Ch.18-Nursing Management of the Newborn

rapid newborn assessment tool

The RAPP assessment

RAPP assessment stands for

and does what

respiratory activity, perfusion/color, and position/tone

provides a method to swiftly evaluate the newborn's condition so that decisions can be made regarding newborn stability

During the initial newborn assessment, look for signs that might indicate a respiratory problem, including: (SHE STRESSED THIS)

Nasal flaring !!

Chest retractions !!

Grunting on exhalation !!

Labored breathing

Generalized cyanosis !!

Abnormal breath sounds: rhonchi, crackles (rales), wheezing, and stridor

Abnormal respiratory rates (tachypnea, more than 60 breaths/min; bradypnea, less than 25 breaths/min)

Flaccid body posture

Pallor

Apneic episodes

Abnormal heart rates (tachycardia, more than 160 bpm; bradycardia, less than 100 bpm)

Abnormal newborn size: small or large for gestational age

The Apgar score, is

used worldwide to evaluate a newborn's physical condition at 1 minute and 5 minutes after birth.

An additional Apgar assessment is done at 10 minutes if the 5-minute score is less than 7 points.

Assessment of the newborn at 1 minute provides

data about the newborn's initial adaptation to extrauterine life.

Assessment at 5 minutes provides

a clearer indication of the newborn's overall central nervous system (CNS) status.

Five parameters are assessed with Apgar scoring. A quick way to remember the parameters of Apgar scoring is:

A: appearance (color)

P: pulse (heart rate)

G: grimace (reflex irritability)

A: activity (muscle tone)

R: respiratory (respiratory effort)

A normal newborn's score should be how many points?

8 to 10 points.

Scores of 4 to 7 points signify moderate difficulty and scores of 0 to 3 points represent severe distress in adjusting to extrauterine life.

The Apgar score is influenced by

the presence of infection, newborn maturity, mother's age, congenital anomalies, birth weight, maternal medications, physiologic immaturity, maternal sedation via medications, labor management, and neuromuscular disorders

Apgar Scoring for Newborns:

Skin color

0 - Cyanotic or pale

1 - Appropriate body color; blue extremities (acrocyanosis)

2 - Completely appropriate color (pink on both trunk and extremities)

Apgar Scoring for Newborns:

Heart rate

0 - Absent

1 - Slow (

Apgar Scoring for Newborns:

Reflex irritability

0 - No response

1 - Grimace or frown when irritated

2 - Sneeze, cough, or vigorous cry

(done by flicking of the soles of the feet or suctioning of the nose with a bulb syringe)

Apgar Scoring for Newborns:

Muscle tone

0 - Limp, flaccid

1 - Some flexion, limited resistance to extension

2 - Tight flexion, good resistance to extension with quick return to flexed position after extension

Apgar Scoring for Newborns:

Respiratory effort

0 - apneic

1 - slow, irregular, shallow

2 - regular respirations (usually 30-60 breaths/min), strong, good cry

The expected length range of a full-term newborn is usually

44 to 55 cm (17 to 22 in). Molding can affect measurement

Typically, the term newborn weighs

2,500 to 4,000 g (5 lb, 8 oz to 8 lb, 14 oz)

Newborns can lose up to ___ of their initial birth weight by 3 to 4 days of age secondary to ...

10%

loss of meconium, extracellular fluid, and limited food intake.

This weight loss is usually regained by the 10th day of life

Newborns can be classified by their birth weight regardless of their gestational age

low birth weight

very low birth rate

extremely low birth weight

Low birth weight is commonly

>2,500 g (>5.5 lb)

Very low birth weight is commonly:

>1,500 g (>3.5 lb)

Extremely low birth weight is commonly:

>1,000 g (>2.5 lb)

Newborns' respirations are assessed when

The newborn respiratory rate is

they are quiet or sleeping

30 to 60 breaths/min with symmetric chest movement

Heart and respiratory rates and temperature are usually assessed every

30 minutes until stable for 2 hours after birth. Once stable, the heart rate and respiratory rates are checked every 8 hours.

In term newborns, the normal axillary temperature range should be maintained at

97.7° to 99.5° F (36.5° to 37.5° C).

Blood pressure is not usually assessed but the typical range is

50 to 75 mm Hg (systolic) and 30 to 45 mm Hg (diastolic)

To determine a newborn's gestational age (the stage of maturity),

physical signs and neurologic characteristics are assessed

gestational age is determined by using a tool such as the Ballard gestational age assessment or Ballard Scale

Ballard Scale scoring

a low score of -1 point or -2 points for extreme immaturity to 4 or 5 points for postmaturity.

The scores from each section are added to correspond to a specific gestational age in weeks.

assess muscle tone and elasticity in order to determine an estimated gestational age. This looks at the physical and neuromuscular stage of the baby.

the physical maturity examination of the Ballard scale include

skin texture

lanugo

plantar creases

great tissue

eyes and ears

genitals

Skin texture—

typically ranges from sticky and transparent to smooth, with varying degrees of peeling and cracking, to parchment-like or leathery with significant cracking and wrinkling.

Lanugo—

soft downy hair on the newborn's body, which is absent in preterm newborns, appears with maturity, and then disappears again with postmaturity.

Plantar creases—

creases on the soles of the feet, which range from absent to covering the entire foot, depending on maturity (the greater the number of creases, the greater the newborn's maturity).

Breast tissue—

the thickness and size of breast tissue and areola (the darkened ring around each nipple), which range from being imperceptible to full and budding.

Eyes and ears—

eyelids can be fused or open and ear cartilage and stiffness determine the degree of maturity (the greater the amount of ear cartilage with stiffness, the greater the newborn's maturity).

Genitals—

in males, evidence of testicular descent and appearance of scrotum (which can range from smooth to covered with rugae) determine maturity; in females, appearance and size of clitoris and labia determine maturity (a prominent clitoris with flat labia suggests prematurity, whereas a clitoris covered by labia suggests greater maturity).

The neuromuscular maturity section typically is completed within 24 hours after birth. Six activities or maneuvers that the newborn performs with various body parts are evaluated to determine the newborn's degree of maturity:

Posture

square window

arm recoil

popliteal angle

scarf sign

heal to ear

Typically, newborns are also classified according to their gestational age as:

preterm/premature

term

psot perm/postdates

post mature

Preterm or premature—

born prior to 37 completed weeks' gestation, regardless of birth weight

Term—

born between 38 and 42 weeks' gestation

Post-term or postdates—

born after completion of week 42 of gestation

Postmature—

born after 42 weeks and demonstrating signs of placental aging

Small for gestational age (SGA)—

weight less than the 10th percentile on standard growth charts (usually >5.5 lb)

number one cause of a SGA baby

smoking

Appropriate for gestational age (AGA)—

weight between 10th and 90th percentiles

Number one cause for a LGA baby

uncontrolled diabetes in the mother

Large for gestational age (LGA)—

weight more than the 90th percentile on standard growth charts (usually >9 lb)

Always keep a bulb syringe

near the newborn in case he or she develops sudden choking or a blockage in the nose. It may be lifesaving.

Ensuring proper identification

-ID bands

-may take newborn picture

-Newborns' footprints

Vitamin k

a fat-soluble vitamin, promotes blood clotting by increasing the synthesis of prothrombin by the liver

recommends that vitamin K be administered to all newborns soon after birth in a single intramuscular dose of 0.5 to 1 mg

Eye prophylaxis

All newborns in the United States, whether delivered vaginally or by cesarean birth, must receive an installation of a prophylactic agent in their eyes within an hour or two of birth to prevent ophthalmia neonatorum, which can cause neonatal blindness.

Erythromycin ophthalmic ointment 0.5%

Ophthalmia neonatorum is

a hyperacute purulent conjunctivitis occurring during the first 10 days of life. It is usually contracted during birth when the baby comes in contact with vaginal discharge of the mother infected with gonorrhea and chlamydia. is potentially a blinding condition in newborns.

​​The average newborn head circumference is

32 to 38 cm (13 to 15 in).

Measure the circumference at the head's widest diameter (the occipitofrontal circumference)

Head circumference may need to be remeasured at a later time if the shape of the head is altered from birth.

A small head might indicate

microcephaly caused by rubella, toxoplasmosis, or SGA status

an enlarged head might indicate

hydrocephalus or increased intracranial pressure

The chest circumference is generally

1 to 2 cm less than the head circumference.

These measures will be equal in about one year.

Sinus arrhythmia is

a normal finding.

Murmurs detected during the newborn period do not necessarily indicate congenital heart disease, but they need to be evaluated further if they persist.

acrocyanosis

Persistent cyanosis of fingers, hands, toes, and feet with mottled blue or red discoloration and coldness

It may be seen in newborns during the first few weeks of life in response to exposure to cold. Acrocyanosis is normal and intermittent.

Common skin variations include

vernix caseosa, stork bites or salmon patches, milia, Mongolian spots, erythema toxicum, harlequin sign, nevus flammeus, and nevus vasculosus

Vernix caseosa is

a thick white substance that protects the skin of the fetus. It is formed by secretions from the fetus's oil glands and is found during the first 2 or 3 days after birth in body creases and the hair.

Stork bites or salmon patches are

superficial vascular areas found on the nape of the neck, on the eyelids, and between the eyes and upper lip. They are considered a normal variant, and most fade and disappear completely within the first year.

Milia are

multiple pearly-white or pale yellow unopened sebaceous glands frequently found on a newborn's nose. They may also appear on the chin and forehead. They form from oil glands and disappear on their own within 2 to 4 weeks.

Epstein pearls

When milia occur in a newborn's mouth and gums

Mongolian spots are

benign blue or purple splotches that appear solitary on the lower back and buttocks of newborns but may occur as multiple over the legs and shoulders. They tend to occur in dark-skinned newborns of all races. The spots are caused by a concentration of pigmented cells and usually disappear spontaneously within the first 4 years of life. They should not be confused with bruises caused by trauma

Erythema toxicum (newborn rash) is

a benign, idiopathic, generalized, transient rash that occurs in up to 70% of all newborns during the first week of life. It consists of small papules or pustules on the skin resembling flea bites. It is often mistaken for staphylococcal pustules. The rash is common on the face, chest, and back. One of the chief characteristics of this rash is its lack of pattern. It is caused by the newborn's eosinophils reacting to the environment as the immune system matures.

Harlequin sign refers to

the dilation of blood vessels on only one side of the body, giving the newborn the appearance of wearing a clown suit. It gives a distinct midline demarcation, which is described as pale on the nondependent side and red on the opposite, dependent side. It results from immature autoregulation of blood flow and is commonly seen in low-birth-weight newborns when there is a positional change. Lasts 20 minutes with no intervention needed.

Nevus flammeus, also called a port-wine stain, commonly

appears on the newborn's face or other body areas. Although it does not grow in area or size, it is permanent and will not fade. Although they may occur anywhere on the body, the majority are located in the head and neck areas. The optimal time for treatment is before 1 year of age. Lasers and intense pulsed light have been used to remove larger lesions with some success, but the efficacy of therapy has not improved

Nevus vasculosus, also called a strawberry mark or strawberry hemangioma, is

a benign capillary hemangioma in the dermal and subdermal layers. It is raised, rough, dark red, and sharply demarcated. It is commonly found in the head region within a few weeks after birth and can increase in size or number. These hemangiomas tend to resolve by age 3 without any treatment.

As many as 90% of the congenital malformations present at birth are visible on the head and neck, so

careful assessment is very important

The anterior fontanel is

diamond shaped

closes by 18 to 24 months

Typically, it measures 4 to 6 cm at the largest diameter (bone to bone).

The posterior fontanel is

is triangular

closes by 6 to 12 weeks

smaller than the anterior fontanel (usually fingertip size or 0.5 to 1 cm)

NORMAL variations in head size and appearance

Molding

Caput succedaneum

Cephalhematoma

Molding is

the elongated shaping of the fetal head to accommodate passage through the birth canal. It typically resolves within a week after birth without intervention.

Caput succedaneum

describes localized edema on the scalp that occurs from the pressure of the birth process. It is commonly observed after prolonged labor.

Clinically, it appears as a poorly demarcated soft tissue swelling that crosses suture lines. Pitting edema and overlying petechiae and ecchymosis are noted. The swelling will gradually dissipate in about 3 days without any treatment.

Newborns who were delivered via vacuum extraction usually have a caput in the area where the cup was used.

Cephalhematoma is

a localized subperiosteal collection of blood of the skull which is always confined by one cranial bone.

This condition is due to pressure on the head and disruption of the vessels during birth. It occurs after prolonged labor and use of obstetric interventions such as low forceps or vacuum extraction.

The clinical features include a well-demarcated, often fluctuant swelling with no overlying skin discoloration. The swelling does not cross suture lines and is firmer to the touch than an edematous area.

Cephalhematoma usually appears on the second or third day after birth and disappears within weeks or months.

abnormalities in head and fontanel size that indicate a problem

Microcephaly

Macrocephaly

Large fontanels

Small or closed fontanels

Microcephaly—

a head circumference more than two standard deviations below average or less than 10% of normal parameters for gestational age, caused by failure of brain development.

Conditions associated with microcephaly include seizures, developmental delay, intellectual disability, hearing loss, and problem with vision, movement, balance, or feeding.

Macrocephaly—

usually a benign condition that does not require intervention. It is a head with a circumference more than 90% of normal, typically related to hydrocephalus

Large fontanels—

more than 6 cm in the anterior diameter bone to bone or more than a 1-cm diameter in the posterior fontanel

possibly associated with malnutrition, hydrocephaly, congenital hypothyroidism, trisomies 13, 18, and 21, and various bone disorders such as osteogenesis imperfecta.

Small or closed fontanels—

smaller-than-normal anterior and posterior diameters or fontanels that are closed at birth. Craniosynostosis and abnormal brain development refer to the premature fusion of cranial sutures, with inhibition of perpendicular cranial bone growth and are associated with a small fontanel or early fontanel closure associated with microcephaly

facial nerve paralysis

caused by trauma from the use of forceps.

Paralysis is usually apparent on the first or second day of life.

Typically, the newborn will demonstrate asymmetry of the face with an inability to close the eye and move the lips on the affected side. Newborns with facial nerve paralysis have difficulty making a seal around the nipple, and consequently milk or formula drools from the paralyzed side of the mouth.

Most facial nerve palsies resolve spontaneously within days, although full recovery may require weeks to months.

Variations involving the lip might include

cleft upper lip (separation extending up to the nose) or thin upper lip associated with fetal alcohol syndrome.

Assess the inside of the mouth for

alignment of the mandible, intact soft and hard palate, sucking pads inside the cheeks, a midline uvula, a free-moving tongue, and working gag, swallow, and sucking reflexes

Normal variations might include

Epstein pearls (small, white epidermal cysts on the gums and hard palate that disappear in weeks)

erupted natal teeth that may need to be removed to prevent aspiration,

thrush (white plaque inside the mouth caused by exposure to Candida albicans during birth) which cannot be wiped away with a cotton-tipped applicator.

due to pressure during birth there may be what noted with the eyes

marked edema of the eyelids and subconjunctival hemorrhages

Test the blink reflex by

bringing an object close to the eye; the newborn should respond quickly by blinking

Assess the newborn's gaze:

he or she should be able to track objects to the midline

Many newborns have what eye abnormalities

transient strabismus (deviation or wandering of eyes independently) and searching nystagmus (involuntary repetitive eye movement), which is caused by immature muscular control.

These are normal for the first 3 to 6 months of age.

Low-set ears and abnormally shaped ears are characteristic of

many syndromes and genetic abnormalities, such as trisomy 13 or 18, and internal organ abnormalities involving the renal system.

An otoscopic examination is not typically done because

the newborn's ear canals are filled with amniotic fluid and vernix caseosa, which would make visualization of the tympanic membrane difficult.

what is the most common birth defect in the United States

Hearing loss

so newborn hearing screening is required by law in most states

The newborn's chest should be

round, symmetric, and 2 to 3 cm smaller than the head circumference

The newborn chest is usually barrel shaped, with equal anteroposterior and lateral diameters, and symmetric.

The xiphoid process may be

prominent at birth, but it usually becomes less apparent when adipose tissue accumulates.

Nipples may be

engorged and may secrete a white discharge.

This discharge, which occurs in both boys and girls, is a result of exposure to high levels of maternal estrogen while in utero. This enlargement and milky discharge usually dissipate within a few weeks.

supernumerary nipples

extra nipples

They are typically small, raised, pigmented areas vertical to the main nipple line, 5 to 6 cm below the normal nipple. May be unilateral or bilateral, and they may include an areola, nipple, or both. They tend to be familial and do not contain glandular tissue.

Supernumerary nipples are generally thought to be benign. Reassure parents that these extra small nipples are harmless.

why would you hear fine crackles in a newborn

Fine crackles can be heard on inspiration soon after birth as a result of amniotic fluid being cleared from the lungs

Murmur after birth

Murmurs are common during the first few hours as the foramen ovale is closing. Although cardiac murmurs in the neonatal period do not necessarily indicate heart disease, they should be evaluated if they persist

Typically, the newborn's abdomen is

protuberant but not distended

The liver is normally palpable

1 to 3 cm below the costal margin in the midclavicular line

The kidneys are

1 to 2 cm above and to both sides of the umbilicus

inspect the umbilical area for

signs of bleeding, infection, inflammation, redness, swelling, purulent drainage or bleeding, erythema around the umbilicus, granuloma, or abnormal communication with the intra-abdominal organs

In the circumcised male newborn, the glans should be

smooth, with the meatus centered at the tip of the penis. It will appear reddened until it heals.