Module 8: Newborn Flashcards
1
Q
What is the best, preferred method of evaluating an infant?
A
Evaluations that cause the least disturbance should be done first.
2
Q
What are two frequently obvious things in an infant?
A
Microcephaly or cranial enlargement is frequently obvious.
3
Q
What is one sign typical of hydrocephalus?
A
If hydrocephalus is present, the forehead is often prominently protrusive (bossing).
4
Q
What does normal flexion of all extremities indicate?
A
Good muscle tone! “BUFF BABY” :-) Trying to pull a little Hillary humor in my life here!
5
Q
What does lack of flexion associate with? Excessive flexion?
A
Lack of flexion is associated with hypotonicity, whereas excessive flexion usually suggests hypertonicity.
6
Q
What would you suspect if an infant will only flex one arm and keep the other straight?
A
If only one arm is consistently straight and the infant does not flex that extremity, brachial plexus injury must be considered.
7
Q
Is acrocyanosis significant?
A
NO! It is normal and is usually seen in hands, feet, and circumoral area.
8
Q
If a baby is having bilaterally identical, repetitive movements, is this normal?
A
No, Bilaterally identical, repetitive movements of the extremities are suggestive of seizure activity. Facial and eyelid twitches are also suggestive of convulsions.
9
Q
What are normal movements for an infant?
A
Sporadic, well-coordinated movements that are not symmetrical.
10
Q
What happens when a baby isn’t moving a certain extremity?
A
Absent or diminished movement of one extremity when the others are used normally is indicative of paresis or paralysis.
11
Q
What are 3 obvious signs of respiratory issues when observing an infant?
A
Retractions, grunting, and stridor.
12
Q
What can cause over expanded lungs in an infant?
A
Increased anteroposterior diameter of the chest (barrel chest) usually indicates an overexpanded lungs, which may be due to meconium aspiration or respiratory distress syndrome type 2.
13
Q
What is a sign of cardiomegaly?
A
One side of the chest is larger than the other.
14
Q
What should happen after the initial inspection?
A
With the infant supine, the abdomen should be palpated immediately. The examiner’s fingertips must be gently placed and held on the abdomen without exerting any downward pressure. Deep palpation should then proceed gradually.
15
Q
When should the examination of the mouth and throat be performed?
A
Examination of the mouth and throat is performed as the last maneuver of the physical evaluation as it is the most agitating to the neonate.
16
Q
Describe the body of the newborn:
A
- Cylindrical
- Head circumference slightly exceeds that of the chest. Avg. 33-35 cm with avg. chest 30-33 cm.
- Sitting height: Crown to rump=head circumference.
- In first few days of life, infant’s posture is result of position in utero.
17
Q
What covers the infants skin at birth?
A
vernix caseosa, a pasty covering chiefly of dead cells and sebaceous secretions that protect the skin of the fetus (thank you webster dictionary). It gives the skin its blush, red smooth appearance right at birth.
18
Q
Jaundice in a newborn between the 2nd and 3rd day that disappears by the 5th and 7th day is usually normal, but what about jaundice within 24 hours?
A
That is not normal and indicates further evaluation.
19
Q
If a baby who was breech has a edematous and blue buttock, feet or legs, what is it indicative of?
A
Venous stasis
20
Q
This is more commonly a sign of acute blood loss, hypoxia, or poor peripheral perfusion due to hypotension.
A
Pallor; Subcutaneous edema may mimic pallor.
21
Q
What can cause ecchymoses in a newborn?
A
Ecchymoses are most frequently due to trauma during difficult labor or to brisk handling of the infant during or after delivery.
22
Q
If a baby presents with petechia what would you expect?
A
Petechiae occur in a number of disease states involving thrombocytopenia and should always prompt an investigation including a sepsis workup and evaluation of the infant for TORCH infections.
23
Q
Irregular areas of blue-gray pigmentation over the sacrum and buttock are what?
A
Mongolian spots. They are common in black infants and in infants of Asian and southern European lineage. Mongolian spots usually disappear by 4 years of age, or earlier.
24
Q
Port wine nevi:
A
- Hemangiomas
- Mass of dilated capillaries in the superficial skin. –Dense concentrations of such dilated capillaries, which may be small and single or multiple and sparse.
- Color varies from pink to deep purple, and they are sharply demarcated.
- Port wine nevi over the face in a trigeminal distribution suggest Sturge-Weber syndrome (cerebral calcification and glaucoma on the same side as the lesions and hemiparesis on the opposite side)
25
Telangiectatic nevi is also called what?
- Stork bites
- flat, red, localized areas of capillaries that are considerably less dense than those seen in port-wine nevi.
- Easily blanched, they are commonly situated on the back of the neck, the lower occiput, the upper eyelids, and the nasal bridge.
- disappear by 2 years of age, but in many children they reappear evanescently during crying episodes.
26
When do strawberry hemangiomas appear?
- They first appear during the second or third week of life.
- bright red, flat spots which are 1–3 mm in diameter and blanch easily. Subsequently, they grow in all directions, protruding prominently from the skin surface. They may not reach their full size for 1–3 months. The temptation to remove these lesions should be resisted because they resolve spontaneously several weeks or months after reaching peak growth.
- Resolution is heralded by one or more pale purple or gray spots on the surface of the lesion, indicating spontaneous vascular sclerosis and obliteration.
27
Cavernous Hemangiomas
- subepidermal layer
- diffuse and less sharply demarcated than capillary hemangiomas.
- Color of the overlying skin may be normal or blue as a result of color transmission from subjacent blood.
- Spongy, but on occasion they are tight cystic masses.
- no other significance.
- resolve spontaneously in a few months to 1–2 years.
- Large cavernous hemangiomas are often associated with serious thrombocytopenia (Kasabach-Merritt syndrome).
28
What are mixed hemangiomas made of?
Mixed hemangiomas are common and are comprised of a superficial strawberry lesion that is continuous with a deeper cavernous one.
29
How many types of GBS are there?
TWO. Early onset that occurs the 1st week of life and Late-onset that occurs from the 1st week to 3 months.
30
What diseases are common with early onset?
Sepsis, Pneumonia, Meningitis.
31
Although seen with early onset, which disease is more commonly seen with late onset?
Meningitis.
32
What are the long term effects of an infant with GBS?
Deafness and developmental disabilities.
33
How many children die in the US from GBS?
4-6%
34
Which race is GBS higher among?
African Americans
35
How many infants get early onset GBS a year?
1200
36
What other complications can GBS cause?
Group B strep can also cause some miscarriages, stillbirths and preterm deliveries.
37
There are two gold standards in preventing early onset GBS. What are they?
- Testing all pregnant women for group B strep bacteria late in pregnancy (35-37 wks)
- Giving antibiotics during labor to women who test positive for the bacteria.
38
What happens if a woman tests positive?
To help protect their babies from infection, pregnant women who test positive for group B strep in the current pregnancy should receive antibiotics (medicine) through the vein (IV) during labor.
39
What do you do if a woman has GBS in their urine during pregnancy or has had a child with GBS disease?
They should receive antibiotics during labor; they do not need to be screened at 35-37 weeks because they should receive antibiotics regardless of the screening result.
40
What do you do if a woman doesn't know if she has GBS or not?
When labor starts, they should be given antibiotics if they have:
- labor starting at less than 37 weeks (preterm labor);
- prolonged membrane rupture (water breaking 18 or more hours before delivery); or
- fever during labor.
41
Can you give antibiotics before labor?
NO, they only work during labor because the bacteria is so fast growing.
42
Which antibiotic is normally given for GBS?
PCN
43
Will giving an antibiotic in labor help prevent late-onset GBS?
NO. To date, receiving antibiotics through the vein during labor is the only proven strategy to protect a baby from early-onset group B strep disease. There is no prevention for late onset GBS.
44
What are the S/S of GBS?
- Fever
- Difficulty feeding
- Irritability, or lethargy (limpness or hard to wake up the baby)
- Difficulty breathing
- Blue-ish color to skin
45
How is GBS tested and diagnosed?
Group B strep disease is diagnosed when the bacteria are grown from samples of a baby’s sterile body fluids, such as blood or spinal fluid. Cultures can take a few days to grow. For both early-onset and late-onset disease, if the doctors suspect that a baby has group B strep infection, they will take a sample of the baby’s blood and spinal fluid to confirm the diagnosis.
46
What is often the source of GBS in a newborn if the mother tests negative?
For a baby whose mother does not test positive for group B strep, the source of infection for late-onset disease can be hard to figure out and is often unknown.
47
Can a mother with GBS breastfeed safely?
YEP!
48
What are the risk factors for GBS in an infant?
- Testing positive for group B strep late in the current pregnancy (35-37 weeks gestation)
- Detecting group B strep in urine during the current pregnancy
- Delivering early (before 37 weeks gestation)
- Developing fever during labor
- Having a long period between water breaking and delivering
- Having a previous infant with early-onset disease
49
Who is more common to develop late-onset GBS disease?
Late-onset disease is more common among babies who are born prematurely (< 37 weeks). This is the strongest risk. Babies whose mothers tested group B strep positive also have a higher risk of late onset disease. The risk factors for late onset disease are not as well understood as for early-onset disease.
50
What is the major cause of Hemolytic disease?
An incompatibility of the Rh blood group between the mother and fetus. Most commonly, hemolytic disease is triggered by the D antigen, although other Rh antigens, such as c, C, E, and e, can also cause problems.
51
Who is at risk for developing HDN?
Pregnancies at risk of HND are those in which an Rh D-negative mother becomes pregnant with an RhD-positive child (the child having inherited the D antigen from the father). The mother's immune response to the fetal D antigen is to form antibodies against it (anti-D). These antibodies are usually of the IgG type, the type that is transported across the placenta and hence delivered to the fetal circulation.
52
Name another cause of HDN?
HDN can also be caused by an incompatibility of the ABO blood group. It arises when a mother with blood type O becomes pregnant with a fetus with a different blood type (type A, B, or AB). The mother's serum contains naturally occurring anti-A and anti-B, which tend to be of the IgG class and can therefore cross the placenta and hemolyse fetal RBCs.
-HDN due to ABO incompatibility is usually less severe than Rh incompatibility.
53
How does the mother develop sensitization to the fetus?
- Sensitization to an antigen occurs when the immune system encounters an antigen for the first time and mounts an immune response.
- Only a small amount of fetal blood need enter the mother's circulation for sensitization to occur. Typically, this occurs during the delivery of the first-born Rh D-positive child. Fetal-maternal hemorrhage is common during labor and is increased during a prolonged or complicated labor, which in turn increases the risk of sensitization.
- Sensitization can also occur earlier in the pregnancy, for example during a prenatal bleed or a miscarriage. It may also occur during medical procedures, such as a termination of pregnancy or chorionic villus sampling.
54
What does the rate of hemolysis determine?
The rate of hemolysis determines whether the nature of HDN is mild, moderate, or severe. In mild cases, the small increase in the rate of hemolysis is tolerated by the fetus.
55
What are S/S of an infant with HDN?
At birth and during the newborn period, symptoms include a mild anemia and jaundice, both of which may resolve without treatment.
56
What can you expect from the bilirubin level in cases with increased rate of hemolysis?
The level of bilirubin may still remain low during the pregnancy because of the ability of the placenta to remove bilirubin from the fetal circulation.
Within 24 hours of birth, the level of bilirubin may rise dramatically. If levels continue to rise, bilirubin may enter the brain to cause kernicterus, a potentially fatal condition that leaves permanent neurological damage in the babies that survive.
57
What two organs help to compensate for the loss of RBCs?
The liver, spleen, and other organs increase their production of RBCs to compensate for their loss.
58
What is the alternative name for HDN?
Immature RBCs (erythroblasts) spill into the circulation, giving rise to the alternative name of this disease, erythroblastosis fetalis.
59
What is hydrous fetalis?
A complication of severe HDN is hydrops fetalis, in which the fetal tissues become swollen (edematous). This condition is usually fatal, either in utero or soon after birth.
60
How do you detect HDN?
The presence of maternal anti-Rh IgG must be identified.
61
How does a direct Coombs Test help with the diagnosis of HDN?
The direct Coombs test detects maternal anti-D antibodies that have already bound to fetal RBCs.
First, a sample of fetal RBCs is washed to remove any unbound antibody (Ig). When the test antibodies (anti-Ig) are added, they agglutinate any fetal RBCs to which maternal antibodies are already bound.
This is called the direct Coombs test because the anti-Ig binds "directly" to the maternal anti-D Ig that coats fetal RBCs in HDN.
62
How is the Indirect Coombs test used in the prevention of HDN?
The indirect Coombs test finds anti-D antibodies in the mother's serum. If these were to come into contact with fetal RBCs they would hemolyse them and hence cause HDN. By finding maternal anti-D before fetal RBCs have been attacked, treatment can be given to prevent or limit the severity of HDN.
For this test, the mother's serum is incubated with Rh D-positive RBCs. If any anti-D is present in the mother's serum, they will bind to the cells. The cells are then washed to remove all free antibodies. When anti-Ig antibodies are added, they will agglutinate any RBCs to which maternal antibodies are bound.
This is called the indirect Coombs test because the anti-Ig finds "indirect" evidence of harmful maternal antibodies, requiring the addition of fetal RBCs to show the capacity of maternal anti-D to bind to fetal RBCs.
63
When is a mother given the anti-D injection to help prevent sensitization?
Usually, Rh D-negative mothers receive on injection of anti-D Ig at about 28 weeks gestation, which is about the time when fetal RBCs start to express the D antigen, and mothers receive another dose at about 34 weeks, a few weeks before labor begins during which the risk of fetomaternal hemorrhage is high. A final dose of anti-D Ig is given after the baby has been delivered. In addition, anti-D Ig is given to cover other events during the pregnancy that may lead to sensitization, e.g., antepartum bleeds and pre-eclampsia.
64
What is the next step once you have determined the mother has become sensitized?
Once the presence of maternal anti-D has been confirmed, the next step is to determine whether the fetal RBCs are a target, i.e., confirm the Rh status of the fetus. If the father is homozygous for the D allele (D/D), the fetus will be D positive. If however the father is heterozygous (D/d), there is a 50:50 chance that the fetus is D positive, and the only way to know the blood type for sure is to test a sample of fetal cells taken from the amniotic fluid or umbilical cord.
65
What steps are taken to monitor the fetus for signs of HDN?
Monitoring includes regular ultrasound scans of the fetus and monitoring of the amount of anti-D in the mother's serum. Active hemolysis is indicated by a rise in anti-D. If a fetal blood test confirms fetal anemia, depending upon its severity, a blood transfusion can be done in utero to replace the lysed fetal RBCs. Blood transfusions may also be needed to correct anemia in the newborn period. During this period there may also be a sharp rise in the level of bilirubin in the neonate, which can be lowered by phototherapy and exchange transfusions.
66
When is a mother given the anti-D injection to help prevent sensitization?
Usually, Rh D-negative mothers receive on injection of anti-D Ig at about 28 weeks gestation, which is about the time when fetal RBCs start to express the D antigen, and mothers receive another dose at about 34 weeks, a few weeks before labor begins during which the risk of fetomaternal hemorrhage is high. A final dose of anti-D Ig is given after the baby has been delivered. In addition, anti-D Ig is given to cover other events during the pregnancy that may lead to sensitization, e.g., antepartum bleeds and pre-eclampsia.
67
What is the next step once you have determined the mother has become sensitized?
Once the presence of maternal anti-D has been confirmed, the next step is to determine whether the fetal RBCs are a target, i.e., confirm the Rh status of the fetus. If the father is homozygous for the D allele (D/D), the fetus will be D positive. If however the father is heterozygous (D/d), there is a 50:50 chance that the fetus is D positive, and the only way to know the blood type for sure is to test a sample of fetal cells taken from the amniotic fluid or umbilical cord.
68
What steps are taken to monitor the fetus for signs of HDN?
Monitoring includes regular ultrasound scans of the fetus and monitoring of the amount of anti-D in the mother's serum. Active hemolysis is indicated by a rise in anti-D. If a fetal blood test confirms fetal anemia, depending upon its severity, a blood transfusion can be done in utero to replace the lysed fetal RBCs. Blood transfusions may also be needed to correct anemia in the newborn period. During this period there may also be a sharp rise in the level of bilirubin in the neonate, which can be lowered by phototherapy and exchange transfusions.
69
Before touching the infant, what should you take note of first?
- Color
- posture/tone
- activity
- size
- maturity
- quality of cry.
70
When you palpate the head, what should you inspect for?
- bruising
- edema
- molding/shape
- sutures
- fontanelles.
71
What should you examine the newborn's neck and clavicles for?
- Range of Motion
- Asymmetry
- Crepitus
- Masses
72
What is the normal heart rate in an infant?
Normal heart rate is 120 - 160 bpm.
73
When assessing the ears, nose, mouth, and throat, be sure to note:
- ear set/shape
- preauricular pits/tags
- nasal shape/patency
- palate, gums
- lips and tongue.
74
What two maneuvers help to evaluate the infant for hip dislocation?
Ortolani and Barlow manuevers are used to evaluate hips for subluxation or dislocation.
75
What is the normal heart rate in an infant?
Normal heart rate is 120 - 160 bpm.
76
Is stool in an infants diaper indicative of rectal patency?
NO.
77
What two maneuvers help to evaluate the infant for hip dislocation?
Ortolani and Barlow manuevers are used to evaluate hips for subluxation or dislocation.
78
Name a few benign skin conditions that occur in newborns?
Erythema toxicum neonatorum, transient neonatal pustular melanosis, sucking blister, miliaria, and mongolian spots.
79
What lab work should be obtained in a newborn with pallor or ruddy complexion?
CBC
80
Neonatal period
First 28 days of life.
81
When is a newborn most responsive?
1-2 hours after eating
82
What is the typical sequence for a newborn exam?
1. Observation
2. Head, neck, heart, lungs, and, genitourinary system
3. lower ext, back
4. Ears, mouth
5. Eyes or whenever they are spontaneously open
6. Skin (as you go along)
7. Neurological
8. Hips
83
When are APGAR scores obtained?
At 1 minute after birth and at 5 minutes after birth. An APGAR must be taken every 5 minutes until the score is greater than 7.
84
When is a newborn most responsive?
1-2 hours after eating
85
What is the APGAR score?
A score card that contains 5 components for classifying the newborns neurological recovery from birth to adaption to life. Scores range from 0-10
86
When are APGAR scores obtained?
At 1 minute after birth and at 5 minutes after birth. An APGAR must be taken every 5 minutes until the score is greater than 7.
87
1 Minute APGARS:
8-10 Normal
5-7 Some nervous system depression
0-4 Severe depression, requiring immediate resuscitation
88
5 minute APGARS:
8-10 Normal
| 0-7 High risk for subsequent CNS and other organ system dysfunction.
89
What do APGARS look at?
- Heart rate
- Respiratory effort
- Muscle tone
- Reflex irritability (suction of nares with bulb)
- Color
90
How are newborns classified?
According to their gestational age and weight.
91
How is gestational age determined?
It is based on specific neuromuscular signs and physical characteristics.
92
How effective is the Ballard scoring system?
It estimates gestational age to within 2 weeks, even in extremely premature infants.
93
What classifies a newborn to be preterm?
<259th day)
94
What classifies a newborn to be term?
37-42 weeks
95
What classifies a newborn to be post term?
> 42 weeks (>294th day)
96
Normal birth weight
> or = 2500
97
Very low birth weight:
<1500 grams
98
What percentile would a child appropriate for gestational age be in?
10-90th
99
What percentile would a child that is large for gestational age be in?
>90th
100
What percentile would a child thats small for gestational age be in?
< 10th
101
Wghat percentile would a child appropriate for gestational age be in?
10-90th
102
What percentile would a child that is large for gestational age be in?
>90th
103
What type of babies are infants of mothers with diabetes?
Large for gestational age, and may have metabolic abnormalities shortly after birth as well as congenital abnormalities.
104
What issues are a preterm AGA likely to experience?
Respiratory Distress syndrome, apnea, patent ductus arterioles with left to right shunt, and infection.
105
What do asymmetric movements mean?
They can suggest central or peripheral neurologic deficits, birth injury (fractured clavicle or brachial plexus injury), or congenital abn.
106
In breech babies, where are the legs and head?
They are extended; the legs of a frank breech baby are abducted and externally rotated.
107
What do tremors after the 4th day of birth represent?
CNS disease from various possible causes, ranging from asphyxia to drug withdrawal.
108
What do asymmetric movements mean?
They can suggest central or peripheral neurologic deficits, birth injury (fractured clavicle or brachial plexus injury), or congenital abn.
109
What can a newborn do?
- Use all five senses
| - can interact dynamically with caregivers
110
What is the ability to selectively and progressively shut out negative stimuli?
Habituation
111
A reciprocal, dynamic process of interacting and bonding with the caregiver.
Attachment
112
Ability to modulate the level of arousal in response to different degrees of stimulation.
State Regulation
113
Ability to regard faces, turn to voices, quiet in presence of singing, track color objects, respond to touch, and recognize familiar scents.
Perception.
