Lecture Ten: Care of the Newborn

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Lecture Ten Care of the Newborn

• NURS 2208
• T. Dennis RNC, MSN

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Neonatal Transition

• Respiratory Adaptations
• Fetal lung development
• Fetal breathing movements
• Initiation of breathing
• Mechanical events
• Chemical stimuli
• Thermal stimuli
• Sensory stimuli

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Fetal Lung Development (681)

• Between 24-28 weeks Surfactant synthesis and
  storage begins to occur.
• Surfactant (composed of a group of surface active
  phospholipids, lecithin and sphingomyelin, which
  are critical for aveolar stability.
• The newborn born before the lecithin/sphingomyeli
  n (L/S) ratio is 21 will have varying degrees of
  respiratory distress.
• May need synthetic surfactant if born with
  respiratory distress.

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Breathing Movements (pg. 681-684)

• Breathing is a continuation of a process that
  began inutero.
• Lungs convert from fluid filled to gas filled
  organs.
• Pulmonary ventilation must be established through
  lung expansion following birth.
• A marked increase in pulmonary circulation must
  occur.
• Mechanical events, chemical stimuli, thermal
  stimuli, and sensory stimuli.
• Factors opposing the first breath 1) aveolar
  surface tension, 2) viscosity of lung fluid
  within the respiratory tract and 3) degree of
  lung compliance.

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Cardiopulmonary Physiology

• Cardio pulmonary adaptation
• Oxygen transport
• Maintaining respiratory function
• Characteristics of newborn respiration

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Transitional Physiology (pg. 686-687)

• 1) Increased aortic pressure and decreased venous
  pressure.
• 2) Increased systemic pressure and decreased
  pulmonary artery pressure.
• 3) Closure of the foramen ovale venosus.
• occurs due to increased pressure in the left
  atrium.
• 4) Closure of the ductus arteriosus.
• 5) Closure of the ductus

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Characteristics of Cardiac Function (pg. 687-689)

• Heart rate
• Blood pressure
• Heart murmurs
• Cardiac workload

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Heart rate

• The average resting heart rate for full term
  newborns is 120 to 160 (when the newborn cries
  the heart rate may exceed 180).
• Apical pulses should be obtained by auscultation
  for a full minute, preferably while the newborn
  is asleep.
• The heart rate should be evaluated fore abnormal
  rhythms or beats.

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Blood Pressure

• The newborn blood pressure tends to be higher
  immediately after birth.
• Blood pressure is sensitive to the changes in
  blood volume that occur in the transition to
  newborn circulation.
• Capillary refill should be less than 2 to 3
  seconds when the skin is blanched.

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Blood Pressure

• Crying may cause an elevation in blood pressure.
• Blood pressure should be taken while the newborn
  is in a quiet state.
• Measurement of blood pressure is best
  accomplished by using the Doppler technique or a
  1 to 2 inch cuff and a stethoscope over the
  brachial artery.

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Heart Murmurs

• Murmurs are usually produced by turbulent blood
  flow.
• 90 of all murmurs are transient and not
  associated with anomalies.
• Usually involve incomplete closure of the ductus
  arteriosis or foramen ovale.

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Cardiac Workload

• Systemic blood volume and pulmonary blood volume
  are not equal in the neonate.
• The right ventricle does most of the work prior
  to birth.
• The left ventricle increases its workload after
  birth and gains in size and thickness.
• Right sided heart defects appear better tolerated
  than left sided defects.

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Hematological Adaptations

• Physiologic anemia of infancy
• Delayed cord clamping and normal shift of plasma
  to extravascular spaces
• Gestational age
• Prenatal or perinatal hemorrhage
• The site of the blood sample

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Temperature Regulation

• Thermal neutral zone (TNZ)
• Heat loss Convection, Radiation, Evaporation and
  Conduction
• Heat production (Thermogenesis)
• Brown adipose tissue (BAT, brown fat)
• Response to heat

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Hepatic Adaptations

• Iron Storage and Red Blood Cell Production
• 1) Iron is stored in the liver until needed for
  red blood cell (RBC) production.
• 2) Newborn iron stores are determined by total
  body hemoglobin content and length of gestation.
• 3) If the mothers iron intake has been
  adequate, newborn iron stores will be stored to
  last until 5 month of age.
• 4) After about 6 months of age, foods containing
  iron or iron supplements may be given to prevent
  anemia.

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Hepatic Adaptations

• Carbohydrate Metabolism
• 1) Neonatal carbohydrate reserves are relatively
  low.
• 2) Energy crunch occurs at birth with the removal
  of maternal glucose supply and increased energy
  expenditure adjusting to extrauterine life.
• 3) Glucose is the main source of energy in the
  first 4 to 6 hours following birth.
• 4) Blood glucose level stabilizes at values of 50
  to 60 mg/dL.
• 5) Glucose level is assessed by using a chemstrip
  method on admission to the nursery and at 4 hours
  of age.

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Hepatic Adaptations

• Conjugation of Bilirubin
• 1) Conjugation of bilirubin is the conversion of
  yellow lipid soluble pigment into water soluble
  pigment.
• 2) Unconjugated (indirect) bilirubin is a
  breakdown product derived from hemoglobin that is
  released primarily from destroyed red blood
  cells.
• 3) Unconjugated bilirubin is not in an excretable
  form and is a potential toxin.
• 4) Total serum bilirubin is the sum of conjugated
  (direct) and unconjugated (indirect) bilirubin.
• 5) Total bilirubin at birth is less than 3mg/dL.
• 6) Direct bilirubin is excreted into the tiny
  bile ducts, then into the common duct and
  duodenum. The direct (conjugated) bilirubin then
  progresses down the intestines where bacteria
  transform it into urobilinogen. This product is
  not reabsorbed but is excreted as a yellow-brown
  pigment in the stools.

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Hepatic Adaptations

• Physiologic Jaundice
• Physiologic jaundice is caused by accelerated
  destruction of fetal RBCs, impaired conjugation
  of bilirubin, and increased bilirubin
  re-absorption from the intestinal tract.
• A normal biologic response of the newborn.
• Six factors give rise to physiologic jaundice 1)
  Increased amounts of bilirubin are delivered to
  the liver, 2) Defective uptake of bilirubin from
  the plasma, 3) Defective conjugation of the
  bilirubin, 4) Defect in bilirubin excretion, 5)
  Inadequate hepatic circulation, and 6) Increased
  re-absorption of bilirubin from the intestines.
• About 50 of full term and 80 of pre-term
  newborns exhibit physiologic jaundice on the
  second or third postpartum day.
• There appears a characteristic yellow color that
  results from increased levels of unconjugated
  bilirubin and a temporary inability to eliminate
  bilirubin.
• The signs of physiologic jaundice occur after 24
  hours after birth.
• Breast milk jaundice is controversial and
  difficult to distinguish from prolonged jaundice.

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Hepatic Adaptations

• Coagulation
• Coagulation factors II, VII, IX, and X are
  activated under the influence of vitamin K and
  are considered vitamin K dependant.
• The absence of normal intestinal flora needed to
  synthesize vitamin K in the newborn gut results
  in low levels of vitamin K.
• Although newborn bleeding problems are rare, an
  injection of vitamin K (AquaMEPHYTON) is given
  prophylactically on admission to the nursery to
  combat potential clinical bleeding problems.

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Gastrointestinal Adaptations (pg.697-698)

• By 36 to 38 weeks gestation, the gastrointestinal
  tract is adequately mature 1) enzymatic activity
  present, 2) able to transport nutrients.
• Lactose is the primary carbohydrate in the
  breastfeeding newborn and is usually easily
  digested and well absorbed.
• By birth the newborn has experienced swallowing,
  gastric emptying, and intestinal propulsion.
• The newborns stomach has a capacity of 50 to 60
  mls.
• The cardiac sphincter is immature, as is neural
  control of the stomach, so some regurgitation may
  be noted.
• Term newborns normally pass meconium (dark green
  to black) within 8 to 24 hours of life and almost
  always by 48 hrs.
• Transitional (thinner brown to green) stools are
  passed for the next day or two then they become
  completely fecal.
• The stools of the breastfed infant are yellow,
  more liquid , and more frequent than formulas fed
  infants.

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Urinary Adaptations (pg. 698-699)

• Full term newborns are less able than adults to
  concentrate urine (reabsorb water back into the
  blood) due to shorter and narrower tubules.
• Concentrating and dilutional limitations of renal
  function are important considerations in
  monitoring fluid therapy to avoid dehydration and
  overhydration.
• Many newborns void immediately after birth. A
  newborn who has not voided by 48 hours should be
  assessed for inadequate fluid intake, bladder
  distention, restlessness, and symptoms of pain.
• The first two days of birth the newborn voids two
  to six times a day, thereafter 5 to 25 times a
  day.
• First voiding frequently appears cloudy,
  occasionally pink brick dust may be observed.
• Pseudomenstruation (related to the withdrawal of
  maternal hormones) may be seen as blood on the
  newborn females diaper.

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Immunologic Adaptations

• Limitations in the newborns inflammatory
  response results in failure to recognize,
  localize, and destroy invasive bacteria.
• The signs and symptoms of infection are often
  subtle and nonspecific in the newborn.
• The newborn has a poor hypothalamic response to
  pyrenogens, therefore fever is not a reliable
  indicator of infection.
• Hypothermia is a more reliable indicator of
  infection in the newborn.
• Passive acquired immunity transfer of
  antibodies (IgG) from the mother to the fetus in
  utero.
• Newborns have maternally induced immunity to
  tetanus, diphtheria, smallpox, measles, mumps,
  poliomyelitis, and a variety of other bacterial
  and viral disease.
• Immunity against common viral infections such as
  measles may last 4 to 8 months whereas immunity
  to certain bacteria may disappear within 4 to 8
  weeks.
• Colostrum, the forerunner of breast milk is very
  high in immunoglobulin IgA which may provide some
  passive immunity to the breastfeeding newborn.

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Neurological and Sensory/Perceptual Functioning

• Intrauterine factors influencing newborn
  behavior maternal nutrition and extrauterine
  environment (noise).
• Characteristics of newborn neurological function
  partially flexed extremities, eye movements are
  observable, may fixate on faces, or geometric
  objects, cry is lusty and vigorous, knee jerk is
  brisk, plantar flexion is present.
• Periods of reactivity First Period of
  reactivity, Period of Inactivity to sleep phase,
  Second period of reactivity.
• Behavioral states of the newborn Sleep states
  and Alert states.
• Behavioral and sensory capacities of the newborn
  Habituation, Orientation, Self-quieting ability,
  auditory capacity, olfactory capacity, taste and
  sucking, and tactile capacity.

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Nursing Assessment of the Newborn

• Assessment of the newborn is a continuous process
  used to evaluate development and adjustments to
  extrauterine life.
• Assess immediately after birth r/o resuscitation
  and allow bonding.
• Assessment within 1 to 4 hours after birth
  progress of newborns adaptation, gestational age,
  ongoing assessment of high-risk problems.
• Assessment procedures in the first 24 hours or
  prior to discharge.

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Nursing Assessment of the Newborn
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Estimation of Gestational Age

• Must be established in the first four hours of
  birth.
• Ballard and Dubowitz.
• Include external physical characteristics and
  neurological or neuromuscular development
  evaluations.
• Some maternal conditions may affect certain
  gestational age assessment components. (PIH,
  Diabetes, analgesia).

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Estimation of Gestational Age (pg 707- 714)

• PHYSICAL CHARACTERISTICS
• Resting posture assessed undisturbed on a flat
  surface
• Skin thin, opaque, peeling
• Lanugo decreases as gestational age increases
• Sole (plantar) creases increase with gestational
  age
• Areola and breast bud tissue increases with age.
• Ear form and cartilage distribution Cartilage
  gives shape. Pinna is firm at term.
• Male genitals Size of scrotal sac, the presence
  of rugae, and descent of the testicles.
• Female genitals size of labia majora and minora.
• Vernix None in the post term infant. More seen
  with prematurity.
• Hair Preterm patchy, term silky.
• Skull firmness increases as the fetus matures.
• Nails long may be a sign of postmaturity.

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Estimation of Gestational Age (pg 707- 714)

• NEUROMUSCULAR CHARACTERISTICS
• The square window sign elicited by flexing the
  babys hand toward the ventral forearm until
  resistance is felt (the angle formed at the wrist
  is measured).
• Recoil test of flexion development. Lower
  extremities are tested first.
• Popliteal angle degree of knee flexion, angle is
  increased in the preterm infant.
• Scarf sign elicited by placing the newborn in
  supine position and drawing an arm across the
  chest toward the newborns opposite shoulder. The
  location of the elbow is noted in relation to the
  midline of the chest.
• Heel to ear extension with advancing age greater
  resistance an smaller angle is noted.
• Ankle dorsiflexion flexing the ankle on the
  shin.
• Head lag Full term may support head momentarily.
• Ventral suspension position of the head, back,
  and degree of flexion in the arms and legs are
  noted.
• Major reflexesevaluated.

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Physical Assessment

• General appearance Head larger than body
• Weight and measurements average birth weight is
  7lbs, 8oz, average length is 18 -22 inches.
• Temperature assessed by axillary method after
  initial rectal temp. 97.7 to 98.6.
• Skin characteristics (719)
• Head 12.5 to 14.5 inches, approximately 2 cms
  larger than the chest circumference.
  Cephalohemotoma, caput succedenum
• Face blue or dark. Chemical conjunctivits,
  subconjunctival hemorrhages. Epsteins pearls or
  thrush.
• Neck looks short, creased with skin folds.
  Fractured clavicle.

• Chestengorged breasts
• Cry strong and of medium pitch
• Respiration 30 to 60 respiratory rate
• Heart 120 -160 HR
• Abdomen appears prominent
• Umbilical cord white and gelatinous, bleeding is
  uncommon, umbilical cord hernia abnormal.
• Genitals may have vaginal discharge in the first
  week of life (white, thick)
• Anus check for imperforate anus or atresia (done
  visually)
• Extremities check for abnormalities,
  polydactyly, Erbs palsy.

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Skin Characteristics (pg 719)

• Acrocyanosis
• Mottling
• Harlequin Sign
• Jaundice
• Erythema Toxicum
• Milia
• Skin turgor
• Vernix caseosa
• Forceps or Vacuum extractor marks
• Telangiectatic Nevi (stork bites)
• Mongolian spots
• Nevus flammeus (port wine stain)
• Nevus Vasculosis (strawberry mark)

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Assessment of Neurological Status (pg. 732)

• Tonic neck reflex
• Grasping reflex
• Moro reflex
• Rooting reflex
• Sucking reflex
• Babinski reflex
• Trunk incurvation (Galant reflex)

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Newborn Behavioral Assessment

• Habituation
• Orientation to inanimate and animate visual and
  auditory assessment stimuli.
• Motor activity
• Variations in quiet alert states, state changes
  and color changes.
• Self quieting activity assessment on how often
  and how quickly newborns quiet themselves.
• Cuddliness or social behaviors.

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Nursing Care Management of the Newborn During
Stay in the Birthing Unit (pg.762-776)

• Nursing Diagnosis
• Risk for ineffective breathing pattern
• Altered nutrition less than body requirements
• Altered urinary elimination
• Risk for infection
• Knowledge deficit
• Altered family processes

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Nursing Plan and Implementation (pg. 762-772)

• Maintenance of cardiopulmonary function
• Maintenance of a neutral thermal environment
• Promotion of adequate hydration and nutrition
• Promotion of skin integrity
• Prevention of complications and preventing safety
• Enhancing parent-newborn attachment

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Maintenance of Cardiopulmonary Function

• Assess vital signs every 6 to 8 hrs or more
  depending on the newborns status.
• Back to Sleep , side lying to prevent
  aspiration and facilitate drainage of mucus.
• Keep bulb syringe readily available.
• Vigorous fingertip stroking of the spine
  frequently stimulates respiratory activity.
• Cardiac/respiratory monitor may be required.
• At-risk indicators pallor, cyanosis, ruddy
  color, and apnea.

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Maintenance of a Neutral Thermal
Environment(pg. 763-764)

• Maintain the newborns temperature within the
  normal range.
• Make certain the infant is dressed and bundled
  appropriately. Small caps may be used for the LBW
  or premature infant.
• Newborns use calories for warmth rather than
  growth.
• Chilling increases the affinity of serum albumin
  for bilirubin.
• Chilling increases oxygen use and may cause
  respiratory distress.
• Overheating will increase respiratory rate and
  activity in an attempt to cool the body, also
  increasing insensible fluid loss.

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Promotion of Adequate Hydration and Nutrition
(pg 764)

• Weigh at the same time each day.
• Weight loss of up to 10 is considered normal
  during the first week of life.
• Birth weight should be regained by the 2nd week
  of life.
• The nurse records voiding and stooling patterns.
• The first void should occur within the first 24
  hours and passage of stool in the first 48 hours.
• Assess for abdominal distention, bowel sounds,
  hydration, fluid intake, voiding pattern, and
  temperature stability.
• Excessive handling may cause an increase in the
  newborns metabolic rate, calorie use and fatigue.

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Promotion of Skin Integrity (pg 764-765)

• Bathing is important for health, appearance, and
  infect5ion control in the nursery.
• Ongoing skin care includes cleansing of the
  buttocks and perineal area with water and a mild
  soap with diaper changes.
• Assess the umbilical cord for signs of bleeding
  or infection 1) apply triple dye on admission to
  nursery and 2) alcohol after each diaper change.
• Cord care with each diaper change.
• Eye and skin care related to phototherapy.
• Skin care following circumcision.

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Prevention of Complications and Promoting Safety
(pg 765-767)

• Pallor may be an early sign of hemorrhage.
• Circumcision is assessed for signs of hemorrhage
  and infection.
• Initial scrub for 2-3 minutes when direct contact
  with the newborn is anticipated.
• Handwashing between each client contact and
  contact with floor, face, or any soiled surface.
• Encourage parents to wash hands prior to holding
  the infant and wear a gown over street clothes.
• Teach parents to limit visitors who may have a
  communicable disease.
• Check namebands with each encounter with the
  parents.
• Instruct clients in security measures in place to
  prevent infant abduction.

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Enhancing Parent-Newborn Attachment (pg. 767)

• Involve the entire family in newborn care
• Infant massage may be encouraged
• Increase skin to skin contact
• Read to or play music for the newborn
• Encourage cuddling and talking to the infant

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Discharge Planning and Preparation (pg. 767-773)

• Parent teaching
• General instructions for newborn care
• Nasal and oral suctioning
• Wrapping the newborn
• Sleep and activity
• Safety considerations
• Newborn screening and immunization Program

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Community-Based Nursing Care for the Newborn (pg.
773-776)

• The family should have access to the birthing
  unit and physician phone numbers.
• The client should be made aware of follow-up
  programs such as PRS, early intervention and
  high-risk referral.
• Referral to the public health department.
• Hospital phone follow-up.

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Questions?