Chapter 17: Newborn Transitioning

Neonatal Period: 1st 28 days. Changes occur during first 6 - 10 hrs. Biggest adaptations are cardio and resp
Respiratory
Fetal Newborn
 Lungs are fluid filled; High pressure system  Lungs are air filled; Low pressure system
 Blood shunted from lungs through ductus  Increased oxygen of blood causes closing of
arteriosus to rest of body ductus arteriosus
 Gas exchange occurs at the placenta
Circulation
Fetal Newborn
 Pressure in right atrium greater than left.  Pressure in left atrium greater than right.
 Encourages blood flow thru foreman ovale  Causes foramen ovale to close
Inside Fetal Heart
 Blood enters right atrium, then
o 2/3 goes to left side of heart
 Goes thru foramen ovale (short cut) to left ventricle, then aorta
o 1/3 of stays on right side (means more pressure on right)
 Enters right ventricle, then exits up to pulmonary artery.
 Majority of blood in pulmonary artery enters aorta through PDA.
 Then travels thru smaller vessels to reach back to placenta.
Cardiovascular System Adaptations
 Umbilical Vein: Carries oxygenated blood from placenta to fetus (oxygenated from mom)
 Ductus Venosus: Allows majority of umbilical vein blood bypass liver & merge w/blood entering IVC
 Foramen Ovale: Allows >50% of blood to go from right to left atrium, bypassing pulm circulation
 Ductus Arteriousus: Connects pulm artery to aorta, allowing blood to bypass pulmonary circuit.

Fetal to Neonatal Circulation Changes

 Before birth, foramen ovale allowed most of O2 blood entering RA from inf vena cava to pass into LA
 First breath- air pushes into lungs incr pulmonary blood flow & pulm venous return to left side of heart
 As a result, pressure of left atrium becomes higher than right atrium and foramen ovale closes.
o Pulmonary vascular resistance decreases
o Pulmonary blood flow increases
o Left atrium pressure increases
o Right atrium pressure decreases Foramen Oval closes
o Onset of respirations causes systemic vascular resistance increases
o Vena cava return decreases
o Blood return to umbilical vein decreases
o Ductus venous closes  Aorta pressure increases  Ductus arteriosus closure
Newborn Heart Rate
- At 110-160bpm (first few minutes) then decreases to 120-130
- Point of Maximal Impulse (PMI): 3rd-4th intercostal space and left of midclavicular line.
- Pulses palpable, and symmetrical.
Heart Rate & Blood Pressure fluctuate in response to changes in newborn’s behavioral state.
o Increases: wakefulness, crying, movement - Systolic 60 to 80
o Decreases: apnea, sedation, hypoxia - Diastolic 40 to 50
Blood Volume Thermoregulation
 Volume vary 25-40% depending on clamp time  Balance between heat loss and heat
o Early: < 30 to 40 seconds production; Need for a neutral thermal
o Late: >3 minutes environment (NTE)
 Benefits of delayed cord clamping:  Average temp of NB: 97.9 – 99.7
o Improve cardiopulmonary adaptation  Heat Production
o Anemia prevention o Non-shivering thermogenesis
o Increased BP o Metabolism of brown fat
o Improved oxygen transport & RBC flow
Four Mechs of Heat Loss in the Newborn
Normal Newborn Blood Values  Conduction
Lab Data Normal range o The transfer of heat when two objects
Hemoglobin 17-23 gm/dL are in direct contact with each other.
Hematocrit 46-68% o Prevent by putting blanket on scale
Platelets 100,000-350,000/uL  Convection: Think cool breeze
RBC 4.5-7.0 o From body to cooler surrounding air, or
(1,000,000/uL) to air circulating over a body surface.
WBC 10-30,000/mm3 o Prevent: Not by open windows, no fan
 Evaporation: Think wet skin
Respiratory System Adaptations o Liquid is converted to vapor.
 Surfactant: liquid protein that lines the lungs, o Insensible-unaware (from skin & resp)
o Reduces surface tension o Sensible –objective & aware
o Prevents alveolar collapse (perspiration)
o Provides the lungs with stability o Prevent by drying, hat, change diaper
 Initiation of Respirations: Adapting from fluid-  Radiation: Cold walls and windows
filled environment to gaseous environment o Loss of body heat to cooler, solid
surfaces in close proximity but not in
Lungs direct contact
 Prior to maintain resp fxn o Prevent by keeping baby away from
o Initiation of respiratory movement outside walls and cold windows
o Expansion of lungs
o Estab functional residual capacity Characteristics predisposing newborn to heat loss
o Increased pulmonary blood flow  Thin skin
o Redistribution of cardiac output  Lack subcutaneous fat
 Large surface area to body mass ratio
Respirations
 30-60 breaths/minute Cold Stress
o Irregular, shallow, symmetrical,  Can lead to respiratory distress
unlabored o Increased need for oxygen   RR
 Periodic Breathing: Cessation last 5-10 sec w/o o O2 & energy divert to brain & cardiac
change in color or heart rate fxn
 Apnea is >15 seconds o Pulmonary vasoconstriction can occur
 Signs of Respiratory Distress   pulm perfusion   PO2 & 
o Nasal flaring blood pH
o Retractions  Can exacerbate hyperbilirubinemia
o Grunting o Anaerobic glycolosis   acid
production
 o Excessive acids displace bilirubin from o Anaerobic glycolysis uses 3-4x amount
albumin-binding sites of blood glucose
 Hypoglycemia can occur o Glucose stores are quickly depleted

Thermogenesis  Bone marrow of NB doesn’t really produce

 Attempt to generate heat new RBCs between birth and about 3-4 weeks
o Increase muscle activity of age (physiologic anemia of new born)- why
o Increase in cellular metabolic activity, we practice cord clamping
esp in brain, heart, & liver oxygen &  More severe anemia in NB can occur when
glucose consume they have RBCs they break down too rapidly.
 Metabolism of Brown Fat o Baby that’s really bruised, big babies
o Brown fat is that adipose tissue that will w/trauma from delivery. Births assisted
be oxidized in response to cold w/vacuum.
exposure
o Richer vascular & nerve supply
o Can increase heat production by as
much as 100%
o Stores are rapidly depleted with cold
stress

Overheating
 Less common than hypothermia
 Environmental causation
o Skin vessels dilate (appear flushed)
ruddy
o Skin is warm to the touch
o Infant’s posture is of extension
 Sepsis causation
o Skin vessels constrict (appear pale)
o Hands & feet are cool to the touch

Carbohydrate Metabolism
 Term baby glucose level is about 70-80% of
maternal glucose level.
 Signs of hypoglycemic baby
o Jittery
o Hypothermia (using lot of energy to
breakdown glucose, causing incr O2
needs)
 If baby showing sign of hypoglycemia, most
important thing nurses can do is initiate feeds.

Hepatic System - Iron Storage

 Newborn iron stores are dependent upon total
body hgb content & length of gestation.
 At birth, the term newborn has iron stores
sufficient to last approximately 4 to 6 months.
Bilirubin Conjugation breastfeed
 Bilirubin  Impaired Bilirubin Excretion
o A yellow to orange bile pigment o Biliary obstruct, sepsis, chromo abnorms
o Produced by the heme portion of (Turner Syn, Trisomy 18, 21), various
hemoglobin when RBCs breakdown drugs
 NB’s liver must conjugate indirect bilirubin
(fat-soluble) into direct bilirubin (water-sol) GI System Adaptations
o Fat soluble means baby cannot excrete  Protective mucosal barrier
it, needs to be water soluble  Stomach capacity= 30-90mL, variable
 Failure to breakdown bilirubinjaundice emptying time of 2-4 hours
 Immature Cardiac sphincter & nervous ctrl of
Jaundice stomachregurgitation and uncord peristalsis
 Yellowing of the skin, sclera, & mucous  Meconium: First stool black, sticky, sterile.
membranes, from increased bilirubin levels.  Transitional: seedy
 Visible jaundice in >50% of all healthy NBs  Breastmilk: watery, thin
 Extremely high blood levels of bilirubin can  Formula: yellowish-brownish, pasty
cause kernicterus…permanent brain damage.
Renal System Adaptations
Three Causes of Jaundice  1st void should occur within 24 hours of age
 Bilirubin Overproduction  Kidneys have limited ability to concentrate
o RH or ABO incompatibility, drugs, urine until they mature at about 3 mo
trauma at birth, polycythemia, delayed  6-8 voids/day, indicating adequate fluid intake
cord clamping, & breast milk jaundice  Glom Fil Rate: Low, limits excrete &
 Decreased Bilirubin Conjugation conservation
o Physio Jaundice, hypothyroid,  Affects ability to excrete salt, water, drugs
Purposes of Responses of the Immune System o Prevents absorption of harmful agents
 Defense: protection from invading organisms o Protects thermoregulation & fat storage
 Homeostasis: elim of worn-out host cells o Protects against physical trauma
 Surveillance: recognition and removal  Skin development is not complete at birth
o fewer fibrils connecting dermis &
Immune System epiderm
 Natural Immunity: Does not require previous o Risk for injury tape, monitor, & handling
exposure to operate efficiently. o Sweat glands not fully fxnl until 2-3
 Acquired Immunity: Development of years
Circulating antibodies or immunoglobulins o Skin color changes occur with both
o Primarily depend on 3 environment & health status.
immunoglobulins:
IgG: 80% of all circulating ABs, in serum & Neurologic System Adaptations
interstitial fluid, crosses placenta. Fights bacteria,  Development follows cephalocaudal &
bacterial toxins, & viruses. proximal–distal patterns (HEAD TO TOE)
IgA: protect muc mems from virus & bac. In GI &  Hearing: well-developed at birth; responds to
resp tract, tears, saliva, colostrum, breast milk. noise by turning to sound
IgM: In blood & lymph fluid. 1st responder to  Taste: Distinguish btwn sweet/sour by 72 hrs
infection. Protects from blood-borne infections.  Smell: Distinguish between mother’s breast
and breast milk from others
Integumentary System Adaptations  Touch: sensitivity pain, tactile stimuli response
 Functions:  Vision: Focus on object only in close proximity
o Limits loss of water (7-12 in away); track objects in midline beyond
(90 in); Least mature sense at birth Behavioral Adaptations
 First Period of Reactivity
o Birth to 30 minutes of life
o Newborn is alert & moving & may
appear hungry
o Respirations & Heart rate are elevated
 Period of Decreased Responsiveness
o 30 to 120 min
o Sleep/decreased activity
 Second Period of Reactivity
o Lasts 2-8 hours.
o Show interest in environmental stimuli.
o Heart & respiratory rates increase.
o Peristalsis increases. Meconium may be
passed.
o Interaction between mother & newborn
is encouraged.
 Orientation: Response to stimuli, shown by
moving their head & eyes to focus on that
stimulus.
 Habituation: process & respond to visual &
auditory stimuli; block out external stimuli
after newborn becomes accustomed to the
activity
 Motor Maturity: ability to control movements
 Self-Quieting Ability: consolability
 Social Behaviors: cuddling & snugglin
 Chapter 18: Nursing Management of the Newborn

Newborn Assessments Vital Continued

 First Assessment- Vitals, APGAR score, l, wt,  Blood pressure
“eyes & thighs” o 50-75 systolic and 30-45 diastolic
 Second Assessment- 1st 24 hrs o Not part of the normal assessment
Head-to-toe- vitals, gestational age,  Pulse oximetry
anthropometric measures, reflex testing. o 96-100% on room air (R hand either
 Discharge assessment foot)
Physical Maturity Assessment
Signs of indicating a Problem
 Skin texture
 Nasal flaring
 Lanugo
 Chest retractions
 Plantar creases
 Grunting on exhalation, labored breathing
 Breast tissues
 Generalized cyanosis
 Eyes and ears
 Flaccid body posture
 Genitalia
 Abnormal respiratory rates
 Abnormal breath sounds New Ballard score system:
 Abnormal heart rates  Total score: 12 areas determine gestation age
 Abnormal newborn size  Preterm or premature: before 37 weeks
 Term: 38 and 42 weeks gestation
Initial newborn assessments  Postterm or postdate: after 42nd week of
 APGAR scoring  Postmature: born after 42 week and
o A: appearance (color) demonstrating signs of placental aging
o P: pulse (heart rate)
Nursing Interventions
o G: Grimace (reflex irritability)
 Maintaining the airway
o A: activity (muscle tone)
 Ensuring proper identification
o R: Respiratory (respiratory effort)
 Administering prescribed medications
 Length and weight, vital signs
o Vitamin K
 Gestational age assessment
 Fat-soluble, promote blood clot by
 Physical maturity (skin texture, lanugo, plantar
incr synthesis of prothrombin by liver
creases, breast tissue, eyes and ears, genitals)
 NB gut sterile, so Vit K not produced
 Neuromuscular maturity (posture, square
until after microorganisms are
window, arm recoil, popliteal angle, scarf sign,
introduced, such as the first feeding
heel-to-ear)
 Single, IM dose of 0.5 to 1 mg
o Eye prophylaxis
Vital signs of the normal newborn
 no longer than 1-2 hours after
 Temperature
 Prevents Ophthalmia Neonatorum
o 97.7-99.5 degrees F axillary
 Maintaining thermoregulation
o Axilla is preferred rectal temperature
o Dry the baby
o Adhesive probes placed over liver
o Wrap the baby
 Heart rate o Warmed blanket on scale
o 120-160 bpm; regular rhythm o Warm stethoscope/hands
 Respirations o Delay bath until stable
o 30-60 bpm o Cap on newborn’s head
o Respiration irregular, shallow, o Skin to skin – 1st, or radiant warmer – 2nd
unlabored o Avoid drafts and exterior walls
o Symmetrical chest movement
Newborn assessment  Vernix Caseosa
 Perinatal history o From secretions of fetus’ oil glands
o Mother’s STIl, bloodborne diseases o Need to be removed entirely
o HIV, Hep B, Rubella, Group B strep o Contains maternal antibodies
o Thick white cheesy-looking, protects skin
o Maternal medical history and
o Found in body creases, ears, etc.
medications
 Lanugo
o Prenatal care o A part of normal gestation
o Social History (drug, alcohol, nicotine) o shoulders, back, cheeks, pinna, forehead
o Blood type of mom and baby o 24-40 weeks gestation
o Meds administered during delivery o Typically, a sign of prematurity
o Cultural considerations o Also attributed to familial traits
 Anthropometric measurements  Milia
o Length: o Unopened sebaceous glands
 Head- heel, supine, one leg extended o Most often on nose, chin, forehead
 Expected full term =19-21 inches o Disappear on their own, 1-2 weeks
o Weight o Clinically insignificant
 Erythema toxicum- Newborn rash
 May lose up to 10% birth weight
o Benign, idiopathic, generalized, transient
 norm, term=2700-4000g (6-9 lb)
o 70% of newborns develop it
 Low (<2500g/5.5 lb) o May develop pustules
 Very low (<1500/3.5 lb) o Resolves on its own, within days
 Extremly low (<1000g/2.5 lb) o Inflammatory resp of immune system
 LGA: weight > 90th%  Nevus simplex- Stork bite
 AGA: 10th% < weight > 90% o eyelids, forehead, upper lip ,nape of neck
 SGA: weight < 10th% o Concentration of immature blood vessels
o Head and Chest circumference o Most visible when infant cries or is upset
 Avg head 13-15 in (32-38cm) o Usually fade within the first year
 Should equal ¼ infant’s length  Nevus Flammeus- Port win stain
 Avg chest 12-14 in (30-36cm) o Most often on the face, Below the dermis
o Permanent and will not fade
 Chest about 2-3 cm < head
o Pulsed dye laser surgery may lighten
Head-to-toe physical examination o Structural malformation, certain cancers
 General appearance survey  Nevus Vasculosus- Strawberry Hemangioma
o Skin color o Benign capillary hemangioma
o Posture o Raised, rough, sharp demarcation
o Often on scalp, neck, or face
o State of alertness
o No treatment. Usually resolves w/in 3 years
o Head size o Common in premies <1500g
o Respiratory status  Mongolian spots
o Gender o Concentrated area of pigmented cells
o Any congenital anomalies o Appears as blue or purple splotches
o Most often on buttock/sacral area
Head to Toe Physical: Skin o Frequently on darked-skinned newborns
 Should be o Usually disappears within first 4 years
o Smooth, flexible, good turgor, warm,  Café au lait birthmark
intact, cracking/peeling common  Harlequin sign
 Color should be consitenttent w/gene o Dilation of blood vessels on 1 side of body
o Distinct midline demarcation is visible
background; acrocyanosis, mottling is common
o Result of immature autore of bloodflow
o Most often occurs in low-birthweight babies
o Transient, No treatment necessary
 o
 Assess for overriding sutures
 Molding
 Elongated shaping of the fetal head as a result of passage through the birth canal
 No intervention or treatment
 Resolves within 3-7 days
 Caput Succedaneum
 Localized Edema on the scalp
 Common with prolonged labor and vacuum extraction
 Crosses suture lines
 Resolves within days
 Cephalhematoma
 Localized effusion of blood below the periosteum of the skull
 Does not cross suture lines
 Often occurs with forceps/vacuum extractions
 Takes several weeks to resolve
 Increases chance for jaundice
 Microcephaly
 Head circumference < 10% of normal parameters for gestational age
 Caused by failure of brain development
 Occurs with
o Familial trait
o Dominant or recessive inheritance
o Infections (zika, cytomegalovirus)
o Trisomy 13 and 18
o Fetal alcohol syndrome
 Macrocephaly
 Head circumference > 90% of normal parameters for gestation
 Typically related to hydrocephalous
o Face
 Observe for symmetry
 Cheeks should be full and symmetrical
 Examine for
 Milia
 Stork bite
 Bruising
 Eyes
 Check for symmetry in shape and size
 Check distance between eyes (rule of 1/3s)
 Test blink reflex
 Evaluate PEARL
 Observe for strabismus
 Observe for nystagmus
 Nose
 Observe size, shape, position, and symmetry
 Test for patency of both nares
  Observe for mucus and drainage
 Note any milia or bruising present
 Nasal flaring is a sign os respiratory distress
 Mouth
 Inspect
o Lips, tongue, mucous membranes, lingual frenulum, palate, uvula, epstein’s
pearls, precocious teeth
o Assess chin size and shape
o Evaluate gag, suck, and rooting reflexes
 Ears
 Observe for size, shape, and symmetry
 Observe for correct placement
 Note the pinna and cartilage
 Test for recoil
 Observe for preauricular skin tags
 Inspect for inner ear patency
o Neck
 Assess range of motion
 Observe for
 Folds, webbing, masses, and palpate clavicles
 Clavicles should be straight and intact
o Chest
 Observe shape and symmetry
 Assess nipples for position and drainage
 Examine for supernumerary nipples
 Auscultate heart and lung sounds
 Palpate for the Point of Maximal impulses (PMI)
 Supernumerary nipples
o Abdomen
 Inspect for shape and movement
 Expect round, slightly protuberant and movement with respirations
 Auscultate bowel sounds
 Palpate gently for masses
 Inspect umbilical cord for 3 vessels (1vein, 2 arteries)
 Inspect umbilical area for bleeding, infection, hernia
 Umbilical hernia
o Genitalia
 Assess male genitalia
 Penis
o Locate urethral meatus
 Hypospadias (ventral side)
 Epispadias (dorsal side)
o Epithelial pearls
o Chordee
 Scrotum
o Size, symmetry, color
o Rugae
o Testes descended or in Inguinal Canal
 o Hydrocele
 Assess female genitalia
 Labia Majora and minora
o Normally edematous
 Clitoris
o In front or urethral meatus
 Vagina
o Hymenal tag; mucoid discharge; pseudo-menstruation
o Anus
 Inspect for
 Position
 Patency
 Assess for anocutaneous reflex (anal wink reflex)
 Meconium passage indicates patency
 First stool should pass within 24 hours of life
o Extremities
 Arms and legs
 Assess flexion, extension, and range of motion
 Inspect for:
o Appearance symmetry
 Length
 Size
 Skin folds
 Assess Moro reflex
 Ortolani and Barlow Maneuvers
 No not perform these maneuvers
 Only advanced practice RNA and MDS perform these maneuvers
 Indicators for hip dislocation
 Hands
 Inspect for
o Size and symmetry
o Palmar creases
o Number of digits
o Polydactyly
o Syndactyly
 Assess
o Range for motion
o Palmar reflex
 Feet
 Inspect for
o Size and symmetry
o Plantar creases
o Number of digits
o Polydactyly
o Syndactyly
 Assess
o Range of motion
o Plantar reflex
 o Babinski reflex
o Back
 Inspect and palpate the spine
 Observe for masses, curvatures
 Inspect for pilonidal dimples, hair tufts, abnormalities
 Inspect shoulders, scapulae, and hips for correct alignment
 Assess galant reflex
 Spina Bifida/Myelomeningocele
- Neuro status
o Blinking
 Persists into adulthood
o Moro
 3-6 mo
o Grasp
 3-4 mo
o Stepping
 1-2 mo
o Tonic neck
 3-4 mo
o Sneeze
 Persists into adulthood
o Rooting
 4-6 mo
o Gag reflex
 Persists into adulthood
o Cough reflex
 Persists into adulthood
o Babinski sign
 12 mo
- Void/stool/feeding status
Nursing Interventions for the Newborn
- Bathing and hygiene
o Use standard precautions
o Bathe per facility protocol (delayed bathing is common)
o Wash from clean to dirty (eyes to diaper area)
o Water only on face and eyes
o Mild soap on body
o Skin-to-skin or radiant warmer post bath
o Sponge bath only until cord falls off
o Bath 2-3 times/week for first year of life
o DO NOT USE lotions, powders, or baby oil
- Elimination and diaper area care
o Use standard precautions
o Gather all supplies prior to diaper change
o Use wipes or mild soap and water to cleanse
o Cleanse girls from front to back to prevent infection
o Check frequently and after feedings
o Fold diaper down in front until cord falls off, to avoid irritation
o Barrier ointment may be used for diaper rash
- Cord care
o Separates within 14 days
o Keep area clean and undisturbed by diapers
o Use Water Only to cleanse the cord area, and only as needed
o Assess for signs of infection
o Assess for bleeding
o Sponge bath only until cord separates
- Circumcision care
o The surgical removal of all or part of the foreskin (prepuce) of the penis
o Decision to circumcise based on informed parental choice, not as a matter of routine
o Three methods: Gomco clamp, Mogen clamp, and plastibell
o Analgesia, anesthesia should be provided
 Oral sucrose solution
 Topical anesthetic application (EMLA)
 Dorsal penile nerve block
 Acetaminophen
 Swaddling
o Monitor the surgical site for bleeding, redness and swelling per hospital protocol
o Apply petroleum ointment (generously) to a gauze pad and place over the head of the penis with
each diaper change for 1 week
o If gauze pad stick to penis, spread petroleum ointment at the site and gently remove
o No ointment necessary if Platibell was used
o Clean site with water only until healed
o Healed when normal flesh tone returns, approx. 1 week
- Safety
o Environmental
 Hospital
 Never leave infant unattended
 Security policies
 Proper badges
 Suctioning with bulb syringe
 Hand washing
 Home
 Never leave infant unattended
 Never leave infant on an elevated surface
 Always supervise infant in the bathtub
 Keep a smoke-free environment
 Place infant on his/her back for sleeping, to prevent SIDS
 Hand washing
 Avoid placing crib/changing table near blinds/curtains cords
 Cover electrical outlets
 Have emergency numbers readily available
o Car
 AAP recommends a rear facing seat until age 2 or the height/weight limits for the seat are
exceeded
 Harness should be in the slots at or below the infant’s shoulders
 Every state in the US requires car seat use for infants and children
o Infection prevention
  Hand washing
 No ill visitors
 Monitor umbilical cord stump and circumcision for s/s of infection
 Provide eye prophylaxis at birth
 Avoid taking infant into crowds
 Watch for early signs of infection
 Fever, lethargy, loss of appetite, labored breathing, loose, green stools
 Drainage
o Cord site, eyes
- Promoting sleep
o “Back to sleep” for SIDS prevention
o Newborns sleep about 15-16 hours per 24 hours period during the first three months of life
o Co-sleeping should be discouraged (40% higher suffocation rates)
o Avoid high temperatures (prevent overheating)
o Keep crib empty of toys, pillows, blankets, crib bumpers
o Avoid crib placement near window cords/blinds
o Circulate air with fan, if possible
- Enhancing bonding
o Encourage skin-to-skin interaction between baby and both parents
o Teach parents feeding cues
o Teach parents infant’s typical reasons for crying
 Wet/soiled diaper
 Hungry
 Too hot/cold
 Painful stimuli
 Gas/air pressure
 Diaper rash
 Clothing twisted/rubbing
 Demonstrate ways to calm baby
 Soothing voice
 Gentle massage
 Swaddling
 Rocking/bouncing
- Assisting with screening testing
o PKU (after 24 hours of age)
o Hearing
 Some degree of hearing loss is present in 3-5 newborns per 1000
 All newborns should be screened prior to discharge
 Newborns never “fail the hearing test”
 Delays in identification and intervention may affect
 Language development
 Academic performance
 Cognitive development
o CCHD
 Critical congenital heart disease
 Pulse ox measurement in R hand and either foot, after 24 hours of age
 O2 sat of 95% or greater + < 3% difference between R hand and either foot = Baby passes
 O2 sat <90% = autonomic fail
- Dealing with Common Cancers
o Transient tachypnea
 Fetal liquid in the lungs is removed slowly or incompletely
 Accompanied by
 Retractions
 Expiratory grunting
 Cyanosis
 Nursing interventions
 Low-dose oxygen therapy
 Ensuring warmth
 Observing respiratory status frequently
 Allowing time for lymphatics to remove remaining fluid
 Explain situation to parents and reassure
o Physiologic jaundice
 Reassure parents its very common in newborns
 Parents should
 Feed frequently
 Observe for and report further yellowing of skin, sclera, or mucous membranes
 Treatment may include
 Promoting hydration
 Phototherapy (converts unconjugated bilirubin into colorless compounds that can be
excreted)
 Exchange transfusion (rarely progresses to this)
 Phototherapy
 Monitor
o Body temperature
o Fluid and electrolyte balance
 Provide and maintain eye protection
 Observe skin integrity
o Diarrhea
o Phototherapy lights
 Encourage parent participation in care
o Hypoglycemia
 Blood glucose level of <35 mg/dL
 Plasma concentration of <40mg/dL (normal = 40-60 mg/dL)
 During pregnancy, mother = primary source of fetal glucose
 Neonatal glucose levels fall to the lowest level within 1-2 hours of birth
 Threshold for intervention for hypoglycemia depends on clinical status, feeding status, and
other sources of stress
 Risk Factors
 Infants of diabetic mothers
 Premature infant
 IUGR and SGA infants
 Sepsis
 Cold stress
 Endocrine deficiencies
 Signs and symptoms
 Jitteriness, tremors
  High-pitched/weak cry
 Respiratory distress/apnea
 Stupor, lethargy
 Refusal to feed
 Seizures
 Interventions
 Monitor infants for signs of hypoglycemia
 Identify “at-risk” newborns
 Initiate early feedings
 Notify MD if hypoglycemia occurs despite early feedings
- Promoting nutrition
o Can’t digest cereal until 3-6 months
o Vitamin D and Iron supplementation
o Require 110cal/kg/day for 1st 3 months
o Only breast milk or formula; no water
o High risk for food allergies the 1st 6 months
o Small frequent feedings, initially
o Advantages of Breastfeeding
 Strengthens immune system
 Stimulates bacteria growth in GI system
 Decreased stomach upset, diarrhea, and colic
 Passive immunity
 Mother-infant bonding
 Reduces constipation
 Readily available, sterile
 Easily tolerated and digestible without anything artificial
 Less likely to result in overfeeding
 Protection against food allergies
 Better tooth and jaw development
 Decrease incidences of type 1 diabetes and heart disease
o Advantages of BF for Mom
 Facilitates weight loss
 Stimulates uterine contractions to help control bleeding
 Promotes uterine involution
 Lowers risk for
 Breast cancer
 Osteoporosis
o Feeding the Newborn
 Breast
 Facilitate breastfeeding within the first hour after birth whenever possible
 Feed “on-demand” or every 2-3 hours
 Each feeding should last 20-40 minutes
 Encourage emptying one breast completely before switching to the other. (ensures
fat-rich “hind-milk” consumption)
 Discourage pacifier use until latch-on is established
 Formula
 Feed “on-demand” or every 3-4 hours
 Burp frequently to prevent air discomfort and fussiness associated with feedings
o Breast Feeding Positioning
 All four positions require mom have
 Lots of pillows
 Lots of patients
o Moms need to have patients for baby to open wide before trying to latch
baby on
 Lots of practice
o Both mom and baby have to learn how to position and latch, so this takes
time and repetition
 Lots of perseverance
o Encourage moms who are having a difficult time, but are committed to
breastfeeding, that they will succeed, it just takes time and in two to three
weeks breastfeeding will be second nature to them
 Four most common positions
 Football
o If properly positioned, this is the easiest position to use while learning to
breastfeed. It allows Mom optimal head control & view
o Surround Mom with pillows
o Place baby on his/her side and “tuck them in” under Mom’s arm. Keep body
& head in alignment
o Ensure Mom keeps her hand at the nape of baby’s neck & fingers extended
on baby’s head for QUICK movement once baby “opens wide”
 Cradle
o This position is the most challenging for first time Moms/breast feeders as it
essentially requires the baby to latch without Mom’s assistance
 Cross-cradle
o Here, baby is lying across Mom’s tummy & her hand is again controlling the
baby’s head to facilitate a QUICK and proper latch
o Again, remember the pillows & encourage Dads to assist with pillows &
positioning once at home
o It is also helpful to have a rolled up baby blanket nearby to put under the
baby’s head so Mom’s wrist can relax once baby has latched on
 Side-lying
o This position is not an easy one to learn to feed with, however it is attainable
and a good option for Moms who have spinal headaches or other medical
conditions where they need to remain in a recumbent position.
o Key Tips to assist w/breastfeeding
 Remind Mom to wash hands & gather pillows
 Have Mom sit as upright as possible
 Always keep baby’s head & body in alignment
 Remind Mom to keep her hand back from the areola so baby can latch onto breast properly
 Stimulate baby to open mouth by using nipple to stroke from top lip to bottom lip until
baby “opens wide” (like a baby bird)
 Once baby “opens wide” encourage Mom to very quickly move baby’s head to the breast
 Remind Mom to aim her nipple toward the roof of the baby’s mouth. This makes the
motion of bringing the baby to the breast almost a “hooking motion”. This will be an off-
center latch with more tissue below, resulting in more comfort for Mom
  Moms worry when babies start/stop feeding after 10-20 seconds. Reassure them this is
normal & encourage them to stimulate baby to continue feeding by rubbing the back of the
head or playing with the baby’s feet. Avoid stroking the cheek because of the Rooting
Reflex
o Cracked nipples/blisters
 Likely cause, improper latch
 Teach mom to wash nipples with Water Only! Soap will cause dryness & cracking
 Apply a few drops of milk to nipples & allow to air dry after feedings
 Good handwashing to prevent infection
 Rotate feeding positions to prevent clogged milk ducts
 Lanolin ointment may be applied before & after feedings
o Engorgement
 Occurs as milk comes in, usually day 3-4
 Mom should continue to breastfeed
 Warm compresses and hot showers will help encourage milk release
 Breasts should be pumped prior to feedings so baby can latch
 Breasts should be emptied to prevent blocked milk ducts
 Temporary condition that resolves within days
 Ibuprofen may be used to provide pain relief
 Ice may be used in short interval, if needed for extreme discomfort
o Yeast Infection
 Itchy, red, shiny nipples
 Deep, burning or knife-like sensation shooting through breast during or after feedings
 Both mom & baby must be treated
 Treatment may include herbal remedies, oral Nystatin for baby, and Diflucan for mom
o Blocked Milk Duct
 Occurs when the breast is repeatedly not emptied completely in certain areas
 Can occur with improper latch
 Rotate feeding positions
 Relief may be felt from soaking breast in warm water and massaging
o Mastitis
 Inflammation of the breast
 Often develops after a milk duct becomes blocked
 Soreness, aching, swelling & redness in the breast accompanied by flu-like symptoms
 Chills, fever, & malaise
 Treatment includes rest, warm compresses, antibiotics, & continued breast-feeding
 Infection will not be passed on to the baby
o Formula Feeding
 Formula today contains docosahexaenoic acis (DHA) & arachidonic acid (ARA), two natural
components of breast milk
 Comes in three forms: Powder, Concentrate, Ready-to-Use
 Frequent checking of flow-rate will prevent choking or aspiration associated with a fast rate
of delivery
 Ensure safety of water being used to mix formula
 Formula should not be heated in the microwave to avoid the occurrence of “hot spots”
 Test the formula temperature on the wrist
 Formula should never be frozen
 The bottle should always be held & never be propped
o Supporting Feeding Choices
  Numerous factors influence parents’ decision about breast feeding vs. bottle feeding,
including
 SES, culture, employment, social support, level of education
 Care interventions
o Pregnancy, birth, early postpartum period
 Support of partner
 Regardless of which method is chosen the nurse needs to respect and support the woman’s
decision
o Weaning and introducing solid food
 Gradual process (may take several months)
 Begin by eliminating a mid-day feeding. Continue this pattern until only the bedtime
feeding remains. It is typically the last feeding to be eliminated
 A sippy cup or regular cup may be substituted
 Only 1 new single-ingredient food should be introduced at a time, to watch for allergies
 Keep the environment calm & unhurried
 Cereals are introduced first, followed by veggies, then fruits, then meats, & then eggs
- Preparing for discharge and ensuring follow-up care
o Most hospitals require mothers to attend a discharge teaching class prior to leaving the hospital
o Typically, newborns see their pediatrician within 2-4 days after discharge
o Ensure parents know under what circumstances to call the pediatrician
o Temperature of 101.4 or higher
o Forceful, persistent vomiting
o Refusal to eat
o Two or more green diarrheal stools
o Lethargy
o Inconsolable crying or fussiness
o Abdominal distention
o Difficult or labored breathing
o Immunization schedules are provided by the pediatrician & may be obtained online
- Providing immunization information
Key Pharmacological Measures to Remember
- ATI Chapter 24
o Newborn Care Meds
 Erythromycin (apply 1-2cm ribbon of ointment to the lower conjunctival sac from inner to
outer canthus)
 Vitamin K (administer 0.5 to 1mg into the vastus lateralis within 1 hour after birth)
 Hepatitis B Vaccine (recommended for all newborns; informed consent must be obtained)
 Hepatitis B infected mothers: Hep B immunoglobulin and the Hep B Vaccine is given within
12 hours of birth. The Hep B vaccine is given alone at 1 month, 2 months, and 12 months
 ***It is important NOT to give the Vitamin K and the Hepatitis B injections in the same
thigh. Sites should be alternated***
- ATI Chapter 25
o Newborn Nutrition
 Review nutritional needs for the newborn (p.169 ATI)
 Review breastfeeding and formula feeding information
- ATI Chapter 26
o Circumcision
 Ring block, dorsal penile nerve block
 Topical anesthetic
  Concentrated oral sucrose
 Liquid acetaminophen (10-15mg/kg every 4-6 hours as prescribed for a maximum of 30-
45mg/kg/day)
 Circumcision bleeding: gelfoam powder or sponge

Chapter 23: Nursing Care of the Newborn with Special Needs

Factors affecting Fetal Growth
- Genetics
- Maternal nutrition
- Environmental factors
- Placental factors
Birth Weight Variations
- AGA: Appropriate for Gestational Age
o Approx. 80% of newborns
o Normal height, weight, head circumference, body mass index
- SGA: Small for Gestational Age
o Weight <2,500 grams (5lb 8 oz) at term
o Weight below the 10th percentile
- LGA: Large for Gestational Age
o Weight > 4,000 grams (8lb 13oz) at term
o Weight > 90th percentile on a growth chart
- LBW: Low Birth Weight
o Infant weighing <2,500 grams or 5.5lb
- VLBW: Very Low Birth Weight
o Infant weight < 1,500 grams of 3lb 5oz
- ELBW: Extremely Low Birth Weight
o Infant weighing < 1,000 grams of 2lb 3oz
Small-for-Gestational-Age Newborns
- Conditions affecting fetal growth
o Early insult
 < 28 weeks
 Leads to overall growth restriction
 These kids never catch up in size
o Late insult
 > 28 weeks
 Results in intrauterine malnutrition
 These kids have normal growth potential with optimal postnatal nutrition and better
prognosis than a fetus with an early insult
- IUGR in some SGA Newborns
o Symmetric
 Equally poor growth rates of the head, abdomen, and long bones
o Asymmetric
 Head and long bones are spared compared to abdomen and internal organs
- SGA Contributing Factors
o Maternal
  Chronic hypertension, DM w/vascular disease, Autoimmune diseases, High altitude
(hypoxia), Smoking, Substance abuse, Hemoglobinopathies, Preeclampsia, Chronic Renal
disease, Malnutrition, TORCH group infections
o Placental
 Abnormal cord insertion, Chronic abruption, decreased surface area, infarction,
Decreased placental weight, Placenta previa, Placental insufficiency
o Fetal
 Trisomy 12, 18. 21; Turner’s Syndrome, Chronic fetal infection, Congenital Anomalies,
Radiation exposure, Multiple gestations
- SGA Newborns Assessment: Typical Characteristics
o Head disproportionately large compared to rest of body
o Waster appearance of extremities; loose dry skin
o Reduced subcutaneous fat stores
o Decreased amount of breast tissue
o Scaphoid abdomen (sunken appearance)
o Wide skull sutures
o Poor muscle tone over buttocks and cheeks
o Thin umbilical cord
- SGA Newborns: Common Problems
o Perinatal asphyxia
o Thermoregulation difficulties
o Hypoglycemia
o Meconium aspiration
o Polycythemia
o Hyperbilirubinemia
o Birth trauma
- SGA Newborns: Nursing Management
o Weight, length, and head circumference measurements
o Vital sign monitoring
o Monitoring for s/s of polycythemia
o Serial blood glucose monitoring
o Early and frequent feedings (IV dextrose 10%)
o Anticipatory guidance
Large-for-Gestational-Age Newborns
- LGA Newborns: Risk factors
o Maternal diabetes mellitus or glucose intolerance
o Prior history of macrosomic infant
o Multiparity
o Post-dates gestation
o Maternal obesity
o Male fetus
o Genetics
- LGA Newborns Assessment: Common Characteristics
o Large body, plump, full-faced
o Proportional increase in body size
o Poor motor skills
o Difficulty regulating behavioral states
- LGA Newborns: Common Problems
o Birth trauma
 o Polycythemia
o Hyperbilirubinemia
o Hypoglycemia
- LGA Newborns: Nursing Management
o Vital Sign monitoring
o Serial blood glucose monitoring
o Initiation of oral feedings (IV glucose supplementation PRN)
o Continued monitoring for s/s of polycythemia and hypoglycemia
o Hydration
o Phototherapy for increased bilirubin levels
Gestational Age Variations
- Preterm -> born before completion of 37 weeks
- Late Preterm: Born between 34 weeks and 36-6/7 weeks
- Early Term -> Born between 37 weeks and 38-6/7 weeks
- Full Term -> Born between 38 and 40-6/7 weeks
- Late Term -> Born between 41 and 41-6/7 weeks
- Post Term ->Born at 42 weeks or beyond
Post-term newborn
- Post-term Newborns Physical Assessment: Common Characteristics
o Inability of placenta to provide adequate oxygen and nutrients to fetus after 42 weeks
o Long, thin extremities
o Dry, cracked, wrinkled skin; creases cover entire soles of feet; possible meconium-stained skin
o Long nails
o Wide-eyed, alert expression
o Abundant hair on scalp
o This umbilical cord
o Limited vernix and lanugo
- Post-term newborns: Common Problems
o Perinatal asphyxia
o Hypoglycemia
o Hypothermia
o Polycythemia
o Meconium aspiration
- Post-term Newborns: Nursing Management
o Resuscitation
o Initiation of feedings (IV dextrose 10%)
o Evaluation for polycythemia
o Blood glucose level monitoring
o Prevention of heat loss
o Parental support
Preterm Newborns
- Preterm Birth Etiology
o Maternal of fetal distress
o Bleeding
o Stretching
o Infections/inflammation
o Huge emotional and financial toll
o The leading cause of death within the first month of life
o 2nd leading cause of all infant deaths
 o Etiology is unknown for about 50%
o Born before completion of the 37th week
- Preterm Newborn Physical Assessment: Common Characteristics
o Weight < 5.5lb
o Scrawny appearance
o Poor muscle tone
o Minimal subcutaneous fat
o Plentiful lanugo
o Poorly formed ear pinna
o Fused eyelids
o Soft spongy skull bones
o Matted scalp hair
o Absent to few creases in soles and palms
o Minimal scrotal rugae; prominent labia and clitoris
o This transparent skin
o Abundant vernix
- Body system Immaturity
o Respiratory system
 Last body system to mature
 Surfactant deficiency -> Respiratory Distress Syndrome
 Unstable chest walls -> Atelectasis
 Immature respiratory control center -> Apnea
 Smaller Respiratory passageways -> Increased risk for obstruction
 Inability to clear fluids -> Transient tachypnea
o Cardiovascular system
 Lower oxygen levels circulating -> less stimulation to facilitate the transition from fetal
circulation to newborn circulation.
 Increased risk of congenital anomalies associated with continued fetal circulation
 Patent Ductus Arteriosus
 Open Foramen Ovale
 Impaired regulation of blood pressure throughout the circulatory system
 Higher risk for intracranial hemorrhage
o GI system
 Weak or absent suck and gag reflex
 Challenges with coordinating suck, swallow, and breathe regimen
 Small stomach capacity
 Limited ability to digest proteins and absorb nutrients
 Compromised metabolic function
 Minimal enteral feeding utilized to prepare gut for oral feedings
 Perinatal hypoxia can cause oxygen shunting to the heart and brain -> GI ischemia and
damage
o Renal system
 Reduced ability to concentrate urine
 Reduced glomerular filtration rate
 Increase risk for fluid retention -> fluid and electrolyte imbalances
 Increase risk for drug toxicity
o Immune system
 Increased susceptibility to infections
  Thin skin, fragile blood vessels, immaturity of immune system
 Deficiency of IgG, as transplacental transfer occurs after 34 weeks gestation
 Impaired ability to manufacture antibodies
o Central nervous system
 Susceptible to injury/insult -> long-term disability
 High risk for heat loss
 Highly susceptible to hypoglycemia
- Preterm Newborn: Common Problems
o Hypothermia
o Hypoglycemia
o Hyperbilirubinemia
o Problems related to immaturity of body systems
- Preterm Newborns: Nursing Management
o Oxygenation
 Asphyxia: when a newborn fails to establish adequate, respiration after birth
 Can lead to brain injury, intellectual disability, cerebral palsy and seizures
 Surfactant: preterm infants have insufficient amounts. Surfactant reduces surface
tension int eh alveoli and stabilizes them to prevent their collapse. Atelectasis can
quickly occur.
 Asphyxia -> Hypoxia -> Acidosis and Hypercarbia -> Inhibition of the transition to
extrauterine circulation -> Cyanosis -> Hypotonic and Unresponsive
 Promoting Oxygen
 If the 1 or 5 minute APGAR score is <7, resuscitation efforts are needed
 Diagnostic studies may be done to determine causation (Chest x-ray, blood
cultures, toxicology screen, metabolic tests)
 Continuously monitor vital signs, check blood glucose, maintain neutral thermal
environment (minimizes oxygen consumption)
 Resuscitating the Newborn
 Determining if it is needed -> What is the gestational age of the newborn? Is the
newborn breathing or crying now? Does the newborn have good muscle tone?
 Stabilization
 Ventilation
 Chest compressions
 Administration of epinephrine and/or volume expansion
 Continue resuscitation measures until the newborn’s heart rate is > 100bpm, a
good cry, or good breathing efforts, and a pink tongue.
 Airway, Breathing, Circulation, Drugs
 Depression b/c of narcotics -> Narcan
 Metabolic acidosis -> sodium bicarb
 Improve heart rate -> epinephrine
 Target O2 level
 Condition dependent
 Consider gestational and postnatal age
 Use judiciously – prevent ROP
 Oxygen Hood/Blow By
 Short erm respiratory distress
 Cyanosis
 Nasal Cannula
  Ensure humidified
 CPAP
 Prevents alveoli collapse
 Mechanical vent
 Reduces energy consumption associated with breathing
o Thermal regulation
 Term newborn: non-shivering thermogenesis metabolizes brown fat for heat
production; flexed muscle tone to conserve heat’ average birth weight appropriate to
body size
 Preterm newborn: inadequate supply of brown fat; decreased tone which exposes more
skin to a cooler environment; large body surface area compared to weight allows an
increased transfer of heat to the environment
 Nursing Management
 Cold Stress
o Respiratory distress, central cyanosis, hypoglycemia, lethargy, weak cry,
abdominal distension, apnea, bradycardia, acidosis
 Hypothermia
o Metabolic acidosis, pulmonary hypertension
 Hyperthemia
o Tachycardia, tachypnea, apnea, flushed, warm skin; lethargy, CNS
depression, weak cry
o Nutritional and fluid balance
 Nutritional needs are highly individualized
 Nutrition can be given
 Orally
 Enterally: continuous NG tube feedings or intermittent gavage tube feedings
 Parenterally: Percutaneous central venous catheter for long term venous access
and delivery of TPN
 Nurse Management
 Measure daily weight -> plot on growth curve
 Monitor intake, both fluid and caloric
 Assess fluid state by:
o Weight, urinary output, urine specific gravity, skin turgor, fontanels,
temperature elevation, lethargy, tachypnea
o Serum electrolyte levels, blood urea nitrogen, creatinine, and hematocrit
 Assess for enteral feeding intolerance
 Encourage and support breastfeeding by facilitating pumping
 Kangaroo care if infant is stable
o Infection prevention
 Infection is the most common cause of morbidity and mortality in the NICU population
 Preterm newborns are at an increased risk b/c
 Lack of maternal antibodies for passive immunity
 Limited ability to produce antibodies
 Asphyxia at birth
 Thin, friable skin proving entry portal for microorganisms
 Nursing Management
 Always remove jewelry and scrub prior to entering NICU
 Always wash hands between babies
  Ensure standard precautions and use sterile gloves for all invasive procedures
 Prohibit ill persons from contact with preterm newborns
 Avoid tape on the newborns skin
 Monitor for s/s of infection
o Temperature instability, tachycardia, tachypnea, apnea, poor feeding,
irritability, pallor, jaundice, hypotonia, hypoglycemia
o Stimulation
 Care must be taken to prevent overstimulation
 Heart and respiratory rates decline
 Reduces oxygenation
 Sensorimotor interventions have been found to encourage normal development
 Kangaroo care, rocking, softly singling/music, gentle massage/touch, waterbed
mattress, non-nutritive sucking opportunities
 Preventing overstimulation
 Dim lights
 Low tone/volume of conversations
 Closing doors quietly
 Telephone ringers on lowest volume
 Clustering nursing activites
 Covering isolettes with blankets as light shields
o Pain management
 5th vital sign
 Should be assessed as frequently as the other vital signs
 Assume anything painful to an adult would be painful to a newborn
 Suspect pain if the newborn exhibits
 Sudden high-pitched cry
 Facial grimace (furrowed brow and quivering chin)
 Increased muscle tone
 Body posturing (arching/squirming, kicking/trashing)
 Increase in heart rate, BP, respiratory rate
 O2 desaturation
 Non-pharmacological methods
 Swaddling
 Sucrose and non-nutritive sucking
 Kangaroo care during procedure
 Gentle massage, rocking, cuddling
 Analgesics (watch for adverse effects: respiratory depression, hypotension)
 Morphine
 Fentanyl
 Acetaminophen
 EMLA
o Growth and development
 A philosophy of care that advocates using therapeutic interventions only to the point
they are beneficial. The goal is to promote a stable well-organized newborn who can
conserve energy for growth & development
 Strategies include:
 Clustering care (promotes rest/conserves energy)
  Flexed positioning (simulates in utero position)
 Environmental management (reduce noise & visual stimulation)
 Kangaroo care (skin-to-skin sensation)
 Multiples placed together in crib or isolette
 Use of nesting rolls/devices
 Swaddling (maintains flexed positioning)
 Sheepskin or waterbed (simulates uterine environment)
 Non-nutritive sucking (calms infant)
 Collaboration with parents in planning infant’s care
o Parental support: high-risk status; possible perinatal loss
 Parents of preterm infants often feel anxiety, fear, guilt, loss, and grief
 Separation that occurs immediately after birth along with fear about the newborn’s
survival may interfere with the bonding process
 Nurses can help reduce parental anxiety by
 Reviewing events that have occurred since birth
 Validating parents’ anxiety/concerns as normal
 Providing support during emotional moments
 Encouraging frequent visits to NICU
 Explaining procedures and equipment
 Sharing community resources
o Discharge preparation
 Goal: a successful transition to home care
 Multidisciplinary support required
 Parental education must be reinforced
 Feedings, s/s complications, infant care/safety, medication administration, CPR,
equipment operation, any special care procedures
 Family support & reassurance
 Coping skills, community resources, financial resources, emergency care plan
Perinatal Loss
- A profound experience as parents grieve the loss of hopes and dreams and an extension of themselves
- Parents should be encouraged to see, hold, touch, dress, care for the infants, and significance and
validate their sense of loss
- Nurses should provide an opportunity for parents to share their feelings, as well as actively listen,
convey concern, and acknowledge the parents’ loss
- Information on support groups/resources should be provided