chapter 15 maternity: nursing care of neonate and family

transition of respiratory system

• establishment of resps is the first physiological change that must occur after birth

• resps combined with cessation of blood flow thru the placenta (umbilical cord clamping), cause the fetus to transition to the neonatal circulatory pattern

transition to neonatal circulation

transition to neonatal circulation pt 2

circulatory system of neonate after birth

• ductus benosus, which connects umbilical vein to inferior vena cava, diverts most of the blood away from the liver/ the DV closes w cessation of blood flow through the placenta and umbilical cord

• formane ovale an opening btwn right atrium and left atrium, closes when left atrial pressure exceeds right atrial pressure as PVR decreases and SVR incr

• ductus arteriosis which connects the pulmonary artery with aorta, normally closes within 15 hours in most term infants, and by 96 hrs in neraly all neonates. permenant closure occurs within 3 months

how are newborns different from adults when it comes to dealing with cold stress?

• they dont shiver

• primary heart production is in infants thru non-shivering thermogenesis (NST)

• NST is the metabolism of brown adipose tissue (BAT) to produce heat

what is the thermoregulatory system

• neonates responses to temperature changes during the first few weeks are often delayed and place the neonate at risk for hypothermia and cold stress

what is cold stress

• describe excessive heat loss that results in the utilizatin of compensatory mechanisms to maintain the neonates body temperature

possible consequences of cold stress are

• hypoglycemia

• hypoxia

• metabolic acidosis

• decreased surfactant production

• respiratory distress

• incr. bilirubin and jaundice

• poor feeding and weight loss

• apnea

• neonatal death

loss of body heat from evaporation, conduction, convection, or radiation: evaporation

• loss of heat that occurs when moisture on the neonates skin is converted to vapors, such as during bathing or directly after birth

loss of body heat from evaporation, conduction, convection, or radiation: conduction

• transfer of heat to cooler surface by direct skin contact, such as cold hands of caregivers or cold equipment

loss of body heat from evaporation, conduction, convection, or radiation: convection

• loss of heat from the neonates warm body surface to cooler air currents, such as air conditioners or oxygen masks

loss of body heat from evaporation, conduction, convection, or radiation: radiation

• transfer of heat from neonate to cooler objects that are not in direct contact with neonate, such as cold walls of the isolette or cold equipment near the neonate

what is the neonatal assessment consist of

• apgar

• vitals

• general survey

• head to toe

also

• physical assessment

• gest. age assessment

• pain assessment

when is a complete head to toe done on a baby

• within 2 hours of birth

what is a general survey

• completed before physical assessment

• observe respiratory pattern, auscultate lung and heart sounds

• assess the skin for color, signs of hypoxia (central cyanosis), and birth trauma

• observe the level of alertness and activity

• assess muscle tone and posture

technique and assessment of posture

• unwrap the newborn and observe posture when the neonate is quiet

expected findings for term neonate of posture

• extremities are flexed with symmetrical movements

• hands are clenched

deviations from normal posture

• limp or floppy

• birth injuries

head circumference technique and assessment

• measure by placing tape around head just above the ears and eyebrows

expected findingss for term neonate of head circumeference

• 32-36 cm

deviations from normal head circumference

• microcephaly: head circumference is below the 10-=th percentile

• macrocephaly: jead circumference is >90th percentile. this can be related to hydrocephalus

chest circumference technique and assessment

• measure by placing tape around the chest over the nipple line

expected findings for term neonate for chest circumference

• 2-3 cm less than head circumference

length technique and assessment

• measure length of body by securing tape on a flat surface. place top of neonate head at the top of tape

expected findigs for neonate length

• 46-52 cm

deviations from normal length

• molding may interfere with accurate measurement

weight technique and assessment

• zero scale, place naked neonate on scale, record weight

expected weight findings

• 2,500 - 4100 (5.5 to 9.0 lbs)

• weight loss of 5% - 10 % of birth weight during first week is normal

deviations from normal weight

• >90th% likely mother was diabetic

• <10% may be d/t prematurity, IUGR

• >7% weight loss, assess feeding

temperature neonate assessment

• usually via axillary

expected temparature

• 97.7F-99

deviation temperature

• hypothermia or hyperthermia is related to infection, environmental extremes, or neurological disorders

neonatal respirations

• assess respiratory rate by auscultating and observing rise and fall of chest and abdomen

expected respirations for neonate

• 30-60 breaths per minute

• unlabored

• irregular with pauses up to 15 seconds (periodic breathing), with no color change - normal

deviations of respirations for neonates

• tachypnea

• periods of apnea >20 secs, esp with color change

• observe infant color

  • pallor may indicate infant hypoxia

    • obtain hemoglobin/hematocrit or a CBC

pulse for neonate

• assess apical pulse by auscultating for 1 full minute

expected pulse for neonate

• 110-160 bpm

  • rate may incr. with crying and decr. with sleeping

deviation of pulse

• tachycardia >160

• bradycardia <100

expected integumentary

• milia, lanugo, peeling/cracking >40 wks GA

• slate gray patch (previously mongolian spot)

• strawbery hemangioma - raised red lesions

• erythema toxicum - newborn rash

• cafe-au-lait: permanent, light brown areas that occur anywhere, usually harmless

  • 6 or more spots OR spots larger than 0.5 cm are associated with neurofibromatosis (genetic neural tissue condition)

vernix caseosa

milia

lanugo

erythema toxicum

slate gray patch

strawberry hemangioma

cafe au lait

deviations from integumentary

• central cyanosis - after first 10 mins of life is caused by reduced oxygen saturation and hypoxia

• circumoral syanosis with pink mucous membranes may be benign

• jaundice, pallor, greenish or yellowish vernix from meconium

• marks from delivery

  • forceps or vacuum marks

circumoral cyanosis

jaundice

meconium stained vernix

expected head assessments

• fontanels are open, soft, intact, and slightly depressed, they muay bulge with cryig

  • anterior fontanel is a diamond shaped, aprox. 2.5-4cm (closes by 18 months of age)

  • posterior fontanel is a triangle shape that is aprox. 0.5-1cm (closes btwn 2 and 4 months)

deviations of head assessment

• fontanels that are firm and bulging and not related to crying are a possible indication of incr. intracranial pressure

• depressed fontanels are a possible indication of dehydration

• bruising and laceration are observed at the site of the fetal scalp electrode or vacuum extractor

• presence of caput succedaneum or cephalohematoma is observed

caput succedaneum

cephalohematoma

forceps or vacuum marks

eyes assessment

• assess for blink reflex, red light reflex, and pupil reaction to light

expected eyes assessment

• eyes are equal and symmetrical in size and pacement

• neonate is able to follow objects within 12 inches of the visual field

• subconjuncitval hemorrhage may be present due to pressure during labor and birth

deviations of eye assessment

• absent red light reflex indicattes cataracts

• unequal pupil reactions indicate neurological trauma

• examined for abnormalities and signs of inflammation

• conjuncitivitis may result from infection or a chem reaction to meds

  • maternal honorrhea can cause ifnec of the infant during birth resulting in opthalmia neonatorum which can lead to blidnness

  • prophylactic erythromycin antibioti cplaced in newborns eyes

expected findings of ears

• top of pinna is aligned with external canthys of ears

• pinna si without deformities, well formed and flexible

• neonates reposnds to noises with positive startle signs

deviations for ears

• low set ears are a/w with down syndrome

• absent startle reflex is associated with possible hearing loss

• skin tags, dimpling, or other lesions may be associated with kidney or other abnormalities

mouth assessment

• inspect the lips, gums, tongue, palate, and mucous membranes

• open the mouth by placing gentle pressure on the lower lip

• test for rooting, sucking, swallowing, and gag reflex

mouth expected findings

• lips, gums, tonhue, palate, and mucous membranes are pink, moist, and intact

• reflexes are position

deviated findings of mouth

• cyanosis

• cleft lip or palate

• natal teeth

• thin philthrum may be indicative of fetal alcohol syndrome

cleft lip or palate

natal teeth

epsteins pearls

chest and lungs assessment

• inspect shape, symmetry, and chest excursion

• inspect the breast for size and drainage

• auscultate breath sounds

expected chest and lungs

• barrel shapes, symmetrical

• breast engorgment

• clear, milky fluid discharge from nipples

• clear lung sounds

breast engorgement

supernumerary

• note placement of nipples and look for extra nipples which may appear on chest or in the axilla

deviations of chest and lungs

• pectus excavatum (funnel chest) is a congenital abnormality

• chest retractions are a sign of resp. distress

• persistent crackles, wheezes, stridor, grunting, paradoxical breathing, decr. breath sounds, or prolonged periods of apnea (>15-20 secs) are signs of respiratory distress

abdomen assessment

• inspect size and shape of the abdomen

• palpate the abdomen, assessing for tone, hernias, and diastasis recti

• auscultate for bowel sounds

• inspect the umbilical cord and surroundig skin

abdomen expected findings

• soft round

• cord is opaque or whitish blue with 2 arteries and one vein, and covered with Wharton’s jelly

• skin around umbilical cord should be assessed for infection and have no redness, swelling, drainage, or foul smell

expected umbilical cord

AVA

deviation of umbilical cord

• yellow brown or green tinge may indicate meconium stain, redness around the umbilical cord may inficate an infection called OMPHALITIS

omphalitis of newborn

abdomen deviated findings

• assymetrical abdomen indicated a possible abd. mass

• hernias or diastasis recti are more common in black neonates and usuallyr esolve on their own within the first year

• one umbilical arter and bein is associated with heart or kidney malformation