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OB Exam 2
OB chapter 18
| Question | Answer |
|---|---|
| Acrocyanosis | Persistent cyanosis of fingers, hands, toes, and feet with mottled blue or red discoloration and coldness |
| APGAR score | used worldwide to evaluate a newborn’s physical condition at 1 and 5 minutes after birth A: appearance (color) P: pulse (HR) G: grimace (reflex irritability) A: activity (muscle tone) R: respiratory (respiratory effort) |
| Erythema toxicum neonatorum | benign, idiopathic, generalized, transient rash consists of small papules or pustules on the skin resembling fleabites caused by the newborn’s eosinophils reacting to the environment as the immune system matures |
| Milia | multiple pearly white or pale yellow unopened sebaceous glands frequently found on a newborn’s nose form from oil glands and disappear on their own within 2 to 4 weeks |
| Molding | refers to elongated shaping of the fetal head to accommodate passage through the birth canal |
| Nevus flammeus | port wine stain a capillary angioma located directly below the dermis flat with sharp demarcations do not regress, but grow in proportion to the child’s growth, becoming thicker and darker in color with age |
| Pseudo menstruation | vaginal discharge composed of mucus mixed with blood may also be present during the first few weeks of life |
| Stork bites | superficial vascular areas found on the nape of the neck, on the eyelids, and between the eyes and the upper lip caused by a concentration of immature blood vessels and are most visible when the newborn is crying |
| Vernix caseosa | thick white substance that protects the skin of the fetus formed by secretions from the fetus’ oil glands and is found during the first 2 or 3 days after birth in body creases and the hair |
| Like our pediatric & adult patients, neonates need a | comprehensive head to toe assessment - obtain info about newborn by looking at their chart and doing your own assessment (observation) |
| Why is a good assessment so important? | to gather data to use that info to develop a plan of care and determine what to evaluate, potential risks |
| Timing of Major Newborn Assessments | 1) After Birth 2) Admission to "newborn nursery" 3) At the time of discharge |
| 1) After Birth | Eval APGAR - 1 and 5 min Measurements - length and weight Transition - shunts are open and don't close for hrs/days Meds - erythromycin, vitamin k |
| erythromycin (ointment) | Provides bactericidal and bacteriostatic actions to prevent Neisseria gonorrhoeae and Chlamydia trachomatis conjunctivitis Prevents ophthalmia neonatorum |
| vitamin k (injection) | Provides the newborn with vitamin K (necessary for production of adequate clotting factors II, VII, IX, and X by the liver) during the first week of birth until newborn can manufacture it Prevents vitamin K deficiency bleeding (VKDB) of the newborn |
| 2) Admission to "newborn nursery" | (2-4 hours of life) Head to toe |
| 3) At the time of discharge | Screening Measurements - daily weights until d/c |
| Preparing for Birth & Newborn Resuscitation | Review pregnancy & labor history Perform safety checks for newborn resuscitation Alert additional personnel if needed…. |
| What are some potential findings that warrant consideration at delivery? | newborn's airway, breathing, circulation, temperature stability, or blood glucose, and prepare the appropriate team and equipment before delivery when risks are anticipated |
| Perform safety checks for newborn resuscitation | Preheated warmer Oxygen Suction |
| Thermoregulation | Keeping newborns warm is CRUCIAL Check temperatures q 30 minutes for first 2 hours or until temperature has stabilized Minimize heat loss |
| nursing considerations for thermoregulation | drying the infant immediately, promoting skin-to-skin contact, using warm blankets and a hat, monitoring temperature, and preventing heat loss to avoid cold stress, hypoglycemia, and increased oxygen consumption |
| Assessing for Distress at Birth: APGAR | APGAR score is standard method for assessing newborns immediately |
| APGAR | A: appearance (color) P: pulse (HR) G: grimace (reflex irritability) A: activity (muscle tone) R: respiratory (respiratory effort) |
| color | mostly pink |
| pulse | 110-160 |
| grimace/response to stimuli | irritability, crying, tight fist |
| tone | not limp, have muscle tone |
| respiratory effort | rise and fall of chest |
| An additional Apgar assessment is done at 10 minutes if | the 5-minute score is less than 7 points |
| scoring for APGAR | Each parameter is assigned a score ranging from 0 to 2 points A score of 0 points indicates an absent or poor response; a score of 2 points indicates a normal response |
| Initial Assessment - Red Flags that require intervention | Generalized cyanosis or pallor (whitish) Respiratory distress – evidenced by irregular respirations Abnormal heart rate Flaccid body Bulging or sunken fontanels Apneic episodes and decreasing HR simultaneously Stimulation and no crying |
| Initial Assessment – Nursing Interventions | Maintain airway patency Ensure proper infant identification Give newborn medications |
| newborn medications | vitamin K erythromycin first dose of the hepatitis B vaccine |
| vitamin K | single injection of 0.5 - 1 mg given in thigh prevents hemorrhage by day 8 of life, newborns produce their own |
| eye abx | Precaution against ophthalmia neonatorum Abx varies, but usually: erythromycin, Tetracycline, Silver nitrate |
| Silver nitrate isn't used as much because | eyes become red and swollen |
| first dose of the hepatitis B vaccine | recommended at birth requires consent IM injection up to parents discretion - controversial now |
| Newborn Measurements allow | HCPs to compare size of infant to expected measurements for the gestational age and maturity |
| Tracking head circumference and length allows us to | plot points on growth curves ---providing information about growth, development, & infant well-being |
| Abdominal circumferences can be done if | any GI issues are suspected |
| length of NB | The average length of most newborns is 50 cm (20 in), but it can range from 48 to 53 cm |
| weight of NB is affected by | genetics, maternal age, size of parents, moms nutrition, moms prenatal weight, gestational duration, pregnancy complications, cigarette use by mom, age of the mom, substance misuse during pregnancy, and placental perfusion |
| weight of NB | ranges from 2,500 to 4,000 g (5 lb, 8 oz to 8 lb, 13 oz) |
| head circumference of NB | The average newborn head circumference is 33 to 35.5 cm (13 to 14 in) |
| chest circumference of NB | The average chest circumference is 30.5 to 33 cm (12 to 13 in). It is generally equal to or about 1 to 2 cm less than the head circumference |
| length is measured | From head to heel Unclothed Must manually extend newborn leg |
| weight is measured | Naked Baseline is important for subsequent assessments driven by genetics |
| Gestational Age Classifications (by weight) | AGA LGA SGA |
| AGA | Appropriate for gestational age 80% of newborns most healthy |
| LGA | Large for gestational age >90% >4,000 grams (8lb 13oz) at term |
| SGA | Small for gestational age <10% <2,500 grams (5lb 8oz) at term |
| LGA & SGA infants are | at risk for certain complications and require closer monitoring and follow-up care |
| Gestational Age Assessment Tool | Ballard Tool |
| Gestational Age Assessment Tool used when | gestational age is uncertain or unknown, accurate for 20-44 wks |
| Gestational Age Assessment Tool is composed of | two domains, each with sub-domains |
| Ballard Tool two domains | Neuromuscular maturity: Within 24 hours after birth Physical maturity : Within 2 hours after birth |
| Prior to comprehensive head to toe assessment, why do you review perinatal and delivery history? | to determine GA |
| Newborn Physical Examination is completed within | 24 hrs of life, APGAR immediately |
| when should you do newborn physical exam | Best to postpone assessment until newborn is stable, quiet, and calm |
| what to do you begin a newborn physical exam with | a general survey, observe first so you don't irritate and disturb |
| temp | 36.5 C – 37.5 C 97.7 F – 99.5 F |
| HR | 110 – 160 |
| RR | 40 – 60 |
| BP | MAP (mean arterial pressure) should correlate with gestational age --- NICU specific info |
| Newborn Head to Toe Assessment | Comprehensive Range of normal findings and variations of normal findings Must know normal to be able to identify abnormal and provide reassurance and education to parents |
| Skin (Integumentary Assessment) Normal | smooth, flexible, elastic hydrated, warm |
| Skin (Integumentary Assessment) Variations | Milia, erythema toxicum acrocyanosis |
| Skin (Integumentary Assessment) Problematic | jaundice Signs of trauma |
| Head & Face Assessment: Normal | fontanels flat & soft sutures approximated symmetric facial features intact soft & hard palate |
| Head & Face Assessment: Variations | molding - head Epstein pearls - mouth |
| Head & Face Assessment: Problematic | cephalohematoma / caput succedaneum facial nerve paralysis full / bulging fontanels malformed or blocked nare |
| cephalohematoma / caput succedaneum is a byproduct of | trauma |
| facial nerve paralysis is caused by | use of forceps during birth, causes facial nerve paralysis |
| full / bulging fontanels can be caused by | infections |
| Caput succedaneum | swelling of the scalp in a newborn Crosses suture lines begins to decrease after few days |
| Cephalohematoma | Pressure on the fetal head ruptures small blood vessels vacuum assist births Does not cross suture lines ONE SIDED |
| Neck & Chest Assessment: normal | Neck - short, midline, creased & moves freely Chest - round, symmetric, evenly spaced nipples |
| Neck & Chest Assessment: variations | Chest - breast buds / whitish discharge Chest - Protruding xiphoid process |
| Neck & Chest Assessment: problematic | Neck - restricted movement, crepitus / clavicular fractures Chest - asymmetrical movement, barrel-shaped, retractions |
| Head & Neck Assessment Findings | torticollis normal neck subcostal retractions extra skin folds at neck xiphoid process breast buds barrel shaped chest clavicular fracture |
| Abdominal Assessment: normal | Soft, bowel sounds present, 3 vessel cord |
| Abdominal Assessment: variations | two vessel cord umbilical hernia diastasis recti - PCP needs to know |
| Abdominal Assessment: problematic | distended, dusky color, tender upon palpation absent bowel sounds |
| Genitalia Assessment: normal | Male - smooth glans, meatus at tip of penis, testes descended or undescended Female - swollen labia majora & minora |
| Genitalia Assessment: variations | Male - edematous scrotum Female - vaginal discharge, pseudo menstruation |
| Genitalia Assessment: problematic | Male - hypospadias Female - labial bulge, ambiguous genitalia |
| Extremities & Spine Assessment: normal | Spine - straight, flat, easily flexible Extremities - 10 fingers, 10 toes :-), symmetric, equal movement, normal creases |
| Extremities & Spine Assessment: variations | polydactyly or syndactyly |
| Extremities & Spine Assessment: problematic | Spine - tuft of hair, pilonidal dimple midline, cyst, or mass Extremities - abnormal creases, asymmetric gluteal folds, abnormal finding on Ortolani & Barlow maneuvers |
| Extremities & Spine Assessment Findings | creases syndactyly (stuck together) polydactyly (an extra finger) Asymmetric gluteal folds dimple with hole/pit dimple with visible bottom |
| Detecting Hip Dysplasia: Ortolani Maneuver | Place newborn supine – flex hips and knees to 90-degree angle at hip Abduct thighs and lift femur forward Listen for sounds & feel for abnormalities (There should be NO clunk) |
| Detecting Hip Dysplasia: Barlow Maneuver | Keep same position Adduct thighs and apply outward and downward pressure Feel for a clunk (pop or click is benign) |
| Nursing Management of Newborn | Providing general care Promoting sleep & nutrition Enhancing Bonding: 1st hour Assisting with Screening tests Preparing for discharge |
| General newborn care | Bathing and Hygiene Elimination and Diaper Care Cord and Circumcision Care Safety and Infection Prevention Circumcision Care |
| Bathing and Hygiene | 1st bath after 24hrs females need to wipe front to back document pseudomenses |
| Elimination and Diaper Care | wash hands prior to cleaning extend neck, pat dry head to foot, don't need soap because they have no sweat glands |
| Cord and Circumcision Care | delay cut to increase oxygen and blood flow provider wait until cord stops palpating (several seconds PP) |
| do not delay cord cutting for | respiratory issues |
| safety and infection prevention | "do you have a carseat" |
| after bathing | place the newborn under the radiant warmer and wrap them securely in blankets to prevent chilling |
| Perform the bath | quickly, drying the baby thoroughly to prevent heat loss by evaporation |
| Regardless of the type of diapers used, | up to 10 diapers a day, or about 70 a week, will be needed. |
| Newborn elimination patterns are highly | individualized |
| Breastfed newborns typically pass | mustard-colored, soft, seedy stools |
| Formula-fed newborns pass | yellow to brown, soft stools with a pasty consistency |
| The use of lotions, baby oil, and powders is | not recommended |
| Within 7 to 10 days, cord | sloughs off and the umbilicus heals |
| what should be emphasized to caregivers about cord | Keeping the cord clean and dry and using only soap and water |
| There are three commonly used methods of circumcision | Gomco clamp, the Hollister Plastibell device, and the Mogen clamp |
| plastibell | Plastibell is fitted over glans, excess foreskin is pulled over suture is tied around the rim to apply pressure to the blood vessels > hemostasis foreskin is cut plastic rim remains in place until healing plastic ring loosens and falls off in 1 week |
| Preoperative circumcision preparation should include confirmation of the following | at least 12 hours old received standard vitamin K prophylaxis voided normally at least once since birth has not eaten for at least 1 hr written parental consent infant has been correctly identified when brought to the procedure room |
| Immediately after circumcision, | the tip of the penis is usually covered with petroleum jelly–coated gauze to keep the wound from sticking to the diaper |
| Breast milk and formulas contain approximately | 20 cal/oz |
| Fluid requirements for the newborn and infant range from | 100 to 150 mL/kg daily |
| The AAP has also recommended that all infants (breastfed and bottle-fed) receive | a daily supplement of 400 IU of vitamin D, starting within the first few days of life to prevent rickets and vitamin D deficiency |
| nutrition options | breastfeeding formula combination feeding |
| breastfeeding | significant & well documented benefits q 2 - 3 hours for 10 - 20 minutes best nutrition for baby and helpful for mom |
| formula feeding | q 3 - 4 hours (not as frequently as bf) 1/2 oz to 1-2 oz make sure you can see bubbles and milk amount decrease |
| combination feeding | not as effective preferred by some parents recommended if weight gain or glucose |
| what should you encourage for nutrition | one type consistently! |
| The LATCH scoring tool | a breastfeeding charting system that provides a systematic method for gathering information about individual breastfeeding sessions |
| LATCH tool | the system assigns a numerical score of 0, 1, or 2 to five key components of breastfeeding |
| LATCH meaning | Latch Audible swallowing Type of nipple Comfort of nipple Hold (positioning) |
| Breastfeeding Concerns | engorgement nipple pain/discomfort milk supply (over/under) mastitis |
| engorgement | postnatal physiologic painful condition in which distention and swelling of the breast tissue occur as a result of an increase in blood and lymph supply as a precursor to lactation breasts are tight, warm and have blockages with moving milk |
| what to teach mom about engorgement | encourage mom to increase times of feeding, 10 min each breast |
| nipple pain/discomfort | result of poor placement of baby care for nipple with h2o |
| milk supply (over/under) | if over: encourage not to feed as frequently bc will lead to spit up if under: breast feed |
| mastitis | infection of breast ducts |
| hypoglycemia in newborns occurs in | up to 40% of full term newborns |
| Why does hypoglycemia happen | when in utero, everything is provided via placenta so when born their glucose begins to drop within 30min-1hr due to glucose being the sole source of energy |
| hypoglycemia is more prominent in | moms with GDM and DM |
| What are the signs and symptoms of hypoglycemia | jitteriness, increased respiration, irritability, crying, lethargy |
| What babies should have regular glucose screening? | babies with moms who are GDM or DM |
| safe sleep | SIDS prevention Back to sleep Room share – NOT bed share, ideally first 6 months Crib / Bassinette safety Hard Surface (firm mattress) No smoking Air circulation Breastfeed if possible |
| Education: Enhancing Bonding | Demonstrate appropriate newborn care, handling behaviors Support parent efforts in caring for newborn Teach parents how to comfort/soothe infants Encourage independence & praise efforts Engrossment (partner) En face |
| Assisting with Newborn Screening | State Screen – Mandatory after 24 hours of life (b/c of feeding/metabolism) Bilirubin Screening for jaundice Hearing screen Congenital Heart Screening |
| State Screen – Mandatory after 24 hours of life (b/c of feeding/metabolism) | PKU Congenital Hypothyroidism Galactosemia Sickle cell anemia |
| Jaundice | breakdown of bilirubin in skin - can stay in brain causing cognitive issues |
| interventions for jaundice | jaundice lights pick up bilirubin levels |
| what leads to jaundice | Failure of the liver cells to break down and excrete bilirubin can cause an increased amount of bilirubin in the bloodstream |
| discharge ready? | Follow-up appointments scheduled? (next slide) Safe home environment Supplies needed for newborn Car seat safety Parent Education! |
| parent education | Newborn care Warning signs When to call the doctor |
| Follow-Up Pediatrician Appointments | 2-4 days after birth 2-4 weeks of age 2 mos 4 mos 6 mos 9 mos 12 mos 15-18 mos 2 years |
| why are Follow-Up Pediatrician Appointments important | developmental milestones opportunity for parent teaching / education vaccinations |
| Education on Warning Signs pt 1 KNOW THESE | Temperature 100.4 or higher Forcefull or persistent vomiting Refusal to eat Abdominal distention Labored or difficult breathing |
| Education on Warning Signs pt 2 KNOW THESE | ≥2 green, watery, diarrheal stools Infrequent wet diapers Change in bowel movements from normal patterns Lethargy or excessive sleepiness Inconsolable crying / fussiness |
Created by:
leh195