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Healthy Newborn
Chapters 17 & 18
Essentials of Maternity, Newborn, and Women's Health Nursing, 3rd Ed, Ricci

Heart, Lungs, Blood
The fetus gets his/her oxygen from Mom via the placenta. Because the oxygen saturation is lower in utero, the fetus needs more what to transport the oxygen?

What is released by the fetus in the birth process that will help him/her adjust to extra-uterine life?

Some major anatomical differences in circulation of the fetus are: foramen ovale, ductus arteriosus, ductus venosus, umbilical arteries and vein. How does the pressure change in the heart after birth?
These fetal structures close soon after birth, the DA may stay open if oxygen sats are low. If oxygen is normal, it should close within a few hours after birth.



Review Box 17.1
Lungs that were full of fluid, must now breathe air. How is vaginal birth better for newborn than c/s in this case?
Surfactant: surface tension reducing lipoprotein that prevents alveolar collapse
Respirations: 30-60 breaths/minute; irregular, shallow, unlabored; short periods of apnea (<15 sec); symmetrical chest movements

Immature Temperature Regulation Abilities
Just imagine you are submerged in a bath tub that is 99 degrees F. Now you jump out into the room air that is 70 degrees F.
Also, you have thin skin; blood vessels close to the surface, are not able to shiver, have limited metabolic back-ups (like glucose, glycogen and fat), have limited use of voluntary muscle activity, have a large body surface area relative to body weight, little subcutaneous fat; little ability to conserve heat by changing posture, no ability to adjust own clothing or blankets to achieve warmth, and can't tell someone you are cold! No wonder babies cry when they are born! Heat production: primarily through nonshivering thermogenesis (brown fat). Temp can drop 3-5 degrees F. Assess q 30mins first 2 hours, then at least every 8 hrs once stable. Too much will lead to cold stress. Need for a neutral thermal environment (NTE).
Are all newborns at risk for cold stress? Which ones more so? What nutrients do they use excessively to keep warm?

Ways newborns lose body heat.
Liver
Though not usually as big a problem, newborns can also OVERheat. Why? Again, large body surface area, limited insulation, limited sweating ability. Where is this going to be really important?

Functions of newborn liver are iron storage, carbohydrate metabolism, bilirubin conjugation. Again, none of these functions were too important in utero. Mom did the work. The ductus venosis helped to bipass the fetal liver. Now, the newborn liver must do the work, and lots of those extra RBCs will be broken down so accumulation of ?


GI & Nutrition
Development of a mucosal barrier to prevent the penetration of harmful substances* discuss 2 reasons this is important!
Physiologic capacity of the newborn stomach is considerably less than anatomic capacity
Cardiac sphincter and nervous control of stomach is immature leading to regurgitation and uncoordinated peristaltic activity

The newborn gut is sterile. Why is this a problem?

Breastmilk is helpful because it passes antibodies and WBCs to help protect immature gut.

Bowel sounds may be hypoactive first 24 hours.

Feed and encourage parents to feed baby small feedings frequently and to burp often. Don't overfeed. Learn babies cues for hunger and satiety.

Pancreatic enzymes and bile are limited until 6 mos. so baby will have trouble digesting fat (fatty stools) or starch (cereal).
Urine
&
Stools
!
Stools: meconium, then transitional stool, then milk stool
Breast-fed newborns: Yellow-gold, loose, stringy to pasty, sour-smelling
Formula-fed newborns: yellow, yellow-green, loose, pasty, or formed, unpleasant odor
Watch for and document stools
GU
Limited ability to concentrate urine until about 3 months of age (urine has a low specific gravity)
6 to 8 voidings/day considered normal
Low glomerular filtration rate and limited excretion and conservation capability
Affects newborn’s ability to excrete salt, water loads, and drugs

Term infants are about 75% water! Preemies even more!
6-8 Wet diapers a day
Urine has low specific gravity
Immune System
Natural immunity: physical barriers, chemical barriers, and resident nonpathologic organisms
Acquired immunity
Development of circulating immunoglobulins; formation of activated lymphocytes
Absent until after 1st invasion by foreign organism or toxin
Newborn primarily dependent on 3 immunoglobulins: IgG, IgA, and IgM
IgG is "G"iven by Mom to fetus through placenta after about 20 weeks gestation-IgG is most abundant class, and the second responder
IgA protects mucous membranes, passed through breast milk
IgM is the first responder, levels are low at birth, baby must make in response to an infection


Neuro & Behavior
Development follows cephalocaudal and proximal–distal patterns
Acute senses of hearing, smell, and taste
Adaptations of respiratory, circulatory, thermoregulatory, and musculoskeletal systems indirectly indicating central nervous system transition
Reflexes: indication of neurologic development and function

What sense is poorest at birth?
Periods of Reactivity & Rest
First period of reactivity
Birth to 30 minutes to 2 hours after birth
Newborn is alert, moving, may appear hungry
Period of decreased responsiveness
30 minutes to 120 minutes old
Period of sleep or decreased activity
Second period of reactivity* Great time for teaching/bonding
2 to 8 hours
Newborn awakens and shows an interest in stimuli
A healthy newborn will have good variability between states of wakefullness


Normal Newborn Behaviors:

Orientation: response to stimuli-like faces and shiny objects
Habituation: ability to process and respond to auditory and
visual stimuli; ability to block out external stimuli after newborn has become used to activity
Motor maturity: ability to control movements
Self-quieting ability: consolability-what are some parental
behaviors to help here?
Social behaviors: cuddling and snuggling

Teaching Needs
Hospital stays are shorter and we have more information than ever to share with new parents!
ALWAYS treat the newborn as precious. You are a role model for parents.
Check out Healthy People 2020 18-1
Nursing Assessment
Signs indicating a problem
Nasal flaring, chest retractions
Grunting on exhalation, labored breathing
Generalized cyanosis, flaccid body posture
Abnormal breath sounds, abnormal respiratory rates
Abnormal heart rates, abnormal newborn size
Apgar scoring (see Table 18.1)

General Assessment and
Gestational Age

Length and weight, vital signs (see Table 18.2)
Gestational age assessment (see Figure 18.3)
Physical maturity (skin texture, lanugo, plantar
creases, breast tissue, eyes & ears, genitals)

Neuromuscular maturity (posture, square window, arm recoil, popliteal angle, scarf sign, heel-to-ear)...should be assessed when newborn is > 24 hours old

A = appearance (color)
P = pulse (heart rate)
G = grimace (reflex irritability)
A = activity (muscle tone)
R = respiratory (respiratory effort)

Gestational Age
Preterm or premature: prior to 37 weeks’ gestation
Term: 38 to 42 weeks’ gestation
Postterm or postdates: after week 42 gestation
Postmature: after week 42 gestation/placental aging
Small for gestational age (SGA)
Appropriate for gestational age (AGA)
Large for gestational age (LGA)

General Nursing Interventions and Assessment of Newborn
IMMEDIATE INTERVENTIONS

Maintaining airway patency-bulb mouth then nose
Ensuring proper identification-before leaving Mom should have one or two bracelets matching hers, pix within 2 hours, some still use footprints, some DNA or digital prints
Administering prescribed medications (see Drug Guide 18.1)
Vitamin K
Eye prophylaxis
Maintaining thermoregulation

Prenatal history---see page 553
Newborn physical examination
Anthropometric measurements: length, weight, head circumference, chest circumference
Length (17-22 in), Weight (5#8oz-8#14oz), Head (13-15 in about 1/4 of length)
Vital signs
Skin: condition and color; common skin variations (see Figure 18.12)
Head: size, fontanels; variations in head size and appearance (see Figures 18.13 and 18.14); abnormalities in head or fontanel size
Face: nose, mouth, eyes, ears
Eyes-PERL, should be able to track to midline, may have some strabismus or nystagmus until 6 mos, watch for chemical conjunctivitis
Ears-should be lined with outer canthus of eyes, low set ears or malformed ears can be a sign of a syndrome, if ears malformed, evaluate kidneys!, most states require hearing screening now (1 in 1000 deaf, 3 in 1000 have hearing impairment), risk factors are cytomegalovirus and prematurity with NICU stay
Neck, chest-watch for brachial plexus injuries in large babies, breech babies or those with shoulder dystocia-injury may take 6 mos to resolve
Abdomen
Genitalia (see Figure 18.16)
Extremities and back-extremities should be equal in length and skin folds, look at spine for any masses, dimples or tufts of hair-to r/o hip dysplasia, note 18.1
Neurologic status
Alertness, posture, and muscle tone
Reflexes (see Table 18.4 and Figures 18.17 and 18.18)

See APGAR video ATI, and Gestational Age video ATI
Common Skin Alterations
Vernix caseosa
Stork bites or salmon patches
Milia
Mongolian spots
Erythema toxicum
Harlequin sign
Nevus flammeus
Nevus vasculosus

Variations in Head Shape/Size (90% of malformations are in head/neck)
Molding-gone in a week
Caput succedaneum-gone in 3 days
Cephalhematoma-doesn't cross suture
lines, appears after birth and may take weeks or months to go away
Abnormalities
Microcephaly
Macrocephaly
Large, small, or closed fontanels
Ant-diamond, closes by age 2
Post-triangle, small, closes by 3 mos

Providing oxygen
Ensuring warmth
Observing respiratory status frequently
Allowing time for pulmonary capillaries and the lymphatics to remove the remaining fluid

Transient Tachypnea is a common concern in the newborn
PKU
Congenital hypothyroidism
Galactosemia
Sicke cell anemia

Typical Screenings: Will depend on state, but the following are the most common:
The heel puncture should be made on the plantar (sole) surface of the foot. The safest area for heel puncture is medial to a line drawn posteriorly from the middle of the
great toe to the heel, or lateral to a line drawn from between the fourth and fifth toe to the heel. Do not puncture on the posterior curvature of the heel, or on previous puncture sites

Procedure Since laboratory analysis of the specimen depends on an assumed amount of blood in the filter paper circle, it is imperative to carefully follow these procedures. Numerous studies have shown the variability occurring due to improper technique in specimen collection (2-5).

Place infant’s leg in a position that will increase venous pressure.

Warm the heel site to increase blood supply to the area by covering the puncture site for three to five minutes with a warm, moist towel which has been run under tap water at a temperature of not more than 42 degrees C.

Cleanse the puncture site with a sterile alcohol pad. Wipe dry with a sterile gauze pad, as residual alcohol may cause hemolysis of the blood specimen resulting in an invalid specimen.

With a lancet or specialty device, puncture the heel skin with one continuous, deliberate motion at a slight angle (a little less than 90 degrees). Wipe away the first drop of blood with a dry sterile gauze pad, as it is likely to contain tissue fluids that contaminate the specimen.

Allow a second, large drop of blood to form.

Lightly touch filter paper to this large drop of blood. Allow blood to soak through and completely fill the preprinted circle with a single application to this large blood drop. (To enhance blood flow, very gentle intermittent pressure may be applied to area surrounding puncture site.) Do not use capillary tubes. Do not touch the same circle to blood several times, as this causes a “layering effect.” Do not “milk” area surrounding puncture site. Milking may cause an admixture of tissue fluids with blood specimen, resulting in an invalid specimen. Apply blood to one side of filter paper only. (Either side may be chosen for this procedure.) Never apply additional blood to a filled circle. Repeated drops are not accepted.

Fill remaining circles in same manner as step 6, with successive drops of blood. If blood flow is diminished, repeat steps three through six with sterile equipment.

Care of skin puncture site should be consistent with your institution’s procedures.

Specimens must be mailed within 24hrs. Allow to dry thoroughly, on level surface, DO NOT STACK OR ALLOW BLOOD TO TOUCH EACH OTHER DURING DRYING

CHECK OFF SKILL!
General newborn care
Bathing and hygiene (see Teaching Guidelines 18.1 and Nursing Procedure 18.2)
Gloves
Plain water on face and eyes; mild soap for rest of body
Elimination and diaper area care
Urine characteristics
Stool pattern
Diaper area care
Cord care (see Teaching Guidelines 18.2)-usually cord clamp comes off in 24 hours, care will depend on facility policy
Circumcision care-assess bleeding every 30 mins for 2 hours, then with diaper changes, watch for and record first void, to wash drip soapy water, rinse and then pat dry, apply vaseline gauze, if plastibell used, will fall off in a week
Safety (see Teaching Guidelines 18.3)
Prevention of abduction-transport in crib at all times
Car safety-rear-facing until 2 yrs, after that will graduate up, for children back seat is best
Infection prevention
Sleep promotion-don't expect to sleep through the night! pros and cons to co-sleeping
Bonding
NOTE! These are parental teaching needs as well!
General newborn care
Bathing and hygiene (see Teaching Guidelines 18.1)
Plain water on face and eyes; mild soap for rest of body
Elimination and diaper area care
Urine characteristics
Stool pattern
Diaper area care-teach wash hands before and after, wipe girls front to back, barrier cream is good, exposure to air is good, no plastic pants!
Cord care (see Teaching Guidelines 18.2)
Circumcision care-if applicable
Safety (see Teaching Guidelines 18.3)
Prevention of abduction-teach parents to entrust infant ONLY with personnel with a special tag
Car safety
Infection prevention
Sleep promotion-discuss pros/cons of co-sleeping, discuss crib
Bonding-see page 575
Nursing Management Nutrition
Physiologic changes
Nutritional needs
Calories (110-120 cals/kg/day)
Fluid requirements
Feeding method choice
Feeding the newborn
Frequency
Measures to decrease air swallowing
Infant needs to mature before starting solid food (sit up, better head control)

Iron- should be ok for first 6 mos, then supplement in formula or in drops for breast-fed babies
Vitamin D-started in first few days of life and given daily
Fluoride-supplemented after 6 mos if infant not getting fluoridated water

Weaning-start cutting out bottles/feedings, leave hs for last, if needs bottle at hs, make it water

New foods should be introduced one at a time, every 3-5 days:
cereal, fruits, veggies, meat, eggs last

Nutrition Teaching Needs
Physiologic changes-baby should double by 4-6 mos, and triple by year!
Nutritional needs
Calories
Fluid requirements
Feeding method choice
Feeding the newborn
Frequency
Measures to decrease air swallowing


Breast Feeding (see Box 18.2)
Composition
Assistance
Positioning
Education
Storage and expression
Concerns
Sore nipples
Engorgement
Mastitis

Breastfeed every 2-3 hrs or WHENEVER! 10-20 mins each breast, use safety pin to keep up with which breast to start with, vary positions, insert a finger to break suction, burp between breasts and at end
6-10 wet diapers a day, baby gaining weight
No supplementation, no other nipples unless painful procedure

See NCP 18.1 and Teaching Guidelines 18.4
See storage of milk page 586

L: How well infant latches onto the breast
A: Amount of audible swallowing
T: Nipple type
C: Level of comfort
H: Amount of help mother needs

Bottle Feeding
Types of formula
Assistance
Positioning
Education
Weaning and introduction of solid foods
Should feed every 3-4 hrs, finishing a bottle in 30 mins
DO NOT PROP!!!
Teach parents about possible equipment-how to test older nipples, discuss differences in ready-to-feed, liquid concentrate and powders, how to warm
Follow-up care: call LIP if: T > 101 degrees F, forceful vomiting, not eating, two or more green/watery BMs, changes in B/B habits, excessive lethargy/sleepiness,
inconsolable crying, extreme fussiness, abdominal distention, difficult breathing
Return visit
Warning signs and symptoms
Immunization information-Hep B in hospital, others start 2 mos

IM to Newborn: Vitamin K and Hepatitis Vaccination

Vitamin K-why is it necessary?
What site will we use?
1" 23 or 25 gauge needle
Always record 5 rights, plus site
If giving immunization:
provide written information
get consent
record manufacturer and lot number
CHECK OFF SKILL!
CHECK OFF SKILL!
Eye Prophylaxis
Why is it done?
When is it done?
How is it done?
Apply from medial lower to lid to lateral lower lid
Don't touch the applicator to the eye
Wipe excess ointment off of face to prevent burning in
warmer


Transient murmurs may be heard during neonatal period and may be normal
Blood volume is 80-85ml/kg in term infant
Factors affecting H&H are delayed cord clamping, and site of blood draw (capillary blood will have higher H&H)
How can we create a NTE?
Dry the infant at birth
Cover the biggest part!
Prewarm blankets and hats and anything baby will come in contact with (cover a metal scale)
Encourage skin-to-skin
Promote early breast-feeding
Keep equipment charged and ready, warm them up
Don't bathe until baby is stable
Put temperature probe over liver area
Keep baby's basinette out of drafts and away from walls

Risk for Hypoglycemia
Infants have a blood glucose level 70-80% of Mom's at birth.
What's going to happen if Mom has high
blood glucose?
Newborn hypoglycemia is < 30 at birth, < 40 in first 72 hrs
Those at risk (Moms with DM, preterms, IUGR, poor feeds, septic, hypothermia, hypothyroid) should be monitored closely
Treat with sugar water or formula feeding, rarely IV will be needed
Three groups of jaundice based on mechanism of accumulation of bilirubin
Overproduction-those excess RBCs aren't needed now that baby breathes room air, also RBCs only live about 80 days compared to 120 in adult
Decreased conjugation-ie. breastfeeding
Impaired excretion-liver can't handle the load either from being immature or from another
problem, can't get the bili into bile and out with the stool
Infants at risk are those who have a blood imcompatibility with Mom, are premature, are breastfeeding, drugs (Pitocin is one), maternal gestational diabetes, infrequent feedings, males, trauma (cephalhematoma or bruising), sibling with h/o, infections with TORCH, Asians or Native Americans

For prevention and treatment: Encourage Mom to feed/nurse often...the more the baby is stooling and the more adequate hydration, the more bili is being eliminated, monitor for jaundice with VS in well-lit room, exposure to sunlight is good, next line of tx is artificial phototherapy, and rarely exchange transfusion
Three levels of assessment for newborn: 1) Immediate: In delivery room (APGAR, listen for cry, watch for nasal flaring, grunting, labored breathing, cyanosis, abnormal breath sounds or rate (<25 or > 60 breaths/min), flaccid posture, abormal heart rate (< 100 or > 160 beats/min)
2) The next assessment is more in depth, done at 2-4 hours
3) The third is most comprehensive and is done before discharge...gestational age, reflexes, hearing screening, etc.
VS every 30 mins X 2 hours, then every 4-8 hours

Listen to apical pulse for full minute (fourth intercostal space)
What is sinus arrhythmia? Should you call the doctor?

Palpate brachial and femoral pulses as well


In boys, are both testes descended?
Is urinary meatus at the tip of the glans?

For girls, is the meatus directly beneath the clitoris?

Warn parents of girls about possible pseudomenstruation
For Nipples: wear a bra (not too tight), don't use soap to wash, change breast pads when wet, apply a few drops of milk to nipples after feeding, let air dry
For engorgement: keep nursing, take warm shower, use warm compresses, wear supportive bra, manually express milk
For Mastitis: keep nursing, seek tx for chills, fever or malaise
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