Newborn Adaptation and Nursing Care Flashcards

Newborn Adaptation and Nursing Care

• Transition to Earthside

  • From fluid-filled to air-filled lungs, capable of gas exchange.

  • Blood must go through the lungs to be oxygenated instead of bypassing them as in the fetus.

  • Liver must start filtering and detoxifying blood.

  • Must maintain stable temperature in a cool environment.

First Breath

• Reflex triggers:

  • Pressure changes, cold, noise, light, tactile stimulation.

  • Chemical triggers:

    • Cord clamping.

    • Increased PO_2.

    • Increased PCO_2.

    • Decreased pH.

• Cardiovascular Changes: Occur very quickly. Watch video on Canvas.

  • Ductus venosus closes: blood goes to the liver.

  • Foramen Ovale closes: stopping shunt between left and right atrium.

  • Ductus Arteriosus closes: forcing blood to lungs for oxygenation – O_2 is the #1 factor in controlling closure!

• Cardiovascular Changes with first breath:

  • Increased systemic vascular resistance.

  • Decreased pulmonary resistance.

Initial Care and Assessment

• Thermoregulation: In a neutral thermal environment, oxygen consumption and metabolism are minimal.

  • Blood vessels are closer to the skin.

  • Larger surface area: body mass ratio.

  • Cannot shiver.

  • Non-shivering thermogenesis by metabolism of brown fat.

  • Premature infants are extremely susceptible to hypothermia because they cannot control their body temperature.

• Decrease temperature = increase O_2 demand = increase RR.

• Cold Stress leads to:

  • Increased O_2 demands.

  • Respiratory distress or worsening RDS.

  • Increased glucose utilization = hypoglycemia.

  • Metabolic acidosis.

  • Jaundice.

  • Hypoxia.

  • Decreased surfactant production.

• Heat Loss

  • Conduction: loses heat from touching a cold surface (warm your bed up).

  • Evaporation: heat loss from wet skin (amniotic fluid) (dry your baby off).

  • Radiation: heat loss from indirect contact of cold surfaces (cold window nearby).

  • Convection: heat lost from surrounding cooler air- doors opening, not having the sides of the warmer up (keep your side rails up).

  • Radiation: heat loss from indirect contact of cold surfaces. (cold window near by)

• APGAR Scoring

  • Performed in the delivery room at 1 & 5 minutes (10, 15 & 20 min PRN).

  • Useful in determining:

    • Success of neonatal resuscitation.

    • The infant's general well-being.

    • Success of transition.

  • Apgars are NOT to be used to determine the need for resuscitation.

  • APGAR Scoring- anything below a 7 at 1 or 5 mins must start resuscitation.

    • Appearance- color (0=cyanotic/pale, 1=acrocyanosis, 2=completely pink).

    • Pulse- heart rate (0=no HR, 1=<100, 2=>100).

    • Grimace- reaction to stimuli (0=no response, 1=grimace with irritated, 2=vigorous cry).

    • Activity- muscle tone (0=limp, 1=some flexion, 2=tight flexion).

    • Respiratory- effort (0=no effort, 1= slow, irregular, 2=regular, strong, good cry).

Med Administration

• Mandated eye prophylaxis: erythromycin ophthalmic ointment.

• Vitamin K injection.

• Hepatitis B vaccine.

• HbIg

• 5/8 inch needle.

• 45-degree angle.

• Fix leg in place

• Quick stick.

• Cover injection site.

Head to Toe Assessment

• Prenatal history: Risk factors or complications of pregnancy (HTN, IDM, drugs), fetal monitoring strip

• Maternal lab work: Blood type, HBsAg, HIV, Rubella, GBS, STDs

• Delivery record: Intrapartum medications, internal monitoring, route of delivery, complications, APGARS, resuscitation, placenta and cord assessment

• VS:

  • Count for 1 full minute

  • Respiratory rate: 30-60 bpm, periodic breathing apnea (<15 seconds) LISTEN to breath sounds

  • Heart rate: 100-160, sinus arrhythmia and murmurs

  • BP: 60-80 systolic, 40-50 diastolic -varies significantly with age, size, and activity

  • Temperature: Rectal or axillary, 36.5 – 37.2; stabilizes by 8-10 hours of age

• General Appearance

  • Color: pink, acrocyanosis vs central cyanosis, physiologic vs pathologic jaundice

  • Respiratory effort

  • Tone

  • Symmetry

  • Sleep-wake states

Skin

• Vernix caseosa

• Lanugo

• Rashes or lesions

• Birthmarks, Mongolian spots, café au lait spots, strawberry hemangiomas, stork bite

• Parchment skin

• Nails

• Veins

• Mottling

Head

• General shape: Molding, caput, cephalohematoma,

• Hair: pattern

• Fontanelles: anterior & posterior; flat, depressed, or bulging

• Sutures: approximated, overriding, ballotable

• Lacerations or lesions, Fetal scalp electrode site, Forceps or vacuum extractor, Amnihook mark

• Head Variations

  • Molding- “cone head” overriding suture lines so that the head will pass through the birth canal- will resolve within a week.

  • Caput- swelling and edema on the scalp from pressure of the birth process. pushing for hours, vacuum delivery. Dissipates within a few days.

  • Cephalhematoma- localized subperiosteal collection of blood confined by one cranial bone.

Nose, Eyes, and Ears

• Nose / Eyes / Ears

  • Facial symmetry

  • Nose

    • Patency of nares

    • Nasal flaring

  • Eyes

    • Lids

    • Absence of tears

    • Scleral hemorrhage/subconjunctival hemorrhage

    • Edema/Drainage

  • Ear

    • Location

    • Symmetry

    • Low set

    • Cartilage

    • Presence of deep pits, sinuses, skin tags

    • Ear problems may be indicative of renal dysfunction

    • Hearing screening

Mouth and Neck

• Mouth/ Neck

  • Mouth

    • Palate and lips

    • Epstein’s Pearls

    • Precocious teeth

    • Rooting reflex

    • Sucking reflex

    • Extrusion reflex

  • Neck

    • Symmetry

    • ROM

    • Tonic Neck reflex

    • Webbing

Cardiac, Chest, and Respiratory

• Cardiac/Chest - Respiratory

  • Clavicles – intact or crepitus

  • Symmetry

  • Retractions

  • Bilateral breath sounds

  • Breast tissue

  • Capillary refill- done on core of body

  • Rate and rhythm

  • Brachial and femoral pulses

  • Rate and rhythm

  • Brachial and femoral pulses

  • Signs of distress- nasal flaring, retractions, grunting.

Extremities

• Extremities

  • Upper

    • Symmetry, movement

    • Brachial

    • Arm recoil

    • Hands

      • Palmar creases

      • Palmar grasp

      • Fingers

        • Number

        • Webbing

        • Syndactyly, polydactyly, skin tags

  • Lower

    • Symmetry

    • Femoral pulses

    • Testing for congenital hip dysplasia- Ortolani maneuver, Barlow maneuver, uneven gluteal folds

    • Toes: number, spacing & webbing

    • Sole creases

    • Plantar grasp reflex

    • Babinski reflex

    • Stepping reflex

    • Moro

Abdomen

• Abdomen

  • General appearance

  • Diastasis recti

  • Tender vs nontender

  • Hernias

  • Round, distended, scaphoid

  • Umbilicus

    • Cord has 2 arteries and one vein

    • S/S of infection

    • Pulsations

  • Bowel sounds

Genitourinary

• Genitourinary (Female)

  • Labia majora should cover labia minora

  • Identify clitoris, urethra, and vagina

  • Discharge – white discharge, pseudomenstruation

  • Skin tags

• Genitourinary (Male)

  • Urethral opening

  • Hypospadias - A birth defect in males where the opening of the urethra is on the underside of the penis instead of at the tip.

  • Epispadius - A rare birth defect where the opening of the urethra is on the top of the penis.

  • Testes - descended vs undescended

  • Scrotum

    • Rugae - In the context of the male newborn's genitourinary assessment, rugae refers to the ridges or folds of the scrotum. The presence of rugae indicates that the testicles have descended.

    • Edema

• Cord Care & Circumcision Care (signs of healing)

• 3 major method's for circumcision

  • Gomco

  • Plastibell

  • Mogen Clamp

• Cord care- air dry, s/s of infections, sponge bath only, will fall off in 7-10 days, yellow to brown to black in color.

Anus and Rectum

• Genitourinary/Anus and Rectum

  • Should urinate within 48 hours (preferably 24)

  • Normal production is 1-3ml/kg/hr

  • 1st 2-3 days of life urine output is minimal due to small oral intake of fluids

  • Urine may have “brick dust” reddish color

  • Rectal temp and passage of meconium to check for patent anus

  • Imporforate anus

  • Normal stool changes

  • I/O’s

Back

• Flip ‘em Over and Check Their Back

  • Skin

    • Stork bites

    • Mongolian spots/ Slate grey Nevi

      • More common in babies of color

      • May cover buttocks, back, and shoulders

      • Document location

    • Bruises don’t blanch

  • Spine

    • Straight and intact

    • Tuft of hair

    • Deep dimples or pilonidal sinus

    • Trunk incurvation reflex

    • Gluteal folds

Measurements

• Measurements

  • Weight

    • >2500 gms is normal wgt

    • 1500-2500 gms is LBW

    • 1000-1500 gms is VLBW

    • <1000 gms is ELBW

  • Length and Weight

    • >90th percentile = LGA

    • 10th–90th percentiles = AGA

    • <10th percentile = SGA

Pain in Neonates

• Pain in Neonates

  • High pitched cry

  • Facial expression

  • Flexion and abduction of limbs

  • Changes in VS

  • NIPS pain scale

  • Nonpharmacologic management – swaddling, nonnutritive sucking, sucrose, skin-to-skin contact with Mom

Gestational Age Assessment

• Gestational Age Assessment

  • Ballard Scale

    • Predictor of survival

    • NBS is accurate as early as 20 weeks gestation

    • NBS is accurate within 1 week of actual gestation

    • Perform no later than 4 days or 96 hours postnatal age

Physical Maturity

• Physical Maturity

  • Skin

  • Lanugo

  • Plantar Creases

  • Breast Tissue

Hypoglycemia

• Hypoglycemia

  • Risk factors

    • Infant of a diabetic mother

    • LGA or > 4000 grams

    • Preterm birth

    • SGA or LBW (<2500 grams) or VLBW (<1500 grams)

    • Post-term with evidence of wasting

    • Exposure to stress – hypoxia in utero, cold stress, sepsis

  • Symptoms

    • Jitteriness or lethargy

  • <40 mg/dl

  • 24 glucose testing protocol

  • Warm heel before stick

  • Early feeds

Routine Care

• Routine Care

  • Bathing – when infant has a stable temperature

  • Neonatal skin care

  • Cord Care

  • Bonding, bonding, bonding

  • Feeding

  • Parent/Family education

Screening Tests

• Screening Tests

  • TCB- transcutaneous bili, TSB-Total serum bili

  • Newborn Metabolic screening – state mandated. Must be at least 24 hours old to test. Amino acid, fatty acid, organic acid, endocrine, hemoglobin, and other disorders

    • PKU

    • Congenital Hypothyroidism

    • Congenital Adrenal Hyperplasia

    • Galactosemia

    • Sickle Cell disease

    • CF

  • Hearing Screen

  • Congenital Heart Defect screening- > 95% in right hand (pre-ductal) and right foot and <3% difference between right hand and foot= passing test

Newborn Nutrition

• Newborn Nutrition

  • Choosing A Feeding Method

    • Support of partner and family

    • Prenatal preparation

    • Cultural beliefs

    • Societal barriers

    • Look for convenience

    • Want fathers involved

    • Confidence of woman

    • Modesty issues

    • Seeing other mothers breastfeeding

  • BREASTFEEDING IS THE RECOMMENDED NUTRITION:

    • The American Academy of Pediatricians (AAP)

    • Exclusive for the first 6 months

    • Primary source for next 6 months as breastfeeding continues to at least the baby’s first birthday, and thereafter as mom and baby desire.

    • Best practice for newborn nutrition into toddlerhood.

Advantages of Breastfeeding

• Moms

  • Decreased bleeding

  • Recovers more quickly

  • Bonding

  • Spacing of children

  • Saves money

  • Postpones cycles

  • Assist with weight loss

  • Convenient

  • Decreased risk of ovarian & breast cancer

  • Reduces risk of metabolic syndrome

  • Improved bone health

  • Lowers stress levels and blood pressure

  • Improves cardiovascular health

• Babies

  • Decreased risk of:

    • Ear infections

    • GI infections

    • Allergies

    • Obesity

    • Diabetes

    • SIDS

    • Leukemia

    • Crohn’s Disease

    • Ulcerative colitis

    • Asthma

    • Respiratory infections

    • Re-hospitalization

    • Diarrhea

  • Enhances brain growth & development

  • Enhances IQ

  • Enhances visual acuity

  • Bonding

• Disadvantages

  • Moms

    • Inconvenient

    • Painful

    • Commitment

    • Embarrassing

  • Babies

    • There are no disadvantages for the infant

Lactogenesis and Milk Volume

• Lactogenesis

  • Milk production

    • Lactogenesis I: Initially occurs with or without suckling by infant

    • However, more frequent stimulation at breast creates more prolactin receptors and enhances milk volume

    • Begins during the pregnancy

    • Endocrine control

    • Upon delivery of the placenta

      • Progesterone & estrogen levels drop

      • Prolactin levels begin to rise

      • Stimulates alveolar cells to make milk

    • Lactogenesis II: Onset of copious amounts of milk

    • Mature breastmilk “coming-in”

    • Autocrine control

    • Around 72 hours after delivery of the placenta

• Milk Volume

  • How it works:

    • Each time the baby feeds at the breast, prolactin levels rise

    • In establishing a good milk supply, it is recommended that the baby feed 8-12 times or more per 24 hours

  • To Increase milk supply

    • Feed more frequently at the breast

    • Empty the breasts more thoroughly

    • Use massage/compression during feedings

    • Express milk after feedings

    • Skin to skin care with the baby

  • If mom leaves milk in the breast

    • There is a Feedback Inhibitor of lactation (FIL) in the breast

    • Involution begins

Positioning and Latch

• Positioning and Latch

  • Support baby at breast level

  • Keep baby’s body snuggled into mom’s

  • Nose opposite nipple

  • Infants’ ear, shoulder and hip in alignment

Signs of Good and Bad Latch, Expressed Breastmilk

• Signs of a Good Latch

  • Flanged lips

  • Tongue may be visible when bottom lip is pulled down

  • Cheeks are rounded

  • Audible swallowing

  • Breast compression

  • Nipple is non-distorted

  • Emptying of the breast is noted

  • Infant ends feeding with signs of satiety

• Signs of a Bad Latch

  • Lips rolled in

  • Cheeks are dimpling

  • Breast slides in and out of infant’s mouth

  • Mother’s nipple is flattened or creased

  • Little or no breast changes after feeding

  • Inadequate stools and or voiding for age

• Taking the baby off the breast

  • Break suction

  • Placing a finger in baby’s mouth

  • Don’t pull or tug at baby

  • Burp between breasts

• Expressed Breastmilk

  • Advantages of EBM for preterm infants

    • Protect from NEC

    • Infection prevention

    • Increase feeding tolerance

    • Decreases risk for allergies

    • Tailored for gestational age

    • Can use Donor EBM if needed and consent given

• Expressed Breastmilk Differences Between Preterm and Term EBM

  • Preterm EBM has:

    • Increased protein

    • More anti-infective properties

    • Specific lipid content

    • Increased IgA concentration

    • Lactose in preterm EBM allows for increased absorption

Is Baby Getting Enough?

• How do I know my baby is getting enough?

  • Audible or visible swallows

  • Breasts are softer after feeding (once the mature milk is in)

  • Signs of satiety after feeding

  • Wet and Soiled diapers

  • Signs of normal hydration

  • Adequate weight gain

  • Stable temperature and blood glucose

NICU Equipment

• Weight Division

  • Low Birth Weight (LBW) (<2500g)

  • Very Low Birth Weight (VLBW) (<1500g)

  • Extremely Low Birth Weight (ELBW) (<1000g)

  • SGA (below 10th%)

  • AGA (10-90th%)

  • LGA (>90%)

  • Use Gestational Age and BW to determine…

• NICU Equipment

  • Cardiorespiratory Monitoring

  • Oxygen Saturation Monitoring

  • BP Monitoring (Invasive and noninvasive)

  • UAC or PAL – can monitor BP, blood sampling for labs, and infusion of fluids

  • Line Access:

    • PIV

    • UVC/UAC

    • PICC

    • ETT

    • Chest tubes

    • NG/OG

  • Safety and Equipment

    • Equipment:

      • Isolettes

      • Radiant Warmer

      • Open Crib

      • Suction

      • Oxygen (Bag, Mask, Source)

    • Ventilation

      • Ventilators

      • HFOV (High flow oxygen ventilator)

      • Conventional Ventilator

      • HFJV (High flow jet ventilator) vs. Oscillator

      • CPAP

      • NC, HFNC, (Nasal cannula, high flow nasal cannula

    • Used to correct the acid/base imbalance and respiratory effort in the neonate.

    • Ventilation vs Oxygenation

Temperature Maintenance and Kangaroo Care

• Temperature Maintenance

  • Premies must be able to maintain temperature AND weight when moved to open crib

  • Must be able to nurse/bottle feed entire volume in 30 minutes or less

  • Getting cold= increased calorie and O_2 demands

• Kangaroo Care

  • Skin to Skin contact

  • Both parents can participate

  • Improves physiologic self-regulation, decreases stress/crying, decreases pain, and helps with neonatal development

  • Improves milk supply

TTN and PPH

• TTN- Transient Tachypnea of the Newborn

  • Delayed reabsorption of the normal lung fluid – usually occurs within hours of birth

  • Generally seen in term/late preterm infants with history of C-section

  • S/Sx: respiratory distress, tachypnea, retractions, grunting, flaring

  • Tx: usually oxygen, Will usually resolve in 72 hours

• Persistent Pulmonary Hypertension (PPH)

  • Pulmonary hypertension causing R to L shunting and hypoxemia

  • Normally the initial breathes increase O_2 concentration resulting in decreased pulmonary vascular resistance

  • In this case, that does not occur = increase resistance = shunting of blood and fetal shunt (DA) fail to close = murmur and low O2 level despite 100% O2 given to infant.

RDS and MAS

• Respiratory Distress Syndrome (RDS)

  • Due to immature lungs with lack of surfactant

  • History of prematurity, C-Section, asphyxia, IDM, sepsis, Surfactant protein deficiency

  • Assessment: tachypnea, grunting, flaring, retractions, decreased breath sounds, rales, decreased SpO_2 (right to left shunting R/T pulmonary vascular resistance from acidemia)

  • RDS Treatment

    • Surfactant

    • CPAP- nasal/endotracheal

    • Ventilator- intermittent or synchronized

    • High frequency oscillation or jet ventilator

    • Oxyhood, nasal cannula

    • Inhaled Nitric Oxide: causes pulmonary vasodilation, but still experimental tx

• Meconium Aspiration syndrome (MAS)

  • Passage of fetus’s first stool in utero, possibly from hypoxic event

  • Black, tarry, sterile

  • When inhaled, can cause blockage of airway leading to hypoxia inflammation of airways and chemical pneumonitis, decreases surfactant production

Feeding and CLD/BPD

• Delay Feeding with Respiratory Distress

  • Either because suck/swallow impair due to prematurity, maternal medications, or tachypnea

  • Or because while infant having respiratory issue = blood diverted away from gut

  • Suck, swallow, and breath can be a lot to ask all at once

• Chronic Lung Disease/ Bronchopulmonary Dysplasia (CLD/BPD)

  • “Chronic” phase of RDS, will see increased respiratory distress

  • Will see impaired gas exchange

  • Due to constant/recurrent lung injury

  • Often need bronchodilators, steroids and diuretics

  • More than 50% are hospitalized within the first 2 years with RSV

  • May place trach if cannot wean off ventilator

ROP and IDM

• Retinopathy of Prematurity (ROP)

  • Develops in 84% of preterm infants less than 28 weeks

  • In 80% of cases, ROP regresses without visual loss

  • With increased oxygen, retinal vessels constrict and become necrotic. This causes a stimulation of vessels to proliferate to reestablish circulation.

  • May extend into vitreous and cause retinal scar formation, traction on the retina, detachment, and blindness

  • Considered a disease of prematurity because once vascularization is complete, the retinal vessels cannot be injured

  • The best treatment is prevention. May do so through monitoring oxygen saturations with oxygen administration.

  • Use ranges of acceptable oxygen saturations based on gestational age and disease process.

  • Use of laser therapy is the standard treatment. The laser light coagulates the retinal tissue and stops abnormal vessel growth.

  • Infants who meet specific criteria will be examined by an ophthalmologist throughout their hospitalization and afterwards.

• Infant of Diabetic Mother (IDM)

  • Major risk of congenital malformation if uncontrolled in 1st trimester (Cardiac**, skeletal, CNS, GI, GU)

  • LGA – risk for birth traumas, shoulder dystocia, C/S birth, RDS, hyperbilirubinemia

  • Lethargic after birth (not always related to hypoglycemia)

  • Monitor for birth trauma – treat appropriately

  • Monitor F&E balance

  • Risk for hypoglycemia – (less than 40mg/L lethargic, irritable, tachypnea, poor feed, hypotonia, seizures)- monitor within 30 minutes then AC and if symptoms

  • Treat hypoglycemia: early to breast or bottle feeding, IV dextrose if feeding not correcting with PO feeds

Hyperbilirubinemia and NEC

• Hyperbilirubinemia

  • Jaundice is the obvious sign of Hyperbilirubinemia

  • Caused by breakdown of RBC and infant’s livers inability to repackage (conjugate -convert into water soluble pigment) it to be excreted

  • Anything that increases RBC breakdown – increases risk

  • Infant RBCs live approximately 70 days vs 90 for adult RBC – so must conjugate faster

  • Start in face and moves down

  • See when skin is blanched

• Physiologic Jaundice

  • Normal peak about 3-4 days of life

  • Rate of decline slower in breastfed infants vs bottle fed – most likely due to slight decrease in feeding volume early on. (Hint: early and frequent breastfeeding)

• Pathologic Jaundice

  • Usually appears in first 24 hours with higher levels seen (most commonly from Rh isoimmunization** and ABO incompatibility, polycythemia and acidosis)

  • Bilirubin encephalopathy: yellow brain staining – causes severe neurologic sequela

  • Hyperbilirubinemia Treatment

    • Phototherapy (conjugates bilirubin)-expose as much skin as possible, eye protection, turn q 2 hrs, monitor temp and I&O, daily weights, feed q 2-3 hours

    • Prevent Rh isoimmunization with Rhogam

    • Intrauterine or newborn transfusion (exchange transfusion)

• Necrotizing Enterocolitis (NEC)

  • Acute inflammatory disease of the GI tract

  • Complications: sepsis, perforation

  • Occurs in 5% of infants of VLBW

  • Contributing factors: asphyxia, RDS, UAC, transfusion, formula feeds, hyperosmolar feeds, PDA, CHD, polycythemia/anemia, shock, sepsis

  • Assessment Findings:

    • Feeding intolerance, abdominal distention, bloody stools, lethargy, shock, cyanosis, respiratory compromise, metabolic acidosis

    • Free air on KUB with perforation

  • Diagnostic & Treatment:

    • Abdominal films, CBC, CRP

    • NPO/TPN/Lipids, Respiratory support, Bowel resection with or without ostomy

Late Preterm Newborns and Summary

• Special Note: Late Preterm (Near term) Newborns

  • EGA: 34 to 37+6 – Not just a small normal newborn -look term, but:

  • Increased resp. distress, late-onset sepsis, $, thermo-regulation issues, risk brain bleed/injury

  • Risk Hyperbilirubinemia, hypoglycemia, sepsis

  • risk of psycho-social disorders (ADHD, developmental delays)

• Summary

  • Warm & Dry!!!!!

  • AIRWAY

  • BREATHING

  • O_2$$

  • CIRCULATION

  • DRUGS

  • EDUCATION AND FAMILY

• Common Nursing Actions for Newborns

  • Warm and Dry: Immediately after birth, dry the newborn thoroughly to prevent heat loss through evaporation. Place the newborn under a radiant warmer or skin-to-skin with the mother to maintain body temperature.

  • Bulb Syringe: Use a bulb syringe to clear the newborn's mouth and nasal passages of excess mucus and fluids to ensure a patent airway.

  • Warmer/Skin-to-Skin: Place the newborn under a preheated radiant warmer or initiate skin-to-skin contact with the mother to stabilize temperature.

  • Identifying Newborn: Apply matching identification bands to the newborn, mother, and partner (if applicable) to ensure proper identification.

• APGAR Scoring

  • Assign an APGAR score at 1 minute and 5 minutes after birth to assess the newborn's transition to extrauterine life. If the 5-minute score is less than 7, continue scoring every 5 minutes up to 20 minutes.

  • Components: Appearance (color), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), Respiration (breathing effort).

• Systematic Assessment Sequence

  • General Appearance: Observe color, respiratory effort, tone, and activity.

  • Vital Signs: Measure respiratory rate, heart rate, blood pressure, and temperature.

  • Skin: Assess for vernix caseosa, lanugo, rashes, birthmarks, and lesions.

  • Head: Palpate fontanelles and sutures. Assess for molding, caput succedaneum, or cephalohematoma.

  • Nose, Eyes, Ears: Check for facial symmetry, nasal patency, eye drainage, and ear placement.

  • Mouth and Neck: Assess palate, lips, reflexes (rooting, sucking, extrusion), neck symmetry, and range of motion.

  • Cardiac, Chest, and Respiratory: Auscultate breath sounds, assess symmetry, and check for retractions or signs of distress.

  • Extremities: Evaluate symmetry, movement, pulses, and congenital hip dysplasia.

  • Abdomen: Assess general appearance, umbilical cord, and bowel sounds.

  • Genitourinary: Check for normal genitalia and urinary function.

  • Anus and Rectum: Confirm patent anus and passage of meconium.

  • Back: Inspect skin, spine, and reflexes.

  • Measurements: Weight, length, and head circumference.

• Normal Variations vs. Abnormal Deviations

  • Normal Variations: Acrocyanosis, mottling, Mongolian spots, vernix caseosa, lanugo, caput succedaneum, physiologic jaundice.

  • Abnormal Deviations: Central cyanosis, pallor, jaundice within the first 24 hours, cephalohematoma, bulging or depressed fontanelles, nasal flaring, grunting, retractions, abdominal distention, bloody stools.

• Nursing Care Management and Patient Teaching

  • Thermoregulation: Keep the newborn warm and dry. Teach parents about the importance of maintaining a stable temperature.

  • Respiratory Support: Clear airway with bulb syringe. Monitor respiratory rate and effort.

  • Feeding: Initiate early feeding. Teach parents about breastfeeding or formula feeding techniques.

  • Bonding: Encourage skin-to-skin contact to promote bonding between parents and newborn.

  • Education on normal newborn behaviors, feeding cues, and safety.

• Physiologic Changes and Challenges

  • Transition from fluid-filled to air-filled lungs.

  • Closure of fetal circulatory shunts (ductus venosus, foramen ovale, ductus arteriosus).

  • Thermoregulation: Maintaining stable temperature in a cool environment.

  • How to prevent complications: Ensure proper airway clearance, provide warmth, promote early feeding, and monitor vital signs.

• Stabilization and Resuscitation

  • Thermoregulation: Use radiant warmers, skin-to-skin contact, and warm blankets to prevent cold stress.

  • Airway Management: Clear airway with bulb syringe or suction.

  • Breathing Support: Provide oxygen or ventilation as needed.

  • Circulation Support: Monitor heart rate and blood pressure.

• Challenges by Major Systems

  • Respiratory: Establishing and maintaining effective gas exchange.

  • Cardiovascular: Closing fetal shunts and adapting to increased systemic vascular resistance.

  • Thermoregulation: Preventing heat loss and maintaining a stable body temperature.

  • Metabolic: Preventing hypoglycemia.

  • Hepatic: Conjugating bilirubin and preventing jaundice.

  • Gastrointestinal: Initiating feeding and digesting nutrients.

• Infant Security Plan

  • Matching identification bands for newborn, mother, and partner.

  • Electronic security tags.

  • Staff education on security protocols.

  • Controlled access to the newborn unit.

  • Encouraging parents to question anyone without proper identification.

• Newborn Screening Tests

  • Importance: Early detection of metabolic, endocrine, and genetic disorders.

  • Parental Teaching: Explain the purpose of the tests, the disorders being screened for, and the importance of follow-up if results are abnormal.

• Discharge Education Plan

  • Feeding: Breastfeeding or formula feeding techniques, frequency, and amount.

  • Elimination: Expected number of wet and soiled diapers.

  • Sleeping: Safe sleep practices to reduce the risk of SIDS.

  • Bathing and Cord Care: Instructions on how to bathe the newborn and care for the umbilical cord.

  • Immunizations: Schedule and importance of vaccinations.

  • Follow-up Appointments: Dates and times for pediatrician appointments.

  • When to contact the healthcare provider: Signs and symptoms of illness or complications.

• Assessment and Intervention for Trauma and Birth Injuries

  • Assessment: Evaluate for bruising, swelling, fractures, or nerve injuries (e.g., Erb's palsy).

  • Interventions: Provide supportive care, pain management, and monitor for complications.

• Hyperbilirubinemia

  • Assessment: Monitor for jaundice, especially within the first 24 hours. Measure bilirubin levels.

  • Interventions: Phototherapy, frequent feeding, and monitoring of temperature and hydration.

  • Prevention: Promote early and frequent breastfeeding.

  • Management: Ensure adequate hydration, monitor bilirubin levels, and provide phototherapy as needed.

Newborn Complications

1. Common Complications:

   • Respiratory Distress Syndrome (RDS)

   • Meconium Aspiration Syndrome (MAS)

   • Transient Tachypnea of the Newborn (TTN)

   • Persistent Pulmonary Hypertension of the Newborn (PPHN)

   • Hyperbilirubinemia

2. Identifying At-Risk Newborns:

   • Variations in Birthweight and Gestational Age:

     • LGA (Large for Gestational Age): >90th percentile.

       • Increased risk for birth traumas, hypoglycemia, and hyperbilirubinemia.

     • SGA (Small for Gestational Age): <10th percentile.

       • Risk for hypothermia, hypoglycemia, and polycythemia.

     • Preterm: <37 weeks gestation.

       • Immature organ systems, increased risk for RDS, IVH, NEC, and ROP.

     • Post-term: >42 weeks gestation.

       • Risk for meconium aspiration, placental insufficiency.

3. Pathophysiology and Management:

   • Respiratory Distress Syndrome (RDS):

     • Pathophysiology: Lack of surfactant leading to alveolar collapse.

     • Management: Surfactant administration, CPAP, mechanical ventilation.

   • Meconium Aspiration Syndrome (MAS):

     • Pathophysiology: Aspiration of meconium leading to airway obstruction and inflammation.

     • Management: Suctioning, oxygen therapy, mechanical ventilation, antibiotics.

   • Transient Tachypnea of the Newborn (TTN):

     • Pathophysiology: Delayed absorption of lung fluid.

     • Management: Oxygen therapy, monitoring.

   • Persistent Pulmonary Hypertension (PPHN):

     • Pathophysiology: Failure of normal circulatory transition leading to R-to-L shunting.

     • Management: Oxygen therapy, mechanical ventilation, inhaled nitric oxide.

   • Intraventricular Hemorrhage (IVH):

     • Pathophysiology: Bleeding into the ventricles of the brain, common in preterm infants.

     • Management: Supportive care, monitoring, prevention of increased intracranial pressure.

   • Necrotizing Enterocolitis (NEC):

     • Pathophysiology: Inflammation and necrosis of the intestinal tract.

     • Management: NPO, antibiotics, surgical intervention if necessary.

   • Retinopathy of Prematurity (ROP):

     • Pathophysiology: Abnormal blood vessel development in the retina of preterm infants.

     • Management: Laser therapy, monitoring, prevention through careful oxygen administration.

4. Assessment Findings of Major Acquired Congenital Anomalies:

   • Central Nervous System:

     • Neural tube defects (e.g., spina bifida): Assess for sac on back, motor and sensory deficits.

   • Respiratory System:

     • Diaphragmatic hernia: Assess for respiratory distress, scaphoid abdomen.

   • Gastrointestinal System:

     • Esophageal atresia/tracheoesophageal fistula: Assess for choking, cyanosis, and inability to feed.

     • Omphalocele/gastroschisis: Assess for abdominal contents outside the abdominal cavity.

   • Genitourinary System:

     • Hypospadias/epispadias: Assess for abnormal placement of the urethral opening.

   • Musculoskeletal System:

     • Clubfoot: Assess for foot deformity.

     • Hip dysplasia: Assess for uneven gluteal folds, limited hip abduction (Ortolani and Barlow maneuvers).

5. Nursing Care Plan for NICU Infant:

   • Assessment: Complete head-to-toe assessment, monitor vital signs, assess respiratory status, assess nutritional status, monitor I/Os.

   • Interventions:

     • Maintain thermoregulation.

     • Provide respiratory support.

     • Ensure adequate nutrition.

     • Prevent infection.

     • Promote bonding.

   • Evaluation: Monitor response to interventions and adjust as needed.

6. Coomb's and Indirect Coomb's Test:

   • Direct Coomb's: Detects antibodies on the surface of the newborn's red blood cells (RBCs), indicating hemolytic disease.

   • Indirect Coomb's: Measures antibodies in the mother's serum, indicating sensitization to fetal RBC antigens.

7. Nursing Strategies for Abnormal Newborn Course:

   • Hypothermia:

     • Prevention: Dry newborn immediately after birth, place under radiant warmer or skin-to-skin.

     • Nursing Care: Monitor temperature, warm slowly, and treat underlying cause.

     • Family Teaching: Educate parents on maintaining a warm environment.

   • Hypoglycemia:

     • Prevention: Early feeding, monitor glucose levels.

     • Nursing Care: Check glucose levels, feed or administer IV glucose as needed.

     • Family Teaching: s/s of hypoglycemia, importance of regular feedings.

   • Hyperbilirubinemia:

     • Prevention: Early and frequent feedings.

     • Nursing Care: Monitor bilirubin levels, phototherapy, hydration.

     • Family Teaching: Explain jaundice, phototherapy, and need for follow-up.

   • Hypoxemia/Asphyxia:

     • Prevention: Monitor fetal heart rate during labor, ensure adequate resuscitation.

     • Nursing Care: Administer oxygen, assist with ventilation.

     • Family Teaching: Explain need for respiratory support and monitoring.

   • Infections:

     • Prevention: Hand hygiene, sterile technique.

     • Nursing Care: Administer antibiotics, monitor for sepsis.

     • Family Teaching: s/s of infection and the importance of completing the antibiotic course.

   • Pain:

     • Prevention: Gentle handling, cluster care.

     • Nursing Care: Assess pain using pain scale, non-pharmacologic pain management (swaddling, sucrose), administer analgesics as needed.

     • Family Teaching: Educate parents on recognizing pain cues.

8. Nursing Care of the High-Risk Infant:

   • Comprehensive assessment.

   • Monitoring vital signs and lab values.

   • Providing respiratory support.

   • Ensuring adequate nutrition.

   • Maintaining thermoregulation.

   • Preventing infection.

   • Administering medications.

   • Providing emotional support to family.

   • Educating parents on care.

9. Neonatal Abstinence Syndrome (NAS):

   • Nursing Care:

     • Assess using a scoring system (e.g., Finnegan).

     • Swaddle the newborn.

     • Provide a quiet, dimly lit environment.

     • Administer medications.

     • Monitor feeding and weight gain.

     • Provide emotional support to the mother.

10. Breastfeeding/Infant Nutrition:

    • Current Recommendations for Feeding:

      • Exclusive breastfeeding for the first 6 months, followed by continued breastfeeding with complementary foods for at least the first year.

    • Advantages of Breastfeeding:

      • Nutritional benefits, immunologic protection, bonding.

    • Disadvantages of Breastfeeding:

      • Time commitment, potential discomfort, social constraints.

    • Interventions:

      • Early initiation, proper latch, frequent feedings, support from lactation consultants.

11. Infant Feeding Issues and Nursing Interventions:

    • Breastfeeding:

      • Poor latch: Assist with positioning and latch.

      • Sore nipples: Assess latch, offer lanolin cream.

      • Low milk supply: Encourage frequent feedings, pumping after breastfeeding.

    • Bottle Feeding:

      • Nipple confusion: Offer bottle only after breastfeeding is well established.

      • Gas and colic: Burp frequently, hold upright after feeding.

12. Medication Calculation

    • Medication Calculation is not described in the context provided.