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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.