NUR 365 - Exam 3 (Combined)

First Period of Reactivity

Phase of Transition which:

• Lasts up to 30 minutes after birth

• Newborn’s heart rate rapidly increases (160-180 bpm) but returns to baseline after 30 minutes

• Respirations are irregular (60 to 180/min)

• Audible grunts, nasal flaring, and retractions of chest are present buts should cease after about 24 hours

• Infant is alert and may have spontaneous tremors, crying, and lateral head movements

• Audible bowel sounds present and meconium may be passed

Period of Decreased Responsiveness

Phase of Transition which:

• Lasts 60 to 100 minutes after birth

• Infant is pink

• Respirations are rapid (up to 60 breaths per minute) and are shallow and unlabored

• Audible bowel sounds and peristaltic waves may be noted over rounded abdomen

• Sleeping or has a marked decrease in motor activity

Second Period of Reactivity

Phase of Transition which:

• Occurs between 2 and 8 hours after birth and lasts 10 minutes to several hours

• Brief periods of tachycardia and/or tachypnea may occcur

• Increase in muscle tone, changes in skin color, mucus production

• Meconium commonly passed

• Experienced by most healthy newborns regardless of gestational age (unless very premature) and method of birth

Shallow and irregular with brief periods of pausing

Describe breathing patterns of a newborn

Mongolian Spots

Bluish-black areas of pigmentation that can appear over any exterior surface of the body including the extremities but are most commonly seen in the back and buttocks

• Most seen in ethnic origins from Latin, America, Asia, Africa, and the Mediterranean area

Lanugo

Fine hairs that may be noted over the face, shoulders, and back

Vascular Nevi

The result of superficial capillary defect and occurs in up to 80% of newborns

Most commonly seen on the upper eyelids, nose, upper lip, and nape of the neck

• Not clinically significant and requires no treatment

Nevus Flammeus

Visible at birth due to an asymmetrical postcapillary venule malformation

Usually pink and flat at birth and is found most commonly on the face and neck

Erythema Toxicum

A transient rash that can appear suddenly anywhere on the body and is thought to be an inflammatory response

• No clinical significance and requires no treatment

Vernix Caseosa

A complex substance that contains sebaceous gland secretions and has antioxidant properties

• Has positive benefits for neonatal skin such as decreasing pH, decreasing skin erythema, and improving skin hydration

Caput Succedaneum

Generalized, easily identifiable edematous area of the scalp caused by sustained pressure of the presenting part against the cervix which compresses local vessels and slows venous return

Most often seen on occiput

Extends across the suture lines of the skull and disappears within three to four days

Acrocyanosis

Bluish discoloration of the hands and feet

• Normal finding in the first 24 hours of birth

Cephalhematoma

Collection of blood between a skull bone and its periosteum

• Usually resolves in two to eight weeks but can cause hyperbilirubinemia (jaundice) as a result

Petechiae

Skin bruises that can be observed on the head, neck, and face of a newborn with a cord around the neck

• Can be persistent if increased pressure was applied to an area and can indicate underlying problems such as low platelet count or infection

Hip Dysplasia

Assessed by:

• Asymmetrical skin folds

• One leg being longer than the other

• Straight up flexion of a leg

• Perineal and hips area showing purple discoloration

• Purple discoloration of the vulva and vaginal discharge

Babinski Reflex

All toes hyperextend with dorsiflexion in response to the stroking of the lateral aspect of the sole of the foot

Moro Reflex

Symmetric abduction and extension of arms and fingers fanning out to form a C with the thumb in response to being in a semi-sitting position or supine on a flat surface

Tonic Neck Reflex

Tested by placing infant in a supine neutral position with head turned quickly to one side

• Arm and led extends to same side head is facing while others are flexed

Stepping Reflex

The simulation of walking in response to being held vertically under the arms or on trunk with one foot on a table-like surface

Grasp Reflex

Curling of fingers/toes in response to a finger being placed in the hand/foot

97 to 99.5

Normal newborn temperature (°F)

110 to 160

Normal newborn heart rate (beats/minute)

30 to 60

Normal newborn respirations (breaths/minute)

95-75/55-37

Normal newborn blood pressure AT BIRTH

Normal Renal Function

S/S are:

• Voiding at time of birth

• 2 to 6 voids/day for days 1 and 2

• 6 to 8 voids/day after day 4

• Straw-colored and odorless urine

• Uric crystals sometimes appear

Abnormal Renal Function

S/S are:

• A lack of steady urine stream

• Enlarged or cystic kidneys

Initiation of respirations

Stimulated by a combination of chemical, mechanical, thermal, and sensory factors

• Chemoreceptors in carotid arteries

• Intrathoracic pressure and crying

• Stimulation of respiratory center in medulla in response to temperature

• Suctioning of mouth and nose and drying

Evaporative Heat Loss

Loss of heat that occurs when a liquid is converted to a vapor

• Prevented by wrapping the baby in a blanket and initiating skin-to-skin contact

• Most significant cause of heat loss in the first few days of life

Convective Heat Loss

Flow of body heat from the body surface to cooler, ambient air

• Neonates are wrapped in blankets to avoid this

Radiant Heat Loss

Loss of body heat due to a cooler solid surface not in direct contact but in proximity (such as a vent)

• Surfaces like vents are placed away from infant to avoid this

Conductive Heat Loss

Loss of heat from the body to cooler surfaces in direct contact

• Prewarmed blankets and protective scale coverings are used to prevent this

Physiologic Jaundice

Occurs in roughly 60% of neonates and appears after 24 hours and usually resolves without treatment

Pathologic Jaundice

Occurs due to unconjugated hyperbilirubinemia that is either pathologic in origin or severe enough to warrant further evaluation and treatment

Vitamin K

Administered in response to a lack of intestinal bacteria (in the liver) needed to synthesize this vitamin

• Lack of this can lead to transient blood coagulation deficiencies between the second and fifth days of life

Bilirubin Conjugation

The process of making the waste produce of red blood cells water-soluble and more readily able to be excreted or eliminated via the bloodstream

0

Apgar Scoring for:

Absent Heart Rate

1

Apgar Scoring for:

Heart rate < 100

2

Apgar Scoring for:

Heart rate ≥ 100

0

Apgar Scoring for:

Absent Cry

1

Apgar Scoring for:

Slow, weak cry

2

Apgar Scoring for:

Good, strong cry

0

Apgar Scoring for:

Flaccid muscle tone

1

Apgar Scoring for:

Some flexion of extremities

2

Apgar Scoring for:

Well-flexed extremities

0

Apgar Scoring for:

No reflex irritability/response to stimuli

1

Apgar Scoring for:

Grimace in response to stimulation

2

Apgar Scoring for:

Crying in response to stimulation

0

Apgar Scoring for:

Blue, pale appearance

1

Apgar Scoring for:

Acrocyanosis

2

Apgar Scoring for:

Completely pink appearance

0 to 3

Apgar score which indicates severe distress

4 to 6

Apgar score which indicates moderate difficulty adjusting to extrauterine life

7 to 10

Apgar score which indicates minimal or no difficulty adjusting to extrauterine life

Eye infection

The purpose for the administration of erythromycin eye ointment is…

• Given within the first hour of birth and is mandated by law in most states

Vitamin K

This is given due to the lack of intestinal flora to synthesize this vitamin (which the baby will be able to do by 7 days of living)

• Prevents deficiency bleeding (hemorrhagic disease)

Frequent feeding, skin assessment, and monitoring TSB levels

Interventions for Jaundice include…

Phototherapy

Uses light energy to change the shape and structure of unconjugated bilirubin, converting it into a conjugated form that can be excreted through urine and stool

• Delivered by lamp, blanket, pad, or cover-body device

• Severity determines the device and strength as well as duration of treatment and location of the treatment itself

Circumcision Care

This includes:

• Attaching the diaper loosely to prevent pressure and change at least every 4 hours

• Monitor for urination, bleeding, and signs of infection

• Cleaning the glans gently with warm water

  Not removing the yellow crust over the glans

Vastus Lateralis

IM injections are given here for infants

IM Injections

These include:

• Hep B

• Vitamin K

• Erythromycin

• Tetanus

• Measles

• Hib

Safe Sleep

Precautions include:

• Placing newborns supine in a bassinet that are free of pillows, blankets, toys, and supplies such as diapers or wipes

• No bed-sharing

• Use of a pacifier

• Avoidance of overheating while asleep

Bulb Syringe

Teaching includes:

• Suctioning mouth before nose

• Compressing before inserting it into mouth

• Suctioning one nostril at a time

• Suctioning the sides of the mouth rather than the middle

Detection of genetic diseases

The purpose of newborn screenings is…

Infant Abduction

Precautions include:

• ID bands on the mother, infant, and any significant other

• Verification of ID bands

• Security sensors in place

• Instructing parents to identify all care personnel who interact with the baby

Nonpharmacological pain management

This includes:

• Music Therapy

• Sweet solutions such as sugar-water

• Pacifier

• Breastfeeding

Feeding Readiness Cues

These include:

• Sucking or mouthing motions

• Hand-to-mouth or hand-to-hand movements

• Rooting Reflex

Effective Feeding

Signs include:

• Firm tugging sensation on the nipple with no pain

• Infant’s cheeks are well-rounded

• Audible infant swallowing

• Tingling sensation of the breast (milk ejection)

• Shallow sucking present

• Maternal feelings of relaxation and/or drowsiness

• Leakage of milk from opposite breast

6 to 8

This many wet diapers every 24 hours after day 4 indicates effective feeding

Ineffective Feeding

Signs include:

• Inadequate weight gain

• Minimal output

• Constant feeding

Engorgement

Common response of the breasts to the sudden change in hormones and the onset of significantly increased milk volume in lactogenesis stage II

Engorgement interventions

These include:

• Use of cold or warmth

• Cabbage leaves

• Antiinflammatory medications

• Breast massage

• Hand expression or pumping

• Reverse pressure softening

• Ultrasound, acupressure, acupuncture, Gua sha

Reverse pressure softening

Manually displaces the areolar interstitial fluid inward, softening the areola and making it easier for the infant’s mouth to grasp the nipple and areola with a latch

Increasing feeding frequency and improving technique

Intervention for poor weight gain is…

6 months

Breastfeeding is exclusively recommended for infants for this number of months then should be continued for another 12

Vitamin D

The only vitamin not provided by breast milk is…

Vitamin B12

This vitamin intake in an infant depends on the mother’s dietary intake

Mastitis

S/S include (similar to influenza):

• High fever

• Chills

• Malaise

• Body aches

• Headache

• Nausea/vomiting

• Localized breast pain and tenderness

Mastitis Treatment

This includes:

• Bed rest

• Antibiotics

• Antiinflammatory medications

• Continued lactation

• Complete emptying of the breast

• Adequate fluid intake

Waking a sleepy infant

Interventions include:

• Unwrapping infant

• Changing the diaper

• Sitting baby upright

• Speaking with variable pitch

• Gently massaging baby’s chest or back

• Stroking the palms or soles of the baby

Breast milk

This is better than formula or cow’s milk because:

• Nutritionally superior

• Provides many immunoglobulins (especially IgA)

• Promotes colonization and maturation of infant’s microbiome

• Provides all vitamins except for D

• Has a 2:1 calcium-to-phosphorus ratio

• Better iron absorption

Oxytocin

This stimulates the milk ejection reflex

Prolactin

This stimulates milk production

Smoking

Teaching for mothers who do this include:

• Can impair milk production

• Risk of secondhand smoke (SIDS and respiratory allergies)

• Nicotine is transferred to the infant through breastfeeding

Nipple Trauma

The prevention of this is done by inserting a finger into the baby’s mouth between the gums and leaving it there until the nipple is completely out of the baby’s mouth

10 days, 3 weeks, 6 weeks, 3 months, and 6 months

Growth spurts happen at these times…

Breastfeeding Contraindications

Includes:

• Baby having galactosemia

• Mother having an infection or disease such as:

  • HIV, Ebola, illicit drug use, TB, varicella, etc.

Infant benefits

These include:

• Reduced infant and child mortality

• Reduced risk for several conditions/diseases/infections

• Enhanced neurological development

Maternal benefits

These include:

• Reduced risk for ovarian cancer and breast cancer, type 2 diabetes, HTN, and MI

• Reduced risk for postpartum hemorrhaging

• Enhanced maternal-infant bond

Societal benefits

These include:

• Convenient and cost-effective

• Lower healthcare costs

• Better for the environment

Breastfeeding Limitations

These include:

• Cultural factors

• Family support

• Employment

• Knowledge from HCP

Maternal risks

These risks of poor glycemic control include:

• Macrosomia (should dystocia and c-section birth)

• Ketoacidosis

• Hyperglycemia or Hypoglycemia

Neonatal risks

These risks of poor glycemic control include:

• Miscarriage

• Cardiovascular and CNS abnormalities

• Hyperinsulinism/hypoglycemia

• Macrosomia

• Birth injuries (shoulder dystocia)

Strict maternal glucose control

The key factor to an optimal outcome for diabetic mothers is…

Metabolic changes during pregnancy

These changes include:

• Increased insulin production

• Decreased glucose production

• Increase in glycogen stores

• Decreased insulin resistance

First Trimester

Insulin needs during this trimester is decreased due to the increased production from the pancreas and increased sensitivity to insulin

Second Trimester

Insulin needs during this trimester is increased due to an increase in placental hormones, cortisol, and insulinase (insulin antagonists)

Third Trimester

Insulin needs during this trimester is doubled to quadrupled

Day of birth

Insulin needs are dramatically decreased on this day of the gestational period

Less than 70 mg/dL

The blood glucose level that indicates hypoglycemia is…

Treatment for hypoglycemia

Includes:

• Familiarizing with s/s of hypoglycemia

• Orange juice, regular soda, hard candies, and skim milk

• Resting for 15 minutes then retaking blood glucose levels