Flashcards in Week 11 Deck (24):
Maternal diabetes can lead to
LGA, plumper faces, hyper/hypoglycemia. Congenital abnormalities can include: Cardiac malformations (15x greater risk for cardiac malformation), lumbosacral agenesis (motor or sensory defects), enlarged hearts, lumbosacral problems, obesity later in life.
After hospital discharge of healthy baby: Recommend newborn assessment with primary care provider within
48-72 hours of discharge.
Initial Newborn Assessment
*Always check for birth injuries. Large babies are more likely to have birth injuries.*
• Check voiding patterns (urine and stool). With males, **check to make sure testes are descended.** Look for circumcision, and hypospadia.
• Check for imperforate anus in both male and female.
• Make sure female has vaginal openings.
• Assess head. Caput succedaneum vs cephalohematomas. **Caput may cross suture lines (not confined), but cephalohematoma never extends across suture lines.** Treatment for cephalohematomas: watch. Most resorb within 3 months. Caput doesn’t usually increase in size. No treatment either. Usually resolves much faster: within a few days. Did they have forceps or vacuum-assisted birth?
• **Most common fracture: Clavicle.** Assess reflexes. Fencing reflex is off. Asymmetry in movement. Crepitus and small bump over the fracture usually found upon palpation. Possibly absent Moro reflex on injured side. Treatment: **Usually heal without treatment.** Immobilize for 2-4 weeks.
• Nerve injuries: Most common nerve injury is brachial plexus nerve injury. Also called Erb’s palsy. Paralysis occurs as a result of nerve compression from either hemorrhage or edema. Permanent paralysis can occur from tearing of the nerve or avulsion of the nerve root from the spinal cord. The involved arm is adducted, prone, and internally rotated. Treatment for brachial plexus injuries is supportive and consists of exercises and splinting of the arm. Pinning the T-shirt sleeve across the chest is a good method for splinting the arm in the appropriate position. **Most recover on their own within 4 months (80%).**
• Tendon reflexes are tested by sharp percussion with examiner's finger over the tendon. **The biceps reflex and the patellar (knee jerk) reflex can be tested in the newborn.**
• Look for major and minor malformations. Refer with 2 major, 1 major and 2 minor, or 3 minor.
• Umbilical cord should be cleaned with each diaper change.
• Apply alcohol to the base of the cord to encourage rapid drying, which helps to prevent infection.
• Diaper should be folded and secured below the cord to avoid irritation and moisture.
• **Serous, purulent, or sanguineous drainage from the umbilicus or circumferential erythema at the base of the cord is abnormal** and requires immediate evaluation for omphalitis, which can be life-threatening and requires parenteral antibiotic therapy.
• **Delayed cord separation (>2 weeks) requires evaluation** for persistent urachus or deficient neutrophil function and chemotaxis.
• Granulation tissue may form as a solid yellow mass and requires desiccation with silver nitrate. Inspect area to rule out the possibility of everted intestinal mucosa that would permit the entrance of a probe.
1. When should the cord be separated?
2. When do you have them back?
1. Within 2 weeks. A little bit of bleeding is normal.
2. If more than 2 weeks or abnormal cord. Serous, purulent, or sanguineous drainage from the umbilicus or circumferential erythema at the base of the cord is abnormal and requires immediate evaluation for omphalitis, which can be life-threatening and requires parenteral antibiotic therapy. Delayed cord separation (>2 weeks) requires evaluation for persistent urachus or deficient neutrophil function and chemotaxis.
Duties After Birth
• Vitamin K, Hep B, eye ointment.
• Take complete hx. Maternal hx, APGARs, newborn genetic screening, birth trauma, major/minor malformations. Know what is normal and not normal. • • Make sure they make an appt for assessment within 48-72 hours post hospital discharge.
Eye ointment after birth: why?
Vitamin K after birth: why?
Needed for clotting. Infants can’t make it on their own. Not mature enough at birth.
Newborn Cardiac Considerations
• Most common cardiac lesion is ventral septal defect.
• High pitched murmur can be red flag.
• Benign murmur is no louder than 2/4. Soft, quiet. Normal HR. No abnormal or irregular heartbeats. No respiratory distress.
• Can be present in first few hours or days. Murmurs can be caused by closing of fetal shunts.
• Normal HR range is 80-160.
• 3 major shunts: Ductus arteriosus, foramen ovale, ductus venosus.
• See edema in adults but usually respiratory distress in babies.
• Listen to heart at lower left sternal border for 1 full minute. Look for point of maximal impulse. Should not be displaced. Around 4th left intercostal space is normal (pneumothorax or cardiac defect could cause displacement). No thrills or heaves. Check for symmetrical pulses other both sides. Look at skin color.
• Make sure murmur is benign with no other s/s of cardiac issues.
• Not uncommon to hear S3 (likely benign if no other s/s), but never want to hear S4. Gallop rhythm (S4) could be congestive heart failure.
Newborn Abdomen Considerations
Umbilical cord should have 2 arteries and 1 vein. Anything else could indicate genetic anomalies.
Moro reflex (also known as the startle reflex)
Hold infant in a supine and neutral position several centimeters off the bed. Support the head and neck with hand. Allow head to drop into examiner's hand while still supporting it. In the first response, the arms extend and abduct and hands open. That response is followed by an inward movement with flexion of the arms and closing of the hands. A cry may follow. Complete absence of the reflex is abnormal. Asymmetric movements may indicate a localized neurologic defect.
Plantar flexion occurs after stimulation of the sole of the foot. A positive response occurs if extension or flexion of the toes occurs. Consistent absence of the reflex is abnormal and may indicate central nervous system depression or a spinal nerve innervation problem.
Elicit the rooting reflex by lightly stroking the cheek lateral to the edge of the mouth, causing the infant to open its mouth and turn its head to the stroked side in anticipation of sucking; this will allow easier examination of the neck. The infant's head should be able to turn as far as the shoulder in both directions and slightly farther if premature.
Activity, Pulse, Grimace, Appearance, Respiration
• Heart rate
• Respiratory effort
• Muscle tone
• Reflex irritability (response of skin stimulation to feet)
Do them at 1 and 5 minutes.
3 transition phases
• First Stage: Up to 30 minutes might still have rapid HR, grunting, flaring, rales. Brief periods of apnea (Less than 10 seconds is normal). Muscle tone is increased. Motor activity increases. Body temp should be within normal range. It decreases during this stage. Body temp going up could be abnormal.
• Second stage (30-2 hours): Start to hear bowel sounds. Color should be excellent.
• (2-8 hours) Third stage: Responsiveness returning. Color, tone, bowel sounds good. Should start feeding. Respond to external stimuli.
Babies at risk for abnormal transition
Preterm, breech, C-section, maternal complications (HTN, GDM, preeclampsia, infections, drug abuse), birth trauma, major malformations.
Abnormal signs of transition
Grunting/flaring persisting into stage 2, labored respirations in stage 2, rales in lungs, unstable temp, neuro problems, excessive oral secretions (choking). Know what to expect and what is not normal.
Muscle tone testing in newborn
Phasic tone is tested by evaluating the resistance of the upper and lower extremities to movement (scarf sign; arm and leg recoil). Tendon reflexes are tested by sharp percussion with examiner's finger over the tendon. The biceps reflex and the patellar (knee jerk) reflex can be tested in the newborn. Weak or absent reflexes may be seen with birth asphyxia, sepsis, or dysfunction of the motor unit. Sustained clonus (>8–10 beats) is abnormal and may be seen in drug withdrawal or cerebral irritation. Postural tone is tested by evaluating the resistance to gravity. It is best tested by the traction response (pull-to-sit maneuver). By grasping the neonate's hands and pulling slowly from the supine position, the infant will pull back with flexion at elbows, knees, and ankles. The head comes with the body with minimal lag and falls forward when sitting is obtained. In the term newborn, more than minimal head lag is abnormal and may indicate hypotonia.
Reflex testing in newborn
patellar and brachial (biceps) deep tendon reflexes.
Cranial nerve testing in babies/newborn
Can check in babies.
• Olfactory (I): Test by placing a strong-smelling substance (oil of cloves, peppermint, or anise) under the nose and evaluating for startle, grimace, or sniffing.
• Optic (II): Test by checking pupils for size and constriction in response to light. Also evaluate the ability of the neonate's eyes to fix on an object and follow it over an arc of 60 degrees.
• Oculomotor (III), trochlear (IV), and abducens (VI): These nerves supply the pupil and the extraocular muscles. Test by observing pupillary response to light. Evaluate spontaneous movements of the eye, its size, and symmetry. Movement of the eyes as the head is turning is evaluated. The "doll's eye" test consists of rotating the head from side to side and evaluating for movement of the eyes away from the direction of rotation. A normal response is the eyes deviating to the left when the head turns to the right. If eyes remain in a fixed position, or move in the same direction as the head, brainstem or oculomotor nerve dysfunction may be present.
• Trigeminal (V): Supplies the jaw muscles and sensory innervation of the face. Test by touching the cheek. The infant should turn the cheek toward the stimulus. Also evaluate the biting portion of the suck by placing a gloved finger in the neonate's mouth.
• Facial (VII): Controls facial expression. Note asymmetric facial movements. Severe injury can result in obvious facial weakness or an inability to wrinkle the brow or close the eyes with crying.
• Auditory (VIII): Tested grossly as described in "Sensory function" above.
• Glossopharyngeal (IX): Evaluate by inspecting tongue movement and eliciting a gag reflex.
• Vagus (X): Supplies soft palate, pharynx, and larynx. Evaluate by listening to the cry and assessing presence of hoarseness, stridor, or aphonia. Assess ability to swallow.
• Accessory (XI): Supplies sternocleidomastoid and trapezius muscles. Test by turning supine infant's head to one side; infant should attempt to bring head to midline.
• Hypoglossal (XII): Supplies muscles of the tongue. Evaluate sucking, swallowing, and gagging.
Rashes in newborns
Most common rash is milia. Most rashes are self-limiting. Erythema toxicum has erythematous base. Milia is pearly, opaque and is d/t epidermial cysts. Self-limiting and usually disappear.
Symptoms of abnormal color in newborn
blueness (cyanosis), redness (plethora), yellow (jaundice), pale (anemic), bruised (birth trauma). Plethora can be a sign of polycythemia vera. Especially don’t want to see it in full-term infants. Not uncommon in preterm infants. Look at skin, tongue, oral mucosa. Excessive bruising d/t birth trauma.
Approximately 40% of full-term infants have multiple yellow or pearly white 1-mm papules (pinhead-sized). They are usually scattered on the chin, nose, forehead, and cheeks. They are benign, represent tiny epidermal cysts in connection with a sebaceous follicle, and disappear within a few weeks.