NURS 2111 MB Module 5B – Newborns Study Guide Questions with Answers
Mother Baby Mod 5B notes April 2021
NEWBORNS:
Newborn
... [Show More] adaptation:
• Circulatory changes - as newborn takes 1st breath, the 3 shunts close
o Ductus arteriosus, ductus venosus, foramen ovale
▪ Establishment of respiratory function
▪ Cutting of cord- Most critical extrauterine adjustment as air inflates the lungs with first breath
• Surfactant - prevents lungs from collapsing
o Starts making before 24 - 28 weeks of gestation.
o At 35 weeks gestation most have enough to keep their lungs open.
o Gestation age is not enough to determine if infant is able to keep lungs open though
Quick Newborn Assessment: Immediately following birth APGARS
• 1 & 5 minutes of life
• Assess adaptation
o 0-3: Severe distress
o 4-6: Moderate distress
o 7-10: None/ minimal distress
Equipment
• Bulb syringe - suction mouth first then nose (in side of mouth, don’t use the center because it can stimulate the gag reflex and baby will aspirate)
• PEDIATRIC/ NEONATAL stethoscope - to evaluate breath sounds, heart tones, and bowel sounds
• Axillary temp - no rectal temps on infants
• Tape measure
o Length (crown of head to heel of feet), abdomen (measure right above the umbilicus),
chest (along the nipple line)
o Measured In CM
External
• Skin color, peeling (can indicate a post-term baby), foot creases (gestational age), nasal patency ( nose is open)
Chest
• LISTEN heart tones & respirations
• Flaring, grunting (could be respiratory distress) Abdomen
• Rounded
• I vein & 2 arteries Neuro
• Tone, fontanels (full or depressed -- indication of dehydration) Gross observation
• Any defects? Is everything even and proportional? Normal measurements
• Weight: 2.5 kg – 4 kg
• Length: 45-55 cm
• Head: 32-36.8 cm (should be 2-3 cm larger than chest circumference)
o Greater than 4 cm could be hydrocephalus
o Less than 32 cm is microcephaly (could have brain development abnormalities)
• Chest: 30-33 cm REFLEXES
• Sucking reflex- gently stimulating the newborn’s lips by touching them. The newborn will typically open the mouth and begin a sucking motion. Placing a gloved finger in the mouth will also elicit a sucking motion.
• The Moro reflex- also called startle reflex, occurs when the baby is startled. Motion as if you were going to drop the baby, the baby’s hand should fly out
• Stepping reflex- holding baby upright with soles of feet touching a flat surface, the baby should make a stepping motion
• Tonic neck reflex- often called the fencing reflex; lie baby on back, turn the baby’s head to one side, the arm toward which the baby is facing should extend away from the body; the arm on the opposite side is flexed and fist is clenched tightly.
• Rooting reflex- stroke the newborn’s cheek. The newborn should turn toward the side that was stroked and should begin to make sucking movements
• Babinski reflex- stroke the lateral sole of the newborns foot from the heel toward and across the ball of the foot. The toes should fan out
• Palmar grasp- place finger in newborn’s pal, baby’s hand will close around the finger, will
`tighten if you try to remove finger
• Plantar grasp- place finger just below the newborn’s toes. The toes typically curl over the finger
Ballard Score:
• Completed at 2-24 hours of life
• Combined score gives an estimated gestational age
• SEVERAL assessments
o Each scored 1-4/5
• NB maturity rating: Two parts
o Neuromuscular (score from -1 to 5)
o Physical maturity (score based on how eyes look, lanugo, etc)
Periods of reactivity:
• 1st period of reactivity
o Alert, sucking, rapid HR and RR then will stabilize
o About 30 min post birth
• Period of relative inactivity
o Quiet, sleeps
o 60 min – 100 min post birth
• 2nd period of reactivity
o Reawakes and responsive
o Gags and chokes on mucus accumulation
Classification of the Newborn: Weight and GA
• AGA weight - 10-90 percentile on growth chart (AGA appropriate for gestational age)
• LGA - > 90th percentile (Large for gestational age)
• SGA below - 10 percentile (small for gestational age)
• Low birth weight - <2500g (5.5 pounds)
• Term 37-42
• Pre-term- prior to 37 weeks
• Late-term 34-36 weeks
• Post-term after 42 weeks
• Post-mature after 42 weeks with placental insufficiency
Vital Signs:
• Resp (baby at most quiet, non-agitated state), HR, BP, & Temp (do in this sequence)
o Q15-30 x2 then 1x hourly then Q4
• Respiratory Rate
o Normal: 30-60
o Apnea (should last no longer than 15 seconds)
o Crackles, Wheezing? Sign of infection
o Grunting, nasal flaring? Sign of respiratory distress
o https://www.youtube.com/watch?v=NB A9iigiDgk
• HR
• B/P
o Normal: 110-160
o Full minute
o Heart murmurs? Indicates abnormality in heart structure or flow
o Heart rate less if sleeping
o Heart rate more if crying
o Usually not assessed on well NB
o Hypotension: LATE SIGN of any type of complication
• Temp
o Normal: 97.7-99.5 F
o Within the first 12 hours of life, the baby is at risk for cold stress increase in oxygen demandsacidosisdecreased BS/seizures
NB Assessment: Normal Deviations:
• Skin: pink, acrocyanotic (blue hands or feet-- last place the body shunts the blood to) with NO jaundice for the 1st day; 2-3rd day jaundice and decreasing
o Vernix (thick-cheesy covering), lanugo (blonde hair)
o Milia: NB Acne
o Lanugo – fine hair
o Mongolian Spots (bluish/purple pigmented spots (common in darker-skin babies) -- document & show parents.
o Telangiectatic Nevi (stork bite - flattened/red on face, neck or nose)
o Erythma toxicum – newborn rash; benign and idiopathic; small papules on skin resembling flea bites; common on face, chest, and back, lack of pattern
• Head: Fontanels- soft/ flat, sutures- palpable, separated/approximated and can overlap
o Caput: Crosses suture lines - localized swelling of tissues during labor, resolves 3-4 days
after delivery. (page 602)
o Cephalohematoma: Does NOT cross suture lines; Trauma during labor- forcep or vacuum delivery causes a collection of blood between the skull bones) (page 602)
o Hydrocephalus: bulging fontanels greater than 4 cm
o Depressed fontanelle: Dehydration
o Microcephaly - head measuring less than 32 cm.
• Ears: In line with eyes; should respond to noise
o Low-set ears: Trisomy 21, Kidney anomalies
• Eyes: Symmetry in size/ shape
o Helps R/O chromosomal anomalies
• Spine: midline
• Extremities: full ROM, gluteal folds bilaterally; bowed legs and flat feet; Soles
o Extra digits
• Genital: anus should be patent
o Pass urine in 24 hours
o Meconium in 24 hours
o Testes descended into scrotum
o Vaginal blood tinged discharge: NORMAL in females (pseudomenstruation)
o Urinary meatus should be at the tip of the penis
• Neck: short thick with no webbing, move freely from side to side
• Chest: clavicles intact;
• Mouth: soft and hard palate intact
• Nose: midline, flat
o NBs are NOSE breathers!
Labs:
• Glucose: 50-60 mg/dL (warm infants foot to increase circulation, clean with alcohol and make sure its dry (use lancet that is no more than 2.4 mm deep (to prevent penetration of infants bone-- stick outer aspect of foot. Done within the first 2 hours of life.
• SGA and LGA will be on hypoglycemia protocol- will check temps more
o LGA- gestational diabetic moms
o SGA- check BS because of smaller weight; transitional process it a little more difficult
Ongoing Tasks and Nursing Care:
• Weight: Q 24 hours
• Cord Inspection (keep dry, top of diaper folded down so it doesn’t rub the area, sponge-bath until cord falls off 10-14 days after delivery) infection (odor, oozing, red, moist)
• Pain assessment: Q8-24 hours and after painful procedures
o NIPS—neonatal inventory pain scale: every 8-12 hours and after painful
procedures; assess facial expressions, breathing pattern, cry, muscle tone, how the baby is moving extremities.
o If doing a painful procedure-- pain assessment before, during, and after
• If ordered: Hgb/ Hct
• Blood glucose
• Metabolic screening
o 24 hours of life (must have formula before test can be done)
o If done < 24 hours will repeat in 1-2 weeks
o Sickle cell, PKU, galactosemia, maple syrup urine disease, hypothyroidism
• Hearing Screen (done before they leave the hospital)
Infant Security/ Identification:
• ID in delivery room
• Footprint sheet
o NB footprint and mom’s fingers
• ID Band - MATCHES mom and babies
• ALWAYS VERIFY - when you bring the baby back to mom, verify the baby bracelet and mom’s bracelet. Never give a baby to anyone that does not have a bracelet on!!!
• Code PINK
Thermoregulation- NBs keep warm by metabolizing brown fat. Very unique to babies. Brown fat is going to activate by stimulation of the sympathetic nervous system. Baby converts it into energy. Once a baby is using it to keep warm, it can’t get it back. You do not want baby to use up brown fat reserve.
4 types of Heat Loss:
• Conduction: caused by putting a baby directly on a cold surface
• Convection: flow of heat from body surface to a colder surface (placed in bassinet close to ac or fan)
• Evaporation: Loss of heat as surface liquid (having cold blankets stay on them, sweating
• Radiation- loss of heat from body surface to a colder surface (keep away from cold window)
Signs of hypothermia: Temp less than 97.7, Cyanotic, Increased RR
Treatment: Skin to skin helps prevent heat loss, Hat on baby, Double/warm blankets and swaddle baby
Bathing: 1st 1 to 2 hours after delivery, but can be extended up to 8 hours if the baby is not maintaining its heat and only expose 1 part of the body, like legs
• Must have stable temp - do not give bath if body temp is less than 97.7
• Under heat source - done under a radiant heat warmer
• Wear gloves
• Skin to skin - recheck temp in 30 minutes
Newborn Care:
• Feeding - feed the baby within 30-60 minutes of life!!!!
o 1st breastfeeding: ASAP following birth and on demand
▪ Make sure baby has a good latch
o Formula feeding: 2-4 hours of age on demand every 3-4 hours
▪ 8-12 times in 24 hours
▪ Make sure breast are stimulated every 2 hours
o Sterile water test
o Monitor and document - amount
• Sleep
o 16-19 hours/day
o On their BACKS to SLEEP
o No co-sharing of bed
▪ No bumper pads, blankets, or toys
▪ These increase the risk of SIDS
o 6 sleep-wake states
- Deep sleep- very quiet. Infant has no eye movement
- Light (alert) sleep- moves extremities, stretch, might be sucking on arm or hand, rapid eye movement
- Drowsy – between sleep and awake. Eyes usually remain closed at this time. If they open, they appear unfocused.
- Quiet alert- baby has some body movement but very minimum. Perfect time to feed the baby.
- Active alert- infant is fussy, restless, aggravated, and mad. Do not try to feed it.
- Crying- baby is at a crying state.
o Best time to feed the baby is during the quiet/alert state
• Elimination
o 1st void/BM in 24 hours (Meconium is green and dark tarry looking)
o 6-8 wet/daily
o Meconium transitional (green brownish yellow looking)
• breast/bottle feed stool
o 3-4 dirty/ daily
o Breastfed: yellow-seedy stool
o Bottle-fed: yellow brown)
o Clean bottoms with plain water and rags
• Infection Control
o Why are NBs at risk? Because of their immature immune system
o Staff scrub in
o Good handwashing
o Prevent cross-contamination of germs from parent to infant
• Umbilical Cord Care
o Clamp in place for 24-48 hours (removed after infant leaves the hospital)
o Assess for redness, edema or drainage
o Fold diaper down and away from cord
o No submersion baths until cord has fallen off (usually 10-14 days)
o Goal is to prevent infection and hemorrhage
• Hemorrhage
o HOLD pressure
• Bonding
o Encourage mother/ family involvement
o WATCH them perform care (be there to assist if needed & give support-- do not take over)
o DOCUMENT
Medications: Thighs and Eyes
• Thighs
o Vitamin K (produced in the colon once infant ingest foods-- 7 to 8 days after delivery)
o Prevent bleeding
o Vitamin K is produced in the colon once feedings are introduced into the GI tract at day 7-8
o 0.5- 1 mg IM into Vastus Lateralis
o Within 1 hour of birth
• Hepatitis B Vaccine
o ALL newborns, 1 month and 6 months
o Must have informed consent
o Mothers who are Hepatitis B +: Hep B IG and hep B vaccine is given within 12 hours then Hep B vaccine as 1 month, 2 months and 6 months
o DIFFERENT SITES
• Eyes
o Erythromycin ointment (1-2 cm in each eye)
o Prevents ophthalmia neonatorum
o N. Gonorrhoeae and Chlamydia
o Blindness
Circumcision: removal of foreskin from penis.
• Personal choice
• Should NOT be done immediately following birth. Why? Because vit K is given right after delivery to help give the baby clotting factors.
• Benefits
o Cancer benefit
o Hygiene, decrease risks of STIs and UTIs
• Contraindications
o Hypospadias (urinary meatus is up under the penis/ Epispadias (on top of the penis)
o Family HX of bleeding disorders (puts baby at risk for hemorrhage)
• Equipment
o Gomco, Mogen clamp or Plastibell
o Anesthesia - Dorsal penile nerve-block, topical anesthetic, oral glucose (give before circumcision)
• Swaddling, non-nutritive sucking (pacifier), do the pain assessment
• Nursing Care:
o Informed consent
o Assist with procedure
▪ Restraining board to prevent aspiration
▪ No bottles of feedings 2-3 hours before procedure to prevent aspiration
o Complications
▪ Bleeding- HOLD pressure
o Post-procedure
▪ Monitor bleeding q15 min x 1 hour then qhr x 12hrs
▪ Watch and document 1st voiding
▪ Vaseline gauze
▪ Tylenol if ordered
▪ Prevent infection
o Teaching
▪ Keep diaper clean, apply vaseline or petroleum jelly with every diaper change
▪ No tub baths until healed. Trickle water down penis
▪ Avoid wipes (alcohol)
▪ Yellow film is normal- part of healing process
▪ Watch for swelling, foul discharge, tenderness, excessive crying or a decrease in urination
▪ Will sleep after procedure and may be fussy
▪ Tylenol given to help with pain
Car Seats:
• It’s the LAW
• Backseat in the middle
• Until age 2 (infant car seat)
• Booster (age 8, 4’9”, 80 pounds)
Newborn Complications:
Neonatal Abstinence Syndrome: NAS
• Infant exposed during pregnancy to a group of opioid drugs
• Opiates, heroin, methadone, marijuana, amphetamine, tobacco & alcohol
o Fetal Alcohol Syndrome: facial anomalies, heart defects, developmental delays (the drug
passes through placenta to baby during pregnancy)
• Long-term complications
o CP, MR, delayed growth & development, microcephaly, poor
• Drug withdrawal vs CNS disorder?
o Drug screen: urine and meconium done on baby
• Symptoms
o CNS: high pitched cry, irritability, tremors, hypertonicity, seizures
o Nasal congestion, apnea, retractions, sweating
o GI: poor feeding projectile vomiting, constant
• Treatment:
o Treatment depends on substance and physician
o Morphine, methadone, and phenobarbital
o NAS scoring (on-going, done every 2 hours)
o Nursing Care
▪ NAS scoring
▪ Reduce stimuli
▪ Cluster care
▪ Child protective services
▪ Aid with feeding difficulties
▪ Non-nutritive sucking
▪ Swaddle
▪ Monitor for F & E imbalances
Birth Trauma
Injuries due to forcep delivery, vacuum delivery
Types: fractures (most common from should dystocia), brachial plexus injury, cranial nerve trauma, head trauma
Nursing Care: Assess RF, do physical and neurological assessment (bruising, bumps, swelling, paralysis, and symmetry of structure and function) on these babies. Sometimes the assessment can be continuous. Provide support, education, and referrals if necessary.
Hypoglycemia:
• < 40 mg/dL (heel stick done during first 2 hours of life)
• Routine assessment for all newborns
• Policies for further assessment of
• SGA and LGA infants
• Untreated: seizures and death
• Risk factors: DM mother, stress at birth
• Symptoms
o Jittery, weak cry, sweating, poor tone, apnea
• Treatment
o FEED
o IV dextrose
o Follow-up
o Can massage breast to get milk from mom
o Skin to skin
Respiratory Distress Syndrome: The Wimpy White Boy Syndrome:
• Surfactant deficiency poor gas exchange ventilator failure
• Birth weight alone/gestational age is NOT an indicator of fetal lung maturity
• Risk factors: Preterm infants, meconium, perinatal asphyxia, maternal complications
• Assessment:
o Respiratory distress
o Tachypnea
o Nasal flaring
o Grunting
o Retractions
o Labored breathing
o Fine crackles
o APNEA (longer than 15 seconds)
• Diagnostics/Labs:
o CXR
o Blood glucose
o ABGs (in order to correct acidosis)
o R/o infection
o Cultures: blood
• Treatment:
o Respiratory support (ventilator) to correct respiratory acidosis
o Sodium bicarbonate to correct metabolic acidosis
o Decrease stimuli (cluster care)
o Lung Surfactant through ET tube
Neonatal Sepsis:
• Life-threatening blood stream infection
• Risk factors: PROM, chorioamnionitis, TORCH infections, premature delivery, maternal infections (UTIs)
• Labs CBC with diff, CRP, cultures, chemistry
• Life-threatening blood screen infection
• Signs and symptoms: SUBTLE!!
o Temperature instability (always low), poor tone, poor feeding, s/s of respiratory distress,
hypo/hyperglycemia, color changes, tachycardia
• LATE: hypotension, bradycardia
• Nursing Care:
o ALWAYS be mindful of subtle symptoms and “that feeling..”
o Assess infection risk of mom and baby
o Isolation precautions (limit visitors)
o Infection control
o IV: D10 or TPN (electrolyte replacement)
o Transfer to level III NICU
o Respiratory support
o ANTIBIOTICS - Ampicillin, Gentamicin, Vancomycin
Hyperbilirubinemia:
• Elevation of serum bilirubin (hemolysis of RBCs)
• Jaundice
• Progresses head downward
• Pathologic
o PROBLEM; due to an underlying disease
o Liver problem, RBC disorder, ABO incompatibility or infection
o Jaundice < 24 hours
• Physiologic
o Benign to a degree
o Due to breakdown of fetal RBCs
o Jaundice appears > 24 hours
• S/S:
o Press in cheek or abdomen and release
o Yellow tint
▪ Sclera, skin and mucous membranes
o Note time of onset… WHY?
Treatment:
o Transcutaneous bili vs serum bili
o Labs
▪ Serum bilirubin
▪ Bili monitor (scan forehead or chest of infant to determine levels)
▪ Electrolyte levels: dehydration
• Phototherapy
o Overhead, bili bed (levels should decrease every 4 to 6 hours)
o Eye mask at all times (to protect cornea and retina)
o Undressed; for males cover penis (keep diaper on) with surgical mask
o NO lotions or ointments
o Turn off lights to drawn labs
o Remove lights and mask q3-4 hours (allows for bonding with family)
o FEED! Feed! FEED! (removes bilirubin from body through stool)
• Exchange transfusion
• Complications:
o Acute bilirubin encephalopathy
▪ Deposits in the brain
▪ Levels > 25 mg/dL
▪ Permanent damage (cognitive impairment, hearing loss, muscle contractions, MR)
o Kernicterus
▪ Irreversible chronic result of toxicity
▪ Progression to hypotonia and severe cognitive impairment
Preterm Newborn:
• Before 37 weeks GA NICU admission or < 2.5 kg (less than 5.5 pounds)
• Goals in care: Meet growth and development needs, anticipating and managing associated complications
• Discharge: Keeping up their own temperature, eating all bottles, and breathing on their own
o Suck, swallow & breathe: 34-35 weeks
• Main priority: cardiac and respiratory support
• Complications:
o RDS, Bronchopulmonary dysplasia, aspiration, apnea because of prematurity,
intraventricular hemorrhage, PDA, necrotizing enterocolitis
o Make sure the baby receives all of the feedings, maintaining temp and gaining weight.
Newborn Asphyxia
Failure to establish adequate respirations after birth
Assessment: RF, look at newborn’s color, work of breathing, HR, temps, APGAR scores
Nursing Care: Resuscitation immediately, continued observation, place in environment where they can maintain their own temps
Meconium Aspiration Syndrome
Inhaling of meconium particles into lungs. Causes inflammatory reaction. Decrease in surfactant production
RF- placental insufficiency, preeclamptic moms, moms on drugs
S/S – respiratory distress, stained amniotic fluid, retractions, cyanosis
Nursing Care: Have NICU at delivery because NICU needs to perform deep suction, make sure environment where baby can maintain temperature [Show Less]