The Normal Newborn • Neonate – birth to 1 month of age • Gestational age – actual number of weeks since conception • Preterm: before 38 weeks • Term: 38-40+ weeks
Assessment immediately after deliver. • Apgar score • Evaluates physical condition of Newborn at birth – done at 1 and 5 minutes of age • Looks at five criteria – heart rate, respiratory effort, muscle tone, reflex irritability, and skin color • Scored 0 – 2 for each category: Highest 10 • Score of 8 – 10 good • Below 8: needs resuscitation after delivery
Vital Signs • Respirations 30 – 60/ min. Apnea briefly, diaphragmatic, rate and rhythm change with activity and stimulation. Take for 15 sec, then x 4. Do before temp. Can do by observation or auscultation. Should be quiet respirations. • Pulse and heart – 110 – 160/ min. Variations normal, regular rate and rhythm, murmurs are common. Count 15 sec, then x 4. Listen before do temp.
Temp. : 97.6-98.6.Temperatures are taken axillary. May do 1st temp rectal to determine patency. More stable 8-10 hours after birth. • Blood Pressure: 60-80/40-50. Take in upper R arm. Should be same in all 4 extremities. Take in all 4 extremities if murmur or resp distress. • Crying will increase SBP. BP only taken on initial assessment.
Gestational Age • Actual number of weeks since conception. • A significant factor in neonatal mortality and morbidity • Calendar based gestational age is unreliable if uncertain of conception. • More reliable criteria based on physical and neurological assessment done within first few hours of life. • Ballard Score/ Dubowitz Assessmentpg 916
Gestational Size • Small for gestational age – SGA – weight less 10th percentile for age • Appropriate for gestational age – AGA – weight between 10th and 90th percentile for age • Large for gestational age – LGA – weight greater than 90th percentile for age • Low birth weight – LBW – weight 2500 grams or less at birth
Characteristics • Body size and shape – head is large, body flexed, abd. prominent with small chest and hips. Cephalocaudal disproportion. • Average weight – 7# 8 oz. (6 – 8 ½ # or 2700 – 3850 Gm) • Average length – 20 inches (19 – 21 ½ in or 47 ½ - 53 ¾ cm) • Head circumference – 13 – 14 in. Usually 1 inch larger than chest. • Chest circumference – 12 – 13 inches.
Nursing Observations of Newborn • Color: pink, appropriate for race • Resp and apical • Presence of increased mucous: suction as needed • Cord condition: clamped and drying • Passage of urine and meconium should have by 24 hrs.
Normal Skin Color • Caucasian – pink to slightly red • African – American – pink to yellowish-brown • Spanish – olive tint to slightly yellow cast • Asian – rosy to yellowish tan • American Indian – light pink to dark reddish brown (varies with tribe)
Acrocyanosis – blue discoloration of hands and feet in infants. • Mottling – a lacy pattern with dilated vessels on pale skin • Jaundice/icterus neonatorum – yellow discoloration due to deposits of bile pigments in newborns. Abnormal in first 24 hrs. • Physiologic jaundice – jaundice occuring 48 hours or later after birth.
Jaundice • Disappears by 7 – 10 days • Can test with transcutaneous instrument • Lab – serum bilirubin will treat over 10-12 mg/dl. Must be over 12-13 for home therapy • Breast fed baby – encourage feeding q 2-3 hours, may supplement with formula • Jaundice is serious if it is seen within the first 24 hours of life. • Can cause brain damage, or death, if untreated
Treatment • Phototherapy – exposes baby to fluorescent blue light. Decreases bilirubin, by converting to water-soluble form to be excreted in urine. does not treat cause • Need to cover baby’s eyes, no clothes, diaper to cover genitals, monitor temp, force fluids, turn baby freq. to expose all of skin • Baby will have greenish stool that is loose • Can do home therapy with bili blanket
Lab Values • Hemaglobin – 14 – 24 g/dl • Hematocrit – 44 – 64 % • Glucose – 40 – 60 mg/dl • Total bilirubin – 1 – 12 mg/dl
ASSESSMENT: SKIN • Vernix caseosa – white fatty substance covers the skin. Preterm has more of. • Lanugo – downy fine hair • Milia – small white spots d/t occluded sebaceous glands • Newborn rash – elevated hive like rash may lead to small vessicles • Telangiectatic nevi/stork bites – flat pink or red marks on eyelids, nose, or nape of neck • Mongolian spots – area of increased pigmentation; bluish black seen on the lumbar dorsal area
Nevus flammeus/port wine stain – reddish purple discoloration usually on face • Strawberry birthmarks – capillary hemangioma – increase in size for several months and then shrink and disappear by early childhood. • Desquamation- peeling skin. Keep clean and dry • Harlequin color change_ imbalance of autonomic vascular regulatory mechanism. Half body white, half red while turned on side
Head • Fontanelles – soft spot consisting of a strong band of connective tissue, touching cranial bones and at the junction of the bones. • Anterior – on top of head closes by 18 months old. – diamond shape • Posterior - on occiput of head, closes at about 2 months, triangular shaped.
Molding – temporary- elongated shape d/t overlapping of bones in skull as baby passes thru birth canal • Caput succedaneum –edema in the soft tissue of the scalp, feels spongy, goes past suture lines • Cephalohematoma –bleeding in periosteum of a cranial bone, does not cross suture line
Face • Receding chin • Flat nose • Round full cheeks • Intact hard and soft palate • Can have teeth • Can have thrush • Epstein pearls: epithelial cells on hard palate
Eyes • Ophthalmia neonatorum – gonorhea infection of Newborns eyes as pass thru birth canal – all babies required to receive AB ointment to eyes within 1 hr birth • Color – slate grey to blue, may be darker • Eyes may be wide set with swollen lids, crossed, and nystagmus (abnormal motion) & strabismus (cross-eyed). Rarely tears. • Near sighted and see best at 8 – 10 inches, prefer black and white
Ears • Ears that are low set may indicate a chromosomal abnormality • Newborns hear high pitched and mom’s voice best. • Hearing assessment done after 24 hrs birth • Nothing inside ear canal.
Umbilical cord • Cord has 2 arteries and 1 vein (AVA) • Anything different may indicate congenital abnormality • Wharton’s jelly. • No Nerve endings • Clamped until dried. Remove clamp before discharge.
Care of Umbilical Cord • Avoid getting Wet • Fold diaper to expose cord • Change diapers ASAP • No tub bath till cord falls off - ~10-14 days • Apply alcohol to stump with diaper changes till 4 days after it falls off. • Report and redness, moistness, or foul odor
Reflexes: • 8 protective reflexes • Rooting: touch cheek, turns mouth towards finger • Sucking • Gag • Swallowing • Blink • Burp • Hiccup • Sneeze
REFLEXES: • Moro – startle reflex – sudden jarring causes extension and abduction of extremities and fanning of fingers. Index and thumb form “C”. Follow with flexion and adduction. Disappears at 3 – 4 months • Tonic neck - when turn head to 1 side quickly – arm and leg on that side extend and opposite arm and leg flex. Disappears at 3 – 4 months
Crawling – when placed on abdomen, infant makes crawling movements with arms and legs. Disappears 6 weeks • Dance/Stepping – when infant held so that the sole of foot touches a hard surface, will flex and extend legs, simulating walking. Disappears 3 – 4 weeks. • Babinski – when sole of foot is stroked toes will fan out and big toe dorsiflexes. Disappears 1 year.
Grasp – Palmar – place fingers in palm and fingers curl around it. • Plantar – place finger at base of toes and they curl downward. Disappears end of 4th month • Galant – infant lays on stomach, stroke the back 1 ½ - 2 inches from spine and trunk curves toward that side and pelvis swings toward that side. Disappears 4 weeks • Traction/Head Lag: pull to sit, has some control of head
Genitals • Pseudomenstruation – blood tinged mucus from vagina of Newborn,” brick dust” • Gynecmasticia – enlarged breasts in male and female newborns • Hydrocele – abnormal collection of fluid around the testicles, causing a swollen scrotum • Cryptorchidism – testicles have not descended into the scrotum
Circumcision • Foreskin of penis is removed – easier to clean and prevent infection • Consent required – Mom must sign • Jewish and Moslem faith do not do in Hospital • Numb with lidocaine before procedure • Give Sucrose water on pacifier during procedure