newborn assessment and care 2

reflexes

• tonic neck reflex

• palmar and planter grasp reflex

• moro reflex

• rooting reflex

• suck reflex

• babinski reflex

• stepping reflex

tonic neck reflex

when newborn is supine and head is turned to one side, extremity on side facing is extended and opposite side is flexed

• disappeared around 4 months

palmar grasp reflex

stimulating newborns palms with a finger or object and newborn will grasp or hold

• typically disappears around 4-6 months of age

planter grasp reflex

toe curling elicited by pressing on bottom of foot

• disappears about 9-12 months of age

moro reflex

stimulated by a loud noise or being lifted or lowered; newborn will straighten arms and hands outward while knees flex inwards, then arms will return to chest and hands form a C shape

• usually disappears around 6 months of age

rooting reflex

stroke side of newborn’s mouth or cheek and baby will turn towards that side and open lips to suck

• if baby has been recently fed, may not easily elicit reflex

• disappears around 4 months of age

babinski reflex

toes fan out when outside edge of foot and under toes stroked

• disappears or changes around 12 months of age (may curl instead of fan later on)

stepping reflex

when held up with one foot on the ground, baby will place feet in front of the other and “walk”

• usually disappears around 3-4 months of age

urinary output

• 93% of newborns void by 24 hours after birth, 100% void within 48 hours after birth

• initial bladder volume is 6-44 mL of urine

• notify physician if newborn has not voided within 48 hours of birth

• typically void 5-25 times a day, look for 6-8 wet diapers per day

meconium stool

thick, dark, sticky stool; typically first few bowel movements look like this

breast-fed stool

yellow in color

imperforate anus

anus is missing or doesn’t have a hole

at-risk neonates

• low socioeconomic status of mother

• limited access to healthcare or no prenatal care

• exposure to environmental dangers

• pre-existing maternal conditions

• medical conditions related to pregnancy

• pregnancy complications

factors influencing outcome of at-risk neonates

• birth weight

• gestational age

• intrauterine growth

• type and length of illness

• environmental factors

• maternal factors

• maternal-neonatal separation

preterm

20 weeks to 36 and 6/7 weeks

late preterm

34 to 36 and 6/7 weeks

full term

39 to 40 and 6/7 weeks

early term

37 to 38 and 6/7 weeks

late term

41 weeks to 41 and 6/7 weeks

post term

42 weeks and greater

low birth weight (LBW)

weight <2500 g (5.5 lbs) regardless of gestational age

very low birth weight (VLBW)

weight <1500 g (3.3 lbs)

extremely low birth weight (ELBW)

weight <1000 g (2.2 lbs)

small for gestational age (SGA)

plot below the 10th percentile

appropriate for gestational age (AGA)

plot between the 10th percentile and 90th percentile

large for gestational age (LGA)

plot abover 90th percentile

intrauterine growth restriction (IUGR)

rate of growth does not meet expected growth pattern

• symmetric IUGR - weight, length, head circumference all affected

• asymmetric IUGR - head normal but body is disproportionately small (<10th percentile)

common causes of indicated preterm birth

• diabetes

• chronic HTN

• preeclampsia

• obstetrical disorders or risk factors in current pregnancy (abruption, previa, gallbladder disease, etc)

• medical disorders that affect pregnancy

• advanced maternal age

• fetal disorders

• twin gestation

twin to twin transfusion syndrome (TTTS)

rare condition that occurs in identical twins in womb where blood supply of one twin moves to the other

• donor twin - twin that loses blood

• recipient twin - twin that receives blood

heal stick blood glucose

should be 40 mg/dl or higher

• if warranted:

  • maternal diabetes

  • LGA/SGA

  • jittery

do stick on outside of heal, not middle of heal

vitamin K shot

used to replace vitamin K not provided in breastmilk or formula to form clotting factors

erythromycin ointment

prevent conjunctivitis from chlamydia or gonorrhea infection

newborn bath

• typically wait about 6 hours after birth

  • prevents baby from getting cold and allows more skin-skin time with family

• only need to bathe babies 1-2 times per week

• only use water on face

• sponge baths until umbilical cord stump falls off

• don’t bathe right after feeding

periods of reactivity

• first period of reactivity

  • occurs about 30 mins after birth

  • usually awake, active, hungry, and have a strong suck reflex

  • promote bonding and breastfeeding during this period

• sleep phase

  • hr and rr may decrease

  • lasts about 2-4 hours

• second period of reactivity

  • awake, alert

  • lasts longer (4-6 hours)

  • hr and rr will return to normal

newborn nutrition

breastfed - typically feed every 2-3 hours and can feed on demand

formula fed - every 3-4 hours

• assess for signs of readiness to feed

  • rooting reflex

  • sucking reflex

  • bobbing of the baby’s head

• assess infant physiologic status during feeding

  • awake and alert

initiating breastfeeding

• place newborn on mother’s chest

• may begin in birthing room

• supply and demand

  • increased stimulation increases milk supply

  • breasts learn how to make milk, how much is needed, and how often

burping infant

burp between each breast or half of formula feeding

• support the head

daily care assessments for newborns

• vital signs

• weight

• feedings

• intake and output

• care of umbilical cord

• observe skin color changes

  • pink

  • central cyanosis/acrocyanosis

  • jaundice

care of umbilical cord

• keep clamp on the cord until its dry

• keep it clean, dry, and out of the diaper

• usually falls off in 7-10 days, can take a couple weeks

jaundice

yellow coloring of skin or sclera due to increased levels of bilirubin from breakdown of RBC

• normal levels - 4-6 mg/dl before jaundice appears

pathological jaundice

• occurs in first 24 hours of life

• possible use of phototherapy

• possible blood transfusion

physiological jaundice

• occurs after first 24 hours of life

• increase feedings/breastfeeding 8-12 times in 24 hours

• possible use of phototherapy

phototherapy

use of high-intensity light to help decrease bilirubin levels in skin by facilitating biliary excretion of unconjugated bilirubin

• need for this treatment based on gestational age and hours old

nursing care for jaundice

• keep infant warm (temp 97.7 or higher)

• monitor amount of stool

• encourage early feedings

• if phototherapy used:

  • wear diaper

  • eye protection

  • monitor hydration

  • allow for bonding

newborn withdrawal (neonatal abstinence syndrome)

condition affecting newborns exposed to opiates in pregnancy

clinical manifestations of NAS

• high-pitched cry

• hyperirritability

• seizures

• increased muscle tone

• vomiting

• diarrhea

• poor feeding

• yawning

• stuffy nose

• hyperthermia

• tachypnea

• sweating

complications of NAS

• respiratory distress

• jaundice

• congenital anomalies

• IUGR
  behavioral abnormality

• withdrawal

modified finnegan neonatal abstinence score sheet

assessment tool that scores severity of withdrawal from opioids

• monitors and documents infants clinical response to withdrawal

• score two hours after birth for baseline

• continue scoring every 4 hours after each feeding until infant is ad lib

• if score is 8 or greater, score every 2 hours until NAS medication started, then every 4 hours or after every feeding while on medication

• ad lib infants will be scored after every feeding

nursing interventions for NAS

• initial treatment - supportive (skin to skin, swaddling, gentle music, quiet environment, minimal stimulation)

• mild symptoms may be managed with supportive care/comfort measures

• cluster care and activities to allow for extensive rest periods between feeds

• encourage/support parental involvement/rooming in

• breastfeeding should be encouraged because it can delay onset and decrease severity of symptoms and decrease need for medication

• moms on methadone or buprenorphine should be encouraged to breastfeed

pharmacologic treatment of NAS

• may require NICU admission

• match drug selection to type of agent causing withdrawal

• morphine and methadone most common first-line medication

• buprenorphine

• adjunctive use of phenobarbital or clonidine therapy

hearing screening

done prior to going home

• sometimes fluid in ears can cause fail, may need to be repeated

PKU testing (phenylktonuria)

amino acid disorder used for body growth

• done after 24 hours of breastmilk or formula

• excess levels can lead to progressive mental retardation

• may need special formulas low in phenylalanine

• done with heel stick

circumcision

removal of foreskin from penis

• use a lot of petroleum jelly during diaper changes because newly exposed skin can adhere to diaper and cause bleeding

• look for signs of bleeding and infection after

swaddle

• keep arms tight but legs loose

• put blanket in diamond, fold down top part behind neck, take one side and wrap tightly around arms, pull side up from legs, take other side and wrap securely around baby

safe sleep and carseat technique

on back is safest position

• have appointment within 1-2 days after discharge to meet with pediatrician and have weight check

forward facing car seat in back seat

effect of prematurity on growth and development

• more premature infant = greater potential effect on infants growth and development

• preterm babies will not perform with same ability as age level peers in areas of growth and development

  • age of all preemies adjusted when development evaluated

    • ex: newborn born at 32 weeks on Dec 1 and evaluated on Jan 1 would be considered 36 weeks gestation; infants correct age at 6 months after birth would be 4 months

factors that predict normal growth and development

preterm baby is usually discharged at 36-40 weeks post-conception age

• when tested for head lag response, baby should raise head parallel to body when lifted from a prone position

• ability to cry vigorously when hungry

• appropriate amount and pattern of weight gain according to growth curves

• neurologic responses appropriate for corrected age

signs of newborn illness

• temp above 100.4 or below 97.7 axillary

• continual rise in temp

• forceful or frequent vomiting

• refusal of two feedings in a row

• difficulty in awakening baby

• cyanosis with or without feeding

• absence of breathing longer than 20 seconds

• inconsolable infant or continuous high-pitched cry

• discharge or bleeding from umbilical cord, circumcision, or any opening

• two consecutive green watery stools

• no wet diapers for 18-24 hours

• fewer than 6-8 wet diapers per day after 4 days of age

• development of eye drainage