NEWBORN12 Student Version

7/30/2019 NEWBORN12 Student Version

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NEWBORN

Lecture 12


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Care of Newborn in Delivery Room:

Adequate breathing pattern established

Mouth suctioned 1st

Nurse wraps infant in warm blanket & places under

radiant warmer Drying motion usually stimulates 1st cry. Drying

helps prevent heat loss

Note time of 1st cry & success at breathing attempts.

May need resuscitative attempts.

infant kept unwrapped on clean/dry radiant warmerto promote thermoregulation


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Apgar Score

Apgar score - assessment scale since 1958to assess newborn well-being at 1 & 5 min.

Newborn observed & rated on 5 components.

Heart rate Respiratory effort

Muscle tone

Reflex irritability

Color


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Apgar score

Score of 0, 1, or 2 - each component

Five scores added & final number @ 1 & 5 min

9/9 common - 2 on HR, Resp, reflexes, muscletone & 1 on color d/t acrocyanosis.

Heavy sedation of mother may lower respiratory effort

or reflex irritability score.

Score of 4 or less indication that infant most likely

needs resuscitative efforts

Score of 4-6 may indicate suctioning and oxygen

therapy.


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Umbilical Cord

Umbilical Cord: After delivery, 2 clamps placed

Cord clamped again 1- 2 inches from umbilicusVessels counted [2 arteries; 1 vein - AVA].

Bleeding may occur if clamp not tight

umbilical stump; falls off by 7th - 10th day

Teach: do not bathe infant until site completely healed

Sponge bath


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Identification of Newborn

Done immediately > delivery by same nurseassisting mother

Prevent giving wrong infant to wrong mom.Identification is 1 band on mom, one on

significant other & 2 on baby. Footprints of infant & mothers thumb print

on footprint sheet.


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Nurses Responsibilities in

Delivery Room

Eye Care: erythromycin ointment > delivery

Eliminates gonorrhea/chlamydia.

Vitamin K Injection: produced in intestinal tract andused by body for coagulation.

Newborn @ risk for bleeding disorders during 1st wkof life. injection given IM within 1st hour [Dose = 0.5mg. to 1.0 mg.] Site: vastus lateralis

In DR, infant given to mom to begin bonding process

& breast feeding started.


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Nurses Responsibilities in

Newborn Nursery

Admission to Nursery

Infant transferred to Newborn Nursery.

Report given by L&D nurse to NBN nurse.

Routine newborn care.

Infant under radiant warmer, VS, measurements,head to toe assessment, bath [98.0 R].

To mom in 4 hrs. if WNL. [98.0]

Universal security system on maternity units -

ensure safety of all newborns on unit. Alarm placed on infant ankle or umbilical cord

stump. All doors in unit are alarmed & locked.


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Newborn Adaptation

Newborns ability to adapt successfully depends

upon conditions in utero, care it receives during

intrapartum period, & newborn period aka neonatal

period = 1st 28 days of life.

2/3rds of all deaths that occur in 1st year of life

occur during neonatal period [1st 28 days of life].


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Head to Toe Assessment of Newborn

Head: General appearance

NOTE: Size: of body size [33-35 cm., 13-14 in. circumference]

Molding: Asymmetry of skull

Cephalohematoma: collection of blood bet. skull bone &periosteum

Caput succedaneum: swelling over presenting partFontanels: soft spot Anterior fontanel diamond shaped, measures 2-3 cm. wide & 3-

4 cm. long. Closes @ 12-18 months. @ juncture of frontal &parietal bones. Overriding sutures w. NSVD. Level C/S

Posterior fontanel - triangular shaped; small [~0.5 cm.] hard tofeel; juncture of occipital & parietal bones. Closes 2 mos.

*Depression indicates dehydration

*Bulging > hydrocephalus

Hair gestational marker; preterm sparse


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Eyes

Eyes: usually blue or gray

Permanent color develops 3 - 12 mos of age. Iris does not

develop color til 3-6 mos.

Lacrimal [tear] glands- not fully mature

Subconjunctival hemorrhage: from stress of vaginal delivery First 6 wks; transient strabismus; not able to focus.

Constant strabismus < 6 weeks, further assessment needed.Strabismus > 6 weeks, referral needed.

Scant purulent discharge > erythromycin ointment

Pupils round & equal; should constrict - normal response to light

PERL =pupils equal & reactive to light


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Nose

Nose: Infants obligatory nose

breathers.

Note size & shape, & presence of nasal

discharge or stuffiness.

Clean nose with bulb syringe; saline

drops.

Observe fornasal flaring


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Mouth

Mouth: Examine palate with index finger Cleft lip and/or cleft palate

Epsteins pearls [small, round, white cysts]

Note size & shape oftongue and length offrenulum membrane

Supranumery teeth aka natal teeth

Sucking reflex- evaluate

Rooting reflex


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Ears/Neck

Ears: Note position of ears in relation to eyes

Pinna should be fully formed and firm.

Term infant: pinna recoils easily

Preterm infant, < 36 wks - relatively shapeless and flat; little

cartilage. Slow recoil. Skin tag harmless; may be associated w. kidney disease.

Hearing test done before newborn D/C home; If fails 2nd time,hearing eval.done as outpt.

Neck: Normal newborn neck short, chubby w.creased skin folds.Head support necessary. Inspect masses, limitation of movement

& webbing.

Clavicles: straight, palpate each clavicle for intactness; crepitus

Common in larger infants delivered vaginally


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Chest

Chest: Inspect shape, symmetry, position,development of nipples; breast tissue.

Chest 12-13 in. [3033 cm.].

Breast engorgement maternal hormones.

Normal respirations 40 60 breaths/minute.Retractions abnormal; indicates respiratory distress.RR can be in 30s [sleep].

After4 hr. transition period, RR 40s.

Grunting [hoarse sound - expiration]

transient d/t mucous in lungs. Suction. If retractions/grunting not clear by 4-6 hrs, may

indicate respiratory distress

TTN; transient tachypnea of NB. RR = 70-80s forseveral hrs. [transition period] if more > 4 hrs., NICU.


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Abdomen/Kidneys

Abdomen: palpate for masses/organs

Umbilical Cord: Inspect 3 vessels (AVA); falls off in7 10 days. Let dry.

If only 2 vessels present, artery and vein, observe

infant closely d/t association with heart or kidneyanomalies.

Kidneys may be felt on right & left side of abdomen bydeep palpation.

S/S infection


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Genitalia - Male

Genitalia: Male:Assess for gestational maturity &sexual ambiguity.

Scrotum in full term infant swollen; + rugae; both R & Ltestes descended into scrotal sac.

Testes may be in processof descending. If one or

both testes are undescended = cryptorchidism, Agenesis [no testes] or closed scrotal sac

Normal length of newborns penis = ~ 2cm long.Assess for urethral opening aka urinary meatusAbnormal placement on dorsal surface *epispadias*;

ventral surface *hypospadias


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Genitalia - Female

Female: Vulva typically swollen. Labia minora

& clitoris large with labia majora covering both

Female infants have pseudomenstruation

Hymenal tag or small piece of pink tissue

protrudes between labia


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Extremities

Extremities:Assess for muscle tone Note length of arms/legs; should be

symmetrical

Limp arm may have nerve damage [birth

injury] aka brachial plexuspalsy. Observe palm: simean crease [single

Assess: syndactyly: webbing of fingers/toes& polydactyly: > than 10 fingers or toes.

Assess sole creases; mature infant: 2/3rds orfull sole w.creases


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Skin

Reddish in color; smooth and puffy At 24 - 36 hours of age, skin flaky, dry and pink in color. Edema

around eyes, feet, genitals.

Acrocyanosis: Bluish discoloration of hands and feet. Lasts for

24-48 hrs. Mucous obstruction may cause central cyanosis

Milia: Pinpoint white papules; Disappear 2-4 wks Neck: Normal newborn neck short, chubby w. creased skin folds.

Support is necessary. Inspect for masses, limitation of movement& webbing

Clavicles: straight, palpate for intactness; feel for crepitus

Commonly found in larger infants delivered vaginally.


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Skin

Lanugo: fine hair covering newborns upper arms, shoulders, &

back that decreases as gestational age increases

Vernix caseosa: white, cream cheese like substance; skin

lubricant.

Erythema neonatorum [toxicum]: NB rash; red rash with flea-biten appearance.

Stork Bites - a.k.a. telangiectasia - pink spots found on nape ofneck, nose, upper eyelids, upper lip. Disappear in 1-2 yrs.

Mottling: Generalized red and white discoloration of skin ofexposed infants with fair complexion.

Mongolian Spots: Collections of pigment cells [melanocytes]that appear as patches across infants sacral area and buttocks.Tend to occur in newborns of Asian, African, or SouthernEuropean descent


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Skin

Capillary Hemangiomas: 3 types, all are vascular

Nevus flammeus: macular (flat), purple or dark redlesions, present @ birth. Aka port wine stain

Strawberry hemangiomas: raised areas formed byimmature capillaries & endothelial cells. Occurstypically in term infant.

Cavernous hemangiomas: Raised; resemblesstrawberry hemangioma Can be surgically removed


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Back/Anus/Rectum

Spine:

Assess for intact spine without masses oropenings. Small indentation @ base of spinemay suggest pilonidal dimple. May be

pilonidal sinus [opening]; represents possiblespina bifida occulta.

Tuft of hair present @ base of spine = Nevuspilosus.

Anus & Rectum:Assess rectal patency [NBN]with 1st temp; lubricated thermometer. Ifrectum not patent, called imperforate anus


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Routine Exam of Newborn Vital

Signs

Vital Signs: admission NBN & q shift. Temperature (ax 97.7 98.6 F) Initial rectal.

Heart Rate: 110160 bpm.

Femoral, radial, brachial pulses can be palpated;. Apical pulseused for HR; auscultate 1 min

Respiratory Rate: 40-60 min. Initial rate 80 /min. BP ~ 80/46 mmHg @ birth. By 10th day, 100/50.

Daily:

Weight: 2,500-4,000 gm (5 lb 8oz - 8 lb 13 oz); compare withprevious day. 5-10 % weight loss acceptable

Assess feedings daily. # voids/stools in 24 hrs.Done once on admission to nursery:

Length: 45-55 cm = 18-22 in

Head: slightly larger than chest; 13-14 in.= 33-35 cm

Chest: 12-13 in. = 31- 33 cm


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SENSORY BEHAVIORS OF THE

NEWBORN

Tactile

Olfactory

Vision (see black & white best)

Auditory

Taste


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REFLEXES

Sucking place finger in mouth; infant sucks right away.

Moro[startle reflex] elicit by loud noise; infantextends arms & legs suddenly.

Rooting touch cheek; turns head in direction of touch.

Babinski stroke sole of foot from top to

bottom; toes fan out. Graspingplace finger in newborns hand;

grabs & hold.

Stepping hold infant upright w. feet on

surface; stepping movements


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Behaviors Sleep/Awake

Predictable Behaviors:

1st 4 hours > delivery: 1st period of reactivity: alert, active state; awake, crying,

sucking.

Then Sleep phase 4-6 hrs.

2nd period of reactivity 2-3 hrs. Sleep/awake during day.Sleep States

1. Deep Sleep

2. Light Sleep

Awake States

Drowsy; Quiet Alert best time for breast feeding/bonding

Active Alert; Crying


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Behaviors

Brazelton Neonatal Behavioral Assessment Scale:

Scale developed in 1970s to evaluate newborns behavior to stimuli

Assesses motor maturity & social behavior. Takes ~ 30 min to do

Ballard Assessment scale:developed 1970s to assessgestational maturity; takes 2-3 minutes to do.

Assesses physical & neuromuscular maturity. Useful indifferentiating between SGA infant & miscalculated due date

SGA infant is mature gestationally.

Full term infant gets score of ~ 3.3 in each category. Compareinfants in NICU to those in NBN.


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Nutrition in Newborn

Bonding process reinforced during feeding w. breast & bottle.

Approx. 64% of women breast feed in early post partum period

29 % still nursing @ 6 months; 16% still nursing @ 1 year.

Growth & caloric requirements during neonatal period & early

infancy are fasterthan any other period of life. Newborns can lose up to 5-10% of birth weight while waiting for

breast milk to come in. Colostrum rich in antibodies but has less

calories than breast milk. Breast milk has no allergies.


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Education

Teach mom: ^ calories by 500/day ^ fluids by 8 glasses/day

Well balanced diet; omit caffeine/alcohol.

Breast feed q2-3 hrs./day; Bottle feed q 3-4 hrs./day

Avoid fish containing mercury.

Teach positions for breast feeding; football hold for C/S. Any position OK as long as baby has nipple & areola; infant can

breathe. Find comfortable position; Use pillows - free up hands.


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Daily Requirements:

Calories: body maintenance & growth.

Birth to 2 months of age: require 110-120 calories/kg/24 hrs.

Up to 6 months, require 108 cal/kg/24 hrs.

6 mos. to 1 yr. require 98 cal//kg/24 hrs.

Protein: needed to form new cells; important for rapid growth.

Up to 2 months, 2.2 g/kg/24hrs required.

6mos.-1yr. 1.6g/kg req.

Fluid: 150-200 mL/kg/24 hrs

75% of NB body composed of water

Fluids: Need 65 ml/kg [30 ml/lb] daily 1st 2 days of life then 100-

150 ml/kg [45-68 ml/lb/day] afterwards. Voids: 1st few days 2-6 voids/day; > 2-3 days: 6 or more voids.


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Fat: [Linoleic acid] found in both breast milk & formulas

Carbohydrates: Lactose most easily digested of carbohydrategroup. Helps to reduce GI illness in newborns by producingstool with gram + bacteria instead of gram negative bacteria.Rare to have infant with lactose intolerance

Iron: Found in breast milk & added to commercial formulas

Flouride: Not found in breast milk or formula; needsupplement starting @ 6 mos. if not found in drinking water

Calcium: needed for bone growth

Vitamins: Start supplement @ 6 months of age


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ADVANTAGES OF BREAST FEEDING

Helps with uterine involution.

May help prevent breast cancer.

Empowering effect on mother; self esteem. Provides morefrequent close contact

Inexpensive. Complete nutrition for baby. Provides extension ofimmunity for up to 6 mos. Colostrum IgA [immunoglobulin] whichbinds to bacteria & viruses; proteins/enzymes destroy bacteria.

Macrophages produce interferon - interfere with virus growth.

Disadvantages of Breast Feeding:Father feels left out. Sore nipples. Painful engorgement.

More frequent feeding required so less time with other children.Embarrassment R/T feeding in public. Mastitis. Infections:Hepatitis B & HIV can pass thru milk.


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ADVANTAGES OF BOTTLE FEEDING

^^ freedom d/t less frequent feedings; infant sleeps longer

periods.

No sore nipples.

No worry over breast feeding in public or pumping at work.

Father can feed infant frequently. Frees up mom with older children.

Disadvantages of Bottle Feeding

More expensive; infant may not tolerate formula

May have to try different formulas before finding right one

More prep time; more shopping time.

^ waste: discard unused portion > 1 hr.

[^bacteria]. No transfer of passive immunity.

G l C f I f t


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General Care of Infant

Bathing q day; Teach parents: sponge bathe daily before

cord falls off and tub bath > cord falls off & healed. Mild soap

Positioning & holding lay infant on back to sleep;

Hold upright to feed formula & burp. Teach breast feeding

positions: cradle hold, side lying, & football hold.

Vaseline to buttocks w. diapering. Record stools/voids.

VS q shift . Teach parents to take temp. if 100.0 R*call MD!

Stools:

Meconium: very dk. green/almost black, sticky.

Transitional stool: yellow/green [> meconium] Breast fed stool: yellow seedy w. sweet odor.

Formula fed stool: green/yellow.


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Adaptation to Extrauterine Life


Cardiovascular: NB must initiate respirations & sustainextrauterine oxygenation

When born, infant forced to take in oxygen thru lungs.

Shunts close & vessels clot off & regress

Respiratory: First breath also in response to temperature &pressure changes, light & noise.

1st breath requires great amt.of pressure; 40-70 cm

H2O. Small amt of fluid present in lungs. 1/3 rd of this fluid forced out by pressure of vaginal birth;

rest absorbed by lung tissue. C/S infants may need more

suctioning & oxygen therapy.


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Renal: Renal function does not fully mature until > 1st yr. 1st voidoccurs within 1st 24 hrs.

No urine for 36 hrs. needs further eval. for obstruction or absentkidneys.

1st voiding may be dk.pink/red d/t uric acid crystals. Disappears

1st few days as kidneys mature. Alarming to parents; harmless

finding.Gastrointestinal: GI tract sterile @ birth; bacteria enters GI tract

thru mouth within 24 hrs.of life. Bacteria needed for prod. Vit.K

Infant: limited ability to digest fats & starches Meconium passed 1st 24-48 hrs. of life

By 2nd - 3rd day, transitional stool passed


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Thermogenesis

Brown fat : helps conserve body heat; produces heat.

Found in upper chest, back of neck, around abdomen.

Is deposited in 2nd trimester; Helps regulate body temp>delivery.

Radiant warmer - helps regulates body temp. by conserving heat.

Newborns can produce sufficient heat in optimal thermalEnvironment if warm enough.

Rapid heat loss occurs in suboptimal environment [cooler].

Infants do not shiver; can go into cold stress quickly.

Uses up extra glucose & oxygen to thermoregulate.

Leads to: metabolic acidosis; respiratory distress

Hypoglycemia; Jaundice; decreased surfactant production


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Thermogenesis

Infants Lose heat in 4 ways: Convection

Evaporation

Conduction

Radiation

IMMUNOLOGIC:

Newborn still prone to infection, handwashing important!

IgG: Infant born with passive immunity from mom. Fetus makesown starting @ 20 wks

IgM too large to cross; makes own after delivery.

IgA do not cross placenta. Produced by infant > birth @ 6-12wks. Found in breast milk.


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Labs

Hemoglobin: 15-20 g/dl.; Hct: 43-61% Blood volume: 80-110 ml/kg. or 300 ml.

WBC: 10-30,000 mm

Glucose 45-60 mg/dl - heel stick < 45 & feed with oz formula.

Repeat within hour. Send serum blood glucose as per protocol.

JAUNDICE:

Breast Fed Jaundice: 1 out of 3 breast feeding infants. Most

common cause: insufficient intake - 1st week of life. Bili can reach

12mg/dl. Theory: Enzymes in breast milk thought to interfere with

conjugation process.

Feed @ least 8-10 feedings in 24 hrs.

Teach moms: ^^ their own po fluids

Kernicterus rare with breast fed jaundice

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NEWBORN12 Student Version