Newborn Assessment / Care – Flashcards
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Initial steps to establish an airway in a newborn
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1. provide warmth 2. suction mouth then nose 3. dry the skin with warm blankets
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Normal breathing pattern at birth
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Shallow and Irregular at a rate of 30-60 seconds with brief apena that shouldnt last longer than 20 seconds
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Symptoms of Respiratory Distress in a newborn
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Nasal flaring, grunting, retractions, RR >60 or <30, labored breathing
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Decreased ____ will cause an ____ O2 demand and the increase in the utilization of _____ leads to _________ __________.
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body temperature increased glucose metabolic acidosis
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_____ ___ _____ assist in thermoregulation but preterm babies have none
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brown fat stores
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Convection
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Heat lost to cold air
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Radiation
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Heat lost to close proximity of cold surfaces
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Evaporation
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Heat lost with drying of moisture on infants body
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Conduction
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Heat lost with direct contact to cold surfaces
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Interventions for Thermo-Regulation
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Warm blankets to dry off infant, warm hat, swaddle, skin to skin contact, bassinet far from windows or doors, warmer.
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Score of 7-10 on Apgar
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No distress
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Score of 0-3 on Apgar
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Severe distress
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Score of 2 on Apgar
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Pink, HR >100, active crying, strong crying, active motions
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Score of 1 on Apgar
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Acrocyanotic, HR <100, grimacing reflex, some flexion, weak cry
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Score of 0 on Apgar
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Blue / Pale, no HR, no reflexes, limp, no respirations
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Where to auscultate the apical pulse on a newborn and how long to listen for?
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4th or 5th intercostal space over the apex and listen for a minute
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Normal newborn body weight
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5Ibs 5oz - 8Ibs 8oz Avg: 7.5 Ibs
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Normal newborn length
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18-22 inches avg: 20 in
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Normal newborn head circumference
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32-36 cm *measure from eyebrow level and around the occipitofrontal which is the widest part
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Normal newborn Chest Circumference
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30-33 cm Measure at nipple line (should be 2cm less than head circumference)
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Normal newborn skin assessment
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warm and pink or acrocyanotic
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Telangiectatic Nevi
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flat red or pink marks on the head and neck that go away by 2 years of age
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Vernix
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White, cheese like covering to protect skin in utero
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Nevus Flammeus
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Port Wine Stain - capillary angioma below the surface of the skin that is purple or red, varies in size and shape, and is commonly seen on the face and does not blanch or disappear
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Erythema Toxicum
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pink rash appears suddenly anywhere on the body of a term neonate during the 1st three weeks
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If newborns head is more than 4 cm greater than the chest, the infant may have . . .
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Hydrocephalus
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Molding
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Process of the cranial sutures of the head overlapping during labor and delivery. Diminishes after a few days
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Caput Succedaneum
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generalized swelling of soft tissues of the scalp due to labor/delivery and usually crosses the suture lines- resolves within 3-4 days with no treatment
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Cephalohematoma
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collection of blood between the periosteum and the skull bone and does not cross suture lines. Result of prolonged labor or use of forceps. May take several weeks to diminish and may cause hemolysis of RBC and hyperbilirubinemia
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Subgaleal Hemorrhage
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Bleeding into the subgaleal compartment. Results from forceps that compress and drag the head through the pelvic oulet.
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Normal newborn Eye assessment
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- Blue/Gray and permanent will develop after 3-12 months - Pupillary and red reflex present - Lacrimal glands immature and crying tearless -Pupils react to light - Sight to 12 inches - Erythromycin ointment given within 1 hour to prevent infection (Gonorrhea and Chlamydia) - May have chemical conjunctivitis R/T Erythromycin ointment (Redness, swelling, drainage; will clear on own) - Eyeball movement will show random jerky movement
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Normal newborn Ear assessment
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Top notch of ears should be at level of outer canthus of eyes (lower could suggest down syndrome), after amniotic fluid drains the hearing should be equal to adults, hearing screen prior to discharge.
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Nose assessment of newborn
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nose breathers - nasal flaring is sign of respiratory distress
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Mouth assessment of newborn
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should be pink (white could indicate thrush or yeast from mom) -Epstein pearls: small white cysts found on the gums that look like teeth but disappear after 3 weeks -Strong suck should be present - Excessive saliva may indicate tracheoesophageal fistula
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Abdomen assessment of newborn
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should be soft, round, and non-distended -BS should be heard within 1 hour - No drainage at umbilical cord -1st stool within 24-48 hours
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Genitalia/Anus assessment of newborn
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- Female newborns may have mucus or pink stained drainage from the vagina due to mothers hormones - Males may have enlarged scrotum and should have descended testes -Rust stained urine after delivery should be due to uric acid crystals
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Rooting Reflex
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When an infants cheek is stroked, the baby will turn his/her head in the direction of the stroke.
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Sucking Reflex
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When a gloved finger or nipple is placed in the babys mouth, he/she will suck
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Tonic-Neck Reflex
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While the newborn is supine, his head is turned to one cause causing extremities on same side to straighten and those on the opposite side to flex
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Step Reflex
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When newborns feet are placed on a flat surface, response is a dancing or stepping movement
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Babinski Reflex
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When the sole of the newborn is stroked upwards from the heel along the lateral aspect of the sole, the toes will fan out and hyperextend
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Moro/Startle Reflex
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Loud noise on one side of the newborns head will abduct its arms and flex its elbows
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Immediately after delivery (Stabilization Period) Nursing Care of the Newborn
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- Establish/maintain airway - Dry and provide warmth - Assess Apgars - Admin Vitamin K (.5 to 1mg IM with 25 gauge in vastus lateralis) - Admin Erythromycin Ointment (to prevent gonorrhea and chlamydia infections) - ID bracelets to mom and baby - Send cord blood if indicated
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Assessment Period (2nd Phase after delivery) of Newborn
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- Head-to-toe assessment - Growth Measurements - Gestational age assessments - Lab studies - 1st bath - Cord Care
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Normal Newborn Hematocrit Level
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44-64%
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Normal NB Hgb Level
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14-24 g/dL
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Normal NB RBC level
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4,800,000 - 7,100,000
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Normal NB leukocytes
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9,000 - 30,000
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Normal NB platelets
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150,000 to 300,000
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Normal NB Glucose
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40-60
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Normal NB billirubin
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0-6 on day 1 <8 on day 2 <12 on day 3
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Circumcision Care
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Usually done day 2 or 3 after delivery with the exception of Jews who wait until day 8. Lidocaine injections, EMLA cream, or tylenol may be used. Non-nutritive sucking or concentrated oral sucrose during the procedure may be used for pain. NIPS pain scale should be used. - Assess site q 15 mins for 1 hour then q 1 hour for 4 hours for bleeding. - Petroleum Jelly should be applied to prevent site from sticking to the diaper -Site will appear beefy red for 24 hours then will develop yellow exudate on the tip, which may last 2-3 days and should not be removed -May take a couple weeks to completely heal -No full body baths until fully healed; warm water used for cleansing -Diaper changes every 4 hours with petroleum jelly applied and diaper fan folded
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Formula Feeding
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Every 3-4 hours feed 1-2 ounces - 6-8 wet diapers a day and 2 stools a day
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Breast Feeding
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- Every 2-3 hours and on demand - 8-12 times a day - One breast first until soft then switch to the other - atleast 1 wet and 1 stool within 1st 24 hours of delivery
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Prolactin
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Responsible for milk production
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Oxytocin
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responsible for milk let-down
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Colostrum
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Secreted the first 2 days (antibody and calorie rich)
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Milk comes in ___ days after delivery
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3-5
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Monitor for weight loss in newborns of up to
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5% body weight but should regain within 10-14 days
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If pumped, milk may be stored in the fridge for up to __ hours and frozen up to __ months
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up to 48 hours up to 6 months frozen
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Elimination of feces in NB
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1st stool - meconium Day 2- 5 : transitional stools >5 days: yellowish brown stools
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Physiological Jaundice
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After 24 hours of birth it appears and it is benign. Bilirubin levels dont increase by more than 5 mg a day and treatment is sunlight and increased feedings and MAY require phototherapy
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Pathologic Jaundice
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Appears within first 24 hours, related to a disease process (ABO incompatability or infection) and billirubin levels are greater than 13. Treated with phototherapy, increased feedings, and monitoring of bilirubin levels and MAY require exchange transfusion
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Hyperbilirubinemia
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RBC's breakdown and release unconjugated or indirect billirubin. The liver conjugates bilirubin. Conjugated (direct) bilirubin may be excreted from the urine and feces. Indirect bilirubin may build up and leave the vascular system into the extravascular tissues, causing yellowish color of skin and mucus membranes from head to toe.
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Kernicterus
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- Results from untreated hyperbilirubinemia - Bili levels >25mg/dL - Neuro syndrome due to bilirubin depositing in brain cells - May cause epilepsy, cerebral palsy, mental retardation, deaf - S/Sx: seizures, fever, poor sucking, high pitched crying, lethargy
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ABO Incompatibility
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Occurs when maternal blood type O and fetus blood type A, B, or AB. Maternal anitbodies cross placenta (anti-a, anti-b). Increased hemolysis of RBC's occurs
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Preterm Infants Assessment
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Shiny skin, smooth, and translucent. Increased lanugo, flat areola without breast buds, wrinkles, LBW, no suck/swallow coordination, weak grasps, poor weight gain
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The cutting of the umbilical cord is ...
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The most critical extrauterine adjustment as the air inflates the the lungs with the first breath
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Vital signs are normally checked in what sequence
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Respiratory Rate: 30-60 with periods of apnea <15 seconds Heart Rate: 110-160 apical pulse for 1 minute Blood Pressure: 60-80 systolic and 40-50 diastolic Temperature: 97.7 to 98.9 axillary
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First Period of Reactivity
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newborn is alert, sucking sounds, rapid HR and RR for the first 15-30 mins after birth
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Period of Relative Inactivity
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quiet and resting, HR and RR will decrease and will last for 30 mins to 2 hours
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Second Period of Reactivity
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reawakened, becomes responsive again, gags and chokes on mucus, occurs 2-8 hours after birth and may last 10 mins to several hours
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Capillary Heel Stick
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Done 24 hours after birth and after being fed for a full 24 hours. Assesses serum billirubin. All states require testing for PKU which is a defect in protein metabolism in which the accumulation of amino acid PKU can result in mental retardation - warm heel first then cleanse with alcohol and allow time to dry and a spring activated lancet is used so that the skin incision is make quickly and painlessly
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Newborn Hearing Screening
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Required in 46 states and the district of columbia. Screened in the nursery to detect early
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Cough Reflex
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Clears most secretions in air passages but routine suctioning of the mouth and nasal passages with a bulb syringe is done to remove excess mucus
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Hypothermia s/sx
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Axillary temp <97.7 Cyanosis Increased RR
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Triple Dye
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Topical Antimicrobial may be used for umbilical cord care, this may include applying it to the stump or cleansing with neutral pH cleanser and sterile water as recommended.
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Signs of Hypoglycemia of Newborn
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jitteriness, twitching, weak high pitched cry, irregular respiratory effort, cyanosis, lethargy, eye rolling, seizures, and a blood glucose level less than 40 mg/dL by heel stick
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Healthy newborns need .....
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100 to 140 mL/kg/day of fluid 110 kcal/kg/day for first 3 months 100 kcal/kg/day for 3-6 months *breast milk and formula provide 20 kcal/oz 2.25 to 4g/kg of protein a day
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Vitamin D may be deficient in
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breast milk so it must be added in supplements
