OB Exam 4

surfactant

-surface tension reducing lipoprotein that prevents alveolar collapse

events leading to maintenance of respiratory function

-Initiation of respiratory movement

-expansion of lungs 

-establishment of functional residual capacity 

-increased pulmonary blood flow 

-redistribution of cardiac output 

characteristics predisposing newborn to heat loss

-thin skin; blood vessels close to surface

-lack of shivering ability; limited stores of metabolic substrates (glucose, glycogen, fat)

-limited use of voluntary muscle activity 

-large body surface area relative to body weight 

-lack of subcutaneous fat; little ability to conserve heat by changing posture

-no ability to adjust own clothing or blankets to achieve warmth 

-infants can’t communicate that they are too cold or too warm 

conduction 

-transfer of heat from object to object when the two objects are in direct contact with each other 

convection

-flow of heat from body surface to cooler surrounding air or to air circulating over a body surface 

evaporation

-loss of heat when a liquid is converted to a vapor 

radiation

-loss of body heat to cooler, solid surfaces in close proximity but not direct contact 

thermoregulation of the newborn

-over heating

^large body surface area

^limited insulation

^limited sweating ability 

-need for a neutral thermal environment (NTE)

heat production: primarily through non-shivering thermogenesis 

hepatic system function

-billirubin conjugation

-three groups of jaundice

^overproduction

^decreased conjugation

^impaired excretion 

gastrointestinal system adaptations

-to gain weight the newborn requires an intake of 108 kcal/kg/day from birth to 6 months of age

characteristics of newborn stool

stools: meconium, then transitional stool, then milk stool

-breast-fed newborns: yellow-gold, loose, stringy to pasty, soure-smelling  

-formula-fed newborns: yellow, yellow-green, loose, pasty, or formed, unpleasant odor

renal system changes

-limited ability to concentrate urine until about 3 months of age

-6 to 8 voids per day considered normal

-first pee may be rusty or brick

behavioral patterns of newborns

first period of reactivity

-birth to 30 minutes to 2 hours after birth

-newborn is alert, moving, may appear hungry 

^best time to bond and feed baby 

period of decreased responsiveness

-20 to 120 minutes old 

-period of sleep or decreased activity 

-best time for visitors 

second period of reactivity 

-2 to 8 bours 

-newborn awakens and shows an interest in stimuli 

newborn behavioral responses

-Orientation: response to stimuli

-habituation: ability to process and respond to auditory and visual stimuli; ability to block out external stimuli after newborn has become used to activity 

-motor maturity: ability to control movements 

-self-quieting ability: consolability  

-social behaviors: cuddling and snuggling 

initial newborn assessment 

signs indicating a problem:

^nasal flaring, chest retractions

^grunting on exhalation

^generalized cyanosis, flaccid body posture 

-apgar score 

-gestational age assessment

-physical maturity (skin texture lanugo, plantar creases, breast tissue, eyes and ears, genitals)

-neuromuscular maturity (posture square window, arm recoil, popliteal angle, scarf sign, heal to ear

apgar score

a= appearance

p=pulse

g=grimace

a=activity

r=respiratory

newborn vital signs

temperature= 97.7-99.5

heart rate=110-160

respirations=30-60

blod pressure= 50-75/30-45

neuromuscular maturity 

-posture
-square window

^measures wrist flexibility 

-arm recoil 

-popliteal angle 

-scarf sign 

^how baby’s arm can fold across chest (elbow resists before midline is a good sign)

-heel-to-ear 

^checking flexibility by bringing foot to head  

immediate newborn period

-vitamin K

^for blood, very important

^if pt. falls can hemorrhage

-eye prophylaxis

common skin variations in newborns

-Vernix caseosa

^white cheesy coating that protects baby’s skin before birth
-Stork bites or salmon patches

^pink/red flat marks on eyelids, nose,or neck; fade over time
Milia

-think white bumps on nose or cheeks; go away on own 
Mongolian spots

-bluish-gray patches (usually on back or buttocks), harmless, fade with age 
Erythema toxicum

-newborn rash with red spots and white/yellow centers; normal and temporary 
Harlequin sign

-half body turns red the other half pale when lying on side; temporary color change 
Nevus flammeus

-flat, purple-red birthmark;does not fade
Nevus vasculosus

-raised red birthmark; often fades within first few years

common concerns during newborn transition

-transient tachypnea of the newborn

-physiologic jaundice (hyperbilirubinemia)

-hypoglycemia 

nursing interventions for hypoglycemia

-check glucose on the foot

-plasma glucose concentration less than 45 mg/dL in the first 72 hours of life 

-rapid acting glucose source 

^dextrose gel

^breastfeeding 

^formula feeding 

*give baby food before other interventions*

selected screening for newborns

-phenylketonuria (PKU)

-congenital hypothyrodism

-galactosemia

-sickle cell anemia

-hearing (universal screening)

nursing management early newborn period

-plain water on face and eyes… mild soap for rest of the body

-leave the umbilical cord

circumcisions

-gomco clamp=take it off most invasive 

-plastibell=just scrunch it down

newborns and safe sleeping education 

DO

-place baby alone

-on their back s

-in an approved crib, play yard, or bassinet 

DON’T

-put anything else in the sleeping area with the baby (a crib mattress and a tight sheet,… that is it)

LATCH method for assessing breastfeeding sessions

L=how well infant latches onto the breast

A=amount of audible swallowing

T=nipple type

C=level of comfort 

H=amount of help mother needs 

factors affecting fetal growth

-maternal nutrition

-genetics

-placental function

-environmental factors 

small gestation 

low birth weight 

-infant weighing 5.5 lbs or less than2,500 grams

very low birth weight 

3 lbs 5 oz or less than 1,500 grams 

extremely low birth weight 

-2 lbs 3 oz or less than 1,000 grams 

-less than 28 weeks to overall growth restriction (never catch up in size)

-more than 28 weeks intrauterine malnutrition 

SGA newborns assessment

-head normally larger than the rest of the body

-scaphoid abdomen (sunken appearance)

-wasted appearance of expremities (loose dry skin)

-wide skull sutures 

-reduced subcutaneous fat stores 

-poor muscle tone over buttocks and cheeks 

-decreased amount of breast tissue 

-thin umbilical cord 

SGA common problems

-perinatal asphyxia= lack of oxygen and blood flow before, during, or shortly after birth

-difficulty with thermoregulation

-hypoglycemia

-polycythemia

-meconium aspiration

-hyperbilirubinemia

-birth trauma

SGA newborns: nursing management

-serial blood glucose monitoring

-early and frequent oral feedings; IV infusion of dextrose 10%

-monitoring for signs and symptoms of polycythemia

-anticipatory guidance 

risk factors associated with LGA

-maternal diabetes mellitus or glucose intolerance

-multiparity

-prior history of a macrosomic infant 

-postdated gestation

-maternal obesity 

-male fetus 

-genetics 

LGA newborns: common problems

-birth trauma

-hypoglycemia 

-polycythemia 

-hyerbilirubinemia 

LGA newborn: nursing management

-blood glucose monitoring

-initiation of oral feedings with IV glucose supplementation as needed

-continued monitoring for signs and symptoms of polycythemia and hypoglycemia 

-hydration

-phototherapy for increased bilirubin levels  

post-term newborn

-inability for the placenta to provide adequate oxygen and nutrients to fetus after 42 weeks

-dry, cracked, wrinkled skin; possibly meconium stained

-long, thin extremities, long nails, creases cover entire soles of feet

-wide-eyed, alert expression

-abundant hair on scalp

-thin umbilical cord

-limited vernix(the white coat on baby when born) and lanugo (hair on baby’s body)

post term: common problems

-perinatal asphyxia

-hypoglycemia

-hypothermia

-polycythemia

-meconium aspiration 

pre-term newborn: assessment

-plentiful lanugo

-fused eyelids

-poorly formed ear pinna

-soft spongy skull bones

-matted scalp hair

-absent to few creases in soles and palms

-minimal scrotal rugae; prominent labia and clitoris

-thin transparent skin

-abundant vernix 

pre-term newborn: common problems

-hypothermia

-hypoglycemia

-hyerbilirubinemia

-problems related to immaturity of body systems 

pre-term newborn: nursing management

oxygenation

-stimulation

-thermal regulation

-pain management

-discharge preparation

-nutrition and fluid balance

-provide developmental care

-infection prevention

-parental support: high-risk status; possible perinatal loss

acquired disorders

-develop after birth

-often preventable

examples: infections, birth trauma 

congenital disorders

-present at birth 

-genetic or environmental origins

-all require surgery

examples: heart defects, neural tube defects

acquired conditions of the newborn

-hypoxic-eschemic encephalopathy

-transient tachypnea of the newborn

-respiratory distress syndrome

-meconium aspiration

-persistent pulmonary hypertension of the newborn 

-peri/intraventricular hemorrhage 

-necrotizing enterocolitis

-infants of diabetic mothers 

-birth trauma

-newborns of perinatal substance- abusing mothers 

-hyperbilirubinemia

-newborn infections

hypoxic-ischemic encephalopathy

-occurs when adequate breathing is not established after birth, insufficient oxygen delivery to meet metabolic demands

nursing assessment: risk factors, newborn’s color, work of breathing, heart rate, temperature, apgar score

nursing management: immediate resuscitation, continued observation, neutral thermal environment, blood glucose levels, parental support, and education

HIE severity classifications

-severe

^coma, seizures, poor prognosis

-incubator 

moderate

^lethargy, hypotonia (decreased muscle tone), occasional seizures

mild

^hyperalertness, irritability, good prognosis 

transient tachypnea of the newborn

caused by delayed clearance of fetal lung fluid

clinical presentation: rapid breathing, grunting, mild cyanosis within 6 hours of birth

diagnosis: chest x-ray

prognosis: self-limiting, resolves within 48-72 hours

IV fluid or gavage until breathing improves 

-nasal canula 

cluster care to minimize stress 

-c-section baby’s at higher risk 

respiratory distress syndrome

surfactant deficiency, alveolar collapse

RF: prematurity, maternal diabetes, second twin

clinical signs: retractions, grunting, cyanosis, tachypnea, see saw respirations, nasal flaring, crackles, tachypnea, tachycardia 

diagnosis: chest x-ray:

respiratory distress syndrome: nursing management 

-respiratory modalities: ventilation (CPAP,PEEP), surfactant, oxygen therapy 

-antibiotics for positive blood cultures, correction of metabolic acidosis 

-gavage or IV feedings

-blood glucose level monitoring

-clustering of care; prone or side-lying position

meconium aspiration syndrome

secondary to hypoxic stress

visual indications: green staining of amniotic fluid, nails, skin, or umbilical cord…visible signs immediately after birth

respiratory symptoms: barrel-shaped chest, prolonged tachypnea, respiratory distress, intercostal retractions, and cyanosis may develop 

diagnostic findings: chest x-ray shows patchy infiltrates and hyperaertion….metabolic acidosis 

persistent pulmonary hypertension of the newborn

-right to left extrapulmonary shuntin… leads to severe hypoxemia

-heart murmurs

-hypertension

maternal RF: smoking, obesity, asthma, history of depression before pregnancy, SSRI use in late pregnancy 

newborn RF: hypoglycemia, hypothermia, hypoxia, delayed resuscitation, sepsis

persistent pulmonary hypertension of the newborn: assessment and management 

assessment findings:

^tachypnea within 12 hours of birth 

^marked cyanosis with grunting

^systolic ejection murmur 

^right-to-left shunting on echocardiogram

monitoring

^continuous oxygenation tracking 

^perfusion assessment 

^blood pressure monitoring 

interventions

^immediate resuscitation

^oxygen therapy

^respiratory support

^medications

^clustered care approach 

PVH/ IVH

bleeding occurs due to fragility of cerebral vessels.. most common if first 72 hours of birth

-most common in newborns born under 35 weeks or weighing less than1,500

-can occur in term newborns who experienced birth trauma or asphyxia 

-may lead to hydrocephalus, seizures, cerebral palsy, sensory deficits, and cognitive impairment 

brochopulmonary dysplasia (not on exam 4)

chronic lung disease with need for continued oxygen use after neonatal period 

RF: preterm infants with lung inflammation or injury

assessment: respiratory problems, cyanosis, nasal, flaring, crackles, rhochi, wheezing, O2 saturation 

treatment: supplemental oxygen, diuretics, bronchodilators, corticosteroids, exogenous surfactant 

retionopathy of prematurity

vascular disorder in the retina

RF: born before 31 weeks, low birth weight, mechanical ventilation, surfactant therapy, BPD, history of sepsis, intubation, or IVH

assessment: no signs or symptoms

treatment: supplemental oxygen, mydriatic eye agent-dilate prior to eye exam, cyclopegic eye drops prevent movement during eye exam, follow up every 1-3 weeks until resolved 

periventricular/ intraventricular hemorrhage

RF: preterm birth, low birth weight, traumatic delivery, birth asphyxia

clinical presentation: may present with no symptoms initially, signs include unexplained drop in hematocrit, pallor, poor perfusion, and neurological changes 

diagnostic approach: cranial ultrasonography remains the gold standard … early detection can improve outcomes 

necrotizing enterocolitis: progression

1. initial mucosal injury 

2. bacterial invasion

3. inflammatory cascade

4. potential perforation

-damaged or infected intestines

-normal Apgar 7-10 if lower do every 5 mins

-distended abdomen

necrotizing enterocolitis:

inflammatory disease of the bowel leading to ischemic or necrotic GI tract injury

prevention: enteral antibiotics, parenteral fluids, and breast milk reduce risk 

prophylaxis: antenatal corticosteroids and enteral probiotics show protective effects 

necrotizing enterocolitis:assessment and management

assessment: monitor for abdominal distention, bloody stools, and feeding intolerance 

diagnosis: look for pneumatosis intestinalis and dilated bowel loops on imaging 

medical management: implement bowel rest, antibiotic therapy, and IV fluids 

surgical intervention: prepare for possible resection of necrotic bowel 

infants of diabetic mothers 

nursing assessment:

^full rosy cheeks, ruddy skin color, short neck, buffalo hump, massive shoulders, distended upper abdomen, excessive subcutaneous fat, hypoglycemia, birth trauma

-will have low blood sugar and at risk for developing jaundice

-BS should be between 40-60

hyperbilirubinemia

RF: diabetes, Rh incompatibility, birth trauma

nursing management: 

^reduction of bilirubin levels= frequent feedings, phototherapy, exchange transfusions 

^every 4 hour take break from phototherapy 

^lights off before drawing blood samples 

-monitor wet diapers and poops

newborns exposed to substance abuse

medications: methadone (meth), morphine, (other drugs) phenobarbital (alcohol)

neonatal abstinence syndrome: poor feeding, lethargy, irritability, diarrhea, inconsolable, high pitch cry, cognitive delays 

nursing management:

-swaddling, kangroo care, skin to skin, non-nutritive sucking (pacifier) 

-stimuli reduction, dark room

-nutrition: feedings on demand, high caloric supplements 

-prevention of complications: weaning withdrawal methods 

-parent-newborn interaction 

neonatal infections

neonatal sepsis: bacterial, fungal, or viral microorganisms of their toxins in blood or other tissues

infections: GBS, toxoplasmosis, cytomegalovirus, rubella, meconium, aspiration, (herpes, HIV—-antivirals)

nursing management: risk factor assessment, positive blood cultures, increased BC, fever 

treatment: antibiotics or antivirals 

neural tube defects (congenital condition)

-spina bifida, encephalocele & meningocele requires surgical repair

-anecephaly= may not survive after birth head and brain not fully developed 

treatment: moist sterile dressing until surgical repair

-prone position

-monitor neurologic/motor function, monitor for signs of infection

-anencephaly or microcephaly: usually stillborn or die shortly after birth

esophageal atresia and tracheoesophageal fistula

-lack of normal separation of esophagus and trachea during embryonic development

-inability to swallow, frothy bubbles of mucus, drooling 

-esophageal atresia: congenitally interrupted esophagus 

-tracheoesophageal fistula: abnormal communication between trachea and esophagus 

esophageal atresia and tracheoesophageal fistula: nursing assessment

-hydramnios

-copious frothy bubbles of mucous and drooling 

-abdominal distention 

-coughing

-choking

-cyanosis 

esophageal atresia and tracheoesophageal fistula: nursing management 

-preoperative care:

^keep head elevated 

^NPO, maintain hydration with IV fluids 

^oxygen and suctioning equipment available  

^comfort measures

-postoperative care:

^antibiotics

^TPN

^oral feedings usually within 1 week 

oomphalocele

-umbilical ring defect with evisceration of abdominal contents into external peritoneal sac 

gastroschosis

-herniation of abdominal contents through abdominal wall defect (no peritoneal sac)

-put in a silo

oomphalocele & gastroschosis management

preoperative care:

^preventing hypothermia

^maintaining perfusion to abdominal contents 

^protecting exposed contents from trauma and infection

^preventing intestinal distention

^maintaining fluid and electrolyte balance 

postoperative care:

^assess for infection

^assess intake/output

^promote parent - newborn interaction

imperforate anus

-rectum ending in blind pouch or fistulas between rectum and perineum

-nursing assessment:

^absence of anal opening

^no passage of meconium in 24 hours

^abdominal distention

^bilious vomiting= poopy vomit

-nursing management:

^preparation for surgery

^postoperative care 

bladder exstrophy

-protrusion of bladder onto abdominal wall

-separation of rectus muscles and symphysis pubis 

-boys also with epispadias=missed placed urethra

-moist sterile dressing 

-initial bladder closure within 48 hours of birth; further reconstruction at age 2 to 3 years 

what do you do for a neuro check on newborn

-reflexes