ch. 15/16/17

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1

neonatal period lasts

first 28 days of life

2

what are normal findings to see for a neonate to survive outside the woumb?

  • normal VS
  • stimulation
  • adjusting to life
3

what is the first things we want to do once a baby is first born?

dry them off! why?? HEAT regulation

4

when does transition start for the baby outside the womb?

when the umbilical cord is cut and neonate takes their first breath

5

MOST critical and dynamic changes

occur in the respiratory and cardiovascular systems

6

biggest metabolic risk for neonates?

hypoglycemia

7

most critial and immediate physiological change

transition to extrauterine pulmonary function

8

Change is initiated by

  • compression of the thorax, which forces amniotic fluid from the lungs
  • lung expansion
  • increase in alveolar oxygen concentration
  • vasodilatation of the pulmonary vessels
9

after the cessation of placental blood flow ( cut of the cord)

the first breath which decreases 02 and leads to mild hypoxia

*normal finding (chemical stimuli)

10

2 factors that negatively affect the transition extrauterine function

  • decrease in surfactant
  • persistent hypoxemia and acidosis
11

signs of fetal respiratory distress

  • cyanosis
  • abnormal respiratory pattern
  • retractions of the chest wall
  • grunting
  • flaring of the nostrils
  • hypotonia
12

mechanical stimuli main goal

alveoli remain open

13

chemical stimuli main goal

stimulation of respirations

14

what helps the circulatory system begin

the respiratory system (the first breath)

dec in PVR- inc in pulmonary blood flow - inc in systemic vascular resistance which influences the cardio changes

15

first few weeks the neonates responses in thermoregulation are

delayed

placing the baby at risk for cold stress

16

neutral thermal environment

neutral body temp

17

neonate responses to cold stress

  • inc metabolic rate -- >inc in HR & RR
  • inc muscle activity-->inc in metabolic rate
  • peripheral vascular constriction
  • metabolism of brown fat
18

brown adipose tissue (BAT)

promotes:

  • inc in metabolism
  • heat production through lipid metabolic metabolism
  • heat transfer to peripheral system
19

BAT is

good fat

20

BAT reserves

depleted rapidly during cold stress

21

Neonates at higher risk for thermoregulatory problems

  • higher body surface area to body mass ratio
  • higher metabolic rate
  • limited and immature thermoregulation
22

negative factors in thermoregulatory changes

  • dec in subcut fat
  • dec in BAT
  • large BSA
  • loss of heat
23

loss of heat includes

  • Evaporation
  • Conduction
  • Convection
  • Radiation
24

Evaporation

loss of heat that occurs when water on the neonates skin is converted to vapors, such as bath time

to avoid: dry off

25

conduction

transfer of heat to cooler surface by direct skin contact, such as cold equipment

to avoid: warm blankets/warm countertops

26

convection

loss of heat from the neonates warm body surface to cooler air currents, such as an AC

to avoid: hats

27

radition

transfer of heat from the neonate to cooler objections that are not in direct contact, such as cold walls

to avoid: remove wet towels

28

cold stress

excessive heat loss leading to hypothermia and resulting in compensatory mechanisms to maintain body temperature

29

possible consequences of cold stress

  • Hypoglycemia
  • Metabolic acidosis
  • ↓ surfactant production
  • Respiratory distress
  • Hypoxemia
  • ↑ direct bilirubin
  • Delayed transition from fetal to neonatal circulation
  • Weight loss
30

risk factors of cold stress

  • Prematurity
  • Small for gestational age
  • Hypoglycemia
  • Prolonged resuscitation efforts
  • Sepsis
  • Neurological, endocrine, or cardiorespiratory problems
31

s/s of cold stress

  • Cool skin
  • Lethargy
  • Pallor
  • Tachypnea
  • AX temp below 97.7
  • grunting
  • hypoglycemia
  • hypotonia
  • jitteriness
  • weak sucking
32

Hypoglcemia

  • blood sugar under 40
  • common during the transitional time
33

metabolic system

  • Neonate must balance amount of insulin produced with glucose availability
  • BG ↓’s 1 hr postbirth and stabilize in 2-3 hr
  • Optimal range 70-100
34

Risks for hypoglycemia

  • Neonates of diabetic mothers
  • Neonates weighing more than 4,000 g or large for gestational age
  • Post-term neonates
  • Preterm neonates
  • Small-for-gestational-age neonates
  • Hypothermia
  • Neonatal infection
  • Respiratory distress
  • Neonatal resuscitation
  • Birth trauma
35

s/s of hypoglycemia

  • Jitteriness
  • Hypotonia
  • Irritability
  • Apnea
  • Lethargy
  • Temperature instability
36

hepatic system

  • Carbohydrate metabolism
  • Amino acid metabolism
  • Lipid metabolism
  • Synthesis of plasma proteins
  • *Blood coagulation
    • Vit K administration
  • Conjunction of bilirubin
  • Phagocytosis by Kupffer cells
  • Storage of fat-soluble vitamins (ADEK) and iron
  • Detoxification
37

Vitamin K is given because

  • decrease the risk of bleeding
  • want to help the liver activate the clotting factors
38

breast fed babies lack

Vitamin K more

39

GI system is

immature but rapidly adapts

40

Meconium stool

  • the first stool: happens within 24-48hrs
  • sticky, thick black and odorless
41

Transitional stool

  • begins by the 3rd day
  • black/green, green to brown to yellow/green
42

Breastfed stool

  • yellow & semi formed
  • sour odor
43

Formula stool

  • drier and more formed
  • paler yellow or brow with unpleasant odor
44

Renal system

2 main function

  • fluid & electrolyte balance
  • excretion of metabolic waste
45

with the renal system neonates are at risk for

  • over-hydration
  • dehydration
  • electrolyte disorder
  • drug toxicity
46

what is the first exposure for a neonate for the immune system

maternal genital track

  • Group B streptococcus
  • Escherichia coli
47

Neonates are at risk for infection related to

  • Immature immune system
  • Lack of organism exposure
  • Skin and mucous membrane exposure
48

Which of the following is protective tissue that assists in thermoregulation in the neonate?

  1. Brown fat
  2. Foramen ovale
  3. Bilirubin
  4. Vernix

Brown fat is the protective adipose tissue that can be metabolized to generate warmth in the neonate.

49

the newborn assessment

  • Within 2 hrs after birth
  • Provides baseline data, evaluates neonate’s transition, assists in course of nursing action
50

Initial newborn assessment includes

  • General survey-- head to toe, trauma
  • Physical assessment--testing reflexes, listening to lung sounds
  • Common newborn characteristics
  • Newborn reflexes
  • Gestational assessment
  • Pain assessment
51

General survey includes

  • When neonate is quiet
  • Respiratory pattern, respirations and breath sounds
  • Posture
  • Assess skin
  • Observe level of alertness/activity
  • Muscle tone
52

normal assessment finding

  • Comfort if crying
  • Posture—flexed extremities (frog like)
  • Head circumference—microcephaly and macrocephaly
  • Chest circumference- smaller than the head
  • Length- 18-21in
  • Weight—2500-4000 g (5 lb 8 oz-8 lb 13 oz)
  • Temp
53

what are the most common reasons we see microcephaly

  • alcohol and drug use
  • hydrocephalus
54

normal weight for a newborn

2500-4000 g (5 lb 8 oz-8 lb 13 oz)

55

Respirations

  • 30-60
  • slightly irregular
  • diaphragmatic/abdominal
  • Crackles/wheezing is abnormal (fluid or infection)
  • Grunting/nasal flaring = findings of respiratory distress
56

Pulse

  • 110-160
  • increases with crying
  • decreases when asleep
  • **tachycardia can indicate sepsis, hypothermia, hypoglycemia, resp distress syndrome
57

Tachycardia can indicate

sepsis, hypothermia, hypoglycemia, resp distress syndrome

58

Head findings

  • fontanels:
  • may bulge with crying
  • may pulsate with heartbeat
59

Firm/ bulging fontanels not with crying can indicate

possible indication of increased ICP;

60

depressed fontanels can indicate

possible indication of dehydration

61

you can hear murmurs in up to

30% of newborns

62

Apnea

> 15 secs should be evaluated

63

Acrocyanosis

blue hands or feet

64

circumoral cyanosis

transient cyanosis around mouth

65

mottling

transient pattern pink/white blotches

66

harlequin sign

one side of body pink/ other than white

67

mongolian spots

flat, bluish discolored are on the back

68

milia

baby acne/ white papules on face

69

Erythema toxicum

benign rash with red macules and papules (white to yellowish-white papule in center

70

molding

elongation of head as it fits through birth canal; may cause head to appear asymmetrical; will become more round

71

does molding cause brain damage?

no, it will go away over time

72

Caput succedaneum

soft tissue edema; feels spongy; can cross suture lines

73

Cephalohematoma

hematoma formation; unilateral, appears a few hrs after birth and can increase in size over the next few days; does not cross suture lines

74

gestational age assessment

  • preterm or over 42 weeks
  • diabetic mom
  • wt too small or too big
75

Periods of reactivity

  • Initial period—first 15-30 minutes
    • Alert and active; vigorously responds to external stimuli
  • Period of relative inactivity—30 minutes after birth and lasts 2 hrs
    • Enters sleep state, becomes unresponsive to external stimuli
  • Second period of reactivity—follows period of inactivity—2-8 hrs
    • Alternates between active alert and quiet alert states
76

Brazelton Scale

  • assesses neurobehavioral system
  • Not usually performed on healthy neonates
  • 28 behavioral items and 18 reflexes
77

Nursing care of the neonate

  • 2 time frames
    • 4th stage of labor, from birth through first 4 hours of extrauterine life
    • From 4 hours of age until discharge
78

DANGER SIGNS

  • tachypnea
  • retractions of chest wall
  • grunting
  • nasal flaring
  • abdominal distension
  • failure to pass meconium or urine in first 24hrs
  • convulsions
  • jaundice
  • jitteriness
79

priority to reduce cold sress

DRYING BABY

80

Newborn screening

  • Blood test and hearing test
  • Blood—for infections, genetic diseases, inherited and metabolic disorders—on all babies in the US
81

Circumcision

  • Sucrose-dipped pacifier during nerve block
  • Penile nerve block
  • Gomco clamp, Mogen clamp or Plastibell
  • Surgically removes foreskin
  • Post—assess q15min/1st hr; then q2-3 hrs
  • Acetaminophen q4-6 hrs
  • Assess voiding
  • Parent education
82

The neonate is given which of the following to facilitate blood coagulation?

  1. Oxygen
  2. Erythromycin
  3. Vitamin K
  4. Hepatitis B vaccine

Vitamin K is administered I M after birth to compensate for the absence of vitamin K due to the lack of intestinal flora.

83

newborns unable to suck or swallow

are gavage fed

84

factors that influence the mothers choice to breast or bottle feed

  • Past experiences
  • Cultural beliefs
  • Friends/family
  • Health of woman and baby
  • Support of partner
  • Perceived health effects
  • Discussion with HCP during pregnancy
85

short term benefits of breastfeeding

decreased risk of:

  • Gastroenteritis
  • Hospitalization due to RSV
  • Otitis media
  • Necrotizing enterocolitis
  • SIDS
  • UTIs
86

long term benefits of breastfeeding

decreased risk of:

  • Asthma
  • Atopic dermatitis
  • CVD
  • Celiac disease
  • Childhood IBD
  • Obesity
  • Sleep disorders
87

mothers benefits from breast feeding

short term

  • Decreased blood loss
  • Decreased risk of infection
  • If breastfeeding >3 months — > weight loss

Long term

Decreased risk for:

  • DM
  • Metabolic syndrome
  • Osteoporosis
  • Autoimmune disease
  • Ovarian and breast cancer
88

contraindications for breastfeeding

Mother

  • TB, herpes simplex lesions on breast, HIV

Infant

  • Galactosemia
89

Which of the following is a contraindication for breastfeeding?

  1. Obesity
  2. Tuberculosis
  3. Prematurity
  4. Autoimmune disease

Active or latent tuberculosis in the mother is a contraindication for breastfeeding.

90

patient education for breastfeeding

  • early and frequent feedings
  • support the breast during feedings
  • keep the mother comfortable and pain free
    • nipple/breast care/peri care
  • teach the mother about infant hunger cues and to feed on demand
  • cluster feedings are normal and usually in the evenings
91

determing effective feeding

  • physically and emotionally comfortable
  • newborn properly latches
  • newborn suckles or swallows milk
  • newborn i s drowsy w/ arms and legs relaxed
  • 8 wet diapers and several stools per day
  • newborn recovers their birth weight by 2 weeks
92

preventing nipple tissue breakdown

  • use proper techniques
  • apply warn compress before feeding
  • express colostrum or milk and rub it on the nipple before feedings
  • change position when feeding
  • begin on the less sore nipple
  • wash breast with water only
  • call the provider if nipples bleed or crack
93

storing of breastmilk

  • wash hands
  • stored in glass bottles hard BPA free plastic containers or plastic bags for no longer than 72hrs
  • frozen should not be in the freezer door
  • never use the microwave to heat milk
94

formula feedings

Advantages

  • Infant caring, either parent can feed
  • Leave infant with other people
  • Decreases frequency of feedings

Disadvantages

  • Increased time to prepare
  • Increased cost
  • Increased risk of infection due to lack of antibodies
  • Increased risk of childhood obesity and insulin-dependent diabetes
95

increased risk of infection in newborns due to

lack of antibodies

*colostrum helps with this

96

when growth spurts occur

newborns will require an increase of nutritional needs

97

circumcision care

parents should notify PCP if

  • no void in 24hrs
  • bleeding from site
  • entire penis red, warm or swollen
98

do not apply lubricant to what type of circumcision care

plastibelle

99

increased body heat during sleep

increase risk of SIDs

100

colic

  • uncontrollable crying in healthy infants
  • flexes/curls legs when crying
  • difficulty with pooping
  • irritable after feedings
  • appears in pain
  • frequent cuddling
101

soothing the baby with colic

  • hold and walk around
  • pacifier
  • swaddle
  • place of the belly and tab on back
  • baby bouncer
  • go for a drive
  • stroller
102

safe sleep

  • sleep on back
  • do not swaddle once baby can roll front to back
  • firm sleep surface
  • keep objects from sleeping baby
  • sleep in parents room for 6months
  • avoid overheating
  • women should not drink or smoke
  • plenty of tummy time
103

5 S's for soothing babies

  • Swaddling
  • Side positioning
  • Shushing
  • Swinging
  • sucking
104

swaddling

  • improper swaddling can cause SIDS and hip dysplasia
  • do not swaddle once the baby can roll from front to back
105

The first follow-up visit should take place:

  1. 24 hours after discharge
  2. 48–72 hours after discharge
  3. One week after discharge
  4. It depends

The first follow-up visit should take place 48–72 hours after discharge

106

preterm neonates

  • main reasons of illness and death
  • main reason for a low birthrate
107

very premature

less than 32 weeks

108

premature

32-34 weeks

109

late premature

34-37 weeks

110

biggest reason for premature birth

spontaneous previous premature birth

111

modifiable risk factors for preterm birth

  • age of pregnancy
  • unplanned
  • single
  • low educational level
  • poverty
  • obesity
  • health problems
  • infection
  • smoking/drinking
  • prenatal care
112

signs of respiratory distress on newborn

  • grunting on expiration
  • retractions
  • cyanosis
  • nasal flaring
113

cold stress causing baby to use more

glucose leading to hypoglacemia

114

respiratory distress syndrome (RDS)

  • small underdeveloped alveoli and not enough surfactant
  • lead to atelectasis
  • affects most preemies < 28 wks
115

complications of RDS

  • Patent ductus arteriosus (PDA) Pneumothorax
  • Bronchopulmonary dysplasia
  • Pulmonary edema
  • Hypotension, Anemia
  • Oliguria
  • Hypoglycemia
  • altered calcium/sodium levels
  • Retinopathy of prematurity
  • Seizures
  • Intraventricular hemorrhage
116

s/s of RDS

  • Tachypnea
  • retractions
  • audible expiratory grunting
  • nasal flaring
  • gray or dusky skin color
  • decreased breath sounds
  • crackles
  • increased O2 levels
  • lethargic and floppy
  • can lead to acidosis & tachycardia
117

nursing actions for RDS

  • Keep airway open
  • O2 as ordered
  • neutral thermal environment
  • monitor VS O2 sat & blood gas results
  • I&Os and daily wts
  • support rest
118

bronchopulmonary dysplasia (BPD)

chronic lung problem due to mechanical vent and O2- after 28 days

causes diminished lung compliance and pulmonary functions

119

risk factors of BPD

  • Prematurity
  • RDS
  • O2 toxicity
  • intubation
  • assisted ventilation with positive pressure
  • lower gestational age and birth wt, infection
  • pulmonary vascular damage caused by giving excessive fluids
  • right-to-left shunting d/t patent ductus arteriosus
  • and increased airway resistance
120

complications of BPD

  • Pneumonia
  • upper respiratory infections
  • ear infections
  • CHF
  • developmental delays
  • cerebral palsy
  • hearing loss
  • retinopathy of prematurity, sudden death
121

patent ductus arteriosus (PDA)

  • Ductus arteriosus doesn’t close after birth
  • normally closes few hrs after birth but can take up to 96hrs
  • fluid restriction
122

complications of PDA

  • CHF
  • chronic lung disease
  • kidney failure
  • NEC
  • intraventricular hemorrhage
123

intraventricular hemorrhage (IVH)

  • mostly preemies
  • happen in the 1st week of life- most in the first 96hr of life
  • bleeding into germinal matrix tissue surrounding lateral ventricles
124

risk factors for IVH

  • prematurity
  • amniotic fluid infection
  • perinatal asphyxia
  • RDS/resp failure that requires ventilatory support
  • Increased arterial pressure
  • low 5-minute APGAR score
  • maternal general anesthesia
  • low birth wt
  • hypotension/hypertension
  • acidosis
  • hypercarbia
  • low Hct
  • pneumothorax
125

signs that hemorrhage is getting worse

  • apnea
  • drop in BP
  • increased need for vent support
  • acidosis
  • seizures
  • full and tense fontanels and rapid increase in head size
  • decreased activity or LOC
126

necrotizing enterocolitis (NEC)

  • Inflammation and necrosis of the bowel
  • Most often in proximal colon or terminal ileum, usually after the introduction of enteral feedings
  • 90% of NEC occurs in preterm neonates where as 5-10% happened in term babies
  • In term babies most often the cause of NEC r/t decreased GI blood flow and intestinal ischemia
127

Retinopathy of Prematurity (ROP)

  • Retina isn’t fully vascularized & is vulnerable to stress or injury; can cause scar tissue that pulls and changes the retina and dislocates the macula
  • Can cause retinal detachment.
  • The risk of ROP increases with younger gestational age and lower birth weights
  • prolonged O2 use is the main cause
128

postmature neonate

  • Baby born after the completion of 42 wks gestation
  • Can cause dysmaturity from placental insufficiency or LGA if the placenta continues to function properly
129

complications of postmature neonate

  • meconium aspirations
  • persistent pulmonary HTN
  • fetal hypoxia
  • neurological complications
  • hypoglycemia
  • hypothermia
  • polycythemia
  • injuries r/t birth trauma
130

first sign of postmature neonate

jitteriness

131

meconium aspiration syndrom (MAS)

  • Passes meconium in utero and aspirates meconium stain fluid at delivery
  • Can lead to a partial obstruction in lower airways, chemical pneumonitis & increases risk of pulmonary HTN and atelectasis
  • barrel chest/crackles
  • resp depression at birth
132

persistent pulmonary HTN of the newborn

  • Occurs when expected vasodilation of the pulmonary vascular bed does not happen
  • Causes increased pulmonary vascular resistance, right ventricular HTN, and right to left shunting of blood through the foramen ovale and ductus arteriosus
133

most common things that pt the newborn at risk for PPHN

  • hypoia
  • asphyxia
134

Small for Gestational Age(SGA)&Intrauterine Growth Restriction(IUGR)

  • Weight is less than the 10th percentile for gestational age
  • UGR
  • Symmetric-weight, head circumference and length are all below the 10th percentile for gestational age
  • Asymmetric-head circumference and length are appropriate for gestational age, but weight is below 10th percentile
  • Increased risk of not tolerating labor, meconium aspiration, hypoglycemia, and hypocalcemia
135

Large for Gestational Age (LGA)/Macrosomia

  • Weight above the 90th percentile for gestational age
  • Can be preterm, full term or post term
  • Increased risk for shoulder dystocia, c-section delivery, operative vaginal birth, breech presentation, birth trauma, CPD, hypoglycemia, and hyperbilirubinemia
136

nursing action for Large for Gestational Age (LGA)/Macrosomia

before delivery

  • prepare mom for possible vacuum-assisted/c-section, McRoberts position and suprapubic pressure

After delivery

  • assess for birth trauma, collect early and frequent heel sticks, start early feedings or IV fluids, maintain thermoregulation, assess resp status, monitor hct level, assess for polycythemia, monitor for jaundice
137

Hyperbilirubinemia

  • Elevated serum bilirubin levels.
  • unconjugated and conjugated
  • Serum bilirubin levels >5mg/dl baby will start to have s/s of jaundice
138

´Physiological jaundice

increase in unconjugated bilirubin AFTER the 1st 24 hrs of birth

139

´Pathological jaundice

´happens in the 1 st 24 hrs of life.

140

risk factors for hyperbilirubinemia

increased RBC production or breakdown, delayed cord, Rh or ABO incompatibility, decreased fetal liver function, oxytocin or bupivacaine use during labor, maternal use of diazepam salicylates, or sulfonamides close to birth, breastfeeding, delayed or infrequent feedings, excessive wt loss after birth, bruising or cephalohematomas, prematurity, bacterial or viral infections

141

Central Nervous System Injuries

Many different CNS injuries

injuries can be caused by intracranial hemorrhage, hypoxia, and ischemia during the prenatal, intrapartum, or even after birth

142

infants of diabetic mothers

monitoring baby for s/s of resp. distress, birth trauma, congenital abnormalities, hypoglycemia, hypocalcemia, polycythemia, and hyperbilirubinemia. Monitor blood glucose, give early and frequent feedings, keep a neutral thermal environment

Congenital abnormalities-cardiac abnormalities, skeletal defects, small left colon syndrome and kidney abnormalities

143

hypoglycemia

  • Once umbilical cord is clamped baby’s passive source of glucose stops
  • Any type of physiological stress can lead to hypoglycemia
  • Normal glucose level for a healthy term baby is 30-60 mg/dL