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Newborn lecture nurs 3340 fall 2014

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  • Newborns must withstand extreme changes as they leave a thermo-constant, watery, completely life-sustaining environment (intrauterine) and enter a variably pressurized atmosphere that demands profound physiologic alterations for survival (extrauterine).
    The first vital task in newborn adaptation is the initiation of respirations.
    Profound changes in the circulatory system occur after the first breath and clamping of the umbilical cord.
    With 24 hours after birth, the newborn’s neurologic, hematologic, gastrointestinal (GI), liver, and urinary systems must function sufficiently to maintain life outside of the womb.
    In most settings, the nurse provides direct care to the newborn immediately after birth. Nursing care of the newborn is based on knowledge of these changes.
  • The first vital task in newborn adaptation is the initiation of respirations. Because the alveoli are collapsed, the infant’s first breath requires a much larger negative pressure (suction force) than subsequent breaths.
    Breathing is initiated by chemical, thermal, and mechanical factors that combine to stimulate the respiratory center in the medulla of the brain and trigger respirations at birth.
  • Asphyxia: insufficient oxygen and excess carbon dioxide in the blood and tissues.
    Hypoxia: Reduced availability of oxygen to the body tissues.
    Hypoxemia: Reduced oxygenation of the blood.
    First breath—inflation of lungs in response to chemical factors (transient hypoxia/asphyxia):
    Decreased Pa02, increased PaC02 and lower pH stimulate the respiratory center in the medulla.
  • The sudden change in environmental temperature at birth stimulate skin sensors, which then stimulate the brain’s respiratory center.
    Fetal chest compression during vaginal birth forces additional lung fluid from the chest.
    Added stimuli to breathe include suctioning, drying, holding, sounds, and light.
  • Suction the mouth and then the nose to remove mucous from the airways. Infants often gasp when the nose is suctioned and may aspirate secretions from the mouth into the lungs.
    Begin PPV with a bag and mask if the infant fails to breath spontaneously with initial stimulation (suctioning, rubbing back, flicking feet).
  • Surfactant lines the alveoli and reduces surface tension to keep the alveoli partially open between respirations.
    Surfactant is a lipoprotein (soap-like substance) produced by the lungs of the mature fetus.
    Sufficient surfactant is usually produced beginning at 34 to 36 weeks of gestation.
    Fetal lung fluid moves into the interstitial spaces before, during, and after birth and is absorbed by the lymphatic and vascular systems.
    Surfactant is first produced at 22 weeks gestation. By 34-36 weeks gestation, production of surfactant is usually mature enough to enable the baby to breathe normally outside of the womb.
    Birth before 34 weeks – critical period.
    At risk for respiratory distress syndrome (hyaline membrane disease).
  • Thermoregulation—maintenance of body temperature.
    The fetus does not have to produce any heat in utero, due to the consistently warm temperature of the amniotic fluid.
    The newborn’s temperature may drop several degrees after delivery, because the external environment is cooler than the intrauterine environment.
    The neonate must produce and maintain heat in order to survive.
  • Infants are predisposed to heat loss because:
    Thin skin
    Little insulating subcutaneous fat
    Blood vessels are close to the surface
    Large skin surface area (greater ratio of surface area to body mass, several times more surface area than adults)
    Heat readily transferred from internal organs to skin
    Poor mechanisms for body temperature regulation during first days of life.
    Normal newborn flexed position reduces the amount of skin surface exposed to the surrounding temperature and decreases heat loss.
    Premature or sick infants do not maintain a flexed position, so they are even more at risk for heat loss.
  • A neutral thermal environment is one is which the infant can maintain a stable body temperature without an increase in oxygen consumption or metabolic rate. The range of environmental temperature that allows this maintenance is called the thermoneutral zone. In healthy, full-term newborns, an environmental temperature of 32 to 33.5 degrees Celsius (89.6 to 92.3 degrees Fahrenheit) provides a thermoneutral zone.
  • Infants lose heat by evaporation, conduction, convection, and radiation.
  • Dry baby off as soon as possible after delivery. Keep the infant dry!
  • Keep the baby wrapped and away from cool surfaces. Warm hands and stethoscopes before touching baby.
  • Keep baby away from air currents and drafts.
  • Keep baby away from nearby cold surfaces, outside walls.
  • Conduction
    Conduction
    Radiation
    Evaporation
    Convection
  • Heat is produced in newborns by nonshivering thermogenesis, vasoconstriction, and an increase in metabolism.
    These factors increase oxygen and glucose consumption, and may cause the dangerous side effects of respiratory distress, hypoglycemia, acidosis, and jaundice.
  • Brown fat: Highly vascular specialized fat found in the newborn that provides more heat than other fat when metabolized. This highly vascular fat is located primarily around the back of the neck; in the axillae; around the kidneys, adrenals, and sternum; between the scapula; and along the abdominal aorta. As brown fat is metabolized, it generates more heat than white subcutaneous fat. Blood passing through brown fat is warmed and carries heat to the rest of the body.
    Thermogenesis—heat production.
    Nonshivering thermogenesis—process of heat production, without shivering, by oxidation of brown fat. Brown fat helps maintain infant temperature, since newborns are not able to shiver. It generates heat for distribution to other parts of the body.
  • “A” correct.
  • Cold stress in the neonatal period can be defined as a body temperature measurement less than 97.6° F (36.5° C) rectally with system wide associated negative consequences. Cold stress (hypothermia) in the newborn can be quite severe or lethal even for a vigorous, full-term newborn.
    Nonshivering thermogenesis begins when thermal receptors in the skin detect a drop in skin temperature. Thermal receptor stimulation causes release of norepinephrine, which initiates metabolism of brown fat.
    Newborns at greater risk due to reduced stores of subcutaneous fat or glycogen reserves: premature, post-term, SGA newborns, and intrauterine growth restricted infants (failure of a fetus to grow as expected for gestational age). These infants have a thin layer of subcutaneous fat that provides poor insulation.
    Preterm infant—an infant born before the beginning of the 38th week of gestation.
    Post-term infant—an infant born after 42 weeks of gestation.
    Small-for-gestational-age infant (SGA)—an infant whose size is below the 10th percentile for gestational age.
    Intrauterine growth restriction (IUGR)—failure of a fetus to grow as expected for gestational age.
  • Nursing care: institute warming measures according to facility policy and check in 30 minutes; check blood glucose
  • For the infant challenged with cold stress, the stores of brown fat may be depleted. Cold stress may lead to hypoxia and hypoglycemia due to the energy requirements needed to maintain body heat. 
    The consequences of cold stress can be quite severe. 
    Cold stress results in respiratory distress from the need for more oxygen and glucose because of the increased metabolic rate. The increased need for oxygen causes respiratory distress and hypoxia. Cold stress also causes less surfactant, which will lead to further respiratory distress. The increased need for glucose will cause hypoglycemia. The metabolism of brown fat will release fatty acids from anaerobic metabolism causing metabolic acidosis. Elevated fatty acids in the blood interfere with transport of bilirubin to the liver, causing jaundice. As the infant attempts to conserve heat, vasoconstriction of the peripheral and pulmonary blood vessels occurs. The infant will have pale, cold, mottled skin. Vasoconstriction of the pulmonary vessels will cause increased pulmonary resistance which will lead to a return to fetal circulation patterns (shunts reopen). This will further increase respiratory distress.
  • Respiratory distress
    Acidosis
    Hypoglycemia
    Hyperbilirubinemia
  • Infants also respond poorly to hyperthermia. With an elevated temperature, the metabolic rate rises, causing an increased need for oxygen and glucose. In addition, vasodilation leas to increased insensible fluid losses.
    Newborns may be overheated by poorly regulated equipment designed to keep them warm. When infants are under radiant warmers, warming lights, or in warmed incubators, the temperature mechanism must be set to vary the heat according to the infant’s skin temperature and thus prevent heat that is too high or too low. Alarms must be set.
    Nursing care: Use skin temperature probe when in radiant warmer or under warming lights; check radiant warmer temperature setting and set controls to vary heat according to the infant’s skin temperature. Check thermometer for accuracy. Set the alarms to sound if baby’s temp is too high or too low.
    Remove excessive clothing.
    Check for dehydration.
  • Ineffective Thermoregulation: protect from cold stress
  • “A” correct
  • “A” is correct.
  • Count respirations first, before performing other vital signs.
    Assess respirations when the infant is quiet or sleeping, if possible, so that lung sounds can be heard more clearly. Count for a full minute. Count the respirations (and apical pulse) before disturbing the infant for other assessments.
    At birth, respirations are very unstable, high.
    Newborn is a nose breather and abdominal breather.
    Should stabilize after first hour—around 30 to 60 breaths per minute.
    Assess respirations for one full minute, from apex to bases, anterior and posterior.
    Watch the movement of the chest—should be symmetric.
  • Tachypnea after the first hour needs further investigation.
    Periodic breathing: breathing pauses of 5-10 seconds without color change or bradycardia. These pauses are followed by 10 to 15 seconds of compensatory rapid respirations.
    Periodic breathing is very common in premature infants and decreases as the infant’s gestational age increases.
    Apnea, on the other hand, is a pause in breathing that lasts 15 to 20 seconds. This is not normal, but can be life-threatening.
  • Observe for respiratory distress.
    Tachypnea is the most common sign of respiratory distress.
    Occasional mild retractions are common immediately after birth but should not continue after the first hour.
    Grunting is one of the most significant signs of respiratory distress syndrome and necessitates notifying the physician.
  • Early sign: Color changes—pale, mottled, circumoral cyanosis. Central cyanosis involves the lips, tongue, mucus membranes, and trunk and shows true hypoxia. It indicates that not enough oxygen is reaching the vital organs and requires immediate attention.
    Late signs: See-saw respirations (chest retracts as abdomen rises)
    Apnea in the newborn is a pause in breathing that lasts 15 seconds or more, especially with a cyanotic color change.
  • Check apical pulse for one full minute.
    Rhythm regular. Point of maximal impulse (PMI) at third to fourth intercostal space, slightly to the left of midclavicular line, may be visible.
    Crying will increase HR; sleeping will decreased HR.
    Peripheral pulses (brachial, femoral, and pedal pulses) should be present and equal bilaterally.
  • Tachycardia—respiratory problems, anemia, infection, cardiac conditions
    Bradycardia—perinatal asphyxia (inadequate oxygen delivery to the fetus), increased intracranial pressure
    Murmurs—Murmurs in the neonatal period are often due to transitional circulation and are usually a normal finding. However, all murmurs should be followed-up and referred to the physician for medical evaluation.
    Arrhythmias
    Absent or unequal pulses—coarctation of the aorta
  • Temperature—very immature regulatory center at birth. Needs to be observed carefully.
    Axillary temperatures are preferred over rectal temperatures because they are safer and provide accurate measurement.
    Tympanic temperatures are not used with newborns.
    Glass—5 minutes
    Electronic—when indicator sounds
    Decreased—cold environment, hypoglycemia, infection, CNS problem.
    Institute warming measures per facility policy and recheck in 15 – 30 minutes. Check blood glucose.
    Increased—infection, environment too warm.
    Remove excessive clothing, check for dehydration.
  • The infant should be quiet when the blood pressure is taken because crying elevates it.
    Choose correct size of cuff: this is important for accuracy of measurement. Cuff bladder should cover 2/3’s the length of the upper arm or thigh. Width of the cuff should cover the upper arm or leg without encroaching on the joints.
    Doppler blood pressure by electronic measurement (Dinamap machine) is most accurate.
    If the infant has unequal pulses or murmurs, the blood pressure is taken in all extremities. A blood pressure in the upper extremities than is over 15 mm Hg higher than that in the lower extremities may indicate coarctation of the aorta.
  • “A” correct.
  • Newborn with foot wrapped for warmth to increase blood flow to extremity before heel stick.
    Wrap foot loosely in pamper that has been damped on the interior with warm water (test with wrist). Leave on for about 5 to 10 minutes to help dilate the vessels before sticking.
  • In performing heel sticks for blood glucose, the nurse must choose the site carefully to avoid damage to the bone, nerves, or blood vessels of the heel.
    Heel stick—best place is lateral side of heel—towards little toe. May also use medial side of heel. Want to avoid damaging nerves, arteries, bones, causing infection.
    Warm the infant’s foot for a few minutes if it is cold. Dampen a diaper with warm water and fasten it over the heel. Warming causes vasodilation.
    Wear gloves. Clean the area with alcohol and dry with sterile gauze or allow to air dry. Wipe away the first drop with gauze (contaminated).
    Puncture the side of the heel with a lancet to a depth of less than 2 mm to avoid piercing the bone and causing bone infection (osteomyelitis). Wipe away first drop with gauze. Avoid excessive squeezing of the foot.
    Green and yellow lancets are used for term babies.
    Purple and blue lancets are used for preterm babies.
    Normal blood glucose at birth: 40 – 60 mg/dl.
    Should stabilize by day three: 50-90
  • The brain needs a constant supply of glucose and may be damaged without it.
    Readings below 40 signify hypoglycemia: may need laboratory verification.
    Neonatal hypoglycemia is common and often asymptomatic.
    Left untreated, it may – in combination with other factors – lead to compromised neurological development, or in extreme cases, death.
  • Feed infant according to agency policy.
  • Feed infant according to agency policy.
  • “A” correct.
  • APGAR is a quick test performed on a baby at 1 and 5 minutes after birth. The 1-minute score determines how well the baby tolerated the birthing process. The 5-minute score tells the doctor how well the baby is doing outside the mother's womb.
    If the infant’s condition is unstable, the APGAR scoring is repeated at 10 minutes.
  • Each factor is given a score of 0, 1, or 2, with a possible total score of 10.
    APGAR scoring is done routinely at 1 and 5 minutes after birth. If the infant’s condition is unstable (less than 7), it is repeated at 10 minutes.
    Most of the time, a low score at 1 minute is near-normal by 5 minutes.
    Heart rate and respiratory efforts: most important assessments
    Cry should be lusty, strong.
    Each category is scored with 0, 1, or 2, depending on the observed condition.
    Breathing effort:
    If the infant is not breathing, the respiratory score is 0.
    If the respirations are slow or irregular, the infant scores 1 for respiratory effort.
    If the infant cries well, the respiratory score is 2.
    Heart rate is evaluated by stethoscope. This is the most important assessment:
    If there is no heartbeat, the infant scores 0 for heart rate.
    If heart rate is less than 100 beats per minute, the infant scores 1 for heart rate.
    If heart rate is greater than 100 beats per minute, the infant scores 2 for heart rate.
    Muscle tone:
    If muscles are loose and floppy, the infant scores 0 for muscle tone.
    If there is some muscle tone, the infant scores 1.
    If there is active motion, the infant scores 2 for muscle tone.
    Grimace response or reflex irritability is a term describing response to stimulation such as a mild pinch:
    If there is no reaction, the infant scores 0 for reflex irritability.
    If there is grimacing, the infant scores 1 for reflex irritability.
    If there is grimacing and a cough, sneeze, or vigorous cry, the infant scores 2 for reflex irritability.
    Skin color:
    If the skin color is pale blue, the infant scores 0 for color.
    If the body is pink and the extremities are blue, the infant scores 1 for color.
    If the entire body is pink, the infant scores 2 for color.
  • A score of 7, 8, or 9 is normal and is a sign that the newborn is in good health. A score of 10 is very unusual, since almost all newborns lose 1 point for blue hands and feet, which is normal for after birth.
    Any score lower than 7 is a sign that the baby needs medical attention. The lower the score, the more help the baby needs to adjusting outside the mother's womb.
    Most of the time a low APGAR score is caused by:
    Difficult birth
    C-section
    Fluid in the baby's airway
    If your child has a low Apgar score, he or she may receive:
    Oxygen and clearing out the airway to help the baby breathe
    Physical stimulation to get the heart beating at a healthy rate
  • Grimacing (reflex irritability): 1
    Respiratory rate 20, irregular: 1
    Heart rate 150: 2
    Muscle tone (some flexion, not active movement): 1
    Color: centrally pink with acrocyanosis: 1
    TOTAL: 6
    “C” correct answer.
    EQUALS Moderate Difficulty
  • The New Ballard Score is frequently used to estimate the infant’s age from conception. It is based on neuromuscular and physical characteristics.
    A score is given to each assessment, and the total score is used to determine the gestational age of the infant.
    It alerts the nurse to possible complications of age and development, especially prematurity.
    Preterm infant—an infant born before the beginning of the 38th week of gestation.
    Why estimate gestational age? Gestational assessment is helpful in meeting a baby’s needs if the dates of a pregnancy are uncertain. For example, a very small baby (small for gestational age) may actually be more mature than it appears by size, and may need different care than a premature baby.
    Pick up problems early: for instance, if the newborn rates less than 37 weeks, then he/ she is at risk for respiratory problems. Less than 34 weeks—at risk for RDS.
    Plan care: early intervention
    Most problems develop with a newborn who is preterm or small/ large for gestational age.
  • This is a phase of instability during the first 6 to 8 hours of life through which all newborns pass, regardless of gestational age or nature of labor and delivery.
    Nurse monitors the neonate closely and intervenes promptly with appropriate care.
    After the first period of reactivity the newborn either sleeps or has a marked decrease in motor activity. This period of decreased responsiveness lasts from 60 to 100 minutes. During this time the infant is pink and respirations are rapid and shallow (up to 60 breaths per minute), but unlabored.
    The second period of reactivity occurs roughly between 2 and 6 hours after birth and lasts from 10 minutes to several hours. Brief periods of tachycardia and tachypnea occur, associated with increased muscle tone, changes in skin color, and mucous production. Meconium is commonly passed at this time. Most healthy newborns experience this transition regardless of gestational age or type of birth; extremely and very preterm infants do no because of physiologic immaturity.
  • During the first and second periods of reactivity, newborns are active and alert and may be interested in feeding. Parents enjoy this phase, as the infant gazes directly at them when held in the face-to-face position. It is an important time for bonding. If allowed to nurse, many infants latch on the the nipple and such well.
    They may have elevated pulse and respirations, and excessive respiratory secretions.
    Respirations during the first and second periods of reactivity may be as high as 80 breaths per minute. The heart rate may be elevated to 180 beats per minute. There may be crackles, retractions, nasal flaring, and increased mucous secretion.
  • Nurses assess newborns immediately after birth to detect serious abnormalities. If no problems are detected with a quick assessment, a more comprehensive examination is performed.
  • A healthy infant’s position is one of flexion—that is, the extremities are flexed and close to the body and the fists are tightly clenched. Movements are symmetric. Any attempt to alter this flexed position is met with resistance.
    The flexed tone helps preserve body heat as the newborn cannot shiver. “Floppy,” limp baby—preterm, hypoxia, medications, CNS trauma.
    Jitteriness or tremors—low glucose or calcium level.
    Hypertonic, stiff, seizures—CNS damage.
  • The head should be approximately one fourth of infant’s length.
  • Measurements are an important way to learn about growth before birth. Abnormal measurements alert the nurse that the newborn is at risk for complications.
    Growth rate is the greatest during the neonatal period than at any other time.
    Regain birth weight within first 2 weeks.
  • Flexed extremities resist extension, return quickly to flexed state. Hands usually clenched. Movements symmetric.
    Slight tremors on crying.
  • The preterm infant’s extremities are extended.
  • Head lag—can’t hold head up when lifted from supine position. Poor head control—head must be supported!
    Large head is equal to one fourth total length of the body, twice the proportion for an adult.
    When prone, turns head side to side. Holds head and back in horizontal plane when held prone. Ability to hold head momentarily erect
  • Skin helps protect the infant.
    Note color at rest and with activity—eating, cry, movement.
    Note color changes: dusky (dark); mottling (road map on skin); jaundice (yellow); cyanosis (blue); pallor (white); ruddy (very red).
    Vernix caseosa: white, odorless, cheesy lubricant on skin, usually found in creases
    Produced in utero
    Diminishes close to term
    Gradually absorbed or washed off after birth
    Lanugo:
    Fine, downy hair on shoulders, back, upper arms, forehead, and cheeks
    Assessed with the gestational age assessment
    More abundant with preemies
    Gradually disappears close to term
  • Vernix Caseosa:
    The white, cheesy substance covering the newborn's body. Often present only in the skin folds.
    Yellow or greenish vernix is abnormal. Signals meconium staining (respiratory distress)
  • Lanugo:
    Fine downy body hair usually distributed over shoulders, sacral area, and back of newborns. Usually disappears before birth or shortly after birth.
    Excessive lanugo—preterm.
  • Marks on the skin should be documented, including location, size, and a general description.
    Explain marks to parents, and offer emotional support if they are upset.
  • Permanent purple birthmark.
  • Bluish discoloration of the hands and feet due to poor peripheral circulation. Peripheral circulation not yet well established. Newborns have very thick blood with a high level of red cells.
    Normal/common during first 24-48 hours of life.
    Cover hands and feet for acrocyanosis to increase warmth.
    Simply straightening the limb will often restore the pink color.
  • Mongolian spots—irregularly dark pigmented bruise-like marks on the buttocks that occur mostly in newborns of African American, Asian, Native American, or Hispanic descent.
  • “Road-map” type pattern on skin.
    Check baby’s temperature. Institute warming measures, if necessary.
    Continue to monitor closely, as mottling can also be a sign of systemic infection or sepsis.
  • About 60% of newborn babies develop jaundice from a buildup in their bodies of bilirubin, an orange-yellow pigment that results from the natural breakdown of red blood cells.
    Most of these cases of jaundice are physiologic (transient and normal). Physiologic jaundice occurs in normal newborns after the first 24 hours of life as a result of hemolysis of red blood cells and immaturity of the liver.
    Before birth, babies have high levels of RBCs because low oxygen levels available to them in fetal life. When the baby is born, these excess RBCs are not needed anymore and start to break down, releasing bilirubin. The newborn’s liver is immature and may not be able to effectively get rid of all the excess bilirubin (hyperbilirubinemia). Bilirubin then seeps out of the blood and into the tissue, coloring the skin and sclera yellow (jaundice).The blood level of bilirubin rises quickly up to the fifth day and then it declines. The jaundice usually clears up by the end of the week.
    Evaluate the jaundice by blanching the tip of the nose, the forehead, the sternum, or looking at the sclera (in the appropriate lighting). If jaundice is present, the area will appear yellowish immediately after blanching.The further down the body that the jaundice appears, the more severe is the jaundice. (Jaundice of the face/neck occur first, then jaundice of the upper trunk).
    Jaundice may be hard to see in infants with dark skin. Best way is to examine the sclera or hard palate.
    Today, with shortened hospital stays of 24–48 hours and the increased rate of breastfeeding, bilirubin levels peak after discharge. Educating the parents is very important. Tell them, if they notice a yellowish tinge to the baby's skin, the baby seems lethargic or very sleepy or refuses to eat, they need to call their pediatrician immediately.
  • Jaundice that occurs during the first 24 hours after birth OR bilirubin level > 12 mg/dl in a term infant, 10 mg/dl in a preterm infant.
    Caused by excessive destruction of RBC’s. This may be due to incompatibilities between the mother’s and infant’s blood types (Rh incompatibility, ABO incompatibility), infection, metabolic disorders (hypothyroidism, certain enzyme deficiencies).
    Requires treatment with phototherapy. Light breaks down the bilirubin in the skin, and allows it to move into the bloodstream, where it moves into the liver, then into the bile and out into the feces for removal from the body. Need plenty of fluids, to facilitate excretion of the excess bilirubin. May also need glycerin shaves per rectal if not stooling while under the bili lights.
    Kernicterus—staining of brain tissue caused by accumulation of unconjugated bilirubin in the brain. Bilirubin level of 20 mg/ dL or above. May cause irreversible damage to the brain, leading to cerebral palsy and retardation. Signs of neurologic damage: a high-pitched cry, decreased muscle tone, becoming hypotonic or floppy) with episodes of increased muscle tone (hypertonic) and arching of the head and back backwards (opisthotonus).
    May need exchange transfusion in addition to phototherapy to prevent irreversible brain damage.
  • The most common cause of jaundice in breast-fed infants is insufficient intake. Infants who are sleepy, have a poor suck, or who nurse infrequently are at risk.
    True breast milk jaundice is caused by a non-harmful substance in the breast milk of some women. While the jaundice caused by this form of jaundice can last longer, it does not tend to have high fluctuations in the levels of bilirubin.
    Treatment involves close monitoring and at least 8 to 10 feedings in each 24 hour period. If the bilirubin levels become too high, treatment includes phototherapy, replacing breastfeeding with formula for 24 to 48 hours, or both.
  • Two types of phototherapy: bili lights and bili blanket.
    Bili lights: The newborn is placed in an incubator under phototherapy lights so that the light can help break down the bilirubin. The infant must wear an eye mask to protect the eyes and a “string bikini” as a small diaper (face mask) to protect genitals. Body surface should ideally be about 12” from the light.
    With the fiberoptic blanket, the light stays on at all times, and the newborn is accessible for care, feeding, and diaper changes. The eyes are not covered and the light is wrapped directly against the skin.
    Nursing Interventions (phototherapy):
    Baby nude except for eyes and reproductive organs (to expose as much skin as possible to the light).
    Guard against dehydration (check: fontanel, mucous membranes, skin turgor, urinary output).
    Change the baby’s position every 2 hours so that the light reaches all areas of the body.
    Feed the baby every 2 to 3 hours (prevents dehydration; need frequent urine and stools to get rid of bilirubin).
    Monitor intake and output (weigh diapers).
    Place and skin probe and monitor infant’s temperature (to guard against hyperthermia).
    Frequent monitoring of serum bilirubin; update parents
  • “Flea-bite” rash that appears within 24 – 48 hours of birth and occurs from unknown cause. Has blotchy red areas that may have white or yellow papules in the center.
    Harmless (benign) and disappears within a few days.
    Must be differentiated from rashes found in infections.
  • The areas where the bones join together are called the sutures.
    The bones are not joined together firmly at birth (this allows the head to accommodate passage through the birth canal). In an infant, the spaces where two sutures intersect form a membrane-covered "soft spot" called a fontanel.
    The fontanels allow room for rapid brain growth during an infant's first year.There are two main fontanels that are normally present on a newborn's skull—at the top (anterior) and back (posterior).
    The fontanels gradually ossify and become closed, solid bony areas. The posterior fontanel usually closes by the time an infant is 1 or 2 months old. The anterior fontanel usually closes by 12 to 18 months of age.
  • Palpate the fontanel in the upright position, or with the head supported in a semiupright position.
    The fontanels should feel firm and very slightly concave to the touch. A tense or bulging fontanel occurs when fluid accumulates in the skull cavity or when pressure increases in the brain (increased intracranial pressure).
    Crying, lying down, or vomiting can make the fontanel look like it is bulging, but it will return to normal when the infant is in a calm, head-up position.
  • Full or bulging at rest signals hydrocephalus or increased intracranial pressure.
  • Caput succedaneum is swelling and bruising that usually occurs on the top of the scalp, caused by the birth process (pressure against the cervix). It is edema of the soft scalp tissue that occurs within 24 hours after birth. This area extends across suture lines and feels like a soft, spongy mass. The outline is ill defined—pressure causes pitting of edema. This soft, spongy mass is absorbed and disappears in 3-4 days.
  • A cephalhematoma is a collection of blood between the periosteum (the covering of the skull bone) and the skull. It is caused by rupture of blood vessels from pressure during birth. Often associated with delivery by forceps. The swelling does not cross suture lines and may occur on one or both sides. It appears on second and third day after delivery. The outline is well-defined against the edge of bone margin and the mass is soft. It spontaneously resolves in 3 – 6 weeks.
    Jaundice may occur as blood cells are broken down as the swelling resolves.
  • Molding:
    Refers to the process by which the neonates head is shaped during labor as it passes through the birth canal. The head may become elongated due to the overlapping of the cranial bones at the suture lines.
    Molding of the head is normal during birth and may cause the head to appear misshapen.
    Reassure parents. Remind parents of Back to Sleep and need for changing head position with sleep.
  • A few minutes after birth, most infants open their eyes and start to look around at their environment. Newborns have good vision, but they probably don't focus well at first, which is why their eyes may seem out of line or crossed at times during the first 2 to 3 months. Because of the puffiness of their eyelids, some infants may not be able to open their eyes wide right away.
    Ideal vision—12 inches from an object. Touch, hold, and cuddle.
  • Strabismus—a turning inward (“crossing”) or outward of the eyes due to poor muscle tone (eyes are pretty weak).
    Nystagmus—constant, uncoordinated movement of eye
    Normal unless remains.
    Should resolve by age 4 months.
  • No response to sound
    Deafness
    Refer for evaluation
  • Skin tags on or around ears
    Preauricular sinus
    Kidney anomalies
    Check voiding if ears abnormal
  • It is very common for babies to have nasal congestion and noisy breathing. Instruct the parents to suction the nose with a plastic suction bulb. If unable to suction anything out, they may add a few saline drops to the nose (the baby will not like this), wait a few minutes, and then try suctioning again.
  • Choanal atresia: abnormality of the nasal septum that obstructs one or both nasal passages.
    Problems arise because infants usually breathe only through their noses (obligate nose breathers).
    Other problems: Nasal flaring—with each breath, movement of the nostrils open and closed
  • White patches on cheeks or tongue signal candidiasis.
  • Retractions: movement of the skin of the infant’s chest between each rib with breathing.
  • Cord with one vein and two arteries
    Cord clamp tight and cord drying
  • The newborn’s first void occurs within 24 hours. Infants void 2 to 6 times the first 2 days and 5 to 25 times daily thereafter.
    The first bowel movement a baby has is called meconium.  Meconium is composed of amniotic fluid, mucus, lanugo (the fine hair that covers the baby’s body), bile, and cells that have been shed from the skin and the intestinal tract. Meconium is thick, greenish black, sticky, tarry.
    Should occur within 24 – 48 hours of birth.
  • Omphalitis: The umbilical stump is necrotic tissue in the process of separating from the abdominal wall. Omphalitis can present as erythema, warmth, or drainage; the infection may be localized or may be a source for a systemic infection.
  • Think necrotizing enterocolitis.
  • Cryptorchidism—failure of one or both testes to descend into the scrotum.
    Epispadias—abnormal placement of the urinary meatus on the dorsal (upper) side of the penis.
    Hypospadias—abnormal placement of the urinary meatus on the ventral (lower) side of the penis.
  • Meningomyelocele
  • Two transverse palm creases.
    Creases on anterior two thirds of sole (full term).
  • Associated with Down Syndrome.
  • Syndactyly—webbing between fingers or toes.
  • “A” is correct.
  • Newborns depend on their inherent, primitive reflexes for survival.
    Only way to tell if newborn CNS is intact is by reflexes.
    Absence, weakness, or extended duration of these reflexes may indicate a problem with the baby's central nervous system.
    Newborn reflexes are important indicators of the newborn’s normal development.
    Just after birth, the newborn will be assessed for reflexes.
  • The Moro or startle reflex appears with a sudden loud noise or any intense stimulation. The arms and legs extend and the fingers fan outward, with the thumb and forefinger forming a C-shape. This reflex usually disappears by six months.
  • Palmar and Plantar Grasp Reflexes - the baby will grasp an object placed in his hands or curl his toes around fingers placed near his toes. The palmar reflex usually lasts 3-4 months and the plantar 8 months.
  • Babinski's Reflex - the baby's toes will fan (flare outward) with dorsiflexion of the big toe when the lateral side of his foot is stroked upward from the heel to the ball of the foot. In adults, toes curl.
    This reflex disappears within a year.
    Pathology if abnormal—cerebral palsy or spinal cord defects.
  • Rooting Reflex - if you lightly stroke the cheek, the newborn will turn towards the stroking and open her mouth to accept the nipple.
    This response helps the infant find the nipple for feeding.
    Reflex is stronger when the baby is hungry.
    Disappears at approximately 3-4 months.
  • Sucking Reflex: when a finger or nipple is placed into the baby's mouth, the baby begins to suck.
  • Tonic Neck: the baby appears like a "fencer" when lying flat on her back and facing to the side. Whichever direction his face is turned, that arm will extend and the other will be flexed.
  • Stepping Reflex - when the newborn is held upright with the feet on a flat surface, the baby will make stepping motions. This reflex diminishes by 4 weeks and does not return until the baby begins to stand and walk.
  • “B” correct.
  • Laboratory values for erythrocytes (RBC’s), hemoglobin, and hematoctrit are higher for newborns than for adults because oxygen available to them in fetal life was less than after birth (polycythemia—compensation).
    Kidney function is immature. The ability of a newborn’s kidneys to conserve urine is limited. Regulation of sodium and water balance is limited. Normal neonate urine specific gravity levels are much lower than adults. It takes 3 to 6 months for urine concentrations to reach adult levels. This limited ability of the newborn to conserve water may result in dehydration more quickly than in the older infant or child. Infants also will go into fluid overload more quickly and cannot handle too much intravenous fluids.
  • Infection is one of the major causes of death.
    Neonate is less effective in fighting off infection than the older infant of child. Their leukocytes are immature and not as efficient in destroying pathogens.
    Infants are not capable of producing many antibodies until the 2nd or 3rd month of life, and rely on passive immunity of antibodies that were transferred by the placenta while in utero. We must protect them. Always wash hands; screen visitors. Do not use other baby items (cross-contaminate).
    Signs of infection such as fever and increased WBC’s may not be present in the newborn with infection.
    Immunoglobulins (antibodies) help protect the newborn from infection.
    Takes weeks to months for infants to produce own immunity.
  • Full-term newborns received antibodies from the mother during the last trimester of pregnancy.
    If the mother breastfeeds, the infant continues to receive antibodies in breast milk. Breast-fed infants receive protection that formula-fed infants do not.
  • Infection is a major cause of neonatal death.
    Signs are often masked due to neonate’s immature immune system.
  • “D” correct
  • Precautionary measure against ophthalmia neonatorum, which is an inflammation of the eyes resulting from gonorrheal or chlamydial infection contracted by the newborn during passage through the mother’s birth canal.
    Want to wait (if possible) for newborn to have opportunity to bond with parents before instilling the ointment.
    Gently clean the newborn’s eyes to remove any drainage, blood, or vernix.
    Place a finger and thumb near the edge of each lid, gently press against the periorbital ridges to open the eyes, avoiding pressure on the eye itself. Retract the lower eyelid outward to instill ¼ inch long strand of ointment from a single-dose tube along the lower conjunctival surface, into each conjunctival sac, starting at the inner canthus. It is instilled only once in each eye.
    Massage eyelids gently to distribute the ointment.
  • Helps prevent hemorrhagic disease of the newborn.
    Vitamin K by injection is essential for newborns to prevent intracranial and/or gastrointestinal hemorrhage, even if your baby is a girl or you're not circumcising, even if you delivered without any trauma, even if your pregnancy was completely healthy all the way through. The truth of the matter is that your baby CANNOT make enough endogenous Vitamin K in the first months of life to protect them from significant or even life-threatening bleeding. They need the shot.
    Located on the anterior lateral thigh. The middle third of the muscle. Well developed at birth. Recommended as the site of choice for intramuscular injections for infants 7 months and younger. No major blood vessels or nerves in the area.
    Estimated by dividing the area between the greater trochanter of the femur and the lateral femoral condyle into thirds and selecting the middle third. The infant is positioned supine.
    Vastus lateralis in a neonate can only accommodate a maximum of 0.5 ml at a time.
  • North Carolina Immunization Law requires 3 doses of hepatitis B: one dose by age three months, a second dose before age five months and a third dose by age 19 months.
  • “D” is correct.
  • The infant is susceptible to airway obstruction due to—short neck, poorly supported tongue, small nasal and oral passageways.
  • If the baby's cord should happen to show increased redness, swelling, drainage, or have a bad odor, infection might be present.
    Also, you should not bathe your child until the cord has fallen off, but rather, you should give him or her sponge baths. Fold the diaper down or use the new diapers with the cord cut-out to keep moisture off of the cord. If the cord does get moist, clean it with rubbing alcohol to dry it out. Should you note any persistent or bloody discharge, swelling or redness, then please call me at the office. A small amount of bleeding is normal when the cord falls off, but should not be persistent.
  • “A” is correct.
  • Squeeze soapy water over circumcision site once a day.
    Rinse area off with warm water and pat dry.
    Apply small amount of petroleum jelly (unless a Plastibell is in place) with each diaper change.
    Fasten diaper loosely over penis.
    Check for any foul-smelling drainage or bleeding at least once a day.
    Let Plastibell fall off by itself (about 8 days after circumcision).
    Plastibell should not be pulled off.
    Light, sticky, yellow drainage (part of healing process) may form over head of penis.
  • “D” is correct.
  • To prevent the effects of disease, the sample should be drawn during the infant's first two to three days of life.
    A filter paper blood spot sample is required by state law (GS 130A-125) to be submitted to the North Carolina State Laboratory of Public Health for each infant born in North Carolina.  The sample is tested for certain genetic conditions or inborn errors of metabolism that may cause mental retardation or death, if untreated.
    Before the baby leaves the hospital nursery, his or her heel will be pricked and a few drops of blood will be collected.  This blood specimen will be sent to the State Public Health Laboratory in Raleigh for testing. When the infant is at least twenty-four hours old, the nursing staff will complete a hearing screening. It requires special equipment and will indicate whether the baby requires additional hearing tests.
    When the infant is at least twenty-four hours old, the nursing staff will complete a hearing screening. It requires special equipment and will indicate whether the baby requires additional hearing tests.
    PKU is an autosomal recessive disorder that results in irreversible mental retardation if untreated. The baby is not able to process a particular building block of protein called phenylalanine. This is due to a deficiency of the enzyme phenylalanine hydroxylase, which is necessary to convert phenylalanine into tyrosine for use. Very high levels of phenylalanine accumulate in the blood, tissues, and the central nervous system, causing irreversible mental retardation and urinary excretion of phenylketones. Early treatment is vital to prevent permanent central nervous system damage. The infant will be started on a low-phenylalanine formula immediately and the child must follow a special protein-restricted diet for the rest of his or her life.
  • For lab tests, the sample should be drawn during the infant's first two to three days of life.
    Small quantities of blood are collected on filter paper cards.
    Warming the baby's heel so that the blood flows easily; this approach requires about a half hour of preparation, and the stabbing/bleeding event takes relatively little time.
  • Correct answer: “C”
  • Fluid intake and excretion are seven times greater than an adult’s per weight.
    Fluid requirements are high because the newborn cannot concentrate urine.
    Kidney function is immature. Regulation of sodium and water balance is limited.
    Fluid need increase further during illness or hot weather. Give extra breastmilk or formula—NOT supplemental water.
  • 374 to 408 ml of fluid daily
  • Lactose improves absorption of calcium, phosphorus, magnesium and promotes growth of normal bacterial flora in intestines
  • DHA is one of the least saturated fatty acids in the human body, and is highly enriched in the membrane lipids of rod photoreceptors in the human eye, but also concentrates in the brain.
    Docosahexaenoic acid is sometimes referred to by nutritionists as "brain oil," because it is one of the primary structural components of brain tissues, which are 60 percent fats.
    Docosahexaenoic acid (DHA) and arachidonic acid (ARA) must be added to formulas.
  • Vitamin C must be added to commercial formulas to match the levels in human milk.
  • Formula: recommended that infants be fed iron-fortified formulas. This is because the higher levels of casein protein in cow’s milk-based formulas interfere with iron absorption.
  • First feeding (especially if formula fed): Nurse observes for choking, coughing, and cyanosis, indicating a connection between the trachea and the esophagus (tracheoesophageal fistula).
    If the baby is breastfeeding, the nurse observes the infant’s response at the breast with first feeding.
    Keep head elevated during feeding to prevent aspiration.
    The shoulder is good for burping the baby. You can also site the baby on your lap and support the head and chest with one hand while gently patting or rubbing the infant’s back with the other hand. Helps rid stomach of air bubbles to minimize regurgitation.
    Place on right side after feeding to facilitate digestion, minimizes regurgitation.
  • Early breast milk: Colostrum (first week; thick, yellow)
    a. Provides antibodies.
    b. High in protein, fat-soluble vitamins, and minerals.
    c. Helps establish normal bacteria in the intestines.
    d. Helps pass meconium (laxative effect).
  • Although nurses should encourage breastfeeding as the best method of feeding in most circumstances, they should be supportive of the mother’s chosen method once her decision is made.
    Returning to work or school is a major cause of discontinuation of breastfeeding by 10 to 12 weeks.
    Preterm infants may require a more concentrated formula with more calories in less liquid.
  • Unmodified cow’s milk is not suitable for infants younger than 12 months.
    Modified cow’s milk is the source of most commercial formulas. Manufacturers specifically formulate it for infants by reducing protein to decrease renal solute load. Saturated fat is removed and replaced with vegetable fats. Vitamins and other nutrients are added to simulate the contents of breast milk.
  • Examples of commercial formulas are Similac, Enfamil, and Good Start.
  • The stools progress from thick, greenish-black meconium to loose, greenish-brown transitional stools to milk stools.
    Transitional stools usually occurs by third day and are green brown-yellow brown in color.
    After day four:
    Stools of breast-fed infants are frequent, soft, seedy, yellow to golden-colored, with sweet-sour milk odor. These stools are loose, but not watery.
    Stools of formula-fed infants are pale yellow to light brown, firmer, less frequent, strong odor (stink); more prone to constipation.
  • The bonding process is a big part of the feeding event
    The child bonds to the mother and the mother to the baby
    The quality of touch plays an important part
  • Identification is accomplished by matching the imprinted numbers on the adult’s wrist band with the infant’s identification band. The nurse should visually match the numbers of have the parent read the imprinted numbers from his or her band.
  • Placing babies on their backs to sleep reduces the risk of Sudden Infant Death Syndrome (SIDS), also known as "crib death."
  • “A” is correct.
  • Transcript

    • 1. Nursing Care of the Newborn & Family Joy A. Shepard, PhD(c), RN-C, CNE Joyce Buck, MSN, RN-C, CNE 1
    • 2. Objectives 1. Discuss the physiologic adaptations that the neonate must make during the period of transition from intrauterine to extrauterine environment 2. Explain the mechanisms of thermoregulation in the neonate 3. Describe how to perform a physical assessment of a newborn 4. Describe how to perform a gestational age assessment of a newborn 5. Recognize newborn reflexes and differentiate characteristic response from abnormal responses 6. Identify signs that the neonate is at risk, related to problems with each body system 7. Explain the elements of a safe environment 2
    • 3. Normal Newborn (Neonate) • Full-term newborn – Born between end of week 37 and end of week 42 • Gestational age: 38 – 42 weeks • Neonatal period—from birth to 28 days • At birth, neonates experience complex physiologic and behavior changes to adapt to life outside of the womb 3
    • 4. Other Terms (pp. 569, 895) • Preterm (premature): born after 20th week and before completion of 37th week of gestation, regardless of weight • Post-term (postmature): born after 42 weeks of gestation, regardless of weight • Small-for-gestational age (SGA): birth weight below 10th percentile for gestational age • Large-for-gestational age (LGA): birth weight above 90th percentile for gestational age 4
    • 5. Goals of Newborn Care • Nursing responsibilities in the initial postpartal period: – Establish and maintain an airway and support respirations – Maintain warmth and prevent hypothermia – Safety • Protection from injury, infection, or hemorrhage • Identification – Identify actual or potential problems that might require immediate attention – Facilitate parent-infant interaction 5
    • 6. Initiation of Respirations • First vital task in newborn adaptation to extrauterine life • Large force required for first breath • Chemical, thermal, mechanical factors 6
    • 7. Initiation of Respirations—Internal • Chemical changes brought about by the transitory hypoxia/asphyxia that occurs with normal birth ∀ ↓ Pa02 level ∀ ↑ PaC02 level ∀ ↓ pH • Stimulate respiratory center in medulla • First breath: forceful contraction of the diaphragm, causing air to enter lungs 7
    • 8. Initiation of Respirations—External • Thermal • Mechanical factors – Drop in temperature (most important), noise, light, sound stimulate respiratory center – Chest compression / release cause air to be drawn into lungs by negative pressure – First breath 8
    • 9. Initiating Respirations • Tactile stimuli may be necessary in initiating respirations – Rubbing back – Flicking heel 9
    • 10. Assisting Respirations • If no spontaneous respirations / gasping respirations: – Suction (mouth, then nose) – Humidified oxygen – Ambu bag (positive pressure ventilation) – Endotracheal tube – Ventilator 10
    • 11. Continuation of Respirations • Surfactant required to keep alveoli partially open between respirations • Remaining fetal lung fluid moves into interstitial spaces, where it is absorbed by the lymphatic and vascular systems • Complete absorption may take 24 hours • Lungs may sound moist when first auscultated but become clear a short time later 11
    • 12. Thermoregulation 12
    • 13. Newborn Characteristics Leading to Heat Loss • Skin is thin • Little insulating SQ fat • Blood vessels close to skin surface • Large skin surface area • Heat more easily lost from internal organs to skin • Poor mechanisms for body temperature regulation during first days of life • Flexed position reduces heat loss 13
    • 14. Neutral Thermal Environment (p. 533) • One in which the infant can maintain a stable body temperature without an increase in 02 consumption or increase in metabolic rate • For clothed, swaddled infants in open bassinets, need nursery to be 75° F (24° C) 14
    • 15. Methods of Heat Loss • Four methods of heat loss in the neonate: – Evaporation – Conduction – Convection – Radiation 15
    • 16. Methods of Heat Loss—Evaporation • Conversion of water to vapor • Loss of heat from drying of the skin or insensible water loss (skin, respiratory tract) • Bathing; wet linens, clothes, or diapers 16
    • 17. Conduction • Loss of heat from direct contact with cold objects • Cold hands, cold stethoscope, cold metal scale 17
    • 18. Convection • Loss of heat from air movement surrounding the infant • Drafts, air conditioning, air currents 18
    • 19. Radiation • Loss of heat from being near cold surfaces (not touching) • Heat transfer to cooler objects that are not in direct contact with the infant: sides of the incubator, outside walls/windows 19
    • 20. What Type of Heat Loss Can Occur in Each Situation? • Placing the newborn on a cold, unpadded scale • Using a cold stethoscope to listen to breath sounds • Placing the infant’s crib by a window on a snowy day • Partially drying the infant’s hair after the bath • Placing the infant’s crib near an air conditioner vent 20
    • 21. Heat Production in Newborns • Nonshivering thermogenesis • Vasoconstriction • Increase in metabolism • Result: ↑ 02 and glucose consumption – May cause respiratory distress, hypoglycemia, acidosis, and jaundice 21
    • 22. Nonshivering Thermogenesis: Brown Fat Oxidation 22
    • 23. Question • Brown fat is used to: – A. Maintain temperature – B. Facilitate digestion – C. Metabolize glucose – D. Conjugate bilirubin 23
    • 24. Hypothermia • Cold stress • Definition: a drop in the newborn’s body temperature below 36.5º C (97.7º F), produced by rapid heat loss due to the environment • All newborns are at risk for heat loss • Newborns at greater risk: Premature, postmature, SGA 24
    • 25. Reasons for Hypothermia • Cold environment • Hypoglycemia • Infection • CNS problem • Nursing care: institute warming measures; check blood glucose 25
    • 26. Hazards of Cold Stress • Lowdermilk, p. 534 • Increased oxygen need • Respiratory distress • Decreased surfactant production • Hypoglycemia • Metabolic acidosis r/t anaerobic metabolism • Jaundice • Return to fetal circulation patterns 26
    • 27. Identify 4 Consequences of Cold Stress…. • Respiratory distress • Acidosis • Hypoglycemia • Hyperbilirubinemia 27
    • 28. Hyperthermia (p. 534) • Elevated temperature (> 37.5° C / 99.5° F) will cause: ↑ Metabolic rate ↑ 02 and glucose consumption ↑ Insensible fluid losses (vasodilation) ↓ Ability to sweat (immature sweat glands) ∀ ↑ Risk of hyperthermia – With radiant warmers, warming lights, warmed incubators, too many blankets • Use skin temp probe – Set controls to vary heat according to infant’s skin temp – Alarms: high/low temp – Remove excessive clothing 28
    • 29. Nursing Diagnoses / Goals • Hypothermia • Hyperthermia • Ineffective Thermoregulation • Goals: – Newborn will expend a minimal amount of extra energy in the production of heat – Newborn will be free from periods of hypothermia or hyperthermia 29
    • 30. Nursing Interventions • Prevent heat loss in delivery room – Dry rapidly – Place on mother’s skin, in warmed isolette, under radiant heater, or in warm blanket, place cap on head • Monitor newborn’s temperature frequently • Place crib or incubator away from drafts or windows • Keep portholes in incubator / isolette closed • Wrap in blankets if in crib 30
    • 31. Question • Becoming cold can lead to respiratory distress primarily because the infant: – A. Needs more oxygen than he or she can supply to generate heat – B. Breathes more slowly and shallowly when hypothermic – C. Reopens fetal shunts when the body temperature reaches 36.1° C (97° F) – D. Cannot supply enough glucose to provide fuel for respirations 31
    • 32. Question • An infant’s axillary temperature is 35.9° C (96.6° F). The priority nursing action is to: – A. Recheck the infant’s temperature – B. Have the mother breast-feed the infant – C. Place the infant in a radiant warmer – D. Chart the normal axillary temperature 32
    • 33. Vital Signs 33
    • 34. Vital Signs—Respirations • Range 30 to 60 • Irregular, shallow, unlabored • Nose breather • Abdominal breathing • Breath sounds present and clear bilaterally • Chest movements symmetric (synchronized with abdominal movements) 34
    • 35. Vital Signs—Respirations • Common variations: – Transient tachypnea – Moist breath sounds may be present shortly after birth – Periodic breathing: breathing pauses of 5-10 seconds without color change or bradycardia 35
    • 36. Signs of Impending Neonatal Respiratory Distress • Tachypnea (respirations >60) after the first hour • Retractions (intercostal, substernal) that continue after the first hour • Grunting, especially expiratory • Nasal flaring after the first hour 36
    • 37. Signs of Impending Neonatal Respiratory Distress • Cyanosis involving the lips, tongue, and trunk (central cyanosis) • Seesaw respirations, asymmetry of chest expansion • Apnea ≥ 15 seconds (especially with color change) • Tachycardia (early); bradycardia (late) • Bradypnea (late) < 25 37
    • 38. Vital Signs—Heart Rate • Range 120 to 160 beats per minute • Rhythm regular • Brachial, femoral, and pedal pulses present and equal bilaterally • Common variations – Heart rate range to 100 when sleeping to 180 when crying – Color pink with acrocyanosis – Heart rate may be irregular with crying 38
    • 39. Vital Signs—Heart Rate • Signs of potential distress or deviations from expected findings – Tachycardia (> 160 BPM) – Bradycardia (< 100 BPM) – Murmurs – Arrhythmias – Absent or unequal pulses 39
    • 40. Vital Signs—Temperature (p. 556) • Temperature - range 36.5º to 37.2º (97.7º to 99º F) axillary (preferred) • Common variations – Crying may elevate temperature – Stabilizes in 8 to 10 hours after delivery • Signs of potential distress or deviations from expected findings – Temperature is not reliable indicator of infection – Temperature < 36.4º; > 37.5° 40
    • 41. Vital Signs—Blood Pressure • Not done routinely • Factors to consider – Varies: activity level, gestational age – Appropriate cuff size important – Average newborn (1-3 days): 80/45 upper, lower extremities 41
    • 42. Vital Signs—Blood Pressure • Sign of potential distress or deviations from expected findings – Systolic pressure arms ≥ 15 mm Hg higher than legs (coarctation of the aorta) – Hypotension (hypovolemia, shock, sepsis) 42
    • 43. Question • The nurse notes slight resistance when first inserting a rectal thermometer to take a newborn’s first temperature. The best nursing action is to: – A. Notify the infant’s pediatrician – B. Rotate the thermometer to the left while inserting – C. Listen for the presence of bowel sounds – D. Check for rectal patency using the fifth digit 43
    • 44. Assessing Blood Glucose in the Newborn 44
    • 45. Warming Newborn Foot for Heelstick 45
    • 46. Assessing Blood Glucose in the Newborn (pp. 577; 579-580) Normal blood glucose: 40 – 60 mg/dl Hypoglycemia: < 40 mg/dl By day 3: 50-90 mg/dl 46
    • 47. Hypoglycemia • Blood glucose < 40 mg/dl • Can cause permanent brain damage • May show no signs • Early signs: – Jitteriness, crying a lot – Poor muscle tone – Respiratory signs (dyspnea, apnea, cyanosis) – Hypothermia • Late signs: – High-pitched cry – Lethargy – Seizures – Coma 47
    • 48. Hypoglycemia • First 4 – 6 hours, slight risk – Baby not feeding well – Breastfeeding (not receiving enough) • Risk factor: Maternal diabetes 48
    • 49. Hypoglycemia • Nursing interventions: – Prevention: Allow infant to breastfeed ASAP after delivery – Assess frequently for signs of hypoglycemia – Protect from cold stress – If hypoglycemic: • Notify physician/midwife • Feed infant ASAP according to agency policy – Formula – Do NOT give glucose water • By 3rd day, usually goes back up 49
    • 50. Question • While performing an admission assessment on a term newborn, the nurse notes poor muscle tone and slight jitteriness. The appropriate nursing action is to: – A. Assess the infant’s blood glucose level – B. Stop the assessment and wrap the infant tightly in blankets – C. Check the mother’s chart to see if any narcotics were given late in labor – D. Give supplemental oxygen by face mask 50
    • 51. Assessment by Apgar Scoring 51
    • 52. Assessment by Apgar Scoring • Evaluates the newborn’s physical condition at birth (1 & 5 minutes) • Based on: – Heart rate – Respiratory effort – Muscle tone – Reflex irritability – Color 52
    • 53. Apgar Scoring Chart (p. 554) Score 0 1 2 Heart rate Absent Slow (below 100) Over 100 Respiratory effort Absent Slow, irregular, weak cry Good, crying Muscle tone Flaccid Some flexion of extremities Well flexed Reflex irritability No response Grimace Vigorous cry Color Blue, pale Body pink, extremities blue Completely pink 53
    • 54. Apgar Score • Scores of 0 to 3 represent severe distress • Scores of 4 to 6 signify moderate difficulty • Scores of 7 to 10 indicate absence of difficulty 54
    • 55. Question • A term infant is born. At 1 minute the nurse determines the grimacing infant’s respiratory rate to be 20 and irregular; heart rate 150; muscle tone: arms and legs with some flexion, but not actively moving; color: centrally pink with acrocyanosis. • Based on this date, the nurse should assess the Apgar score to be: – A. 3 – B. 5 – C. 6 – D. 7 – E. 9 55
    • 56. Gestational Age Assessment 56
    • 57. Gestational Age Assessment • Estimates infant’s age from conception • Alerts to possible complications of age and development • Early intervention: Pick up problems early • Plan care: Proper care initiated • Review pp. 566-569 (know signs of prematurity) 57
    • 58. Transition Period 58
    • 59. Transition Period (pp. 528-529) • First and second periods of reactivity • Period from birth to 6-8 hours • Immediate initiation of respirations • Changes in the circulatory system • Neonate adapts to extrauterine life and total independent function • Vulnerable period for the neonate—may periodically exhibit irregular behaviors 59
    • 60. First & Second Periods of Reactivity (pp. 528-529) • Bonding: alert & active • Breastfeeding – Rooting, hungry, interested in feeding, may pass meconium • Unstable VS, status – Rapid respirations (may reach 80 BPM), periods of apnea – Excessive mucous, transient crackles, nasal flaring, retractions, choking, gagging – Rapid heart rate (may reach 180 BPM) • Once periods of reactivity are over, the infant is usually stable 60
    • 61. Newborn Admission’s Assessment (Comprehensive Head-to-Toe) 61
    • 62. Normal Newborn: General Appearance • Well-flexed, full range of motion, spontaneous movement • Common variations – Legs extended (frank breech) • Signs of potential distress or deviations from expected findings – Limp, flaccid, “floppy” – Asymmetry of movement – Jitteriness, twitching, persistent tremor – Hypertonic, stiff, seizures 62
    • 63. General Measurements—Head Circumference (p. 558) • Head circumference 33-35 cm (13- 14”) • Expected findings – Head should be 2 to 3 cms larger than the chest – Molding of head may result in lower head circumference measurement 63
    • 64. Other General Measurements • Chest circumference – 30-33 cm (average 32) • Weight range - 2500-4000 g (5 lb,8 oz-8 lb,13 oz) • Weight loss up to 10% first 3 to 5 days • Length range - 46-55 cm (18-22”) 64
    • 65. General Measurements • Sign of potential distress or deviations from expected findings – Small head circumference (SGA, microcephaly, anencephaly) – Large head circumference (LGA, hydrocephalus, increased intracranial pressure) – Low weight (SGA, preterm, IUGR) – High weight (LGA, maternal diabetes) – Weight loss above 10% (dehydration, feeding problems) 65
    • 66. Normal Newborn Neuromuscular • Expected findings: – Maintains position of flexion – Hands clenched – Movements symmetric – Slight tremors on crying 66
    • 67. Flexion of Preterm Infant 67
    • 68. Newborn Neuromuscular—Head Control Head lag is seen when the newborn is supine and the body lifted Newborns can hold their heads up when placed in a prone position 68
    • 69. Question • A new mother should be taught to support her baby’s head when holding the infant because: – A. Doing so will promote better eye contact and bonding – B. The baby’s muscles are too weak to support the heavy head – C. It allows better guidance of the head toward the breast – D. Less regurgitation of gastric contents will occur 69
    • 70. Newborn Neuromuscular—Deviations from Normal • Limp extremities, hypotonia • Quivering • Straightening of extremities,hypertonia • Jerking • Paralysis • Arching of back (opisthotonus) 70
    • 71. Skin Assessment • Expected findings: – Skin reddish in color, smooth and puffy at birth – At 24 - 36 hours of age, skin flaky, dry and pink or tan in color – Edema around eyes, feet, and genitals – Vernix caseosa – Lanugo – Turgor elastic and mobile (quick recoil) 71
    • 72. Vernix Caseosa If yellow or greenish-tinged vernix: watch respiratory 72
    • 73. Lanugo ↑ lanugo = premature 73
    • 74. Birthmark—Stork Bite (Telangiectatic Nevi) • Red spots found on back of neck, bridge of nose, and eyelids • Usually disappear spontaneously between first and second year of life 74
    • 75. Birthmark—Port Wine Stain (Nevus Flammeus) • A type of vascular malformation • Varies in type and location • Will not disappear • Becomes a darker, more purplish color with age 75
    • 76. Skin—Common Variations • Acrocyanosis • Bluish discoloration of the hands and feet • Poor peripheral circulation • Common during first 24-48 hours of life • Wrap the neonate warmly • Mouth and central body areas should not by cyanotic at any time 76
    • 77. Skin—Common Variations • Mongolian spots • Dark bruise-like places most often found on buttocks and sacrum • African-American, Asian, Native American, or Hispanic descent • May disappear by school age 77
    • 78. Skin—Common Variations • Mottling • Transient discoloration of skin when exposed to decreased temperature • Resulting from vasoconstriction, lack of fat, and hypoxia 78
    • 79. Skin—Common Variations • Physiologic jaundice • Yellow discoloration of newborn skin and sclera caused by excessive bilirubin in the blood (greater than 5 mg/dl) • Appears after 1st 24° • Peaks: days 2 - 4 • Common: 60% of newborns • Usually clears up by end of first week • Assess by blanching nose or sternum • Begins in head • Determine how far down it extends 79
    • 80. Pathologic Jaundice (p. 538) • Abnormal, requires further investigation • Jaundice appears in the first 24 hours after birth OR • Total bilirubin level > 12 mg/dl – If total bilirubin level > 20 mg/dl—may cause irreversible brain damage (kernicterus) • Caused by excessive destruction of RBC’s • Teatment: Phototherapy, push fluids (increase feedings), monitor bilirubin levels frequently 80
    • 81. Breast Milk Jaundice (pp. 538-539) • Begins later than physiologic jaundice, due to substances in mature breast milk • Occurs after first week of life • Peaks at 2 to 3 weeks of age • Treatment: close monitoring of serum bilirubin, increase feedings, phototherapy, discontinuation feedings for 24 – 48 hours 81
    • 82. Phototherapy for Newborns With Jaundice Monitor temperature, hydration, and stooling 82
    • 83. Skin—Common Variations • Milia • “Baby pimples” • Pinpoint white papules on cheeks, across bridge of nose, or on chin • Caused by plugged sebaceous glands • Requires no treatment • Disappears in a few weeks 83
    • 84. Skin—Common Variations • Erythema toxicum (newborn rash) 84
    • 85. Skin—Post-Term Infant • Post-term: > 42 weeks gestation • Excessive peeling, cracking, dry skin • No vernix 85
    • 86. Newborn Head—Fontanels • Areas where the sutures of the head meet • Anterior fontanel diamond shaped (2-4 cms) • Posterior fontanel triangular (0.5-1 cm) 86
    • 87. Palpation of Anterior Fontanel • The infant’s head is elevated for accurate measurement • Infant needs to be calm—vigorous crying may cause the fontanel to bulge • Normal to pulsate when infant is asleep • Flat, soft, and firm • Bulging—increased intracranial pressure • Depressed, sunken— dehydration 87
    • 88. Bulging Fontanel 88
    • 89. Caput Succedaneum (“Caput”) (pp. 542-543) Caput succedaneum crosses sutures Disappears in 3-4 days 89
    • 90. Cephalhematoma (p. 543) Cephalhematoma does not cross sutures Resolves in 3-6 weeks 90
    • 91. Molding • Shaping of the fetal head (cranial bones) during movement through the birth canal • Cranial bones return to their proper placement in 2 – 3 days • Provide reassurance 91
    • 92. Newborn Eyes • Expected findings: – Symmetric – Slate gray or blue eyes – No tears – Fixation at times - with ability to follow objects to midline – Red reflex – Blink reflex – Cornea bright and shiny – Pupils equal and reactive to light 92
    • 93. Eyes—Common Variations • Uncoordinated eye movements due to poor muscle tone – Strabismus—”cross- eyed” – Nystagmus—constant, uncoordinated movement of eye • May focus for a few seconds 93
    • 94. Eyes—Deviation from Normal • Discharges, chemical conjunctivitis • Unequal pupils • Failure to follow objects (blindness) • Setting-sun sign (hydrocephalus) • Yellow, blue sclera 94
    • 95. Newborn Ears • Pinna top on horizontal line with outer canthus of eye • Loud noise elicits Startle Reflex • Flexible pinna with cartilage present 95
    • 96. Ears—Deviations from Expected Findings • Low-set ears • Chromosomal abnormalities (Down Syndrome) • Kidney anomalies 96
    • 97. Skin Tags/ Preauricular Sinus 97
    • 98. Newborn Nose • Expected findings – Nostrils patent bilaterally – Obligate nose breathers • Common variations – Sneezes to clear nostrils – Bridge appears absent (flattening from pressure during birth) – Thin white nasal mucus discharge http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/2677.jpg 98
    • 99. Nose—Deviations from Expected Findings • Choanal atresia and discharge • Malformation • Nasal flaring beyond first hour after birth 99
    • 100. Newborn Mouth and Throat • Mouth, gums, tongue moist, pink, intact • Tongue normal in size and movement (does not protrude) • Lips and palate intact 100
    • 101. Newborn Mouth—Common Variations • Epstein's pearls on ridges of gums • Precocious teeth 101
    • 102. Newborn Mouth—Deviations from Expected Findings • Cleft lip or cleft palate • Thrush (candidiasis) • Circumoral pallor • Asymmetry • Drooping of mouth 102
    • 103. Newborn Chest • Evident xiphoid process • Cylinder shape • Equal anteroposterior and lateral diameter • Bilateral synchronous chest movement • Nipples present, symmetrical, and in expected locations • Common variations: • “Witch‘s milk“ – Thin, milky discharge from breast tissue • Enlarged breasts 103
    • 104. Newborn Chest—Deviations from Normal Findings • Sternum depressed • Retractions • Asymmetrical chest movements • Bowel sounds auscultated in chest (diaphragmatic hernia) 104
    • 105. Newborn Abdomen • Rounded, soft • Skin intact • Abdominal respirations • Well-formed umbilical cord • Three vessels in cord • Clamp tight and cord drying 105
    • 106. Newborn Abdomen cont’d… • Bilaterally equal femoral pulses • Bowel sounds auscultated within 1 hour of birth • Voiding within 24 hours of birth • Urine light, odorless • Meconium within 48 hours of birth 106
    • 107. Newborn Abdomen—Deviations from Normal Findings • Sunken abdomen • Abdominal distention; visible loops of bowel • Bowel sounds absent after 1st hour • Palpable masses • Abdominal wall defects (hernias, omphalocele) • Cord with two vessels • Base of cord with redness or drainage 107
    • 108. Bowel Loops Visible Through Abdominal Wall 108
    • 109. Normal Newborn Female Genitalia • Expected findings: – Edematous labia and clitoris – Labia majora are larger, dark and surround labia minora – Vernix between labia – Urinary meatus and vagina present • Common variations: – Pseudomenstruation (bloody discharge from vagina) – Ecchymosis and edema after breech birth – "Red brick" pink- stained urine (uric acid crystals) 109
    • 110. Female Genitalia—Deviations from Expected Findings • Ambiguous genitalia • Widely-spaced labia majora (preterm) 110
    • 111. Normal Newborn Male Genitalia • Expected findings: – Urinary meatus at tip of glans penis – Palpable testes in scrotum – Large, edematous, pendulous scrotum, with rugae – Stream adequate on voiding 111
    • 112. Male Genitalia—Deviations from Expected Findings • Non palpable testes (cryptorchidism, preterm) • Epispadias • Hypospadias • Scrotum smooth (preterm) • Ambiguous genitalia 112
    • 113. Normal Newborn Back • Expected findings: – Intact spine without masses or openings – Patent anal opening 113
    • 114. Newborn Back—Deviations from Expected Findings • Imperforate anus • Failure of vertebra to close (spina bifida) • Tuft of hair 114
    • 115. Normal Newborn Extremities • Expected Findings: – Ten fingers and ten toes – Flexion – Equal and bilateral movement and tone – Full range of motion all joints – Legs appear bowed – Feet appear flat 115
    • 116. Normal Newborn Extremities cont’d… • Palmar creases present • Sole creases present 116
    • 117. Simian Crease 117
    • 118. Normal Newborn Extremities cont’d… • Negative hip click 118
    • 119. Newborn Extremities—Deviations from Expected Findings cont’d… • Positive hip click • Unequal length • Asymmetrical skin creases posterior thigh (hip dislocation) 119
    • 120. Question • The nurse in the newborn nursery has just received report. Which of the following infants should the nurse see first? – A. Two-day-old infant is lying quietly alert with a heart rate of 185. – B. One-day-old infant is crying and the anterior fontanel is bulging. – C. 12-hour infant is being held; the respirations are 45 breaths per minute and irregular. – D. Five-hour-old infant is sleeping and the hands and feet are blue bilaterally. 120
    • 121. Normal Newborn Reflexes 121
    • 122. Protective Reflexes • Blink • Sneezing • Coughing – Do not outgrow 122
    • 123. Moro and Startle • In response to sudden movement or loud noise • Arms and legs extend and the fingers fan outward, with the thumb and forefinger forming a C-shape • Most significant reflex • Disappears by 6 months 123
    • 124. Palmar Grasp Reflex • Occurs when newborn’s palm is touched near base of fingers • Hand closes in tight fist • Disappears by 3-4 months 124
    • 125. Plantar Grasp Reflex • Similar to the palmar grasp reflex • Newborn’s tendency to curl toes downward over finger when sole of foot is touched • Disappears by 8 months 125
    • 126. Babinski Reflex Baby's toes fan with dorsiflexion of big toe Disappears by 1 year 126
    • 127. Rooting Reflex 127
    • 128. Sucking Reflex • Essential for normal life • Sucks on anything placed in mouth • Well-coordinated with swallowing by 32 – 34 weeks of gestation • Disappears by 1 year 128
    • 129. Tonic Neck Reflex • “Fencer’s position” • Posture assumed by newborns in a supine position when head is turned to one side • The extremities on the same side extend • Flexion occurs on the opposite side • Disappears by 4 months 129
    • 130. Stepping (Walking) Reflex • Newborns tend when held upright to take steps in response to feet touching a hard surface • Lift one foot and then the other • Disappears by 4 weeks 130
    • 131. Question • Which newborn reflex can help the new mother learn to breast-feed? – A. Tonic neck – B. Rooting – C. Palmar grasp – D. Moro 131
    • 132. Newborn Labs 132
    • 133. Normal Newborn Lab Values (p. 577) • Total blood volume: 300 ml (less than a Coke can) • Born with ↑ erythrocyte count – RBC = 4.8-7.1 mm3 – Hgb = 14.5-22.5 g/dl – Hct = 48-69 % • Total serum bilirubin level = < 12 mg/dl • WBC = 9.0-30.0 mm3 • Urine specific gravity: 1.001 – 1.020 • Serum glucose: – 40-60 mg/dl (day 1) – 50-90 mg/dl (day 3) 133
    • 134. Immunity • Leukocytes immature, less effective in fighting off infection • Risk for Infection (infection is one of the major causes of death) • May not have fever or ↑ WBC if infection is present (masked infection) • Immunoglobulins (antibodies) help protect the newborn from infection • Infant immune system immature—Infants generally rely on passive immunity until the 3rd month of life 134
    • 135. Immunity • IgG crosses the placenta in utero (temporary immunity to certain bacteria and viruses) • Colostrum/breast milk: IgA (protection of GI and respiratory systems from infection) 135
    • 136. Signs of Newborn Infection • Low or elevated temperature • Signs of localized infection (redness, edema, discharge, foul-odored drainage) • Lethargy • Poor feeding • Periods of apnea without obvious cause • Any unexplained change in behavior 136
    • 137. Question • Infection in the newborn often has subtle signs because: – A. Body temperature rises slowly in response to pathogens – B. Passive antibodies from the mother fight infection early – C. High urine output causes a lower body temperature – D. Leukocyte response and inflammatory signs are immature 137
    • 138. General Care of the Newborn 138
    • 139. Erythromycin Eye Ointment (pp. 572-573) • Required by state law • Applied within first hour of birth • To prevent eye infections acquired in the mother’s birth canal (gonorrhea and chlamydia) • A ribbon of ointment is gently squeezed into each conjunctival sac 139
    • 140. Vitamin K (Phytonadione) • Necessary for normal blood coagulation • Infant’s GI tract is sterile, lacking microorganisms that make it • 0.5–1 mg IM within the first hour (vastus lateralis) • Prevention of hemorrhagic disease of the newborn 140 Moms of injured babies join CDC's new education effort
    • 141. Hepatitis B Vaccination • Hepatitis B immunization given IM (vastus lateralis) • Promotes manufacture of antibodies against this viral infection of the liver 141
    • 142. Question • The correct site for injection of hepatitis B immunization for a newborn is the: – A. Subcutaneous tissue of the thigh – B. Dorsogluteal muscle – C. Deltoid muscle – D. Vastus lateralis muscle 142
    • 143. Using a Bulb Syringe (p. 570) • To keep airway patent • Susceptible to airway obstruction • Remove secretions or regurgitated feedings from the infant’s mouth or nose • Mouth, then nose (M & N) • Compress the bulb before inserting • Insert @side of mouth 143
    • 144. Cord Care ∀ √ Bleeding / oozing • Cord clamp must be securely fastened • Treat with triple-dye, or alcohol (most common) • Alcohol only used @ VMC • Clean cord with alcohol TID to prevent infection • Signs of infection: redness at the cord base, swelling, drainage, foul odor • Keep clean, dry – Diaper tucked below – No tub baths until cord is detached and area totally healed – Cord becomes black @ 2-3 days; falls off @ 10-14 days 144
    • 145. Question • Choose the correct parent-teaching about cord care: – A. Fold the diaper below the cord to speed drying – B. Expect the cord to detach in no more than 7 days – C. Tub baths are safe as soon as the cord detaches – D. The cord site may be red until it detaches 145
    • 146. Bathing • As soon after birth as temperature is stable (infant temp needs to be 97.7° F, 36.5° C) • Early bathing decreases exposure to maternal blood • Nurse wears gloves • Mild soap solution • Dry well and return to radiant warmer quickly 146
    • 147. Newborn Footprint • Done before the baby leaves nursery 147
    • 148. Circumcision Care (pp. 586-588) • Observe site at each diaper change • Notify physician if: – No UO within 6-8 hrs – Bleeding more than few drops – Displacement of Plastibell – Infection: redness, edema, tenderness, discharge • Yellow crust over area is normal, should not be removed • Nothing applied to Plastibell site • Petroleum jelly applied to Gomco site 148 See Box 24-7 “Care of the Circumcised Newborn,” P. 588See Box 24-7 “Care of the Circumcised Newborn,” P. 588
    • 149. Question • Choose the normal circumcision assessment: – A. Slipping of the Plastibell onto the shaft of the penis – B. Oozing of blood from the site after a Gomco circumcision – C. Delay in urination for 12 to 16 hrs – D. Development of a dry yellow crust on the site 149
    • 150. Newborn Screening Tests • N.C. State law – Galactosemia – Primary hypothyroidism – Congenital adrenal hyperplasia (CAH) – Sickle cell disease – Fatty acid oxidation disorders – Organic acid disorders – Amino acid disorders - Phenylketonuria (PKU) • Screening for hearing loss http://slph.state.nc.us/Newborn/ConditionsTested.asp 150
    • 151. Blood Sample for Screening Tests • Heel-stick blood collected on special absorbent paper (Guthrie card) • Five one-inch circles must be filled with blood • The sample is allowed to dry and then sent to a laboratory for analysis 151
    • 152. Newborn Nutrition 152
    • 153. Aspects of Newborn Nutrition • Weight loss / gain • Nutrient requirements; RDA • Hydration/urinary output • Proper technique; precautions • Breastfeeding vs formula • Stool/ Feeding patterns • Psychosocial aspects 153
    • 154. Weight Loss • Weight loss up to 10% is acceptable for first 5 days • The infant will lose weight because of decreased fluid intake, loss of meconium, urine, loss of excess fluids from body tissues • Weight should become stationary at ~ 5 days after birth, and then increase to original weight by 10-14 days 154
    • 155. Question • The home-health nurse is assessing a 5-day-old, breast-fed newborn who weighed 8 lbs. 12 oz. at birth. The infant’s mother is now very concerned that the infant weighs 7 lbs. 2 oz. The most appropriate nursing intervention is which of the following? – A. Recommend supplemental feedings of formula – B. Explain that this weight loss is within normal limits – C. Assess the child further to determine the cause of excessive weight loss – D. Encourage the mother to express breast milk for bottle-feeding the infant 155
    • 156. Weight Calculations • 8 lbs 12 oz must be converted to decimal weight before deducting 10% • 8lbs + [12 oz × 1 lb/16 oz] = 8.75 lbs • 10% = 8.75 lbs × 0.1 = 0.875 lbs • 8.75 − 0.875 = 7.875 lbs after 10% deducted • Must convert decimal weight back to pounds and ounces • 7.875 lbs = 7 lbs + [0.875 lbs × 16 oz/1 lb] = • 7 lbs + [0.875 × 16] = 7lbs + 14 oz = • 7 lbs 14 oz (the difference after 10% deducted) • 7 lbs 14 oz is the maximal allowable weight loss for this infant • 7 lbs 2 oz is below this allowable weight 156
    • 157. Nutrient Requirements 157
    • 158. Calorie Needs (p. 610) • 110 kcal/kg/day • Human milk and formula provides 20 kcal/oz • Calorie needs steadily decline with age 158
    • 159. Fluid Needs / Output (p. 610) • 100-150 ml/kg/24º – Human milk or formula supplies adequate amounts – Does not need extra water • Output: 6-8 voids/day – Indicates adequate hydration – Notify physician if there are no wet diapers in 12 hours 159
    • 160. Question • How much fluid does a 3-day old infant need who weighs 3.4 kg? • 340 to 510 ml of fluid daily 160
    • 161. Carbohydrates, Proteins, and Fats • Protein – Greater need for protein than at any other time (brain development) – Human milk preferred • Protein easier to digest (high ratio whey to casein) • Less allergenic • Carbohydrates – Lactose main carbohydrate • Easy to digest • Higher level in breast milk – Infant has limited ability to form glucose from amino acids or glycogen stores; infants need plenty of lactose 161
    • 162. Carbohydrates, Proteins, and Fats • Fats—30-55% of calories – Human milk preferred – Fat in human milk is easier to absorb than formula – Fat in human milk contains essential fatty acids (DHA, ARA) • Vital for brain growth, normal visual and CNS development 162
    • 163. Vitamins and Minerals • Vitamins and minerals usually sufficient in breast milk • Must be added to formula • Vitamin C—adequate • Vitamin D—infant needs 30 minutes of exposure to sunlight per week • Vitamin K—insufficient at birth – Administer Vitamin K IM – S/S of deficiency: bruising, petechiae, prolonged bleeding from circumcision 163
    • 164. Vitamins and Minerals • Iron: milk of all types low in iron • Human milk: iron better absorbed – Because of ↑ RBC’s in fetus, iron stores usually sufficient until 6 months – After this, needs iron- containing foods • Formula: recommended that infants be fed iron-fortified formulas • Sodium, calcium, phosphorus higher in cow’s milk – Can stress kidneys (high renal solute load) • Human milk ideal – Contains proper amounts and ratios 164
    • 165. Vitamins and Minerals • Fluoride: fluoride levels in human milk and formulas are low • Fluorosis (spotting) of the permanent teeth has been noted on children who received supplements • Fluoride supplements are given to infants after 6 months and only to those with low- fluoride levels in the water supply 165
    • 166. Newborn Feeding 166
    • 167. Newborn Feeding—Proper Technique • First feeding: observe for choking, coughing, cyanosis (TEF) • Stomach holds only 30 – 90 ml at birth • Formula feeds: don’t overfeed • Normal to regurgitate a little • Keep head elevated during feeding • Burping important • Place on right side after feeding 167
    • 168. Newborn Feeding—Precautions • If infant becomes dusky, cyanotic, or apneic while feeding: – Stop feeding immediately – Suction if necessary – Stimulate the infant to cry by rubbing the back – May be a sign of congenital cardiac disease – Coughing, choking, cyanosis: tracheoesophageal fistula 168
    • 169. Choices for Newborn Feedings • Human milk (breast feeding) • Commercial formula 169
    • 170. Breastfeeding • Advantages: – Recommended – Nutritionally superior – Antibodies present – Less allergies, less colic – Less likely to be overfed, less incidence of obesity – Convenient, ready to use – Increased bonding – Less incidence respiratory, ear, GI infections, & SIDS • Disadvantages: – Need more frequent feedings than formula – Mother may need to watch diet – Caffeine, alcohol, drug intake, certain medications can affect child • Contraindicated: – Hepatitis,TB, HIV,CMV – Some maternal medications (chemotherapy) 170
    • 171. Commercial Formula • Simulates breast milk • Special formulations for preterm or infants with special needs • Will need 6 feedings per day • Don’t overfeed • Position on the right side following the feeding (prevents regurgitation, aids digestion) 171
    • 172. Cow’s Milk • NOT recommended for infants under 12 mos • Can cause GI bleeds, anemia, allergies • Too much protein (casein), potassium and sodium • Not enough iron, linoleic acid • Has adequate calcium, but low in phosphorus • Must be diluted to lower protein and then it does not meet caloric requirements 172
    • 173. Commercial Formula Cont’d… • Do NOT prop the bottle (may aspirate, promotes ear infections, causes dental caries) • Warming is optional (do NOT use microwave; follow instructions) • Do NOT dilute ready-make formulas • Powdered formula: – Water from uncontaminated source – Mix at proper concentration 173
    • 174. Stool Patterns of Newborns • Meconium—first bowel movement (24-48° after birth) • Transitional—usually occurs by day three (green brown-yellow brown in color) • After day four: • Breastfed—yellow to golden, loose to pasty, sweet-sour odor • Formula-fed—pale to light yellow, firmer, strong odor 174
    • 175. Demand Vs Scheduled Feedings • Demand feeding: feeding when signaled by infant behaviors • Scheduled feedings: on a routine, such as every 4 hours • Bottle-fed: need to be fed about every 4 hours about 6 times per day • Breast fed: need to be fed about every 2- 3 hours, 10 – 12 times per day 175
    • 176. Psychosocial Aspects • Erickson’s Stage: Trust vs Mistrust • The feeding cycle is closely related to the beginning of formulating trust • The child has discomfort, cries, and is fed, cuddled and relieved (Trust) • If this cycle is continuously broken, then the child becomes frustrated which leads to an unhappy child (Mistrust) 176
    • 177. Safety and Accident Prevention 177
    • 178. Identification • Armband—done before leaving delivery room • 3 armbands: 2 for baby, 1 for mother • Check arm band from baby to mother every time 178
    • 179. Preventing Infection • Always wash hands • Wear gloves with first bath • Visitors—screen to make sure they do not have a cold or infectious disease • Wear patient gowns when picking up infant 179
    • 180. Preventing Infant Abduction • Only hospital staff with proper identification may transport infants • Never leave infants unattended at any time • Entrances to the maternity unit or nurseries are equipped with locks that open to codes 180
    • 181. Back to Sleep • Placing babies on their backs to sleep reduces the risk of Sudden Infant Death Syndrome (SIDS), also known as "crib death" 181
    • 182. Choking / Suffocation • Place on right side after feeding • Do not cover nose • Avoid pillows, thick blankets, sheepskin in crib • Firm mattress only – NEVER place baby on water bed, sheepskin • Should not sleep with parents 182
    • 183. Motor Vehicle • Car seat is a must (it’s the law) • Must be rear- facing • Must be FDA approved • Back seat only • Safest place: rear middle 183
    • 184. Question • A nursing student has been caring for a woman and her newborn all morning. The student takes the infant to the nursery for screening tests prior to discharge. When the infant is returned to the mother, the correct procedure is to: – A. Have the mother read the printed band number and verify that it matches the infant – B. Ask the mother to state her name and the name of her infant – C. Call out the mother’s full name before leaving the infant with her – D. Return the infant with no special procedures since the student knows both mother and infant 184