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

-think 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:

^nasla 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 scruntch it doen 

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 

pret-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

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

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: fluid in fissures, hyperinflation

prognosis: self-limiting, resolves within 72 hours

IV fluid or gavage until breathing improves 

cluster care to minimize stress 

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: ground glass patter 

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

maternal RF: smoking, obesity, asthma, depression, 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

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

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

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 

newborns exposed to substance abuse

medications: methadone, morphine, phenobarbital

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

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

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

-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 ob abdominal contents into external peritoneal sac 

gastroschosis

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

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

-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

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