Flashcards in Lecture 7 Care of the newborn and newborn complications Deck (66):
Which clinical findings would alert the nurse that the neonate is expressing pain?
Cry face; eyes squeezed; increase in blood pressure. [Crying and an increased heart rate are manifestations indicative of pain in the neonate. Typically, infants tightly close their eyes when in pain, not open them wide. In addition, infants may display a rigid posture with the mouth open and may also withdraw limbs and become tachycardic with pain. A high-pitched, shrill cry is associated with genetic or neurologic anomalies.]
*Usually benign - occurs in almost all preterm infants and over 60% of healthy term infants.* An increase in serum bilirubin - reaches 10-12 mg/dL by the 5th or 6th day of life (this is double the usual peak for newborns).
A more severe form of hyperbilirubinemia in the newborn in which jaundice is observed with 24 hours after birth, the cord blood has a concentration above 5 mg/dL, serum concentration exceeds 12.9 mg/dL in a term infant or 15 mg/dL in a preterm infant, or the jaundice persists for more than 14 days in a term infant.
The most common causes of pathologic hyperbilirubinemia are _
Hemolytic diseases of the newborn (typically caused by blood group differences between the mother and the baby).
Rh incompatibility is *only* created when _
An Rh-negative mother is carrying an Rh-positive fetus.
Rh immune globulin (RhoGAM)
1. An injection of passive antibodies against the Rh factor that destroys any fetal RBCs in the maternal circulation and blocks the maternal antibody production.
2. Given only to *Rh-negative mothers*, at *28 weeks of gestation*. Should also be given within *72 hours after delivery* of an Rh-positive fetus (to prevent sensitization for future pregnancies).
*Primary intervention for the prevention/management of hyperbilirubinemia.*
Can be done every 1-2 weeks between 26 and 32 weeks; after 32 weeks, a C-section will usually be performed.
Which statement regarding hemolytic diseases of the newborn is most accurate?
The indirect Coombs’ test is performed on the mother before birth; the direct Coombs’ test is performed on the cord blood after birth.
1. Having less than 300 mL of amniotic fluid.
2. Associated with fetal renal abnormalities.
1. Having more than 2 L of amniotic fluid.
2. Associated with gastrointestinal and other malformations.
Apgar score - timing and interpretation
At 1 minute and at 5 minutes after birth.
3 = severe distress.
4-6 = moderate distress.
7-10 = no distress.
Apgar scoring - heart rate (auscultate chest or palpate umbilical cord)
0 if absent.
1 if less than 100 bpm.
2 if greater than 100 bpm.
Apgar scoring - respiratory effort (observe chest movement)
0 if absent.
1 if cry is slow or weak.
2 if cry is good.
Apgar scoring - muscle tone (observe degree of flexion and movement of extremities)
0 if flaccid.
1 if there is some flexion of extremities.
2 if well flexed.
Apgar scoring - reflex irritability (based on suctioning of the nares or nasopharynx)
0 if no response.
1 if grimaces.
2 if cries.
Apgar scoring - color
0 if blue or pale.
1 if the body is pink, but extremities are blue (acrocyanosis).
2 if newborn is completely pink.
Apgar score - acronym
The "neonatal period" constitutes _
The first 28 days of life.
Day 15 - 8 weeks. Most critical time for organ development; vulnerable to teratogens - substances or exposure that cause abnormal development.
Preterm: Birth before 37 0/7 weeks.
Late preterm: 34 0/7 through 36 6/7 weeks.
Early term: 37 0/7 through 38 6/7 weeks.
Full term: 39 0/7 through 40 6/7 weeks.
Late term: 41 0/7 through 41 6/7 weeks.
Postterm: 42 0/7 weeks and beyond.
Fetal shunt that allows blood to bypass the liver to the inferior vena cava.
Turns into a ligament (ligamentum venosum) after obliteration.
Fetal shunt in which blood passes across the ventricular septum from the right atrium to the left atrium.
*First shunt to close (functionally), due to cord clamping and increased systemic vascular resistance.* Closes structurally during the first months or years.
Fetal shunt that connects the pulmonary artery to the aorta - bypasses the lungs.
Closes in response to increased oxygen and decreased circulating prostaglandins.
First period of reactivity
Lasts up to 30 minutes after birth; newborn’s heart rate increases to 160 to 180 beats per minute but gradually decreases after 30 minutes. The infant is alert.
Period of decreased responsiveness lasts from 60 to 100 minutes; after first period of reactivity, newborn either sleeps or has a marked decrease in motor activity.
Second period of reactivity
Occurs 2 to 8 hours after birth; lasts from 10 minutes to several hours.
Tachycardia, tachypnea occur; increased muscle tone; improved skin color; mucous production; meconium typically passed.
Neutral thermal environment
An environment in which body temperature is maintained within a normal range, while the metabolic rate, and thus glucose and oxygen consumption, is minimal.
Loss of heat to moving air at the skin surface and around the body.
*Drafts from air vents, cold oxygen.
Transfer of heat between two objects in the environment that are not in direct contact with each other.
*Keep cribs away from windows, nursery wall, and air drafts.
Transfer of heat from one object to another when in contact with each other.
*Cold scale, cold bed surface, cold stethoscope.
Liquid converted to a vapor; loss of heat through vaporization of moisture through the skin to the environment.
*Wet baby in delivery or during bath.
Normal neonatal vital signs
Heart rate: 110-160 bpm.
Respirations: 30-60 breaths/min.
Axillary temperature: 97.7 / 36.5 - 99.5 / 37.5.
Blood pressure: 60-80 / 40-50.
Which statement regarding the development of the respiratory system is a high priority for the nurse to understand?
Maternal hypertension can reduce maternal-placental blood flow, accelerating lung maturity. [A reduction in placental blood flow stresses the fetus, increases blood levels of corticosteroids, and thus accelerates lung maturity.]
Which statement concerning neurologic and sensory development in the fetus is correct?
Fetuses respond to sound by 24 weeks of gestation and can be soothed by the sound of the mother’s voice. [Hearing develops early and is fully developed at birth. Brain waves have been recorded at week 8. Eyes are receptive to light at 28 weeks of gestation. The fetal brain is approximately one fourth the size of an adult brain.]
Normal newborn weight
2500 - 4000 grams.
5 lbs., 8 oz. - 8 lbs., 13 oz.
Normal newborn length
45 - 55 cm or 18 - 22 inches.
Premature fusing of the suture lines, must be followed up. Treatment is surgical to allow for proper brain growth.
How would the nurse optimally reassure the parents of an infant who develops a cephalhematoma?
A cephalhematoma may occur with a spontaneous vaginal birth. [The nurse should explain that bleeding between the skull and the periosteum of a newborn may occur during a spontaneous vaginal delivery as a result of the pressure against the maternal bony pelvis. Cephalhematomas gradually disappear over 2 to 3 weeks.]
Which component of the sensory system is the least mature at birth?
Vision. [The visual system continues to develop for the first 6 months after childbirth. As soon as the amniotic fluid drains from the ear (in minutes), the infant’s hearing is similar to that of an adult. Newborns have a highly developed sense of smell and can distinguish and react to various tastes.]
Which cardiovascular changes cause the foramen ovale to close at birth?
Increased pressure in the left atrium. [With the increase in the blood flow to the left atrium from the lungs, the pressure is increased, and the foramen ovale is functionally closed. The pressure in the right atrium decreases at birth and is higher during fetal life.]
Swelling of the tissue over the presenting part of the fetal head caused by pressure during labor - *crosses suture lines*.
Extravasation of blood from ruptured vessels between a skull bone and its external covering, the periosteum - *does not cross suture lines*.
An airway emergency (blockage) - the infant is cyanotic at rest and *pink only with crying*.
Unopened sebaceous glands that appear as tiny, white, pinpoint papules on forehead, nose, cheeks, and chin. Disappear spontaneously in a few days or weeks.
A new father wants to know what medication was put into his infant’s eyes and why it is needed. How does the nurse explain the purpose of the erythromycin (Ilotycin) ophthalmic ointment?
This ophthalmic ointment prevents gonorrheal and chlamydial infection of the infant’s eyes, potentially acquired from the birth canal. [The nurse should explain that prophylactic erythromycin ophthalmic ointment is instilled in the eyes of all neonates to prevent gonorrheal and chlamydial infection that potentially could have been acquired from the birth canal.]
A newborn is jaundiced and is receiving phototherapy via ultraviolet bank lights. What is the most appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy?
Placing eye shields over the newborn’s closed eyes. [The infant’s eyes must be protected by an opaque mask to prevent overexposure to the light. Eye shields should completely cover the eyes but not occlude the nares. Lotions and ointments should not be applied to the infant because they absorb heat and can cause burns. The lights increase insensible water loss, placing the infant at risk for fluid loss and dehydration. Therefore, adequate hydration is important for the infant. The infant should be turned every 2 hours to expose all body surfaces to the light.]
The nurse is performing a gestational age and physical assessment on the newborn. The infant appears to have an excessive amount of saliva. This clinical finding may be indicative of what?
It may indicate that the infant has a tracheoesophageal fistula or esophageal atresia. [The presence of excessive saliva in a neonate should alert the nurse to the possibility of a tracheoesophageal fistula or esophageal atresia.]
The nurse is teaching new parents about metabolic screening for the newborn. Which statement is most helpful to these clients?
If genetic screening is performed before the infant is 24 hours old, then it should be repeated at age 1 to 2 weeks. [All states test for PKU and hypothyroidism but not for other genetic defects. Federal law mandates newborn genetic screening; however, parents can decline the testing.]
The most serious complication of an infant heelstick is necrotizing osteochondritis resulting from lancet penetration of the bone. What approach should the nurse take when performing the test to prevent this complication?
Lancet should penetrate at the outer aspect of the heel. [The stick should be made at the outer aspect of the heel and should penetrate no deeper than 2.4 mm. Repeated trauma to the walking surface of the heel can cause fibrosis and scarring that can lead to problems with walking later in life. The ball of the foot and the area below the fifth toe are inappropriate sites for a heelstick.]
If the newborn has excess secretions, the mouth and nasal passages can be easily cleared with a bulb syringe. How should the nurse instruct the parents on the use of this instrument?
Suction the mouth first. [The mouth should always be suctioned first to prevent the infant from inhaling pharyngeal secretions by gasping as the nares are suctioned. After compressing the bulb, the syringe should be inserted into one side of the mouth. If it is inserted into the center of the mouth, then the gag reflex is likely to be initiated.]
A nurse is responsible for teaching new parents regarding the hygienic care of their newborn. Which instruction should the nurse provide regarding bathing?
Create a draft-free environment of at least 24° C (75° F) when bathing the infant. [To prevent heat loss, the infant’s head should be bathed before unwrapping and undressing. Tub baths may be initiated from birth. Ensure that the infant is fully immersed.]
Petechiae usually occur with a _
Breech presentation vaginal birth.
The nurse should be cognizant of which important statement regarding care of the umbilical cord?
The stump can become easily infected. [The cord stump is an excellent medium for bacterial growth. The nurse should first check the clamp (or tie) and apply a second one. If bleeding occurs and does not stop, then the nurse should call for assistance. The cord clamp is removed after 24 hours when it is dry. The average cord separation time is 10 to 14 days.]
Mnemonic for assessment of infant crying
P - Peak of crying
U - Unexpected - comes and goes
R - Resists soothing
P - Pain - line face
L - Long - lasting up to 5 hours a day
E - Evening or late afternoon
What information regarding a fractured clavicle is most important for the nurse to take into consideration when planning the infant’s care?
No special treatment is necessary. [Fractures in newborns generally heal rapidly. Except for gentle handling, no accepted treatment for a fractured clavicle exists. Movement should be limited, and the infant should be gently handled.]
A pregnant woman at 37 weeks of gestation has had ruptured membranes for 26 hours. A cesarean section is performed for failure to progress. The fetal heart rate (FHR) before birth is 180 beats per minute with limited variability. At birth the newborn has Apgar scores of 6 and 7 at 1 and 5 minutes and is noted to be pale and tachypneic. Based on the maternal history, what is the most likely cause of this newborn’s distress?
Sepsis. [The prolonged rupture of membranes and the tachypnea (before and after birth) suggest sepsis. A differential diagnosis can be difficult because signs of sepsis are similar to noninfectious problems such as anemia and hypoglycemia.]
The nurse should be cognizant of which condition related to skeletal injuries sustained by a neonate during labor or childbirth?
Unless a blood vessel is involved, linear skull fractures heal without special treatment. [Approximately 70% of neonatal skull fractures are linear. Because the newborn skull is flexible, considerable force is required to fracture it.]
The nurse is evaluating a neonate who was delivered 3 hours ago by vacuum-assisted delivery. The infant has developed a cephalhematoma. Which statement is most applicable to the care of this neonate?
In many infants, signs of hemorrhage in a full-term infant are absent and diagnosed only through laboratory tests. [Abnormalities in lumbar punctures or red blood cell counts, for instance, or in visuals on computed tomographic (CT) scans might reveal a hemorrhage. ICH as a result of birth trauma is more likely to occur in the full-term, large infant. Subarachnoid hemorrhage in term infants is a result of trauma; in preterm infants, it is a result of hypoxia.]
Providing care for the neonate born to a mother who abuses substances can present a challenge for the health care team. Nursing care for this infant requires a multisystem approach. What is the first step in the provision of care for the infant?
Neonatal abstinence syndrome (NAS) scoring.
Which information regarding to injuries to the infant’s plexus during labor and birth is most accurate?
If the nerves are stretched with no avulsion, then they should completely recover in 3 to 6 months. [However, if the ganglia are completely disconnected from the spinal cord, then the damage is permanent. Erb palsy is damage to the upper plexus and is less serious than brachial palsy. Parents of children with brachial palsy are taught to avoid picking up the child under the axillae or by pulling on the arms.]
igM - produced by the fetus during the 1st trimester.
IgG - passive immunity from mother (crosses the placenta).
igA - received from breastfeeding.
T - Toxoplasmosis
O - Other (gonorrhea, syphilis, HIV, hepatitis B, varicella, parvovirus B19)
R - Rubella
C - Cytomegalovirus
H - Herpes simplex
The most common cause of neonatal sepsis in the newborn is _
Group B streptococci (GBS).
CRIES pain scale
C - Crying (high pitched suggests pain)
R - Requires O2, for SaO2 below 95%
I - Increased vital signs (HR and BP)
E - Expression (grimace)
S - Sleepless (during hour preceding assessment)
Occurs when the fetus compensates for the anemia associated with *Rh incompatibility* by producing large numbers of immature erythrocytes to replace those hemolyzed.
Through light energy, phototherapy reduces circulating unconjugated bilirubin in the superficial capillaries to a form which is easily excreted by the liver.
*Once phototherapy is started transcutaneous bilimeter is no longer used.*
Monitor I&O; infant is at risk for dehydration due to watery stool (green colored) - monitor diaper area. Urine may appear tea colored.