wvc OB newborn winter 2011
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| Fetal lung fluid | during fetal life the lungs are filled with fetal lung fluid; toward the end of pregnancy this fluid is absorbed in the interstitial spaces and absorption is increased during labor. Fluid must be cleared for normal lung function.
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| Lung surfactant | surfactant reduces alveoli surface tension and aids in keep alveolar tissue inflated. surfactant production begins week 25 & sufficient by week 34/36; preterm infants breathing is complicated by reduced surfactant.
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| Respiratory drive in the infant at birth (the first breaths) | Chemo-receptors in carotid arteries respond to birth related hypoxia; recoil of the chest as it moves through the birth canal; temperature changes; sensory stimulation.
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| Ductus venosus | directs blood away from the liver to vena cava; at birth when the cord is clamped the ductus venosus constricts and normal blood flow to the liver begins.
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| Ductus arteriosus | directs blood from the lungs to the head & upper body (connects the pulmonary artery & aorta); at birth the rise in O2 as breathing begins cause the ductus arterious shunt to constrict
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| Foramen ovale | a flap between the RT and LT atrium where 50% of blood travels through in fetal circulation; at birth as the other shunts close pressure on the LT side of the heart increase and this shunt cannot open.
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| Newborn characteristics leading to heat loss | thin skin; blood vessels close to surface; little sub Q fat; 3X more surface to mass ratio.
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| Evaporation | air drying of the skin that results in cooling.
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| Conduction | movement of heat away from the body when the newborn comes in direct contact with objects cooler than the skin.
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| Convection | transfer of heat to the surrounding air.
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| Radiation | the transfer of heat to cooler objects that are not in direct contact with the infant.
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| Nonshivering thermogenesis | is the metabolism of brown-fat to produce heat. Thermoreceptors release norepinephrine which initiates brown fat metabolism.
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| Brown fat | highly vascular fat that located around the back of the neck; axille; kidneys; sternum; when this heat is metabolized it will produce heat in the infant. Its metabolism can also lead to acidosis & jaundice. Preterm infants have inadequate stores.
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| Effects of cold stress on the infant | increase of metabolism of brown fat leads to acidosis; increased metabolic rate leads to respiratory distress and hypoglycemia vasoconstriction can lead to return using fetal circulatory shunts.
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| Hazards of cold stress | increased oxygen need; decreased surfactant production; respiratory distress; hypoglycemia; metabolic acidosis; jaundice.
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| Neutral thermal environment | unclothed (89.6’f-92.3’f) clothed (72.5’f-80.6’f)
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| Hyperthermia in the infant | sweat glands are immature in the infant, high temps lead to increased metabolic rates, increased need for O2, and peripheral vasodilation leads to increased fluid loss.
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| Erythrocytes and hemoglobin in the infant | infant has more erythrocytes and higher hemoglobin and hematocrit levels; this increased levels allow adequate oxygenation of tissue at birth. This increased level of erythrocytes is a factor in jaundice.
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| Risk of clotting deficiency in infants | several clotting factors need vitamin k to be activated. The newborn has low levels of vitamin k ( intestinal flora is needed for vit. K synthesis) and this can lead to hemorrhage in the infant. IM injections of vitamin k are common at birth.
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| Newborn intestines | intestines in the newborn are comparatively long, this aids in digestion & absorption, but it is also a factor in dehydration.
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| Digestive enzymes in the newborn | pancreatic amylase deficient for 4-6 months (digestion of complex carbs); pancreatic lipase is deficient (digestion of fats)…both of these enzymes are found in breast milk.
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| Meconium | the first stool excreted by the new born; it has a greenish, black thick consistency;
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| Infant stools from breast milk | these are seedy and have the consistency of mustard with a sweet/ sour smell. The infant may secrete 10 breast milk per day (older infants 2-3 per day).
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| Formula stools in the newborn | pale yellow to light brown and they are firmer in consistency than breast milk stools.
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| Hepatic system in the newborn | liver function includes maintenance of blood glucose levels & conjugation of bilirubin.
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| Blood glucose maintenance in the newborn | In the last 4-8 weeks of pregnancy glucose is stored in the liver as glycogen. These energy stores are used until newborn feedings can maintain energy needs. Preterm and small for age infants may not have adequate stores.
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| Sources of bilirubin in the infant | after birth fewer erythrocytes are needed so increased hemolysis occurs causing increased bilirubin in the infant.
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| Normal conjugation of bilirubin | albumin in the plasma bind to the bilirubin & bring it to the liver; in the liver it is conjugated & excreted into the bile then into duodenum and excreted in stool.
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| Total serum bilirubin (TSB) | a blood test for un-conjugated and conjugated bilirubin in the plasma.
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| Factors that increase hyperbilirubin | hemolysis of excess RBCs; short life span of RBCs; lack of albumin binding sites; liver immaturity; preterm & late term infants; lack of GI flora; delayed feeding; acidosis from cold stress or asphyxia; trauma.
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| Kidney function in the newborn | GFR & re-absorption rate in the is decreased; newborn’s kidneys cannot handle large increases in fluids ( neonates can only concentrate urine to 1.2 SG where as an adult can have SG of 1.3 therefore a newborn can become dehydrated more easily)
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| Electrolyte balance in the newborn | solute & bicarbonate are excreted less efficiently by the newborn leading to acidosis and electrolyte imbalances.
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| Immune function in the newborn | leukocytes are delayed in moving to the site of infection & localizing an infection , therefore newborns are more susceptible to sepsis. Signs of infection are non-specific (changes in: activity, tone, color &/or feeding)
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| Intake & outtake of the newborn | 1st two days of life 40-60 mL/kg/day (output 1-2 voids daily)…after 1st 2 days of life 100-150 mL/kg/day (output at least 6 voids daily by 4th day)
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| BSI and the newborn | it is important for the nurse to wear gloves when handling the newborn until they are bathed & blood is removed from the skin.
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| Early assessment of the airway in the newborn | during birth fetal lung fluid is forced into the upper airway, excessive fluid in the upper airway can create breathing difficulties for the newborn.
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| Apnea in the newborn | apnea lasting more than 20 seconds accompanied by cyanosis, heart rate changes or other signs of dyspena.
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| Normal vital signs in the newborn | Axillary 97.7-99.1f / Rectal 97.7-99.8/ pulse 120-160 (sleeping 100, crying 180) respirations 30-60
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| Retractions | result when soft tissue around the chest are drawn in with the effort of pulling air in while breathing.
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| Flaring of the nares | A reflex widening of the nostrils occurs when the infant is receiving insufficient oxygen…Continued flaring indicates a serious respiratory problem.
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| Cyanosis | a purplish blue discoloration that indicates a lack of oxygen. Central cyanosis involves the lips, lounge, mucous membranes and the trunk (cyanosis in this area indicates true cyanosis)
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| Acrocyanosis | peripheral cyanosis involving just the extremities, this is normal the first day of life or if the infant is cold.
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| Grunting | grunting describes a noise made on expiration when pressure is increased within the alveoli to keep them open and allow more oxygen to be absorbed. Grunting may have to be ascultated. It is a common sign of respiratory distress.
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| Seesaw respirations | In the infant with severe respiratory difficulty…the chest falls when the abdomen rises.
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| Asymmetry | chest expansion should be equal on both sides …asymmetry or decreased movement on one side could indicate the collapse of a lung.
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| Choanal atresia | blockage of one or both of the nasal passages; check by closing the mouth of the infant and occulting one nostril at a time.
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| Pallor in the infant | indicates the infant is slightly hypoxic or anemic.
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| Ruddy color | ruddy or reddish skin color polycythemia; these infants with increased RBCs may later develop jaundice.
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| Heart rhythms and murmurs in the infant | heart sounds should be regular and clear; a murmur may be heard until the ductus arteriosus is functional closed.
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| Capillary refill in the infant | checked by depressing the skin over the abdomen or an extremity until it blanches. Cap refill time is less than 3 seconds.
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| Molding in the newborn | refers to changes in the shape of the head from over-riding of the cranial bones at the sutures.
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| Caput succedaneum | often appears over the vertex of the newborn’s head; a result of pressure from the infants head against the mother’s cervix at birth. THE EDEMATOUS AREA CROSES THE SUTURE LINE.
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| Cephalhematoma | results when there is bleeding between the periosteum & the skull. Normally over the parietal bones. The swelling is not present at birth, but develops over the next 2 days. HAS CLEAR EDEGES & ENDS @ SUTURE LINES
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| Umbilical cord | contains 1 vein & 2 arteries. It is surrounded by Wharton’s Jelly.
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| Developmental dysplasia | instability in the hip where the head of the femur can move in and out of the acetabulum.
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| Reflexes to access in the newborn | moro. Palmar grasp; plantar grasp; babinski; rooting; suckling; tonic neck; stepping reflex.
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| Signs of hypoglycemia in the newborn (less than 40-45 mg/dL) | jitteriness, tremors, poor muscle tone, tachypnea, grunting, cyanosis, apnea, diaphoresis, low temp, poor suck, high pitched cry, lethargy, irritability, seizures, coma, no symptoms.
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| Risk factors for hypoglycemia (less than 40-45 mg/dL) | preterm, post-term, intrauterine growth restrictions, large or small for gestational age, asphyxia, cold stress, problems at birth, maternal diabetes, maternal intake of terbutaline.
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| Bilirubin assessment in the newborn | assess for jaundice at least every 8-12 hours and more often with infants that have increased risk factors. Jaundice is assessed by pressing over an infants skin over a frim surface (sternum or nose) as the skin blanches the yellow can be seen.
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| Common risk factors for hyper-bilirubin in the infant | preterm, Cephalhematoma, bruising, delayed or poor intake, breastfeeding, cold stress, asphyxia, Rh or ABO incompatibility, infection, sibling with jaundice, male, polycythemia, infection, preeclampsia, maternal diabetes, Asian, Native
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| moro reflex | when the infants head & back is allowed to drop back 30 degrees when the infant is is in a slightly raised position...the arms & legs abduct w/ the fingers fanning open & thumbs & forefingers forming a "C" Arms return & embrace,to normally flexed state
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| Thrush | although thrush may not be present at birth it can form a few days after birth (exposure to bacteria in the vagina) Lesions resemble milk curds on tongue & cheeks. Lesions will bleed if you try to wipe them away.
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| Abdomen in the newborn | it should be soft, rounded and protrude slightly but not be distended. Palpate when the infant is sleeping.
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| Abnormal stools | stools should not have a ‘water ring’ around them this is a sign of diarrhea. (dehydration and electrolyte imbalance can result from diarrhea in the newborn)
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| Uric acid crystals in the urine | this is common in the first urinations by the infant, it can appear red and may be mistaken for bleeding (‘brick dust staining’ is another name for this).
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| Pseudomenstration | a small amount of vaginal bleeding may occur (this may be a result of the sudden absence of the mother’s hormones.
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| Male scrotum in the newborn | it should appear be pendulous and may be dark brown from maternal hormones. Palpate for both testes. The meatus should be placed at the tip; if the meatus is on the underside (hypospadias) or on the upper side (epispadias )
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| Skin color in the newborn | the skin should be pink or tan, red thin skin occurs in preterm infants; redness in full term may be an indication of polycythemia.
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| Vernix caseosa | Vernix is a thick white substance, resembles cream cheese and provides a protective covering for the fetal skin in utero. A thick covering of Vernix may indicate a preterm infant. Yellow tinged Vernix may indicate jaundice.
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| Mottling | is a lacy red or blue pattern from dilated blood vessels under the skin. It may be normal, but it can also be seen in cold stress, hypovolemia or sepsis.
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| Lanugo | fine heir that covers the fetus during intrauterine life, lanugo is assessed with gestational age.
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| Milia | milia are white crystals 1mm to 2 mm in size caused by the distention of the sebaceous glands. They occur on the forehead, chin and nose. Disappear within a few weeks.
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| erythema toxicum | red blotchy areas that may have white or yellow papules in the center. Commonly called ‘flea bite rash’ (resembles acne). Occurs in half of all full term newborns.
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| Mongolian spots | are bluish black marks that resemble bruises on the sacrum , buttocks, arms & shoulders. Most frequently occurring in in newborns with dark skin.
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| Nevus simplex (aka salmon patch/ stork bite/ telangiectatic nevus) | It is a flat pink or reddish discoloration from dilated capillaries, color blanches when pressed.
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| Nevus flammeus (port wine stain) | is a permanent flat pink to dark reddish purple mark. Varies with size and location.
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| Nevus vasculosus (strawberry hemangioma) | consist of enlarged capillaries in the outer layers of the skin. It is dark red and raised, usually located on the head and should disappear by age 5.
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| Café’ au lait spots | permanent light brown areas that may occur anywhere on the body. Although they are harmless the number and size are important. (6 or more spots are associated with neurofibromatosis)
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| Marks from delivery in the newborn | bruises/ petechiae may appear on the back or the grown (pin point bruises that resemble a rash) /small puncture mark from a fetal monitor scalp electrode was used/ forecep or vacuum extractor marks if used.
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| Gestational age assessment in the infant | assess for: posture/ square window/ arm recoil/ popliteal angle/ scarf sign/ heel to ear/ skin/ lanugo/ plantar surface/ breast/ eyes & ears/ genitals
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| Behavioral assessments in the newborn | orientation/ habituation/ self-consoling activites/ parents response.
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| Cord care | check for bleeding/oozing after birth. Purulent drainage or redness or edema at the base indicates infection. Cord becomes brownish/ black within 2-3 days & falls off within 14 days. Wash with water& keep clean & dry. remove clamp @ 24 hours if dry
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| Positioning the infant | infants placed in prone position is associated with SIDS (some ‘tummy time during play is OK, must be supervised). Parents should use a firm surface for the bay to sleep (avoid soft or loose bedding)
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| Identification of the infant | ID bands are placed on the mother, infant and father (or other support person). Information on the band includes sex/ date/ time/ hospital number and name/ an imprinted number on the band.
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| Instruct parents on | head support/ positioning/ wrapping/ breathing/ use of bulb syringe/ temperature/ using a thermometer/ urine output/ stool/I & O diarrhea/ skin care/ cord care/ diaper area/ bathing/ spone baths/ tub baths/ behavior/ sleep & awake phases/ socialization.
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| Risks for circumcision | hemorrhage/ infection/ over removal/ urethral stenosis/ fistula/ adhesions/ damage to the glans/ pain.
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| Square window | sign is elicited by bending the hand at the wrist until palmis as flat against the porearm as possible with gentle pressure.
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| Arm recoil | nurse holds the neonate’s arms fully flexed at the elbow for 5 seconds and then pulls the hands straight down to the sides and released. The angle of flexion in recorded.
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| Popliteal angle | the lower leg is folded against the thigh, with the thigh on the abdomen. Leg is then straightened until resistance is met. The angle of the popliteal is recorded.
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| Scarf sign | nurse grasps the infants arm and brings it across the infant’s body to the opposite side, (keep back flat on exam table) the position of the infant’s elbow in relation to the midline of the infant is noted.
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| Heel to ear | nurse grasps the infant’s foot and pulls it straight u[p toward the ear while the hips remain flat. When resistance is first felt , the position of the fot and the flexion of the leg are compaired with testing diagrams.
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| Skin | skin is assessed for color, visibility of veins, peeling and cracking. Preterm infant skin is usually red, sticky and fragile.
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| Assessing Lanugo | lanugo appears on the fetus at week 20 and begins to disappear by week 28. Large amounts of lanugo is an indication of younger gestational age.
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| Plantar surface | the plantar surface of the foot has plantar creases at week 32 on the fetus. Absence of plantar creases indicates pre-term.
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| Eyelids | eyelids are fused until week 26-28 on the fetus.
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| Female genitalia | as the fetus matures the labia majora covers the labia minora. If the labia minora is uncovered it is an indication of preterm.
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| Male genitals | the full term infant has pendulous scrotum with deep rugae.
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| Parents with uncircumcised sons should be taught | not to retract the foreskin until it becomes separate from the glans later in childhood/ signs of complications and how to take care of that area.
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| Reasons parents choose circumcision include | fewer UTIs/ reduced risk of penile cancer/ reduced risk for some STDs/ religious or cultural/ lack of knowledge of how to care for foreskin.
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| Assessment of behavior: orientation | The nurse notes the infant’s ability to pay attention to interesting visual or auditory stimuli.
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| Assessment of behavior: habituation | the first response to something interesting is a period of alertness, but after continued stimulation to the same stimuli the infant gradually loses interest in the stimulation.
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| Assessment of behavior: self consoling activities | Normal newborns are able console themselves for short periods. Self consoling activities including attempting to bring their hands to their mouth or sucking on their fists.
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| Palmar grasp reflex | infant’s palm is touched at the base of the fingers; hand closes to a tight fist. Grasp reflex maybe weak or absent if the infant has damage to the nerves of the arms
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| Planter grasp reflex | similar to the planter grasp; infants toes curl over the nurse’s finger
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| Babinski reflex | elicited by stroking the lateral sole of the foot from the heel across the ball of the foot. This causes the toes to flare outward & the big toe to dorsiflex.
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| Rooting reflex | the rooting reflex is important in feeding & can most often be seen when the infant is hungry. When the cheek is touched near the mouth the infant, the infant turns toward the side that is being touched.
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| Suckling reflex | When the mouth or palate is touched by a finger the infant begins to suck. It is assessed by presence and strength. Feeding and swallowing difficulties may be related to a poor suckling reflex.
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| Tonic neck reflex | refers to the posture assumed by the new born when in a supine position. The infant extends the arm & leg on the side which the head is turned and flexes the extremities on the other side.
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| Stepping reflex | it occurs when infants are held upright with their feet touching a solid surface. They lift one foot & then the other, giving the appearance that they are trying to walk.
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