NEWBORN12 Student Version
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Transcript of 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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Nutrition in Newborn
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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Nutrition in Newborn
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
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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Adaptation to Extrauterine Life
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