when brown fat is metabolized - fatty acids can bind to albumin which decreases albumin for bilirubin, asphyxia also produces fatty acids

Development of the Lungs

-Fetal lung fluid: during pregnancy, lungs filled with amniotic fluid which expands alveoli for development. Oligo and polyhydramnios can affect fetal lung maturity. During labor fluid moves to interstitial spaces where it is absorbed - can be delayed in C section birth. With vaginal delivery they are squeezed which helps with extra lung fluid. -Surfactant is produced as lungs mature. - Can give betamethasone in preterm labor: Reduces surface tension within alveoli - helps keep them open as infant exhales, Surfactant usually sufficient by 34 to 36 weeks of gestation -Causes of respirations -First breath must force fluid into interstitial spaces, needs large pressure to do this more so than normal breathing. -Requires negative pressure

Thermoregulation issues with preterm infants

-Heat loss is a major problem due to: •Thin skin •Vessels close to surface •Extension of body—greater body surface area •Temperature control in brain less mature •Not enough or no brown fat (accumulated after 28 weeks) -Complications from heat loss: •Hypoglycemia •Respiratory problems •Metabolic acidosis •Pulmonary vasoconstriction •Respiratory compromise

Effects of cold stress

-Increasing metabolism to produce heat requires oxygen and glucose -May experience hypoxia as oxygen is used for heat production, furthering respiratory distress. -Decreases production of surfactant, furthering respiratory distress. -Glucose is needed in larger amounts - can lead to hypoglycemia. Use of glucose can cause metabolic acidosis. -Metabolism of brown fat can lead to metabolic acidosis. -Vasoconstriction can cause a return to fetal circulation patterns.

Metabolism of drugs

-Inefficient in newborn liver -Careful consideration when giving medications

Urinary system

-Kidney development: Additional perfusion at birth improves -Kidney function: Voiding should occur within 12 to 24 hours of birth, up to 6 times a day by the 4th day, GFR doubles or triples in first week of life, reaches adult level by 1-2 years old. -Fluid balance: Decreased tolerance of volume changes - more susceptible to fluid overload b/c immature kidneys -Water distribution: Extracellular fluid is easily lost from the body - so vomiting and diarrhea can cause issues, Weight loss right after birth because of diuresis.

Viability weight and gestation

500 g and 24 weeks

Phototherapy

A therapy that involves repeated exposure to bright light -If overhead need eye and genitalia protection -Can have single, double, or triple lights.

APGAR scoring system

Assessing cardiopulmonary function and adaptation to extrauterine life. Performed at 1 and 5 minutes. Then every 5 minutes until score is greater than 7 b/c no intervention needed then -Heart rate: 0 absent, 1 below 100 bpm, 2 100 bpm or higher -Respiratory effort: 0 no spontaneous respirations, 1 slow respirations or weak cry, 2 spontaneous respirations with strong lusty cry -Muscle tone: 0 limp, 1 minimal flexion of extremities, sluggish movement, 2 flexed body posture, spontaneous and vigorous movement -Reflex response: 0 no response to suction or gentle slap on soles, 1 minimal response (grimace) to suction or gentle slap on soles, 2 responds promptly to suction or gentle slap on sole with cry or active movement -Color: 0 pallor/cyanosis, 1 bluish hands and feet (acrocyanosis), 2 pink or absence of cyanosis, pink mucous membranes.

Preterm newborns

Born before the beginning of the 38th week of pregnancy. -Appearance: Lie in extended positions: Limbs not tucked in tightly. Head large in comparison to rest of body. Plantar creases absent < 32 weeks. Pinnae of ear flat and soft with little cartilage, so ear will stay in pushed position. Female genitalia - labor majora and minora may not completely cover clitoris. Male genitalia - undescended testes and scrotum smaller with rugae. Abundance of vernix and lanugo. Can be born without nipples, fingernails, and toenails. Will develop later. Lack brown fat -Behavior: Easily exhausted by typical feeding and interaction, Decreased muscle tone, less movement, Cry may be weak and feeble, or "cry-face"

Hyperthermia

Elevated temperature causes increased metabolic rate causing increased need for oxygen and glucose -Vasodilation leads to increased insensible fluid loss: Sweating is often delayed in newborns because sweat glands are immature -Closely monitor warming equipment to prevent overheating of infant

Neutral thermal environment (NTE)

Environment for newborn that helps prevent heat loss -Provide environment where infant can maintain stable body temperature -Clothed: room 98-92 degrees -Unclothes: room 75-80 degrees -Clothing recommendation: whatever you're wearing for that time of year, add one layer to the baby.

Non shivering thermogenesis

Metabolic rate increases in response to falling skin temperatures (95-96.8F, but occurs before decrease in core temp noted). -Leads to Brown fat metabolism to produce heat - in preterm infants may not have adequate stores for this making it even more difficult. Found along back of neck, heart, kidneys, adrenal glands, and along abdominal aorta. -Allows body to maintain internal heat at an even level -IUGR, hypoglycemia, etc: can effect baby's ability to do brown fat metabolism.

Hepatitis B immunization

Helps promote antibody formation to hep B •Included with routine childhood vaccinations, should be given prior to discharge of newborn then other doses during pediatrician visits. •Mother/parents must consent for vaccination •Immunize infant of mother who has acute or chronic infection: -Give vaccine - ASAP -Give Hepatitis B immune globulin (Hbig) -Give globulin within 12 hours of birth -Will receive additional doses in pediatrician office.

Immune System

Less effective at fighting off infection: leukocytes delayed to infection site and can have infections and sepsis: changes in activity, color, tone, or feeding. -Immunoglobulin G (IgG): Crosses placenta and provides passive temporary immunity. Greatest in third trimester. -Immunoglobulin M (IgM): First immunoglobulin produced when exposed to infection. Protects against gram negative bacteria. Rapid production begins right after birth because of environment. -Immunoglobulin A (IgA): Receive some from colostrum and breast milk, Must be produced by the infant, Protects GI and respiratory systems. -Antibodies received from mother in last trimester and passive immunity from breastmilk. So preterm and bottle fed infants will have weakened immune system.

ELBW infant

Less than 1000 g

Periods of reactivity

Important because can tailor how to care for the newborn. •First period of reactivity begins at birth: Lasts 30 minutes: look active, alert, appear awake, rooting, moving arms and legs, appear hungry. Temp may be decreased, RR can be high, HR elevated, Crackles/grunting/retractions/nasal flaring. As this period ends HR and RR will gradually slow as they get sleepy. Parents enjoy watching them and holding them en face. •Period of sleep: Quiet, fall into deep sleep, HR and RR normal, BS audible, may pass meconium. •Second period of reactivity: Lasts 4-6 hours, Periods of alertness and hunger, parents become interested in feeding schedule, may pass meconium, can be tachycardic and tachypneic, secretions increase.

Radiation heat loss

Involves loss of newborn's body heat to cooler solid objects that are not directly in contact with the skin •Nursing Interventions: -Keep bassinets and incubators away from outside walls -Cover the newborn if stable - wrap, swaddle, may cover isolet in NICU

Convection heat loss

Involves the flow of heat from the body surface to cooler surrounding air or to air circulating over body surface •Nursing Interventions: -Avoid currents of air - open door/window -Manage newborns inside incubator, if possible b/c warmed air -Organize work to minimize opening of portholes, if in incubator -Provide warm humidified oxygen

Conduction Heat Loss

Involves the loss of body heat to cooler objects which come in direct contact with baby's skin •Nursing Interventions: -Put the baby on prewarmed sheet -Cover scales and other equipment with warm towel or blanket

Evaporation heat loss

Involves the loss of heat when liquid is converted to vapor •Nursing Interventions: -Keep infant dry, rub all wetness off of skin at birth. -Remove wet diapers -Minimize exposure during baths

VLBW infant

Less than 1500 g

Conjugation of bilirubin

Liver function after birth - maintenance of blood glucose, conjugation of bilirubin, storage of iron, metabolism of drugs, and production of factor necessary for blood coagulation. •Source and effect of bilirubin: Hemolysis of RBCs, Bilirubin is a toxic substance that results from breakdown of RBCs, Excessive amounts of unconjugated bilirubin causes jaundice and kernicterus (can cause encephalopathy and toxicity) •Normal conjugation: Bilirubin binds with albumin in the bloodstream, Bond bilirubin travels to the liver for conjugation where bilirubin is changed from fat soluble to water soluble by enzyme UDPGT. Once conjucgated bilirubin can be excreted from the body in bile with the help of flora. •Issues with conjugation: Beta Gluconorase enzyme in the GI system can deconjugate already conjugated bilirubin which is then carried back to the liver.

Proper technique for latch

L - Latch: grasping breast, tongue down, and lips are flanged (lips pointed out like a duck) A - Audible: hearing swallowing occurring, spontaneous and intermittent T - Type: everted or inverted C - Comfort: nipple should be soft and nontender H - Hold: how the mom is holding the baby during feeding -Comfortable position for feeding with baby propped up enough that mom is not hunched over. Bring baby to breast not breast to baby. -Can stimulate baby to latch by bringing nipple to chin so baby will root. Then chin will move to underside of breast, baby will have wide fanned out mouth to latch.

Substance abuse in pregnancy

•Description: Physical and psychological dependence on substance •Diagnosis and Management: Late prenatal care/No prenatal care are common. Careful assessment of Signs and Symptoms, Methadone or buprenorphine, Used to treat opiate abuse—especially heroin use, Gradual decrease of dose attempted, Newborn must still withdraw after birth (shorter and less severe with buprenorphine, also reduces risk of infection) •Access to treatment resources: methadone facilities and transportation •Encourage bonding •Examining Attitudes & Providing Support : support groups, follow up with social services and case management.

Follow up care for newborn

•Professional follow-up care recommended with early discharge - within 48 hours if taken home less than 48 hours after birth. Similar even after 48 hours. Should at least be seen within one week. •Can be provided in a number of ways

Checking blood glucose

•Protocol for hypoglycemia per institution •Site for heel sticks: Lateral bottom of foot (side of heel)

Eye treatment

•Providing eye treatment to both eyes: Prophylactic treatment to prevent infection of gonorrhea, Required by most states, Administer within 1-2 hours after birth, Apply a ribbon of ointment inside both eyes •Medications: Erythromycin ophthalmic ointment, Can also use Tetracycline -May interfere with vision which can affect bonding and can cause mild inflammation of eyes, but should not have purulent drainage.

LBW infant

infant less than 2500 g (5lb 8oz), has nothing to do with gestation

Respiratory problems with preterm infants

•Apneic episodes > 20 seconds: with bradycardia, cyanosis, etc. •Idiopathic apnea: apnea without identifiable cause. •Other issues: decreased surfactant which reduces surface tension, excessive elasticity of chest wall. •Normal: Cessation of breathing for 5-10 seconds followed by 5-10 seconds of normal respirations. •Respiratory equipment—ventilating the lungs is the single most important and effective action in neonatal resuscitation. Oxygen hood (plastic dome over head and upper body for infants who can breathe independently but need extra oxygen), CPAP (mask or prongs applied to face to keep alveoli open and promotes expansion of lungs), intubation with mechanical ventilation. •Positioning: side lying or prone, help drainage of respiratory secretions. Change position every 2-3 hours. •Suctioning secretions: very small airway and weak cough reflex. 5-10 seconds at a time, do mouth before nose. Can alter HR, BP, and cerebral blood flow. •Maintaining hydration: to maintain mucous secretion clearing,

Early discharge of newborn

•Appropriate for gestational age - normal physical exam and making good transition to life. •Vital signs within normal limits: for 12 hours prior to discharge •Feeding successfully : twice •Passes urine and stool, and had circumcision if applicable. •Screenings completed. Hepatitis B vaccine given. •Car seat available and tested if needed. •Mother able to care for infant, follow up appointments made, discharge teaching provided.

Ongoing assessment after delivery

•Assess every 8 hours: Includes VS, Assess more frequently PRN based on assessment findings, Weight once per day at the same time each day. •Assisting with feedings: breast or bottle?, be sure to witness them being done. First feeding in first hour of life - no more than 30 mL in that feeding. Observe for latch issues, sleeping, mother difficulties with feeding. •Protecting the infant -Preventing abduction: Most common in mothers room and by a woman impersonating a healthcare worker. Should have: ID bands that match baby(ankle and opposite wrist) and parents or someone present for delivery (checked frequently), photos in medical record, footprints in the past, security band typically on foot or umbilical cord that tracks perimeter of women's health unit, pink outlined badge and photo for healthcare workers. Code PINK - infant abduction, all personnel within hospital respond, head count all babies, everyone stay in room, all exits are covered by RN in all departments of hospital. -Preventing infection: recognize early signs of infection, hand washing, discourage visitors with colds or illness

Newborn thermoregulation assessment

•Assessment while skin to skin with mom or in radiant warmer with a temperature probe attached •Most common is axillary (see normal range on following slide) •If decreased: start warming measures (place in radiant warmer set to appropriate temperature, double wrap infant) - cannot swaddle infant under radiant warmer, Look for signs of infection with both increased and decreased temperatures, Reassess every 30 minutes until temp stable

Adolescent Pregnancy cont'd

•Assessment: Difficult to obtain a thorough health history, Determine level of cognitive development: limited abstract thinking, and have egocentrism, Knowledge of infant needs: how will she provide and care for the infant, Family and support assessment •Potential Problems: Late prenatal care, Lack of understanding about physiologic needs of pregnancy: diet modification or substance cessation, Increased family stress •Interventions: Eliminate barriers to health care, Applying teaching and learning principles: may take multiple sessions of education, make diet recommendations, WIC, protection against risky behaviors, reduce stressors if possible, try to avoid talking like a parent, give helpful apps, help with attachment to fetus, postpartum support groups (church, local, and national groups)

Cephalhematoma

•Bleeding between the periosteum and the skull •Can result form trauma or pressure during birth •Clear edges that end at the suture lines •Absorbs slowly and can take up to 3 months to disappear •Risk for jaundice •Monitor head circumference to make sure bleeding isn't increased

Hepatic system

•Blood glucose maintenance -Glucose is stored glycogen in the liver & skeletal muscles during 3rd trimester. Almost completely used by 12 hrs of life. -Stores glucose help meet body demands until feeding are adequate •Risk for hypoglycemia -Preterm infants = no storage of glycogen -Post term infants = may have used it all up -LGA or newborns born from GDM mothers may produce too much insulin which uses up glucose too quickly -Stress (infection, asphyxia, cold stress) may use up glycogen stores more quickly •Normal blood glucose for term infant -40 to 60 mg/dL on first day of life -50 to 90 mg/dL thereafter

Hematologic Adaptation

•Blood values: Heel stick may show elevated blood counts because of poor peripheral perfusion, venous samples will be more accurate. -Erythrocytes: 4.8-7.1, Shorter life span (70-90 days vs 120 days for adults) -Hemoglobin: 15-24, Carries 20-50% more O2 than adults because they need more oxygen carrying capacity -Hematocrit: 44-70% for the first month, above 65% indicate polycythemia, risk for jaundice. -Leukocyte: 9100 to 34,000/mm3, up to 50,000 if preterm. -Infection: indicated by elevated immature leukocytes and decreased platelets. -Risk of clotting deficiency: newborns intestines have no flora which produces vitamin K. So they are without vitamin K, which puts at risk for hemorrhagic disease.

Perinatal loss

•Can occur at any time: sometimes no reason, may do autopsy or genetic testing. Early spontaneous abortion, Ectopic pregnancy, Fetal demise, Stillbirth, Neonatal death •Assessment: Requires sensitivity: b/c very emotional, Symbol or stickers to alert other providers: butterfly, Evaluate support system: SHARE - infant loss support group and counseling •Interventions -Allowing expression of feelings -Acknowledge the infant - memorabilia books, clip hair, foot/handprints, photos, diapers, measurements, nametags, armbands, etc. -Presenting infant to parents - some may not want to hold the baby. Can do in separate room. -Memory packet -Cultural practices -Support groups: Share burial (specific funeral home where mass grave for infant loss) or private burial.

Umbilical cord care

•Cleanse with water when necessary. Fold diapers under the umbilical cord stump. •Check for redness, drainage, warmth, etc. •Keep clean and dry until stump falls off - falls off in 10-14 days

Benefits of breastfeeding for infant

•Decreased allergies •Immunologic properties decrease risk for infections •Decrease in necrotizing enterocolitis (especially in premature infants) •Easier to digest •Contamination issues with formula •Decreased risk of overfeeding •Decreased constipation - b/c laxative properties

Small for Gestational Age (SGA)

•Description—below 10th percentile •Causes: Congenital, chromosomal, genetic, Multiple gestations (twins, triplets, etc.), Fetal infections, Poor placental function - can cause asphyxia, Maternal illness, smoking, alcohol and drug abuse, severe malnutrition •Characteristics of SGA infants: Symmetric: involves entire body, Asymmetric: head normal in size but appears larger than rest of body •Therapeutic Management: Early recognition- hypoglycemia common immediate problem, Best is prevention: Early and consistent prenatal care - serial NST and BPP to determine if delivery necessary, High caloric needs and thermoregulation greatly reduced •Common complications: Low reserves—fetal distress during labor, Aspiration syndrome, Heat loss, Hypoglycemia •Nursing concerns: Assess for complications (Low APGAR, polycythemia, hypoglycemia, inadequate thermoregulation common), Need more calories—early and frequent feedings

Hip assessment

•Dysplasia - instability of hip joint. •Knees - if hip dislocated knees will not be even •Barlow Test - adducts the hips and applies gentle pressure down and back with thumbs. Can feel click/slip of affected hip. •Ortolani Test - abducts the thighs, brings thigh out and applies gentle pressure forward. May feel pop sensation indicating femoral head is back in place. •Hip click - means hearing click sounds, means ligaments being stretched

General newborn assessment

•Face: Symmetrical, Positioning of facial features - Outer eye should line up with top of the ear, if ear is lower then could indicate down syndrome Drooping of the mouth can indicate facial nerve trauma. •Neck & Clavicles: Range of motion should be full. Observe for fractures of clavicle - To examine clavicle slide hand along clavicle bone and move infants arm - may feel lump, swelling, or tenderness. Can also have unilateral morrow reflex. Can splint clavicle if broken but typically just left alone. Can have webbing between shoulder and occiput which could indicate chromosomal anomaly. •Umbilical Cord: Confirm Three vessel (2 arteries will stand up, 1 vein will look like slit), Two vessel cord = abnormalities •Extremities: Hands & Feet examined for extra digits, Creases of hands, Club foot - foot turned inward and cannot be Moved to midline. May need surgery or casting. Poor muscle tone can indicate neuro injury Erb's palsy: Brachial nerve injury, paralysis of shoulder muscles, thumb turned in toward body Polydactyl - extra fingers or toes, fairly common. Can be tied off typically which will cause death and it will fall off. If muscle involvement then may need surgery. Cyldactyl - webbing of fingers or toes If fingernails not present then can indicate prematurity. Simeon creases - if single crease then sign of down syndrome, but can also mean nothing.

Skin issues with preterm infants

•Fragile and easily damaged: use humidifiers to prevent drying, and reposition frequently to avoid pressure injury from equipment. •Not as much fat accumulation •Securing equipment: Cannot use regular adhesive tape. Electrodes, tubes, equipment, etc. Remove adhesive from skin horizontally. •Cleaning and disinfecting the skin can also cause damage to the skin: Cleansers should be pH 5-7

Skin newborn assessment

•Harlequin color change - color division between sides of the body. One side pink/red. Due to vasomotor instability. •Mottling - lacy/red/blue pattern, dilated vessels under the skin. •Vernix caseosa - cream cheese like, protects skin in utero and helps with thermoregulation after delivery, thicker in preterm infants. Wait 8 hours to bathe them. •Lanugo - fine, soft hair. Thinner in term infants, thicker in preterm and dark skinned infants. •Milia - fine white pimples on face typically from clogged pores at birth. Do not squeeze. •Erythema toxicum - red blotchy areas with white/yellow papules in the center. AKA newborn rash. First 24-48 hours. Lasts few days to months. •Birthmarks - size, location, variation, and texture should be documented. Includes Mongolian spot (bluish gray mark, more common in dark pigmented people), Nevus Simplex (flat pink dilated capillaries common on face, disappears at 2 years of age), Nevus Flamius (aka port wine stain, permanent flat pink/red/purple mark that does not blanch), Nevus vasculosus (strawberry hemangioma, enlarged capillaries and raised) •Marks from delivery - bruising, petechia, puncture mark on head, forceps mark on cheeks or ears) •Supernumirary - more nipples on chest or axillary area. Can touch bud under nipple which may excrete Witches milk - caused my maternal hormones •Other skin assessments - look for edema: generalized can indicate heart failure, peeling skin can indicate post date pregnancy, breasts should document placement and symmetry, hair and nails should be silky and nails should reach tips of fingers or extend. Preterm will be wooly and fuzzy, shorted nails can indicate preterm infant.

Newborn screenings

•Hearing loss screening test: Acoustic emissions and brain stem responses. Hearing device applied and see if baby responds with startle reflex, moving extremity, etc, All infants screen prior to discharge, Infants that do not pass should be rescreened. But not more than 2. Will be referred to audiologist for follow up no more than 3 months post birth. •Phenylketonuria (PKU) - blood test: Cannot metabolize the amnio acid phenylalanine, commonly found in proteins even milk related. Positive can result in severe intellectual disability if untreated. Treated with low-phenylalanine diet, amino acids regulated •Hypothyroidism: Congenital, thyroid does not produce enough thyroid hormones, Early treatment necessary to ensure growth. Symptoms if untreated: hoarse cry, large fontanel and tongue, slow reflexes, abdominal distension, lethargy, feeding problems. •Glactosemia: Lacking enzyme for milk sugar conversion of galactose to glucose •Hemoglobinopathies: Sickle cell anemia, thalassemia, etc., Multiple conditions are screens with one blood sample - Piece of paper with bubbles for all these tests, prick heel and fill each bubble with blood. Will get results around 1 week after birth. •Congenital hyperplasia - prevents adequate adrenal hormone and aldosterone. Can have ambiguous genitalia and male characteristics of females. IS a salt wasting crisis - so low sodium and glucose, and high postassium. Tx: corticosteroids and mineralsteroids for life!

Adolescent pregnancy

•Incidence - highest among Hispanic, native American, white women, islander women. 82% are unintended. •Contributing Factors: Homelessness, justice system, foster care, peer pressure, high rate of sex, limited contraception, inaccurate usage of contraception, lack of information, fear of reporting activity, unplanned intercourse, feelings of invincibility, low self esteem, desire for love, escape of present situation, lack of role models. •Sex Education: Clarify values and beliefs, Outline consequences of risky sexual behavior, Measures to prevent STDs/STIs, Importance of setting limits •Implications for Maternal Health: increased risk for complications such as: death, anemia, preterm labor and birth, pregnancy HTN, depression, substance abuse, violence, poor nutrition, stretch marks, lacerations. •Impact on Parenting : difficult to establish bond with unwanted infant, do not possess maturity or patience to parent well, greater risk for child abuse, lack resources. •If abortion: feelings of sadness and guilt but also relief which can be difficult for them to process.

Caput succedaneum

•Localized edema •Result of pressure of fitting through birth canal, or vacuum assisted delivery. •Crosses suture (fontanel) lines •Soft •Disappears within 48 hours after birth.

Fluid and electrolyte issues with preterm infants

•Lose fluid easily - because rapid RR and use of oxygen increases fluid loss from the lungs. Greater prematurity, greater degree of fluid loss •Kidneys ability to dilute or concentrate urine is poor. •Regulation of electrolytes by kidney's is a problem -Assessment: signs of deficit or overload (I & O) -UOP: Should be 1-3 mg/kg/day, after 24 hours less than 0.5 mg/kg is considered oliguria. Plastic bags can cause skin damage, weight diapers (1gm = 1mL) -Weight:show fluid gain or loss (preterm lose 10-15% first few days) •Flushes are 3 mL for preterm infants, IVF with careful titration with double nurse check off. Apply humidified O2.

Stools

•Meconium is the first stool excreted: Greenish black with a thick, sticky, tarlike consistency, First stool is usually passed within 12 hours. If not 48 hrs then obstruction suspected. Consists of particles from amniotic fluid •Transitional stool is the second type. Around day 4: Combination of meconium and milk stools •Breastfed stools: yellow seed like, more frequent, sweet/sour smell •Bottle fed stools: more pale yellow/brown and bulky/firmer, characteristic odor of stool

Newborn head assessment

•Molding - changes to head that occur during birth to allow it to pass through birth canal. Bones override and close off suture lines. Parietal override occipital and frontal typically. Can sometimes feel ridge. Resolves within a few days to a week. •Fontanels - area between sutures. Anterior (diamond shape and 4 x 2.5 cm, closes at 12-18 months) and posterior(triangular, 0.5 to 1 cm, closes at 2 months). Determine whether bulging, flat, or concave. During crying may have bulging sensation which is normal. -Craniostenosis: sutures closed prematurely.

Respiratory Distress Syndrome (RDS)

•Most often < 28 weeks, increases as gestational age decreases •Risk Factors: Birth asphyxia, c section birth, multiple births, male gender, cold stress, and maternal diabetes •Causes—insufficient surfactant production. Lungs are stiff and alveoli not remaining open which causes pulmonary hypertension and reduced blood flow to lungs.. •Manifestations—usually develops within 24 hours: Tachypnea, Tachycardia, Retractions - above and below the sternum, Nasal flaring, Cyanosis, Grunting, Crackles, Acidosis because of hypoxemia, Cloudy appearance of lungs on XR •Therapeutic management: Surfactant replacement therapy—prophylactic or treatment, Oxygen support as needed - CPAP or mechanical ventilation, Inhaled nitric oxide, IVF - carefully titrates, Nursing considerations, Observe for signs of RDS at birth and during early hours

Pain in preterm infants

•Neurological development delayed •Including in vital sign assessments: Should still be assess even though they cannot verbalize their pain, use FACES scale and PIPP-measurements of body to determine if they are or are not in pain. •Signs & Symptoms (see page 640): Increased/decreased HR and/or RR, apnea, Color changes: red, dusky, pale, Increased BP, High-pitched, intense, harsh cry, Whimpering, moaning, Grimacing, Intense rigid muscles, Sleep/wake patterns may change •Nursing Interventions: swaddle with extremities flexed/containment, kangaroo care (skin to skin), breastfeeding, perform least traumatic care first, comfort measures, sucrose with pacifier, talking to them, rocking them, opioids, Tylenol.

Blood glucose

•Normal Blood glucose for full term infant: First day of life 40-60, After 50 to 90. Test in High Risk infants, including SGA, Pre-term, LGA, Infant of diabetic mother. •Not necessary to test BG on full-term healthy infant: Observe for Signs and symptoms of hypoglycemia and need to test •Hypoglycemia: First intervention is typically breastfeeding or formula feeding the newborn •Risk factors for hypoglycemia: Prematurity, post maturity, IUGR, LGA, SGA, asphyxia, cold stress, maternal DM. •Symptoms of baby hypoglycemia: jittery, tremors, tachypnea, low temp, lethargic, grunting, tachycardia, apneic episodes, cyanosis, poor suck, high pitched cry, poor muscle tone, seizures, irritability.

Care for the nurse

•Nurses and professional colleagues also grieve •They must recognize their own potential for grief •Groups in hospitals for grief help and counseling.

Benefits of breastfeeding for mothers

•Oxytocin release which helps uterine involution •Decreased risk for certain cancers: breast cancer •Bonding is increased •Expense decreased •Less preparation of bottles and supplies

Care of the newborn

•Place newborn skin-to-skin with mom if at all possible: -Infant should only go to the warmer if complication (respiratory, cardiac, or maternal issues) or unable to regulate temperature -Mother can decline baby skin to skin •Dry baby off quickly - avoid heat loss: -Even if not breathing, need to dry baby off quickly -Apply warmed blankets, hats, etc. •Replace wet towel or blanket as needed: -Helps to reduce evaporative heat loss •Check for breathing: -Can rub towel on back vigorously to stimulate startle effect to start breathing -If not breathing begin newborn resuscitation protocol immediately

Intimate partner violence

•Pregnancy can be a risk factor for increased incidence of intimate partner violence: Unwanted pregnancy, Increased stressors •Important factors to consider in this population: can be difficult to assess the patient individually •Assessment: may not see anything physical •Interventions: provide plan to keep her safe before discharge, hotlines, shelters.

Circumcision

•Reasons for choosing circumcision: Reduces penial cancer, UTIs in first year of life, HIV infection or transmission of other STIs. Religious, social, or cultural reasons: Less common in Asians and Hispanics •Reasons for rejecting circumcision: Incidence of complications: hemorrhage, infection, removal of too much or too little of foreskin, urinary retention, stenosis of urethra, adhesions, necrosis, injury. Delayed in preterm infants, intubated, hypospadias. Some believe that it is more of a "cosmetic" surgery, and Continuously exposing head of penis which some believe reduces sensitivity for sexual relationships. Rare complications from the procedure •Pain relief: Pharmacological: Dorsile penal nerve block (lidocaine injection into nerve), EMLA cream (numbs skin prior to procedure). Acetaminophen after procedure, pacifiers with oral sucrose common. Nonpharmacological: FACES pain scale •Methods: Restraint device during sterile procedure. RN can help with medications and tools. May use Gomco clamp, Mogen Clamp, Plastibell - go home with this method on and skin of head of penis falls off b/c lack of blood flow. •Care of site: Check for bleeding - monitor for 1 hr post procedure. Normal yellow exudate that forms around wound site should not be removed. Gauze with petroleum jelly over penis in diaper, this will prevent dried blood on the diaper or gauze. Only used first 24 hours post procedure.

Neurological assessment

•Reflexes: Moro, Babinski, Stepping, Rooting, Grasping. Preterm infant can be decreased. •Jitteriness or Tremors: Often caused by hypoglycemia or low calcium levels •Sensory of ears: placement and maturity. Low set can indicate down syndrome. Preocular sinus or dimple (can indicate renal dysfunction). If pull pinna towards ear and it stays down then indicative of prematurity. Hearing begins at 24-34 weeks. Will doing hearing test before baby is discharged - loud startling sound or high pitched voice. •Eyes: should by symmetric and same size. Eyes will be gray/blue/brown and change around 6 months if they're going to. Inner canthus issues in downs. Subconjuncitval hemorrhage can be due to pressure during birth. Conjunctivitis can be indicative of maternal STI - given eyedrops (erythromycin) at birth for prevention. Crossed eyes, doll eyes, setting sun eyes. PEERL. If cataracts present - can indicate rubella or other infection during pregnancy. Tear production at 2 months of life, if excessive can have clogged tear duct. Respond well to black and white, and shapes. •Sense of smell and taste: will have preference to sweet taste and sugar water in high doses can help with pain. •CNS: seizures can indicate injury or metabolic abnormality, high pitched cry can indicate maternal drug use, and infant may stiffen or arch back when held which can indicate CNS injury.

Normal newborn VS

•Resp. Rate: 30 -60 breath-minute, can use hand/stethoscope •Heart Rate: 120-160 beats/minute, Can raise or lower with activity or sleep, listen apically •Blood Pressure: systolic 65-96 / diastolic 30-60, (Not assessed in healthy newborn, only if NICU or septic) •Temp. : 36.5 - 37.9 (97.7 to 99.5) axillary

Newborn cardiorespiratory status assessment

•Respiratory Rate - every 30 minutes for 2 hours, 30-60 bpm. May have higher immediately after birth because of stimulation. Nonlabored and symmetrical. Count for one full minute. •Breath sounds - clear, but crackles common for 1-2 hours after birth because of leftover amniotic fluid in lungs. Crackles more common in c section. •Signs of Respiratory Distress - tachypnea, retractions (substernal, intercostal, supraclavicular), nasal flaring, central cyanosis. Apneic episodes which last 20 seconds or longer accompanied by cyanosis, bradycardia, or decreased muscle tone. •Cyanosis - What is Acrocyanosis? Lower and outer extremities discolored, can be due to cold and decreased perfusion, squeaking noise, see saw respirations, nasal atresia - close one nostril to test for this. Cyanosis will blanch. •Pallor - hypoxemia or anemia. •Ruddy Color - reddish, - excessive RBC (polycythemia), HCT above 65%, increased risk of jaundice. •Heart Sounds - apical for one minute, 120-160. Murmur may be common but will go away. •Brachial and Femoral Pulses - bilaterally •Blood Pressure - Not part of routine assessment of normal newborn. Only taken for sick newborns. Lower extremities should be the same or only slightly higher. •Capillary Refill - assessed over chest, abdomen or an extremity in a newborn. Color return should occur in 3-4 seconds.

High risk newborns

•Risk factors: Low socioeconomic/limited access, Exposure to environmental dangers, Pre-existing maternal conditions, Maternal factors-age, parity, Medical conditions related to pregnancy •Factors that influence outcome: Birth weight: if severely under or overweight then risk for complications. Gestational age: preterm because of immature lungs. Newborn illness: born with immature immune functioning so any illness can cause complications. Environment: at home are they struggling to be fed, around drugs and alcohol, etc., Maternal: pre-existing conditions of mom, conditions that developed during pregnancy. Maternal-infant separation: newborns are separated from mother because if NICU setting so bonding is delated or hindered.

Gastrointestinal System

•Stomach -Capacity expands within first few days of life: 6 mg/kg at birth -Peristalsis is rapid -Cardiac sphincter is relaxed: what causes spitting up -Delayed gastric emptying •Intestines -Long: more surface area for absorption -Prone to rapid water loss with diarrhea -Bowel sounds are present within the first hour -The digestive tract is sterile until feeding begins, can have stools while feeding or shortly after •Digestive enzymes -Cannot digest complex carbohydrates -Ingredients in breast milk more easily digested and quicker than formula

Bathing the newborn

•Timing of bathing and differing practices: Wait for 8 practice - baby not bathed for 8 hours post delivery. To help thermoregulation. •Newborn must have appropriate temperature regulation before bathing: Temperature of 36.7 C (98F) •Perform bathing quickly to prevent evaporative heat loss: Recheck temperature after bath is completed •Cleaning the diaper area: use plain water or mild soap. Wipes should be detergent and alcohol free.

Hyperbilirubinemia

•Visible if greater than 5 g/dL: done with TCB or TSB testing •Blanching of infant's skin on the nose or sternum will reveal yellowing •Identify infant's at high risk •Facilitate adequate feeding •Instruct parent's in what to look for upon discharge

Measurements

•Weight: Normal is between 2500 and 4000 grams (5 lb., 9 ounces and 8 lb., 13 oz). Expected to lose up to 10% of their birth weight during the first week of life. Typically regain or exceed birth weight by 14 days old. •Length: Average is 48 to 53 cm. (19-21 inches), Measured from top of head to heel of outstretched leg. •Head: Diameter of Head is measured around occiput above the eyebrows. Normal range is 32 to 38 cm (13 to 15 inches), small head can indicate microcephaly, large head can mean hydrocephalus. •Chest: Chest measured at level of nipples and is typically 2 to 3 cm smaller than the head. (30-36 cm). Not routinely measured.

Nursing assessment for breastfeeding

●Assess both mother and infant -Maternal - breasts, knowledge of techniques -Infant - readiness (sleepiness?), response (assess palate and latch) ●Assist with first feedings -Preferably within 1st hour of birth (first period of reactivity) ●Teach techniques, positions, latch, length of feedings ●Frequency of feedings -Every couple of hours (on demand) frequent feedings helps establish supply -Cluster feeding around day 2-3. Every 5 to 30 minutes which helps bring transition milk in. ●Overcoming problems -Nipple confusion: may refuse to breastfeed or push it out of their mouth due to confusion between breast and bottle, prematurity -Maternal issues: Engorgement (peaks at day 3-4, due to accumulation of milk - can lead to mastitis or stopping breast feeding, teach to continue to breastfeed, wear supportive bra, prevent excessive stimulation, face away from water in the shower), nipple pain, flat and inverted nipples, plugged ducts - can massage breast during feeding by pushing node towards the nipple, heat during feedings, ice between feedings

Newborn nutritional needs

●Calorie -Breastfed: 85-100 kilocalories per kilogram of body weight per day -Formula Fed: 100-110 kilocalories per kilogram of body weight per day ●Nutrients: do digest simple carbs and proteins. Complex carbs and fats are difficult to digest because of lack of amylase and lipase. ●Water: larger amounts of water needed because of ease of water loss from kidneys, skin, and intestines. Will receive water from breastmilk or formula. ●Infants have a small stomach capacity and fall asleep easily during feeding. ●Can lose up to 10% of weight at birth, but should regain weight by 14 days old

Breastmilk composition

●Lactogenesis I -Colostrum - liquid gold because of benefits and color. Higher in protein, vitamins, and minerals. Lower in carbs, lactose. High in IgA for protecting GI tract from infection. Good laxative effects. -Begins during pregnancy and ends within few days of birth ●Lactogensis II -Transitional milk: high quantity increases rapidly. Decreases in IgA. Increases in lactose, fat, and calories. Vitamins stay the same -Begins 2 to 3 days after birth and lasts 10 days ●Lactogensis III -Mature milk: bluish color (b/c water content), not as thick, contains approx. 20 cal per oz, provides immunoglobulins and antibacterial components to infant. -Breastmilk established by supply and demand -Has been shows male breastmilk is higher in fat and calories than females

Bottle feeding

●Proper preparation: Ready to use, concentrated liquid, or powder. Be sure to know how to prepare and store for each type. Should be able to repeat instructions to you. Mix with spring or distilled water. Use within 24 hours of preparation. Never microwave formula, or send baby to bed with a bottle (can have premature dental issues with this) ●Clean bottles/nipples: different kinds and speeds (premature, slow, and medium flow), certain kinds for mixing cereal. Clean and sterilize if possible. ●Position infant ideally in cradle position (partially upright); face-to-face. Never flat on their back with bottle. Putting nipple in roof of mouth can help with sucking response. ●Burp (after every 15 mL first few days then gradually half-way through feeding): on lap or shoulder, pat pretty firmly between shoulder blades. ●Frequency of feedings (every 3-4 hours) taking cues from infant: rooting, hands in fists bringing towards face, suddenly alert, active kicking and moving,

Breastmilk nutrients

●Protein -Tarrin: Aids in bile conjugation and brain development -Thyrine and pheylalanine: Easier to digest ●Carbohydrates -Lactose is major carb—helps absorption of calcium -Help limit risk of infection developing ●Fat -More easily digested than formula -Amount of fat varies depending on feeding: but most of calories in breastmilk come from fat -Hindmilk: comes later, higher in fat and helps infant gain weight, thicker and creamier in texture. Produces feeling of fullness in baby. -Foremilk: comes out first, less thick, higher in water concentration. Clenches baby's thirst/ ●Vitamins -High levels of vitamins A, E, and C -Low levels of vitamin D - requires supplementation, droplet -Vegan breastfeeding mothers may be low in B12 and require supplementation ●Minerals -Iron is absorbed easier: -Maintain iron stores for 6 months - at 6 months table foods introduced ●Enzymes -Contains pancreatic enzymes necessary for digestion -Lipase for fat digestion -Amylase -These cannot be made in formula: Casein is higher in formula and lower in whey so formula is harder to digest. ●Breastmilk has a lower chance of allergens - if mom consumes a large amount of dairy then may cause baby allergen through breastmilk

Milk storage

●Store in a clean container with a tight cap. ●Fresh, unrefrigerated breast milk should be used within 3-4 hours of pumping. ●Store in refrigerator and use within 72 hours ●Frozen should be used ideally by 6 months: should use oldest milk first, and educate to freeze in amounts that baby is eating. Once thawed milk cannot be refrozen.

Transient Tachypnea of the Newborn

◦Cause—Exact cause is unknown; delay in fetal lung fluid absorption. Causes air trapping ◦Manifestations—rapid respirations soon after birth (usually resolves within 12 to 72 hours) ◦Signs similar to RDS: Tachypnea, grunting, retractions, nasal flaring, hyperinflation of the lungs, fissures on XR ◦Therapeutic Management: Supportive—O2 if cyanosis present. Possible antibiotics until lack of sepsis diagnosis confirmed. Gavage or IV feedings if RR high (prevent aspiration, conserve energy) ◦Nursing Considerations: Similar to respiratory care of preterm infant

Meconium Aspiration Syndrome (MAS)

◦Description—obstruction of airways, chemical pneumonitis, and air trapping. More prevalent in post term, SGA, placental insufficiency, oligohydramnios, cord compression. ◦Causes—gasping movement in utero with asphyxia or acidosis or when infant takes first breaths after birth. Can cause partial obstruction (air can enter but not escape) or complete obstruction. ◦Manifestations: Mild to severe respiratory distress—tachypnea, retractions, cyanosis, nasal flaring, grunting, rales. X-rays shows patchy infiltrates, atelectasis, hyperexpansion ◦Therapeutic Management: Clearing of the airway is priority but want to prevent crying/gasping. Routine care for vigorous infants, Supportive care based on extent of problem - if less than 100 bpm, low rr, or poor tone. Severe—ECMO to allow infant's lungs to rest.

Supporting parents of newborn with infection

◦Take to NICU as soon as possible ◦Holding and interaction as soon as possible: have them provide any care that's possible ◦Provide information ◦Kangaroo care ◦Facilitate interactions: Evidence based practice—parent's who understand cues have less anxiety ◦Increase decision making ◦Alleviate concerns ◦Help with ongoing problems ◦Prepare for discharge: understand equipment at discharge such as apneic monitor.