Lecture 5: Physiological Adaptations/Nursing Care of the Newborn

What 4 things is the newborn’s first breath triggered by?

• light

• cold

• noise

• decreased pO2 / increased pCO2

What does an APGAR score tell us?

an assessment of how a newborn is doing as they transition to the extrauterine environment

What are the 5 things we assess for in APGAR?

• activity (muscle tone)

• pulse

• grimace

• appearance

• respirations

What are the three scores for activity (muscle tone)?

• 0: Flaccid

• 1: some flexion

• 2: well flexed

How does crying help help the transition to extrauterine life?

• increased positive pressure

• air to the lungs

• inflation of alveoli

What are the 4 factors that help stimulate the initiation of breathing?

• mechanical

• sensory

• thermal

• chemical

What does surfactant do?

decrease surface tension and maintain alveolar stability

Why is the patency of the baby’s nares significant?

newborns are obligate nose breathers

What causes cardiovascular adaptations to begin?

cord clamping and first breath

What 3 structures close with cord clamping?

• ductus arteriosus

• ductus venosus

• foramen ovale

Name 2 other cardiovascular adaptations.

• increased blood flow to lungs and liver

• increased O2 to periphery

The transition to extrauterine life is characterized by ____________.

predictable periods of instability

Describe what happens during the first period of reactivity.

• quiet alert state

• HR decreased from 160-180 to consistent baseline of 100-160 bpm

• RR irregular and there may be audible fine crackles, grunting, nasal flaring, and retraction of the chest (should cease by 1 hour of life)

Describe what happens during the second period of reactivity.

HR, RR, muscle tone, GI activity all increase

What happens between the first and second periods of reactivity.

sleep period

What are the sleep states?

• deep sleep

• light sleep

What are the wake states?

• drowsy

• quiet alert

• active alert

• crying

What is the optimal state of arousal?

quiet alert state

Describe vision at birth.

• eye is structurally incomplete

• muscles are immature

What happens to vision accommodation over the first 3 months of life?

improves

How is vision at 6 months?

as acute as in adults

Describe hearing at birth.

• similar to an adult as soon as he amniotic fluid drains from the ears

• infants respond readily to the mother’s voice

Smell at birth in response to breastmilk?

breastfed infants can smell breast milk and can differentiate their mother from other lactating women based on the smell

How do children react to different tastes?

facial expressions

What tastes do newborns favour?

sweet tastes

What parts of newborns are the most sensitive?

• face

• hands

• soles of the feet

What is erythromycin administered to prevent?

ophthalmia neonatorum

What is ophthalmia neonatorum?

inflammation of the eyes caused by a gonorrhea and chlamydia infection

How soon is erythromycin administered?

within 2 hours of birth

What is vitamin K administered to prevent?

hemorrhagic disease of the newborn

Why is the administration of vitamin K important?

newborns do not have the intestinal flora to produce vitamin K in the first week after birth and it promotes the formation of clotting factors in the liver

How much vitamin K is administered for babies >1500 g?

1 mg

How much vitamin K is administered for babies <1500 g?

0.5 mg

What 5 things should you assess for in the general appearance of a newborn?

• posture

• activity

• anomalies

• bruising

• state of alertness

What pulse should be obtained on all newborns? How?

apical pulse; auscultation for a full minute

What state should a newborn be in when auscultating the apical pulse?

quiet alert state

Normal newborn heart rate?

110 - 160 bpm

Normal newborn respiratory rate?

30 - 60 breaths per minute

Where are respirations found? How are they counted?

abdominal; observing

Normal newborn temperature?

36.5 - 37.5 degrees celsius

What does newborn bradycardia often indicate?

congenital heart block

What does newborn tachycardia often indicate?

• RDS

• pneumonia

• fever

What does newborn bradypnea often indicate?

• birth trauma

• maternal narcosis from analgesics or anesthetics

What does newborn tachypnea often indicate?

• RDS

• TTN

• CDH

What does newborn subnormal temperature often indicate?

• infection

• dehydration

What does newborn increased temperature often indicate?

• infection

• chemical dependence

• diarrhea

• dehydration

Thermogenesis in infants?

• fetal position

• brown fat

  • protects the organs and structures

  • breakdown increases heat production

• glycogen stores

What is convection?

heat loss to air

What is radiation?

heat loss to cold solid surface nearby

What is evaporation?

heat loss to vaporization of moisture from skin

What is conduction?

heat loss directly to a cold surface

Name 5 reasons why newborns are at higher risk of getting cold.

• unable to shiver

• large surface area to comparison to weight

• born wet into a cold room

• blood vessels are superficial

• low energy stores

What can result from cold stress in newborns?

• hypoglycemia

• decreased pulmonary perfusion

• respiratory distress

• return to fetal circulation

• hyperbilirubinemia

How does cold stress cause hypoglycemia?

increased energy expenditure

How does cold stress cause decreased pulmonary perfusion, respiratory distress, and return to fetal circulation?

increased oxygen consumption

How does cold stress cause hyperbilirubinemia?

increased metabolic rate which results in glycolysis and acidosis

Interventions to prevent heat loss in newborns?

• place baby skin-to-skin uninterrupted with mom or dad/other parent/family member

• dry baby immediately and thoroughly at birth

• place a warm hat on baby

• minimize skin exposure

• loosely swaddle baby in warm blankets if not skin-to-skin

When do most newborns need to be weighed?

at birth and at discharge

When may a newborn need to be weighed more often? How much more often?

newborns who are small for gestational age; daily weights

What is the birth weight of term newborns?

2500 - 4000 g

Normal skin variations (10).

• mottling

• Harlequin sign

• plethora

• acrocyanosis

• Nevus simplex

• Erythema toxicum neonatorum

• Congenital dermal melanocytosis

• milia

• petechiae

• ecchymoses

Name the 5 steps to assessing the neck.

• palpate the head

• inspect the shape and size

• palpate, inspect, and note status of fontanels

• palpate sutures

• inspect and palpate the neck for movement, flexibility, masses, bruising

What is caput succedaneum?

• generalized and identifiable edematous area of the scalp

• present at birth

• extends across the suture lines of the skull

• disappears spontaneously within 3 to 4 days

How is caput succedameum caused?

compression of local vessels resulting in slowed venous return which causes an increase in tissue fluids within the skin of the scalp

What kinds of infants commonly have caput succedaneum?

vacuum-assisted delivery infants

What is a cephalohematoma?

• collection of blood between a skull bone and its periosteum

• soft, fluctuating, irreducible fullness

• does not bulge when the newborn cries

How quickly does a cephalohematoma resolve?

3 - 6 weeks

How are cephalohematomas caused?

pressure against the maternal bony pelvis or forceps extraction

Main differentiating factor between cephalohematoma vs. caput succedaneum?

cephalohematoma does not cross cranial suture lines

What is a subgaleal hemorrhage?

bleeding into the subgaleal compartment

What are subgaleal hemorrhages associated with?

difficult operative vaginal births (ex. vacuum-assisted)

Signs of subgaleal hemorrhage?

• boggy scalp

• pallor

• tachycardia

• increased head circumference

What 3 assessments do we do for the eyes?

• check placement on face

• check for symmetry in size of shape

• assess for discharge from the eyes

What assessments do we do for the nose?

• observe for shape, placement, patency, configuration

  • midline

  • preferential nose breathers

  • sneezing to clear nose

What 3 assessments do we do for the ears?

• observe size, placement on head, amount of cartilage, and open auditory canal

• assess hearing; wake state influences response

• ensure newborn hearing screening is completed to identify defiicts

What 3 assessments do we do for the face and mouth?

• observe overall appearance and symmetry of face

  • rounded and symmetrical; influenced by birth type or moulding

  • positional deformities associated with intrauterine positioning and cranial moulding may be noted

• assess mouth and palate to ensure they are intact

• assess for reflexes (rooting and sucking)

What 4 assessments do we do for the chest?

• inspect and palpate; circular/barrel shaped

• observe respiratory movements

• evaluate clavicles to ensure they are intact

• assess the rib cage; should by symmetrical, intact, and move with respirations

Signs of respiratory distress.

• nasal flaring

• head bobbing

• tracheal tug

• intercostal or subcostal retractions

• grunting

• stridor

• tachypnea

• centralized cyanosis and duskiness

What is mild transient tachypnea of the newborn?

signs of respiratory distress during the first 1 to 2 hours after birth as baby transitions

Signs of TTN?

• grunting

• nasal flaring

• mild retractions

Treatments for TTN?

supplemental oxygen and/or noninvasive ventilator support

Serious respiratory problems signs/symptoms?

• more pronounced and last beyond the first 2 hours after birth

• RR may exceed 120 breaths per minute

• retractions, grunting, pallor, central cyanosis may occur

• hypotension, temperature instability, hypoglycemia, acidosis, and signs of cardiac problems

Name 4 examples of respiratory complications.

• respiratory distress syndrome

• meconium aspirate syndrome

• pneumonia

• persistent pulmonary hypertension of the newborn

What assessments do we do for the abdomen?

• inspect and palpate the umbilical cord

  • two arteries, one vein

• inspect the size of the abdomen and palpate the contour

  • rounded, prominent, and dome-shaped

• assess colour and observe movement with respirations

• auscultate bowel sounds and note number, amount, character of stools

How soon should bowel sounds be heard after birth?

minutes

How soon does meconium stool pass after birth?

24 - 48 hours

What assessments do we do for the genitalia/GU system?

• inspect and assess for general appearance

  • female genitalia may be edematous

  • male testes should be palpable on each side

• voiding within 24 hours of birth

How often should voids happen after birth?

1 time per day for each day of life

What assessments do we do for the extremities?

• inspect and palpate for

  • attitude of general flexion

  • full range of motion and spontaneous movements

  • muscle tone

  • colour

  • intactness

  • appropriate placement

• count number of fingers and toes

• evaluate joints for full range of motion

• assess reflexes (palmar and plantar)

What assessments do we do for the back?

• assess anatomy

• inspect and palpate the spine, shoulders, scapulae, and iliac crests

• assess base of spine

What should the spine look like at birth?

spine straight and easily flexed

What 3 assessments do we do for the anus and stools?

• inspect and palpate placement and patency of anus

  • passage of meconium within 24-48 hours after birth

• observe the frequency. colour, and consistency of stools

  • meconium is followed by transitional and soft yellow stool

What is biliary atresia?

condition where bile from liver does not get to the gallbladder/intestines

Signs and symptoms of biliary atresia?

• pale stool, dark urine

• jaundice lasting >2 weeks

• irritability

• weight loss

• abdominal distension

Treatment for biliary atresia?

surgical

What assessments do we do for the neurological system?

• assesses newborn reflexes

• provides information about the newborn’s nervous system and state of the neurological maturation

Tests done prior to discharge?

• bilirubin level

• newborn screening

• critical congenital heart disease screening

• teaching (ex. feeding, SIDS, tummy time, etc.)

When does discharge teaching begin?

at admission

Name 4 elements of discharge teaching.

• self care and signs of complications

• sexual activity and contraception

• prescribed medications

• coping with visitors