Newborn Care- Students(1) - Copy (3)

Newborn Care Overview

• Course Code: NUR 113

Adaptations to Extrauterine Life

• Cut cord/first breath: At birth, the cutting of the umbilical cord occurs which leads to the first breath, causing air to inflate the lungs.

• Neonatal transition: The initial 6 hours of life where the newborn's body systems adjust to living outside the womb.

• Nurses’ primary concerns:

  • Cardiac function

  • Respiratory function

  • Thermoregulation

• Newborn period: Refers to the phase from birth through day 28.

Respiratory Adaptations

• In utero, the lungs are filled with fluid.

• Upon delivery, intrathoracic pressure assists in squeezing fluid out, allowing the lungs to expand and commence ventilation.

• There is an increase in pulmonary circulation post-delivery.

Characteristics of Newborn Respiration

• Breathing characteristics:

  • Diaphragmatic

  • Shallow

  • Irregular with short periods of apnea

  • Exhibits periodic breathing

• Breathing patterns:

  • Primarily nose breathers.

• Respiratory Rate (RR): Ranges from 30-70 bpm.

• Other factors: Intercostal muscles involved, observations of cyanosis/acrocyanosis (bluish color in extremities).

Cardiovascular Adaptations

• Normal blood pressure:

  • Systolic BP: 60-80 mmHg

  • Diastolic BP: 40-50 mmHg (assessed in all four extremities, may elevate with crying).

• Heart Rate (HR): 110-160 bpm; varies based on activity.

• Pressure changes prompt closure of the three shunts:

  • Ductus arteriosus

  • Ductus venosus

  • Foramen ovale

• Murmurs: Turbulent blood flow might be present; 90% of murmurs are transient and may be absent in cases of heart malformation.

• Capillary refill: Evaluated; two-point pulse oximetry from right hand and either foot to screen for congenital heart diseases.

Hematopoietic Adaptations

• Physiologic anemia: Occurs during infancy as hemoglobin levels decline within the first two months.

• Influencing factors:

  • Nutrition

  • Delayed cord clamping

  • Gestational age

  • Prenatal/perinatal hemorrhage

  • Blood sampling procedures.

Gastrointestinal Adaptations

• In utero activity: Fetal swallowing alongside gastric emptying and peristalsis increases pre-birth.

• Stomach capacity: Approximately 50-60 mL.

• Regurgitation: May occur due to immature cardiac sphincter and neural control; overfeeding should be avoided and frequent burping encouraged during feeds.

• Meconium: First stool produced within 8-24 hours post-birth, formed from amniotic fluid (thick, tarry-black or dark green).

  • Breastfed stools: Pale yellow, more liquid, frequent.

  • Formula stools: More pale in color.

Immunological Adaptations

• Active acquired immunity: Formed by the pregnant woman in response to infection or vaccination.

• Passive acquired immunity: IgG antibodies passed from the mother to fetus during pregnancy.

• Inflammatory response limitations: Newborns have a limited ability to recognize, localize, and destroy pathogens; signs of infection can be subtle.

• Colostrum: Initial breastmilk, rich in IgA immunoglobulins that confer immunity to the newborn.

Temperature Regulation

• Temperature range: Normal body temperature is between 36.5–37.5 °C (97.7–99.5 °F).

• Newborns are at risk of hypothermia due to:

  • Thinner epidermis and lower subcutaneous fat.

  • Blood vessels are closer to skin, making body temperature susceptible to environmental changes.

• Other factors affecting temperature regulation:

  • Posture: flexed or hypoflexed positions

  • Shivering response

  • Body size and age impacts.

Initial Care of the Newborn

• Immediate actions:

  • Suction mouth and nose with a bulb syringe as necessary.

  • Dry the newborn immediately after birth.

  • Place newborn on mother's abdomen and under a radiant heater; most care can occur while the baby is skin-to-skin with mother.

APGAR Assessment

• Key assessments (scoring on a scale of 0, 1, or 2 for each category):

  • Heart Rate: Most important; <100 requires immediate resuscitation.

  • Respiratory Effort: Absence indicates apnea; vigorous crying indicates adequate breathing.

  • Muscle Tone: Flexion and resistance in extremities is normal.

  • Reflex Irritability: Response to stimuli via back stroking or foot flicking.

  • Skin Color: Indicative of health; acrocyanosis (blue extremities, pink body) is common in 85% of newborns.

APGAR Scoring System (1 & 5 minutes)

• 0 Points: Absent (0) | Less than 100 (<100) | Absent (0)

• 1 Point: <100 (1) | Slow, irregular (1) | Some flexion (1) | Some response (1) | Blue (1)

• 2 Points: >100 (2) | Strong cry (2) | Active movement (2) | Vigorous (2) | Fully pink (2)

APGAR Follow-Up

• Score Interpretations:

  • A score of 7–10 indicates good condition.

  • If less than 7 at 5 minutes, repeat every 5 minutes for up to 20 minutes.

  • Resuscitation measures necessary if the score is <3 at 5 minutes.

Initial Umbilical Cord Care

• Clamping: Clamps should be placed after identifying the vessels (2 arteries and 1 vein, with the umbilical vein being the largest).

  • Position clamps 0.5–1 inch from abdomen; do not clamp abdomen to avoid necrosis.

• Timing: Delays in cord clamping are debated; options for banking cord blood are increasing (though costly).

  • Melting complications warrant immediate notification to the healthcare provider.

Collaborative Care and Assessment

• Collaboration: Involvement of pediatricians, neonatologists, nurses, lactation consultants, audiology specialists, and additional specialists.

• Care changes: Dynamic, evolving within hours post-birth; include parents in discussions and assessments.

• Data Collection:

  • Ongoing process including prenatal history and APGAR scores, vital signs, and head-to-toe assessments.

  • An extensive physical exam should be conducted within the first 24 hours post-birth.

Initial Physical Exam Findings

• External observations: Skin color, peeling, birthmarks, foot creases, breast tissue, nasal patency, and meconium staining.

• Chest: Focus on ease of breathing and heart auscultation for irregular sounds.

• Abdomen: Rounded appearance with intact umbilical structure (1 vein, 2 arteries).

• Neurological: Muscle tone and reflexes such as Moro reflex, with head circumference examined for fullness or bulging (indicative of conditions like dehydration or increased cranial pressure).

Growth Measurements

• Weight: Normal range 2500-4000 g (5.5 to 8.8 lbs).

• Length: Between 45-55 cm (18 to 22 in).

• Head Circumference: 32 to 36.8 cm (12.6 to 14.5 in).

• Chest Circumference: 30 to 33 cm (12 to 13 in).

Gestational Age Assessment

• Conducted within the first 48 hours of birth to assess morbidity and mortality risk.

• Evaluated through both external characteristics and neuromuscular development, as well as using the New Ballard Scale/Dubowitz for baseline assessments.

• Gestational Age Classifications:

  • Preterm: <37 weeks

  • Late preterm: 34 to 37 weeks

  • Term: 37 to 41 weeks

  • Post term: >42 weeks.

Neuromuscular Assessment for Gestational Age

• Posture Evaluation: Ranges from fully extended to fully flexed.

• Specific tests include:

  • Square window formation.

  • Arm recoil test.

  • Popliteal angle measurement.

  • Scarf sign assessment.

  • Heel-to-ear extension.

  • Ankle dorsiflexion test.

Physical Assessment for Gestational Age

• Skin: Variance from sticky & transparent to leathery, cracked, or wrinkled with vernix.

• Lanugo: Measurements of presence and amount noted on scalp.

• Sole creases: Examining for deep creases versus smoothness.

• Breast tissue: Observable development.

• Ears: Texture and retention of folds assessed as indications of gestational age.

• Eye Opening: Recognition of development stages from 22 weeks and unfused by 28 weeks.

Common Neonatal Reflexes

• Reflexes assessed at birth include:

  • Breathing

  • Eye blinking

  • Pupillary reflex

  • Swallowing

  • Tonic neck reflex

  • Stepping reflex

  • Babinski reflex

  • Palmar grasp

  • Rooting and sucking reflexes

  • Moro reflex

Skin Characteristics

• Normal skin presentation: Pink with acrocyanosis (blue hands/feet); hydration checked via turgor.

• Lanugo: Fine hair presence over ears, forehead, and shoulders—usually diminishes.

• Pigmentation: Tends to darken over time, with jaundice not present in the first 24 hours.

• Vernix caseosa: Protective, whitish material present at birth.

Abnormal Skin Findings

• Forceps/Suction marks: Common post-assisted births, possibly leading to mottling.

• Mottling: A lace-like pattern resulting from vascular dilation; may last hours to weeks.

• Harlequin Sign: Deep red coloration on one side of the body.

• Milia: Small white spots on the face, typically resolving spontaneously.

• Erythema toxicum: Pink rash typical in the first weeks.

• Jaundice: Yellow discoloration due to bile pigment accumulation.

Marks and Variations

• Telangiectatic nevi (stork bites): Common marks that fade by the second birthday.

• Mongolian spots: Bluish-purple marks common in darker-skinned infants, especially on the buttocks.

• Nevus flammeus (port wine stain): Permanent vascular birthmark, typically on the face, does not blanch under pressure.

Head and Neurological Examination

• Head size: Typically larger than the chest by 2 to 3 cm; head shape and symmetry are important indicators.

• Conditions: Hydrocephalus (excess fluid) and microcephaly (abnormally small) assessed via palpation of fontanelles.

• Fontanelles: Anterior (diamond shape) and posterior (triangular shape); palpation for fullness or bulging indicates various conditions (e.g., infection).

• Sutures: Notable patterns can indicate pressure and deformation during delivery; should be palpable but not overlapping.

Cephalhematoma vs Caput Succedaneum

• Cephalhematoma: Blood accumulation beneath the periosteum of the skull, does not cross suture lines, often resolves in 2 to 3 weeks.

• Caput Succedaneum: Localized swelling of the scalp that crosses suture lines, resolves in 3 to 4 days.

Eye and Ear Assessment

• Eyes: Ensure symmetry and assess for subconjunctival hemorrhages from delivery pressure.

• Ears: Low-set ears may indicate genetic syndromes, responsiveness to sound noted.

Mouth, Nose, and Neck Examination

• Mouth: Pink lips, sensitivity noted, check for cleft palate and other oral issues.

• Nose: Obligate nasally breathing; blockage risks flaring and cyanosis. Sneezing is a protective response.

• Neck: Short and thick with skin folds, assessment of clavicles is crucial.

• Chest: Generally barrel-shaped; diaphragmatic breathing should be smooth with absence of retractions.

Abdomen Assessment

• Shape and Behavior: Protruding and rounded, should move with respiration; bowel sounds should be clear shortly after birth.

Genital Examination

• Female: Size appropriate, possible discharge known as pseudomenstration.

• Male: Check for scrotal integrity and positioning; must void within 24 hours.

• Anus: Assessment for patent status and presence of meconium within 24-48 hours.

Extremities and Mobility

• Movement: Full range of motion and spontaneous movement should be observed, evidence of congenital issues evaluated through reflex testing and symmetry.

Sensory Development

• Vision: Focus primarily within 8 to 12 inches, responds to light changes.

• Hearing: Similar to adults once fluid is cleared from ears, able to recognize familiar voices.

• Touch: Sensitive to touch, responds positively to gentle handling.

• Taste and Smell: Preference for sweet and highly developed sense of smell, able to recognize scent of mother.

• Habituation: Notable ability to adapt to stimuli, avoiding overload scenarios.

Security Measures

• Identification: ID bands on infant and parents; alarms and locked units should be present in the maternity ward to prevent abduction.

Diagnostic Procedures

• Blood Tests:

  • Cord blood, blood type (ABO and Rh), CBC for anemia or infections; critical values noted.

  • Normal ranges include:

    • Hgb: 14 to 24 g/dL

    • Platelets: 150,000 to 300,000

    • Hct: 44-64%

    • Glucose: 40 to 60 mg/dL

    • RBC: 4.8 to 7.1

    • Leukocytes: 9,000 to 30,000.

Evidence-Based Practice in Newborn Care

• Procedural Pain Management: Utilizing breastfeeding or close holding during minor procedures like heel stick.

  • This practice has been shown to reduce heart rate changes and overall distress.

Metabolic Screening

• Mandatory Genetic Testing: Conducted via heel stick within 24 hours; crucial tests include:

  • Phenylketonuria (PKU)

  • Galactosemia

  • Cystic fibrosis

  • Maple syrup urine disease

  • Hypothyroidism

  • Sickle cell disease.

Nursing Care Protocol

• Vital Signs Monitoring: Conducted at birth and followed up according to schedule (q 30 minutes, hourly thereafter).

• Daily weight checks: Alongside pain assessments and involvement of parents in daily care practices.

• Sleep Patterns: Newborns typically sleep 16–19 hours daily.

• Input and Output Monitoring: Document voiding patterns and stool frequency; normal to void once in first 24 hours, then 6 to 8 times per day.

Newborn Nutrition Guidelines

• First Feedings: Introduction to breastfeeding or bottle feeding is essential; babies may lose 5 to 10% of body weight but should regain by day 14.

  • Recommended weight gain: 110 to 200 g/week during the first three months.

  • Exclusivity in breastfeeding for the first 6 months is advised due to numerous health benefits.

• Parenting Education: Guidance on feeding techniques, hydration, and potential need for lactation consultancy.

Umbilical Cord Care

• Infection Prevention: Cord clamp maintained for 24-48 hours; clean with water without submerging until it falls off (generally within 10-14 days).

Medications and Prophylaxis

• Erythromycin: Eye ointment to prevent infection; applied inner to outer lower conjunctival sac.

• Vitamin K: Administered for hemorrhagic disorder prevention post-birth (IM in vastus lateralis).

• Hepatitis B: Administered with parental consent.

Circumcision Information

• Procedure: Circumcision is surgical removal of the foreskin, typically not performed on the first day.

• Assessment: Requires consent and education about benefits/risks; focus on pain management and postoperative care.

Factors Affecting Neonatal Health

• Maternal and Socioeconomic Factors: Include maternal health conditions and socioeconomic status, which can lead to complications in pregnancies, such as preterm labor or hypertension.

Respiratory Distress Syndrome (RDS)

• Pathology: Deficient surfactant leads to inadequate gas exchange.

• Common complications: Include pneumothorax and bronchopulmonary dysplasia.

Management of RDS

• Key interventions include oxygen administration, suctioning, thermoregulation, and parental support.

Transient Tachypnea of the Newborn

• Symptoms: Increased work of breathing, typically resolves within 24-48 hours post-birth.

Meconium Aspiration Syndrome

• Management: Involves careful monitoring and reduced feeding to prevent shunting oxygen from the gut; nutritional support through TPN may be necessary.

Hypoglycemia Signs and Management

• Monitoring Criteria: At-risk newborns should be checked within the first two hours; interventions may include feeding breastmilk or formula for low levels.

Neonatal Withdrawal Syndrome

• Assessment and Interventions: Look for irritability, feeding challenges, and withdrawal signs; use NAS scoring for assessment.

Fetal Alcohol Syndrome Characteristics

• Symptoms: Notable facial anomalies and developmental delays requiring comprehensive support.

Growth Alterations Categorization

• Weight Classifications:

  • SGA: <10th percentile

  • Very SGA: <3rd percentile

  • LGA: >90th percentile

• Assess risks associated with each category and implement strategies for monitoring and support.

Congenital Anomalies Overview

• Common Conditions: Include neural tube defects, heart defects, and gastrointestinal anomalies; require ongoing evaluation and management post-birth.

Discharge Education for Parents

• Emphasize the importance of hands-on education regarding care practices, monitoring signs of illness, and the necessity of follow-ups and immunization schedules.