Care of the Newborn

Question 1

The first few hours after birth are a critical time of adaptation for the newborn
The primary goal of newborn care is to maintain safety and homeostasis.
The priority nursing interventions are those that support the maintenance of a patent airway, adequate oxygenation/circulation, and thermo-regulation.
their body systems specifically respiratory and cardiovascular move from fetal function to extra uterine life

Answer 1

Adaptations to extrauterine life

Question 2

once the umbilical cord is cut air inflates the lungs with the first breath
the first breath is the most challenging breath for the newborn
subsequent breaths are built on residual air that keeps the alveoli open and requires less exertion
during a vaginal birth some of the fluid is squeezed out or drained from the trachea and lungs
cesarean section babies are more at risk of respiratory distress due to less fluid being squeezed out
healthy infants establish respirations within one minute of Life while the remaining fluid in the lungs is absorbed
a Lusty cry is indicative of good respiratory effort
pulmonary surfactants line alveoli and allow adequate exchange of oxygen and carbon dioxide
Normal
Abnormal

Answer 2

Respiratory

Question 3

Respiratory rate = 30 to 60 per minute
Irregular, rapid
Chest and abdomen rise with inspiration
Residual fluid (amniotic) may be present

Answer 3

Normal - Respiratory

Question 4

common causes of respiratory distress syndrome in the newborn in the first hours of Life are retained lung fluid the maturity of the lung aspiration and sepsis
Sternal retractions
Expiratory grunting
Nasal flaring
Overinflation of chest
Flaccid muscle tone
Respiratory rate > 60 or < 30

Answer 4

Abnormal - Respiratory

Question 5

first breaths combined with increased alveolar capillary distension inflate the lungs and reduce pulmonary vascular resistance to pulmonary blood flow
from the pulmonary arteries pressure drops and pressure in the right atrium declines
increase pulmonary blood flow from the left side of the heart increases pressure in the left atrium which causes a functional closure of heart
kidneys circulating prostaglandin levels also have an important role in closing the ductus arteriosus
functionally closes within the first 24 hours after birth with permanent closure usually occurring within two to three months
the ductus arteriosis becomes a ligament when the cord is clamped and severed the umbilical arteries umbilical vein and ductus spinosis are functionally closed they’re converted into ligaments within 2 to 3 months the hypogastric arteries also occlude and become ligaments
Normal
Abnormal

Answer 5

CV

Question 6

Heart rate: 110-160 bpm
Due to fetal circulatory shunts transitory heart murmur may be present
Acrocyanosis - Blue hands and feet

Answer 6

Normal - CV

Question 7

Heart rate persistently <110 or >160 bpm
Central or circumoral cyanosis

Answer 7

Abnormal - CV

Question 8

heat regulation is critical to the newborn survival during the first 12 hours after birth
Maintenance of balance between heat loss and heat production.
Newborn’s challenges:
Non-Shivering Thermogenesis
Cold Stress

Answer 8

Thermoregulation

Question 9

attempts to achieve thermal balance and adjusting to the extra uterine environmental temperature
is the maintenance of balance between heat loss and heat production
attempt to stabilize their core body temperatures within a narrow range
maintenance of balance between heat loss and heat production
challenges they have a rather large surface area in proportion to their body mass and they have far less subcutaneous fat (brown fat) they have an immature temperature regulating Center
large surface area in proportion to body mass
less subcutaneous fat (brown fat)
immature temperature regulating center
immature cardiovascular system

Answer 9

Newborn’s challenges: - Thermoregulation

Question 10

Brown fat - more vascular than regular fat which we have as adults so this increases heat closer to full term
increased metabolic activity
activity of brown fat

Answer 10

Non-Shivering Thermogenesis - Thermoregulation

Question 11

Brown fat is lost under cold stress
lot of our interventions are aimed at keeping baby warm
we know the absolute best way to do that is skin to skin
will use radiant warmers
we swaddle we put a hat on initially we keep them dry so you know checking their diaper to make sure that they’re not sitting there
hold it close so your body heat is going to help with that temperature regulation for the baby as well
Loss of heat that increases oxygen and energy demands

Answer 11

Cold Stress - Thermoregulation

Question 12

Normal range - 36.5° C and 37.5° C (97.7° F to 99.5° F) axillary
Protect infant against hypothermia and hyperthermia
Don’t lay newborn on cold surfaces (use warmers or mom’s chest)
Don’t use hats (SIDS) after the initial transition period
Keep infant wrapped in swaddle
Encourage Skin-to-skin (Kangaroo care)

Answer 12

Nursing care: thermoregulation

Question 13

take temperatures axillary some of those thermometers may actually be in the mode of Celsius -
do need to protect the infant against hypothermia and hyperthermia
hyperthermia which is just as detrimental
have to keep that fairly narrow range of 97.7 to 99.5
don’t lay the newborn on cold surfaces

Answer 13

Normal range - 36.5° C and 37.5° C (97.7° F to 99.5° F) axillary - Nursing care: thermoregulation

Question 14

greater breastfeeding initiation and exclusivity rates more rapid mother infant interaction earlier infant thermoregulation decreased maternal and newborn stress reactivity and a reduction in newborn pain response during painful procedures

Answer 14

Encourage Skin-to-skin (Kangaroo care) - Nursing care: thermoregulation

Question 15

output is fairly low in that first 24 hours
by the time that they’re a week old we’re getting 6 to 10 voids a day which would indicate adequate formula and or breast milk intake
1 void/day of life
6-10/day after 5 days of life
Assess: # of voids; signs for dehydration
nursing care associated with the urinary system would be to assess the number of voids per day so output is the absolute best indicator of pediatric hydration
so how do you know the breastfeeding is going well - how often is the baby voiding number one fontanels capillary refill
you know babies are going to be lethargic if they’re not getting adequate intake as well

Answer 15

Urinary - System adaptations

Question 16

Capacity 30-60mL
stomach capacity of a neonate is only 30 to 60 mils
only one to two ounces
especially in the first one to two days after delivery they have an immature cardiac sphincter so there is quite a bit of regurgitation which can be fairly normal they’re emptying time is irregular
so your breastfed babies stomachs empty much faster than the bottle fed baby and that has to do with the components of breast milk versus Formula breastfed babies that that nutrition that’s coming in is already broken down to its simplest parts so it doesn’t take long for it to be digested
Stool transition (meconium > breast/bottle)
very first stool that we see in a newborn it would be a meconium stool it’s usually passed in 8 to 24 hours after birth
It is odorless cuz meconium does not have bacteria in it
transitional stool is going to occur about 3 to 5 days after birth and it is loose and a greenish yellow colored and that’s regardless of whether this is breast milk or or formula
the breastfed stool is going to be yellow and soft and loose and it’s not going to have a super foul odor - seedy consistency
bottle fed stool is much paler yellow to a brownish yellow and it may have more of a foul odor it is more formed it’s less a watery
Assess: gag reflex, stool pattern, intake, bowel sounds, abdominal circumference
assess their ability to swallow their sucking reflex the gag reflex we’re going to assess for a patent anus some institutions will assess for that patent anus we are going to assess their stool pattern so we’re going to keep track of how many stools they have in a day and intake
Bowel sounds and abdominal distention - we do an abdominal circumference for the neonate
burp the infant during and after feedings - it’s also very important that we teach these parents that when they’re formula feeding to do that often

Answer 16

GI - System adaptations

Question 17

normal 45 to 90 mg
glucose is essential for the central nervous system
90% of liver glycogen is used by the end of the third hour of life - cost of respirations thermoregulation and muscle activity
we need to get the baby to eat in the first 6 hours Hours
Risk for hypoglycemia: maternal diabetes, preterm infant, LGA/ SGA, cold stress, and asphyxia
depleting events are asphyxia cold or heat stress hypoglycemia sepsis decrease glycogen stores and hyperinsulinemia seen in these babies of gestational diabetic moms
signs of hypoglycemia are apnea cyanosis rapid irregular regular respirations Tremors jitteriness
Assess: tremors, jitteriness, twitches, mottled skin, lethargy, weak cry

Answer 17

Endocrine - System adaptations

Question 18

brain goes through a period of extreme rapid growth and will continue into the second year of life
order of brain development is from simple to complex
immature neuromuscular system makes babies very jumpy they startle easily
they’ll have the chin Quivers
Immature system evident in “jumpy” behavior
Assess reflexes: Moro, Babinski, Palmar grasp, Rooting, Sucking, Stepping

Answer 18

Neuromuscular - System adaptations

Question 19

Vernix
Thick white cream cheese substance referred to vernix
substance that the baby is covered in for the duration of the pregnancy that protects their skin from the watery environment
a lot of it is more indicative of a younger gestation
less is more indicative of an older gestation
Ecchymosis
your term babies and your post date babies ecchymosis is bruising that can be due to birth trauma
Milia
actually appears to be more like a whitehead but it’s actually a plug and it usually opens at about 4 to 6 weeks - if you’re a picker don’t be trying don’t be trying to extract anything out of these immature sebaceous glands - going to end up causing infection and some trauma to their skin
Lanugo
Downy fine hair that covers their body
preterm babies have far more
Slate gray spots
changed the name this is a hyperpigmentation
area on a newborn you’re going to see these in babies of color
Erythema toxicum
refer to as a newborn rash
that has everything to do with the immaturity of the sebaceous glands and the hair follicles and it can look very distressing to some parents and many times this can convert over to cradle cap
stork bites or tolandiatric nevi
another variation
we refer to these is angel wings
they’ll have them over the eyes/between their eyes up there on the forehead and they fade as the child gets older

Answer 19

Integumentary - System adaptations

Question 20

Testes usually descend into scrotum by term
some term babies are born and one or both the testes are not fully descended and so when we do an assessment we’re checking the inguinal canals for the testes
Foreskin
Assess especially those babies that the parents wish for them to be circumcised
make sure that the that the urethra is appropriately placed at the head of the penis
Assess for hypospadia
assess for hypospadia - means that the urethra is actually positioned further down the tip of the penis which many times if the baby has a true hypospadia they will not be able to be circumcised and they’ll be referred to your Urology just to make sure that they’re Anatomy is normal

Answer 20

Reproductive: male - System adaptations

Question 21

Labia swollen at delivery
where the female infant will pass a blood-tinged vaginal mucus and this is just due to circulating maternal hormones both male and female infants
Both male and female infants will also have swollen breast tissue at Birth and this is also due to maternal hormones
Pseudomenstruation

Answer 21

Reproductive: female - System adaptations

Question 22

liver is the most immature of the GI organ so it poorly conjugates Billy Reuben the approximate level of Billy Rubin
Physiologic jaundice
Pathologic jaundice

Answer 22

Hepatic

Question 23

whenever a child is cold stressed prematurity if they have an issue maintaining their glucose drugs and that’s usually maternal drugs and then any bruising or bleeding that occurs because of trauma during the delivery
so when you look at the physiologic this happens usually about 2 to 3 days after birth so we are going to get a bilirubin on all of our babies before their discharge
to get a Baseline and physiologically this is just caused by a breakdown of red blood cells for whatever reason and because of that immature liver you’ll notice a little bit of a yellowish appearance
usually self-limiting and disappears within a week
breakdown of red blood cells
immature liver and GI tract
yellowish appearance of skin, sclera, mucus membranes due to increased bilirubin in blood
occurs 2-3 days after birth
Self-limiting and disappears with a week
Bilirubin under 12 mg
No treatment

Answer 23

Physiologic jaundice

Question 24

happens within the first 24 hours or after a week of birth and it will last longer than a week
treatment is done with phototherapy or blood transfusion
Occurs during first 24 hours of birth, or after 1 week
lasts longer than 1 week
bilirubin level over 12 mg
treatment with Phototherapy light or blood transfusion
Severe case - Rh sensitization and ABO incompatibility - compatibility is one of the big reasons for pathologic jaundice
Predisposing Factors (pathology)

Answer 24

Pathologic jaundice

Question 25

Assessed every 8-12 hours
Draw discharge serum total bilirubin or transcutaneous (12-15 mg/dL)
Ensure adequate feedings
Phototherapy

Answer 25

Nursing care: jaundice

Question 26

In some cases of hyperbilirubinemia phototherapy is necessary to lower bilirubin levels so you need to assess for jaundice by gently applying pressure with a finger to the skin over a bony surface and then release the pressure if the blanched area appears yellow jaundice is present
goal is to prevent severe hyperbilirubinemia and the complications of current interest and bilirubin encephalopathy so if jaundice gets too severe we can definitely have some brain damage
there adequate feeding is essential to jaundice prevention
we have to clear it through the GI tract
photo therapy converts unconjugated bilirubin to conjugated bilirubin so that it may be excreted through urine and stool by the newborns you can see how adequate feeding to increase urine and stooling is so essential in helping with that severe jaundice special blankets and pads
assess them every 8 to 12 hours
we’re going to draw the discharge serum total bilirubin and then while they’re under phototherapy you’re going to draw that once or twice a day ensure adequate feeding so obviously at the baby is under is in an isolette with phototherapy they can be away or out of the phototherapy to nurse or to feed
have to reposition these babies so they’re not laying in one position for terribly Long periods
Monitor their temperature while they have come up with some great sources of phototherapy we still got to be very careful not to cold stress these babies and make the condition worse
want to protect their eyes

Answer 26

Assessed every 8-12 hours - Nursing care: jaundice

Question 27

Repositioned every 2-3 hours
Monitor temperature
Eye shields dependent on source of light

Answer 27

Phototherapy - Nursing care: jaundice

Question 28

24 hours is the most critical time for the newborn immediately after birth
we’re going to clear the airway clamp and cut the cord
immediately dry the infant and place in the mom’s chest when possible obviously if the baby’s in distress or isn’t breathing crying Etc then that drying may need to happen under the radiant warmer
during active assessment they’re going to assign an apgar score at the first in the 5 minutes Clear the airway
Clamp and cut the cord
Dry immediately and place on Mom’s chest when possible
Apgar score

Answer 28

First 5 min - Immediate care of the newborn

Question 29

within the first two hours of life we’re going to administer Hepatitis B if it’s been consented vitamin K and erythromycin both are standing orders and state mandated
vitamin K we give because prevention of bleeding especially brain bleeds
Any of these little boys are going to get circumcised that they will need to get their vitamin K shot
erythromycin is prevention of eye infections from passing through the birth canal or through the skin during cesarean birth
infant protocols for assessing blood glucose - gestational diabetic babies/preterm babies
identification of the newborn - use Footprints & Mom’s right index finger thumbprints Etc and then sometimes also do a another layer of security with another tag on the baby so as to prevent abduction
Hepatitis B Vaccine
Vitamin K
Erythromycin
Protocols for assessing blood glucose (for GDM or preterm babies)
Identification

Answer 29

First 2 hrs - Immediate care of the newborn

Question 30

Apgar the acronym apgar stands for appearance pulse Grimace activity and respiratory effort
higher the number the better the score - the better the baby is doing to transition the lower the score the more that we more interventions that we have to do to raise the score so one in 5 minutes so you’re sitting here thinking this baby is born
then we’re going to reassess the same components in 5 minutes and you’re probably going to even have a better score than you did it the one minute
HR
Respiratory effort
Muscle tone
Reflex irritability
Color

Answer 30

APGAR

Question 31

0: absent
1: <100
2: >100

Answer 31

HR

Question 32

0: absent
1: gasping, irregular, slow
2: good cry

Answer 32

Respiratory effort

Question 33

0: flaccid
1: some flexion of extremities
2: tight flexion/active movement

Answer 33

Muscle tone

Question 34

0: no response
1: weak cry/grimace
2: vigorous, lusty cry

Answer 34

Reflex irritability

Question 35

0: blue, pale, grey
1: body pink, blue extremities
2: completely pink

Answer 35

Color

Question 36

Search for newborn screening there’s two different types of newborn screening that we do one is metabolic and one is hearing both of these screenings are done after 24 hours of life and before discharge
Metabolic
Hearing

Answer 36

Newborn screening

Question 37

result in severe health problems
Detects 35 core disorders
Early detection!
Samples collected between 24 hours after birth and before discharge

Answer 37

Metabolic - Newborn screening

Question 38

the hearing screen is not invasive
non-invasive technology screening provides information about Pathways from the external ear to the cerebral cortex and measures the responsibility infants acoustic nerve
if they don’t pass they’ll repeat that in a few hours and if they persistently fail the hearing screen repeat screening at 3 months of age
Non-Invasive
Performed prior to discharge
If do not pass, repeat in a few hours
Persistent failure refer to audiology at 3 months

Answer 38

Hearing - Newborn screening

Question 39

Male circumcision the American Academy of Pediatrics does not recommend the routine removal of the male foreskin however they do acknowledge the health benefits - decreased UTIs decreased incidence of penile cancer decreased risk for heterosexual transmitted STIs
usually performed two to three days after birth
neonate is secured to a plastic board - a local anesthetic is administered as a dorsal penile block the procedure is done with a plaster bill or a clamp takes just a few minutes
to perform post circumcision care includes assessing for active bleeding and lots of parent education
Parental decision
Procedure
Procedural pain management
Care of the newly circumcised infant

Answer 39

Care management: circumcision

Question 40

The physiologic responses to pain in the newborn can result in significant changes in heart rate blood pressure intracranial pressure vagal tone respiratory rate and oxygenation
crying is the most common behavioral sign of pain in the neonate
every neonate should have an initial pain assessment and Pain Management plan tools used to assess pain
goals of pain management are to minimize the intensity duration and physiologic cost of pain and to maximize the neonates ability to cope
some non pharmacologic techniques include swaddling breastfeeding skin to skin oral sucrose for procedural pain is by far the most commonly used pain control measure
Neonatal responses to pain
Assessment of neonatal pain
NIPS, PIPS, NPASS, CRIES
Management of neonatal pain
Minimize intensity, duration, and physiologic cost of pain
Maximize neonate’s ability to cope with and recover from pain
Non-pharmacologic (i.e. swaddle)

Answer 40

Care management: neonatal pain

Question 41

So let’s look at the temperature instructions about promoting normal body temperature include dressing the infant appropriately for the environmental temperature and protecting the skin from exposure to direct sunlight
to teach them to take an axillary temp and then educate them on that normal temperature range
if they’re going to be outside in the direct sunlight we want to make sure that they’re sensitive skin is covered
Appropriate dressing
Sun exposure
When to notify provider

Answer 41

Temp - Discharge planning and parent edu

Question 42

The nurse provides information to parents regarding the normal characteristics of newborn respirations emergency procedures and measures to protect the infant such as avoiding contact with persons with respiratory illnesses
also a good time to talk to them more about safe sleep and what would be appropriate as far as the position for them to sleep in and making sure that they keep any Suffocation hazards out of their sleeping area
Safe sleep!
Normal respiratory characteristics

Answer 42

Respirations - Discharge planning and parent edu

Question 43

normal elimination patterns of newborns helps parents recognize problems related to voiding or stooling
the desired you’re an output for the infant is at least two to six voidings per 24 hours for 1 to 3 days so important to know first 24 hours
their stools are going to vary
Urine OP 2-6 voids/24 hours for first 1-3 days; 6-8 voids a day by day 4 and beyond.
Stooling varies according to feeding preference

Answer 43

Elimination - Discharge planning and parent edu

Question 44

Temp
Respirations
Feeding
Elimination
Sleep, position, hold
Rashes
Clothing
Car seat safety
Pacifiers
bathing/cord care
Infant follow-up care
Cardiopulmonary resuscitation
Practical suggestions for first weeks at home
Interpretation of crying and use of quieting techniques
Recognizing signs of illness

Answer 44

Discharge planning and parent edu

Question 45

Supine position for sleep during the first year of life is indicated to reduce the incidence of sudden infant death syndrome however we don’t want them to stay on their backs all the time - decreases the risk of positional plagiocephaly
we want them to do quite a bit of tummy time
educate on safety - not leaving them unattended not putting them on a Surface where they could easily roll off
Back to sleep for first year of life
Tummy Time
Safety

Answer 45

Sleep, position, hold

Question 46

commonly known as diaper rash
it’s usually an irritant contact
it’s red can be scaling blisters it’s very uncomfortable to the newborn
this is actually caused by yeast
the diaper area is going create a warm moist environment so you’re going to have an overgrowth of candida
other rashes they can get into contact with just a rough surface or the blankets or even their fingernails and such and they’ll scratch their face and for these little bit older babies once they start sucking on a pacifier that moisture up against their their skin any moisture that gets trapped up against your skin is conducive for any kind of candida

Answer 46

Diaper dermatitis - Rashes

Question 47

It’s just that newborn rash and that’s just caused by their very sensitive immature skin and contact with environmental stressors
end up with in the first few weeks of life

Answer 47

Erythema toxicum - Rashes

Question 48

Dress for comfort
Avoid over-dressing
Don’t over dress the baby so when they’re outside make sure that they’re covered up rear facing until 2 years of age car seat safety talk about a pet peeve I hate driving down the road and seeing a very very young baby in the front seat or not secured properly infants and toddlers to the age of two years of age

Answer 48

Clothing

Question 49

Rear-facing until 2 yrs old
I very very young baby in the front seat or not secured properly infants and toddlers to the age of 2 years of age should travel only in federally approve rear-facing safety seat secured in the rear seat using the vehicle safety belt or an anchor and tether system that faces the rear gives the best protection for an infant’s disproportionately weak neck and heavy head and this position
Best protection for weak neck and heavy head - force spread over head, neck, and back with front crash; supports spine

Answer 49

Car seat safety

Question 50

Sucking provides pleasure - sucking needs not satisfied by feeding alone - infants suck on fingers/pacifiers
Decreased risk for SIDS - compelling evidence
Cleaned often and replaced regularly
Not coated with sweet solution
Delayed use with breastfeeding infants until BF establish well

Answer 50

Pacifiers

Question 51

Opportunity to cleanse skin, thorough phys assessment, promote comfort, parent and fam and infant interaction
Imp to maintain acid mantel - formed from upper most layer of epidermis
Use neutral pH cleanser protect newborn skin - without preservatives that are not tolerated
Anti-microbial cleansers not used
Water warm and deep to cover shoulders
Keep cord dry; falls of 10-14 days
Daily bath not necessary - harm integrity of skin
Daily cleansing of face and perineal
Talk to baby - engaging of imitation
Cord care - decrease risk hemorrhage and infection - clean cord with water during initial bath and routine bathing - not antiseptic methods necessary; leave it alone
Plastic cord clamp removed before discharge with cord dried - cord separation time determined type of birth and cord care and perinatal events - avg 10-14 days

Answer 51

bathing/cord care

Question 52

Occurs with 48-72 hrs at ped clinic/HCP office
Esp imp for BF newborns - monitor weight and hydration status

Answer 52

Infant follow-up care

Question 53

Esp imp for infants preterm or hx cardiac/resp probs

Answer 53

Cardiopulmonary resuscitation

Question 54

Care management point towards helping parents cope with infant care, role changes, altered lifestyle, changes in fam structure with addition of new baby
Classes in prenatal period or postpartum stay helpful

Answer 54

Practical suggestions for first weeks at home

Question 55

Crying first social communication - all cry - hungry, uncomfy, wet, bored, no reason
Longer around infants - learn meaning and respond appropriately
Strategies to calm fussy baby - sensory strategies - tactile, visual, auditory, vestibular - mild, slow, rhythmic, consistent, regularly presenting - pat on bottom, massage back, rock, humming, swaddle - white noises - sound

Answer 55

Interpretation of crying and use of quieting techniques

Question 56

Imp: assessment of jaundice if d/c early - evidence that educated on this
First fever - anything greater than 100.4 or less than 97.7
Poor feeding
Little interest in feeding
More than 1 episode of forceful vomiting or multiple vomiting
Bilius - bright green color emesis
Bright red emesis
2 consecutive green watery stools - severely dehydrated when diarrhea
Decreased BM with BF <3 stools or change in BM
<6-8 urination by 3rd day
Labored breathing with flared nostrils OR apnea for 15+ seconds
Lethargy
Inconsolable crying
bleeding/discharge from umbilical cord or eyes
Cyanosis
In handout or something readily available - imp not give 30 min before send out door

Answer 56

Recognizing signs of illness