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Maternal & Newborn Care - Week 2:
Newborn Assessment & Care Test
Questions and Answers
Neonatal Period - Answer-· The neonatal period includes the time from birth through day 28 of life (first month of life - very important period, babies have to adjust to new environment) · During this time, the neonate must make many adjustments to extrauterine life, most of which occur shortly after birth Behavioural Tasks (for the newborn) Include: - Answer-· Establishing and maintaining respirations · Adjusting to circulatory changes · Regulating temperature · Ingesting, retaining, and digesting nutrients · Eliminating waste · Regulating weight · Establishing a regulated behavioural tempo independent of the mother, which involves self-regulating arousal, self-monitoring changes in state, and patterning sleep · Processing, storing, and organizing multiple stimuli;
· Establishing a relationship with caregivers and the environment The Transition Period - Answer-· First 6 to 8 hours after birth (most critical period) · Period of instability · Major adaptations associated with transition from intrauterine to extrauterine life occur The First Period of Reactivity - Answer-· Lasts up to 30 minutes after birth · Newborn's heart rate increases rapidly to 160-180 bpm (normal) · HR then decreases after 30 minutes to a baseline rate of 100- · Respirations are irregular: rate 60-80 breaths/min · Crackles may be present on auscultation (babies' lungs are fluid - crackles are from the fluid that does not come out during birth) The First Period of Reactivity (continued) - Answer-· The infant is alert · Spontaneous startle reactions, tremors (if they last longer than 30 minutes - neonatal abstinence syndrome - baby withdrawal), crying, and movement of the head from side to side · Decrease in body temperature, generalized increase in motor activity, and an increase in muscle tone · Bowel sounds audible, may pass meconium (always during first poop) After Reactivity - Answer-· After this first period of reactivity, the newborn either sleeps or has a marked decrease in motor activity (normal reaction) · This period of decreased responsiveness, frequently accompanied by sleep, lasts for 60-100 minutes followed by a second period of reactivity Second Period of Reactivity - Answer-· 2- 8 hrs post birth · Lasts from 10 minutes to several hours · Periods of tachycardia and tachypnea
- Seesaw respirations indicate that something is VERY wrong! Important Fact - Answer-· Newborn infants are preferential nose breathers (very important to clear nasal passages). The reflex response to a nasal obstruction is to open the mouth to maintain the airway. This response is not present in most infants until 3 weeks after birth; therefore, cyanosis or asphyxia may occur with nasal blockage Signs of Respiratory Distress - Answer-· Nasal flaring · Retractions (xiphoid process sunken in) · Grunting with expirations · Seesaw respirations · A respiratory rate that is less than 30 or greater than 60 per minute with the infant at rest must be reported · Central cyanosis - body is blue (acrocyanosis is normal - extremities are blue) Surfactant - Answer-· Pulmonary surfactant is a lipoprotein that lines the alveoli · It reduces surface tension, therefore requiring less pressure to keep the alveoli open · Surfactant develops as the infant develops in utero (premature babies do not have surfactant) · Lack of surfactant increases the surface tension making it more difficult to keep the alveoli open Cardiovascular System - Answer-· Term infant resting heart rate between 120-160 (100-160 can be ok) · With crying, HR may accelerate to 180 bpm · Range is 80-100 while asleep in a term infant (80 is very low even for sleeping) · High or low (>160, <100) should be reevaluated within 30 to 60 minutes or when the activity of the infant changes · Immediately after birth the heart rate can be palpated by grasping the base of the umbilical cord
Cardiovascular System (continued) - Answer-· The PMI (point of maximal impulse) in the newborn is at the 4th intercostal space and to the left of the midclavicular line...it is often visible · Always use apical heart rates taken for one full minute · Sinus dysrhythmia may be considered a physiologic phenomenon in infancy and an indication of good heart function · Heart sounds are higher in pitch, shorter in duration, and greater in intensity that adults · Most heart murmurs resolve by 6 months - most are not significant - unless other features Hematologic System - Answer-· At birth RBC's and hemoglobin are higher than those in the adult · Iron stores are generally sufficient to sustain normal RBC production for 5 months, and thus mild, brief anemia is not serious · Leukocytosis (high WBC - usually due to trauma from birth) is normal at birth...serious infection is not well tolerated by the newborn, and a marked increase in the WBC count is unlikely, even in critical sepsis (infection) Hematologic System (continued) - Answer-· Platelet count is essentially the same in newborns as in adults · Levels of factors II, VII, IX, and X, found in the liver, are decreased during the first few days of life because the newborn cannot synthesize vitamin K (vitamin K is synthesized in the guts, and then distributed to the liver - need "bugs" in guts/bowels to synthesize vitamin K - vitamin K shots are given to newborns because they don't have any "bugs" in their guts) · Bleeding tendencies are rare, and clotting is usually sufficient to prevent hemorrhage · Normalizes by 6 months of age Hematologic Adaptations - Answer-· Blood group is genetically determined and established early in fetal life · Cord blood samples may be used to identify the infant's blood type and Rh status · Persistent tachycardia (>160 bpm) may indicate RDS (respiratory distress syndrome) · Persistent bradycardia (<120 bpm) may be a sign of congenital heart block
Jaundice - Answer-· Physiologic or neonatal jaundice or hyperbilirubinemia occurs in almost all newborn infants but is more severe in preterm infants (bilirubin is excreted through the bowels) · At any serum bilirubin level, the appearance of jaundice during the first 24 hours of life or persistence beyond day 7 usually indicates a pathologic problem Jaundice (continued) - Answer-· Kernicterus or bilirubin encephalopathy occurs when bilirubin is deposited in the basal ganglia and brain stem (can cause seizures and brain damage, even death) · All parents need instruction in how to assess jaundice and when to call a health care provider Physiologic Jaundice - Answer-Non-pathologic jaundice
- Appears after 24 hrs and usually self resolves
- Can become pathologic if levels increase and lead to a pathologic condition Breastfeeding Jaundice - Answer-Not caused by breastfeeding, rather lack of or not enough - less fluids = less stooling & less excretion of bilirubin
- Seen at 2-5 days Breast Milk Jaundice - Answer-- Unclear etiology (something in mother's breast milk is causing jaundice)
- Occurs at 5-10 days
- Can persist 3-12 weeks (does not harm them) Integumentary System - Vernix Caseosa - Answer-White, creamy film covering babies' skin - looks like lotion - helps protect baby from getting "prune skin" in uterus Integumentary System - Lanugo - Answer-Hairy baby
Integumentary System - Acrocyanosis - Answer-Blue extremities Integumentary System - Caput succedaneum - Answer-Swelling of the scalp in a newborn Integumentary System - Cephalohematoma - Answer-A collection of blood between a baby's scalp and skull Integumentary System - Desquamation - Answer-Skin is sloughing off - common in babies that are born after term Integumentary System - Milia - Answer-Small white bumps under surface of skin, resemble white heads
- do NOT pop! Integumentary System - Mongolian spots - Answer-Dark area on buttocks - looks like a bruise - often on newborns with darker skin tones Integumentary System - Nevi - Answer-"Stork bites" or "angel kisses" Integumentary System - Erythema Toxicum - Answer-"Newborn rash" or "flea bite" - can resemble acne Integumentary System - Hemangioma - Answer-Bright red birthmark that shows up at birth or in the first or second week of life - "strawberry birthmark" - usually goes away after 1-2 years, can be surgically removed if it continues to grow Integumentary System - Breast Engorgement - Answer-Baby born with large breasts - milk may occur - hormone related, more common in females Integumentary System - Epstein Pearls - Answer-Looks like tooth dot coming out of gums
What Else Should be Assessed? - Environment - Answer-Respond to the environment with temperament, habituation, consolability, cuddliness, irritability, crying Skeletal System - Assess for Hip Dysplasia - Answer-Hip joint did not fully develop - common if baby is breach Assess for Hip Dysplasia - Ortolani maneuver - Answer-Abduct hips - positive if you hear or feel a click Assess for Hip Dysplasia - Barlow test - Answer-If it is positive there is a click - can hear or feel it Assess for Hip Dysplasia - Asymmetry of the gluteal fold - Answer-Asymmetry of thigh folds when looking a baby's back side Hip Dysplasia - Answer-Double diaper babies to open up hip joints Clavicular Fracture - Answer-· Clavicular fratures common with large babies - get stuck in vaginal canal - fracture clavicle getting pulled out
- Indication of pain - nasal flaring Newborn Reflexes - Stepping - Answer-If you take a baby and hold them up they will step their feet - also called dancing reflex Newborn Reflexes - Crawling - Answer-Put them on their belly, touch their feet, and they will crawl Newborn Reflexes - Babinski - Answer-Strike bottom of foot and baby will fan toes - positive in babies is a good thing (positive in adults is bad)
Newborn Reflexes - Pull to sit - Answer-If you hold babies hands they will try to pull themselves to sit up Newborn Reflexes - Grasp- palmar and plantar - Answer-If you put your finger to babies toes and fingers they will wrap them around your finger Newborn Reflexes - Rooting - Answer-Touch their cheek and they will open their mouth Newborn Reflexes - Suck/swallow - Answer-Take pinky finger, put in babies mouth, touch top of mouth, baby will suck your finger - also checking hard palate here Newborn Reflexes - Tonic neck - Answer-Also called "fencing" - one arm out Newborn Reflexes - Moro- startle - Answer-Baby flinch Behavioural Characteristics - Newborns progress through a hierarchy of behavioural developmental challenges: - Answer-- Regulate their physiologic or autonomic system
- Regulate or control their motor behavior
- State regulation, the ability to modulate the state of consciousness
- Attention and social interaction Behavioural Characteristics - Sleep-wake states - Answer-- Six states form a continuum from deep sleep to extreme irritability · Deep sleep, light sleep, quiet-alert, active alert, drowsy, crying (refer to photo)
- The ability to make smooth transitions between states is called state modulation Behavioural Characteristics - Other factors influencing behaviour of newborns include the following: - Answer-- Gestational age (small babies may need to eat more)
· These scores do not predict future neurologic outcome, but the 5-minute score does correlate with the degree of risk for neonatal morbidity and mortality
- If baby is not breathing, resuscitation occurs right away (before 1 minute passes) What's my APGAR? - Answer-Examples in Note - Page 12 Immediate Interventions - Stabilization and resuscitation (bulb, suction, O2, heat support) - Answer-- Airway maintenance - suck gunk out of nose, mouth, eyes, etc.
- Maintaining an adequate oxygen supply
- Maintaining body temperature Immediate Interventions (continued) - Answer-· Identification bands and Hugs security tag (right away!) · Eye prophylaxis against ophthalmia neonatorum (an eye infection from STI transmitted from mother to baby ex., chlamydia, gonorrhea - will make baby go blind) · Vitamin K to prevent hemorrhagic disorders · Umbilical cord care (fold diaper down so it does not rub) · Promote parent-infant interaction · Evaluation Erythromycin - Answer-· Instillation of medication into eye of newborn · Thumb and forefinger are used to open the eye · Medication is placed in the lower conjunctiva from the inner to the outer canthus Care Management: from 2 hours after birth until discharge - Answer-· Weight · Head Circumference and length · Gestational Age Assessment using the New Ballard Score...for example, a flexed posture is seen with a newborn with a gestational age of 40 weeks
- LGA = large for gestational age, AGA = average for gestational age, SGA = small for gestational age · Complete head to toe physical assessment
- Chart - determines what percentile baby is in based on normal range (refer to photo on slide 49 of PowerPoint - ex., 50th percentile is normal) Estimation of Gestational Age - Answer-Refer to Photo on Page 13 of Note Physical Assessment of the Newborn - Answer-· Table 24.1 p. 489 · Table 24.3 p. 492 · Head to toe/systems approach Laboratory and Diagnostic Tests - Answer-· Routine testing for blood and urine · PKU and thyroid at 24 hours of age · Newborn hearing screening · TCB (transcutaneous bilirubin) · Screening for Critical Congenital Heart Disease (CCHD) - done after 24 hours · Remember that good handwashing between each infant handling is the single most important measure in the prevention of neonatal infection Therapeutic and Surgical Procedures - Answer-· IM injections (vitamin K) · Phototherapy (hyperbilirubinia) · Exchange transfusions through umbilical venous catheter · Parent education · Circumcision...care of the newly circumcised infant · Blood glucose monitoring
- Nonopioid analgesia
- Acetaminophen (fever)
- Opioid analgesia
- Morphine
- Fentanyl · Medications not often given unless baby is suffering from neonatal abstinence syndrome (withdrawal) Discharge Planning and Parent Education (1) - Answer-· To set priorities for teaching, the nurse follows parental cues. Knowledge deficits or gaps should be identified before beginning to teach.
- Temperature
- Respirations · Use of bulb syringe
- Feeding
- Elimination
- Sleeping, Positioning and Holding · Safe sleep positions · Sudden infant death syndrome (SIDS) Discharge Planning and Parent Education (2) - Answer-· Rashes
- Diaper Rash
- Other Rashes · Clothing · Car Seat Safety · Pacifiers · Bathing · Umbilical Cord care
· Skin care Discharge Planning and Parent Education (3) - Answer-· Infant follow-up care · Cardiopulmonary resuscitation · Who to call - health unit, PCP, lactation · Practical suggestions for first week at home:
- Interpretation of crying and use of quieting techniques
- Recognizing signs of illness
