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N106 Nursing Care of the Newborn. Immediate Baby Care. Airway - Clean mouth and nose Thermoregulation - Warmth APGAR Gross assessment Identification Bonding – safety against infection Medications. Fetus to Newborn: Respiratory Changes. Initiation of respirations

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N106 nursing care of the newborn l.jpg
N106Nursing Care of the Newborn

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Immediate Baby Care

  • Airway - Clean mouth and nose

  • Thermoregulation - Warmth


  • Gross assessment

  • Identification

  • Bonding – safety against infection

  • Medications

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Fetus to Newborn: Respiratory Changes

  • Initiation of respirations

  • Chemicalsurfactant reduces surface tension 34-36wksdecrease in oxygen concentration

  • Thermalsudden chilling of moist infant

  • Mechanicalcompression of fetal chest during delivery normal handling

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Nursing Process for Respirations

  • Assess for respiratory distress

  • Plan: Maintain patent airway

  • Interventions- Positioning infant – head lower

    - Suction secretions – bulb, keep near head, mouth first, avoid trauma to membranes

  • Evaluation – rate 30-60, no distress

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Fetus to Newborn: Neurological adaptation: Thermoregulation

Methods of heat loss

Evaporation – wet surface exposed to air

Conduction – direct contact with cool objects

Convection- surrounding cool air - drafts

Radiation – transfer of heat to cooler objects not in direct contact with infant

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Nonshivering thermogenesisThe distribution of brown adipose tissue (brown fat)

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Nursing Care – Cold Stress

  • Preventing heat loss – radiant warmer

  • Providing immediate care - dry quickly, cover head with cap, replace wet blankets

  • Providing on going prevention - safety

  • Restoring thermoregulation – if becoming chilled - intervene

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Effects of Cold Stress

  • Increased oxygen need

  • Decreased surfactant production

  • Respiratory distress

  • Hypoglycemia

  • Metabolic acidosis

  • Jaundice

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  • Heart rate – above 100

  • Respiratory Effort – spontaneous with cry

  • Muscle tone – flexed with movement

  • Reflex response – active, prompt cry

  • Color – pink or acrocyanosis

  • 0-3 infant needs resuscitation

  • 4-7 Gentle stimulation – Narcan

  • 8-10 – no action needed

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Early Assessments

  • Assess for anomalies

  • Head – anterior fontanelle closes 12-18 mo posterior fontanelle closes 2-3 months

  • Neck and claviclesfracture of clavicle – large infant, lump, tenderness, crepitus, decreased movement

  • Cord

  • Extremitiesflexed and resist extensionassess fractures, clubfeethipsvertebral column

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Not crossing suture line

Cephalhematoma is a collection of blood between the surface of a cranial bone and the periosteal membrane.

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Crossing suture line

Caput succedaneum is a collection of fluid (serum) under the scalp.

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A, Congenitally dislocated right hip B, Barlow’s (dislocation) maneuver. C, Ortolani’s maneuver

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Measurements B, Barlow’s (dislocation) maneuver.

  • Weight – loss of 10% normal

  • Length

  • Head and chest circumference

  • Normal VStemp 97.7-99.5F axillaryapical pulse 120-160bpm respirations 30-60/min

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head larger B, Barlow’s (dislocation) maneuver.

A, Measuring the head circumference of the newborn. B, Measuring the chest circumference of the newborn.

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Assessment of Cardio-respiratory Status B, Barlow’s (dislocation) maneuver.

  • History

  • Airway

  • Assessrateq 30minX2hrssymmetrybreath sounds - moisture for 1-2 hrs

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Assessment of Thermoregulation B, Barlow’s (dislocation) maneuver.

  • Check soon after birth

  • Set warmer controls

  • Take temp q 30 min until stable

  • Rectal for first temp

  • Insert only 0.5 inch

  • Axillary route rest of time

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Axillary temperature measurement. B, Barlow’s (dislocation) maneuver. The thermometer should remain in place for 3 minutes.

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Assessment of Hepatic Function B, Barlow’s (dislocation) maneuver.

  • Blood GlucoseSigns of hypoglycemia jitteriness respiratory difficulties drop in temp poor suckingTx- feed infant if glucose below 40-45 mg/dl

  • Bilirubinphysiologic jaundice peaks 2-4 days of lifeearly onset may be pathologic

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Jaundice B, Barlow’s (dislocation) maneuver.

  • Hemolysis of excessive erythrocytes

  • Short red blood cell life

  • Liver immaturity

  • Lack of intestinal flora

  • Delayed feeding

  • Trauma resulting in bruising or cephalhematoma

  • Cold stress or asphyxia

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Potential sites for heel sticks. Avoid shaded areas to prevent injury to arteries and nerves in the foot.

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Assessment of Neuro System prevent injury to arteries and nerves in the foot.

  • Reflexes

  • BabinskiGraspMoroRootingSteppingSuckingTonic neck reflex “fencing”

  • Cry

  • Infant response to soothing

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Assessment of Gastrointestinal System prevent injury to arteries and nerves in the foot.

  • Mouth

  • Suck

  • Abdomen

  • Initial feeding

  • Stoolsmeconium – within 12-48 hours of birth dark greenish blackbreastfed – soft, seedy, mustard yellowformula-fed – solid, pale yellow

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Assessment of Genitourinary System prevent injury to arteries and nerves in the foot.

  • Umbilical cord vessels

  • Urine – within 24 hours of birth

  • Voiding – 6 to 10 times a day after 2 days

  • Genitaliafemale – edema normal, majora covers minora, pseudomenstruationmale – pendulous scrotum, descended testes by 36 wks gest., placement of meatus

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Assessment of Integumentary System prevent injury to arteries and nerves in the foot.

  • Vernix – white covering

  • Lanugo – fine hair

  • Milia

  • Erythema toxicum – red blotchy with white

  • BirthmarksMongolian spots – sacral areaTelangiectatic nevus “stork Bite” - blanches

    Nevus flammeus “port wine stain” - no blanchingNevus vasculosus “strawberry hemangioma” usually on head, disappears by school age

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Port Wine Stain prevent injury to arteries and nerves in the foot.

Erythema toxicum

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Fetus to Newborn: prevent injury to arteries and nerves in the foot.Psychosocial adaptation

  • Periods of Reactivityactive – 30-60 minsleep – 2-4 hoursalert – 4-6 hours

  • Behavioral Statesquiet sleepactive sleepdrowsy statequiet alert – best for bondingactive alertcrying state

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Gestational Age Assessment prevent injury to arteries and nerves in the foot.

  • Assessment tool – Dubowitz, Ballard

  • Weeks from conception to birth

  • Used to identify high risk infants

  • Neuromuscular characteristicsPosture – more flexionSquare window – more pliableArm recoil - activePopliteal angle - lessScarf Sign – less crossing Heel to ear – most resistance

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Newborn maturity rating and classification prevent injury to arteries and nerves in the foot.

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Gestational Age Assessment prevent injury to arteries and nerves in the foot.

  • Physical characteristicsSkin- deep cracking, no vessels seen, post-leatheryLanugo – less as agePlantar creases – more with ageBreasts – larger areola Eyes and Ears – stiff with instant recoilGenitals – deep rugae, pendulous, covers minora

  • Gestational Age & Size – may not correspondsmall SGA <10% for weight large LGA >90% for weightappropriate AGA between 10-90%

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Ongoing Assessment and Care age.

  • Bathing

  • Cord care

  • Cleansing diaper area

  • Assisting with feedings

  • Protecting infantidentifying infantpreventing infant abduction – alert to unusualpreventing infection

  • Review beige cue cards in center of book for teach

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LATCH was created to provide a systematic method for breastfeeding assessment and charting.

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Circumcision discharge.

  • Most common neonatal surgical procedure

  • Reasons for choosing

  • Reasons for rejecting – hypospadias, epispadias

  • Pain relief

  • Methods

  • Nursing care

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Other Concerns discharge.

  • ImmunizationsHepatitis B – begin vaccine at birth

  • Screening testsHearingPhenylketonuria – by law

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Further Assessments discharge.

  • Complications r/t poorly functioning placentahypoglycemiahypothermiarespiratory problems

  • Complications r/t LGA infanthypoglycemiabirth injury due to size

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Shoulder Dystocia discharge.

  • Risk factorsdiabetes; macrosomic infantobesityprolonged second stageprevious shoulder dystocia

  • Morbidity- fracture of clavicle or humerus,brachial plexus injury

  • Management – generous episiotomy

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High Risk Infants discharge.

  • Preterm – before 38 weeks gestation

  • IUGR – full term but failed to grow normally

  • SGA -

  • LGA

  • Infants of Diabetic mothers

  • Post mature babies

  • Drug exposed

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Preterm infants discharge.

  • Survive - Weight 1250 g -1500 g – 85-90%500-600g at birth 20% survive

  • Ethical questions

  • Characteristics – frail, weak, limp, skin translucent, abundant vernix & lanugo

  • Behavior – easily exhausted, from noise and routine activities, feeble cry

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Nursing Care of Preterm Infants discharge.

  • Inadequate respirations

  • Inadequate thermoregulation

  • Fluid and electrolyte imbalance – dehydration sunken fontanels <1ml/kg/hr or over hydration bulging, edema and urine output >3ml/kg/hr

  • Signs of pain – high-pitched cry, >VS

  • Signs of over stimulation - >P, >RR, stiff extended extremities, turning face away

  • Nutrition – signs of readiness to nippleresp <60/m, rooting, sucking, gag reflex

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Complications of Preterm Infants discharge.

  • Respiratory Distress Syndrome -RDS

  • Bronchopulmonary dysplasia – chronic lung disease

  • Periventricular-Intraventricular Hemorrhage30% infants <32 wk gest or <1500 g

  • Retrolenthal fibroplasia – visual impairment or blindness from O2 & ventilator

  • Necrotizing Enterocolitis (NEC) – distention, increased residual, Tx - rest bowel

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Respiratory Distress Syndrome discharge.

  • RDS also know as “hyaline membrane disease”

  • Cause – besides preemie, C/S, diabetic mothers, birth asphyxia – interfere with surfactant

  • S & S tachypnea - over 60/min retractions- sternal or intercostal

    nasal flaring cyanosis- centralgrunting- expiratoryseesaw respirationsasymmetry

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Evaluation of respiratory status using the discharge. Silverman-Andersen index.

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Therapeutic Management of RDS discharge.

  • Surfactant replacement therapy

  • Installed into the infant’s trachea

  • Improvement in breathing occurs in minutes

  • Doses repeated prn

  • Other treatmentmechanical ventilationcorrection of acidosisIV fluids

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Post Term Infants discharge.

  • Born after 42 weeks

  • Increase risk of meconium aspiration

  • Hypoglycemia

  • Loss of subcutaneous fat

  • Skin –peeling, vernix sparse, lanugo absent, fingernails long

  • Focus on prevention – “due date”

  • Attention to thermoregulation & feeding

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Meconium Aspiration Syndrome discharge.

  • Occurs most often post term infants, decreased amniotic fluid /cord compression

  • Meconium enters lung – obstruction

  • S & S vary from mild to severe respiratory distress: tachypnea, cyanosis, retractions, nasal flaring, grunting

  • Tx – suction at birth, may need warmed, humidified oxygen, or ventilators

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Hyperbilirubinemia discharge.

  • Pathologic jaundice – occurs within first 24 hours

  • Bilirubin levels >12 in term or 10-14 preterm

  • May lead to kernicterus – brain damage

  • Most common cause – blood incompatibility of mother and fetus, Rh or ABO – only occurs with mother negative Rh or O blood

  • Treatment focus on prevention, assess coombs, monitor bilirubin levels, most common treatment is phototherapy, blood transfusions

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Phototherapy for Hyperbilirubinemia discharge.

  • Phototherapy – bilirubin on skin changes into water-soluble excreted in bile & urine

  • “Bili” lights placed inside warmer, need patches over eyes, infant wearing only diaper or fiberoptic phototherapy blanket against skin

  • Side effects of phototherapy: freq, loose, green stools, skin changes

  • Can use at home

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Other interventions for hyperbilirubinemia discharge.

  • Exchange transfusions – if lights not working

  • Maintain neutral thermal environment – not too hot or too cold

  • Provide optimal nutrition – hydrate

  • Protecting the eyes from retinal damage

  • Enhance therapy by expose as much skin as possible to light, remove all clothing except diaper, turn frequently

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Infant of a Diabetic Mother discharge.

  • Macrosomia – face round, red, body obese, poor muscle tone, irritable, tremors

  • High risk for – trauma during birth, congenital anomalies, RDS, hypocalcemia

  • Hypoglycemia occurs 15-50% of time<40-45 mg/dl, test right after birth, q 2hX4,then q 4 hrX6 until stable

  • Most frequent symptom: jitteriness or tremors

  • Tx – fed, gavage or IV if needed

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Hypoglycemia discharge.

  • Serum glucose is below 40 mg/dL

  • Tx: feed infant formula or breast milk and retest until glucose stable

  • S & S: jitteriness, lethargy, poor feeding, high-pitched cry, irregular respirations, cyanosis, seizures

  • Risk factors: DM, PIH, preterm, post term, LGA, cold stress, maternal intake of ritodrine or terbutaline

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Large for Gestational Age discharge.

  • Infants weight is in the 90th % for neonates same gestational age, may be pre, post, or full term infants

  • LGA does not mean post term

  • Most common cause – maternal diabetes

  • Infant at risk: birth injuries, hypoglycemia, and polycythemia - macrosomia

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Small for Gestational Age discharge.

  • Infant whose wt is at or below the 10th %

  • Results from failure to thrive

  • Is a high risk condition

  • SGA does not mean “premature.”

  • Causes: anything restricting uteroplacental blood flow, smoking, DM, PIH, infections

  • Complications: hypoglycemia, meconium aspiration, hypothermia, polycythemia

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Mother with Substance Abuse discharge.

  • Use of alcohol or illicit drugs

  • Tobacco and alcohol are most frequent

  • Prenatal alcohol exposure is the most commons preventable cause of mental retardation

  • Signs of maternal addition: wt loss, mood swings, constricted pupils, poor hygiene, anorexia, no prenatal care

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Drug Withdrawal in Infants discharge.

  • Signs of drug exposureopiates – 48-72 hourscocaine – 2-3 daysalcohol – within 3-12 hours

  • Symptoms: irritable, hyperactive muscle tone, high-pitched cry

  • High risk for SGA, preterm, RDS, jaundice

  • Obtain infant mec and urine sample for test

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Nursing Care of Drug-Exposed Infant discharge.

  • Feeding – more difficult may need to gavage

  • Rest – keep stimulation to minimum, reduce noise and lights, calm, slow approach

  • Promote bonding

  • Teach measures for frantic crying: rock, coo, dark room, avoid stimulation

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Phenylketonuria - PKU discharge.

  • Genetic disorder causes CNS damage from toxic levels of amino acid phenylalanine

  • caused by deficiency of the enzyme phenylalanine hydroxylase

  • Signs- digestive problems, vomiting, seizures, musty odor to urine, mental retardation

  • Tx – low phenylalanine diet – start within 2 months

  • Screening before 24-48 hours needs to be repeated for accuracy

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Signs Bonding Delayed discharge.

  • Using negative terms describing infant

  • Discussing infant in impersonal terms

  • Failing to give name – check culture

  • Visiting or calling infrequently

  • Decreasing length of visit

  • Refusing to hold infant

  • Lack of eye contact with infant