1. Chapter 21 Care of the NEWBORN
M. Gie Archer, MS, RN, CNE
E.Boyet, RN, MSN, WHNP-BC
C. Lutkenhaus MSN, RNC-OB
Updated 5/2015

2. Chapter 21 Newborn Assessment and Adaptation

3. Initiation of Respirations
Development of lungs
Fluid shifts reduce pulmonary resistance
Surfactant keep alveoli from collapsing
Produced near term (36 weeks)
Can be measured in amniotic fluid
Lung maturity
Accelerated by steroids and certain maternal conditions
Decreased by maternal diabetes
Causes of respirations
Chemical: decrease in PO2 and increase in PCO2
Mechanical: compression of fetal chest at birth
Thermal: sudden changes in skin temp at birth
Sensory: tactile stimulation to facilitate breathing
hyperphysics.phy-astr.gsu.edu

4. Circulatory Adaptation: Ductus Venosus
Shunts 1/3 fetal blood away from liver into inferior vena cava
After birth, shunt closes so blood enters liver
Duct become fibrotic and acts as ligament to hold liver in place; known as “ligamentum venosum”

7. Neurologic Adaptation: Thermoregulation
Newborn characteristics leading to heat loss:
Blood vessels close to skin surface
Little subcutaneous (white) fat
Large skin surface
news.medicalexpo.com

8. Methods of heat loss Evaporation – drying of skin causes cooling
Conduction – coming in contact with cool objects moves heat from body to object
Convection – heat transferred to surrounding area
Radiation – heat transferred to objects not in direct contact with body
labspace.open.ac.uk

9. Thermogenesis Methods of heat production: Increase activity Flexion
Metabolism
Vasoconstriction
Nonshivering thermogenesis (brown fat)

10. Non-shivering Thermogenesis
Infants at risk of inadequate body heat due to inadequate stores of brown fat
Stored in back of neck, axillae, around kidneys/adrenals/sternum, between scapulae, along abdominal aorta
Increased problem for premies, infants with IUGR
Cold → increased metabolism of brown fat → increased need for O2 and glucose for metabolism → decreased surfactant production → respiratory distress, jaundice and hypoglycemia

13. Signs of Hypoglycemia Jitteriness, tremors Poor muscle tone Sweating
Tachypnea
Grunting
Cyanosis
Apnea
Diaphoresis
Low temperature
Poor suck
High-pitched cry
Lethargy
Irritability
Seizures, coma

14. Hematologic Adaptation
Factors affecting blood
Blood volume increases if cord not cut soon
H&H more accurate with venous sample
Blood values
More RBCs increase risk of jaundice
Polycythemia increases risk of jaundice
Elevated WBCs does not indicate infection
Risk of clotting deficiency
Due to lack of vitamin K (synthesized in the gut)
Drugs taken by mom during pregnancy: phenytoin, phenobarbital, aspirin

15. GI System
pregnancy.about.com
Stomach expands from marble-walnut-ping pong ball capacity over 1st 2 weeks
Intestines make infant prone to diarrhea
Normal flora established in first few days after feeding begins
Digestive enzymes not present until 3-6 months
Rationale for cereal (complex carbs) delay

16. Stools
1st stool – meconium – mixture of amniotic fluid & intestinal secretions; thick, dark black/green, & sticky; usually passed in 8 – 24 hrs
Transitional stools – loose & greenish yellow with mucus
Breast milk stools – yellow, soft,
seedy & pasty; 3-6 stools/day
Bottle fed stools – yellow-brown,
more solid, 1-4 stools/day, feces odor
Abnormal – small, putty-like, or bloody
en.wikipedia.org
newborns.stanford.edu

17. Hepatic System Blood glucose maintenance Conjugation of bilirubin
Hypoglycemia constant risk
Conjugation of bilirubin
Lysis of RBCs into unconjugated (indirect) bilirubin
Absorbed by subcutaneous fat causing jaundice
If bilirubin absorbed by brain (kernicterus), can be deadly
Unconjugated bilirubin must be converted in liver to conjugated form for excretion
Requires mature liver to bio-transform unconjugated bilirubin to conjugated bilirubin for excretion in stool.
massonmoms.blogspot.com
Lysis of RBC is what makes bilirubin. Indirect or unconjugated bili is toxic to the baby. Liver changes the indirect bili to a water soluble for by process of conjugation. Conjugate or direct bili is not toxic to the baby and is finally excreted by the baby Unconjugated bili is fat soluble and is absorbed by the subq fat and discolors the skin and tissues. Liver matures by first few days of life. Increased intake whether PO or IV helps the baby to excrete

21. Immune System Inefficient immune response at birth
Maternal antibodies IgG transferred across the placenta and in breast milk to provide baby with passive immunity.
esciencenews.com

22. Behavioral States
Quiet sleep – deep sleep with no eye movements, little or no response to noise
Active sleep – has REM, may move or fuss, more likely to startle, may or may not stay asleep
Drowsy state - transition from sleep to wake, eyes are glazed and unfocused
Quiet alert – excellent time for bonding, alert and interested in surroundings
Active alert – fussy, restless, aware of feeling hungry or cold
Crying – follows active alert if needs untended, may take time to comfort
babysmart101.com

23. Assessment of Cardiopulmonary Status
Airway
Respiratory rate
Breath sounds
Signs of respiratory distress
Tachypnea, retractions, flaring cares, cyanosis, grunting, retractions, asymmetry
Color
Pallor
Ruddy
Heart sounds
Normal
Position of PMI
Rhythm and murmurs
Brachial and femoral pulses
BP R arm, L leg
Capillary refill
albert.uk.com

24. Assessing for Anomalies: Head
Large in comparison to the rest of the body
Head circumference measure above eye brows to widest part of occiput
(most done in cm on growth charts)
health.allrefer.com

25. Molding Head conforms to the size and shape of the birth canal
health.allrefer.com
dou-la-la.blogspot.com

26. Fontanels Unossified spaces (soft spots) on the cranium
Anterior – diamond shaped, pulsating, open &flat
Posterior – triangular shaped

27. Caput succedaneum
Swelling of the soft tissues of the scalp, which crosses the suture line.
More likely to form during a prolonged or difficult delivery.
Subsides without treatment within a few days.
newborns.stanford.edu

28. Cephalohematoma
Collection of blood beneath the cranium but does NOT cross the suture line
newborns.stanford.edu

29. Face Neck and Clavicles
Note symmetry, positioning of features, movement and expression
Report irregularities
newborns.stanford.edu
Neck and Clavicles
Although a classic finding for clavicle fracture, crepitus is not always present. The examiner should have a high index of suspicion for fracture whenever the clavicle cannot be palpated easily and distinctly along the entire length of the bone. No splinting or medications are recommended; babies are typically asymptomatic. A firm lump that often develops in this area over the next few weeks (as new bone development occurs).
Neck is short, should move freely
Clavicles may fracture if infant is large
No treatment necessary, immobilization may be done.

30. homepages.cae.wisc.edu

31. Extremities Limbs in flexion Hands and feet
Lack of movement may indicate nerve damage
Hands and feet
Palmer and plantar creases should be present over palms and soles
Feet without clubbing
Hips symmetrical and negative Barlow and Ortolani tests
rixarixa.blogspot.com

32. Measurements: Length & Weight Average length: 19 – 21
Measurements: Length & Weight Average length: 19 – 21.5 inches Average weight: 6 – 9 lbs (2500g-4000g) Baby loses 5-10% of weight – should normalize after 14 days Weigh baby naked on covered scale
omghealthy.blogspot.com
photography.nationalgeographic.com

34. Visual stimuli & sensory overload
Can see 12 inches from its face & focus on points of contrast
Prefers human face & following objects
Too much stimuli? Sensory overload
babieswithglasses.org

35. GI System Mouth moist Strong suck
Rounded and slightly protruding abdomen
Initial feeding should have coordinated suck, swallow, breathing
Assess stools
suite101.com

36. GU System Observe for first voiding
Voiding 1-2 wet diapers per day is sufficient intake at day 1, consistently increasing per day
Brick dust staining is uric acid crystals that cause urine to look reddish or pink
Female genitalia
Labia majora covers minora
Pseudomenses is expected finding
Male genitalia
Scrotum pendulous with many rugae
Testicles should be descended into scrotum
Meatus should be at tip of penis
webmd.com

37. Vernix caseosa – waxy/cheesy covering on skin to protect from fluid
Integumentary System
Lanugo – body is covered with fine hair that disappears during the first week
Vernix caseosa – waxy/cheesy covering on skin to protect from fluid
Milia – pinpoint pimples caused by obstruction of sebaceous glands
pregnancy.about.com
assets.aarp.org

38. Erythema toxicum: May occur in 50% of newborns
Erythema toxicum: May occur in 50% of newborns. Resolves without treatment within a few days.
umm.edu

39. Mongolian spots – bluish discolorations common in African-American, Native American, & Mediterranean races. Most go away by adolescence
dermis.multimedica.de

40. Assessment of Gestational Age
Ballard Score based on two parts:
1. neuromuscular
2. physical characteristics
Gestational age is appropriate when neonate scores between 10-90th percentiles

41. Gestational Age Assessment (Ballard Score)

42. Posture
“To elicit the posture item, the infant is placed supine (if found prone) and the examiner waits until the infant settles into a relaxed or preferred posture. If the infant is found supine, gentle manipulation (flex if extended; extend if flexed) of the extremities will allow the infant to seek the baseline position of comfort. Hip flexion without abduction results in the frog-leg position as depicted in posture square #3. Hip abduction accompanying flexion is depicted by the acute angle at the hips in posture square #4. The figure that most closely depicts the infant's preferred posture is selected.”
ballardscore.com

43. Square Window:
“The examiner straightens the infant's fingers and applies gentle pressure on the dorsum of the hand, close to the fingers. From extremely pre-term to post-term, the resulting angle between the palm of the infant's hand and forearm is estimated at;
>90°, 90°, 60°, 45°, 30°, and 0°”
ballardscore.com

44. Arm Recoil
“With the infant lying supine, the examiner places one hand beneath the infant's elbow for support. Taking the infant's hand, the examiner briefly sets the elbow in flexion, then momentarily extends the arm before releasing the hand. The angle of recoil to which the forearm springs back into flexion is noted, and the appropriate square is selected on the score sheet. The extremely pre-term infant will not exhibit any arm recoil. Square #4 is selected only if there is contact between the infant's fist and face. This is seen in term and post term infants.”
ballardscore.com

45. Popliteal Angel ballardscore.com
“…assesses maturation of passive flexor tone about the knee joint by testing for resistance to extension of the lower extremity. With the infant lying supine, and with diaper re-moved, the thigh is placed gently on the infant's abdomen with the knee fully flexed. After the infant has relaxed into this position, the examiner gently grasps the foot at the sides with one hand while supporting the side of the thigh with the other. Care is taken not to exert pressure on the hamstrings, as this may interfere with their function. The leg is extended until a definite resistance to extension is appreciated. In some infants, hamstring contraction may be visualized during this maneuver. At this point the angle formed at the knee by the upper and lower leg is measured.”
ballardscore.com

46. Scarf Sign
“The examiner nudges the elbow across the chest, felling for passive flexion or resistance to extension of posterior shoulder girdle flexor muscles. The point on the chest to which the elbow moves easily prior to significant resistance is noted. Landmarks noted in order of increasing maturity are: full scarf at the level of the neck (-1); contralateral axillary line (0); contralateral nipple line (1); xyphoid process (2); ipsilateral nipple line (3); and ipsilateral axillary line (4).”
ballardscore.com

47. Heel to Ear
The examiner supports the infant's thigh laterally alongside the body with the palm of one hand. The other hand is used to grasp the infant's foot at the sides and to pull it toward the ipsilateral ear. The examiner fells for resistance to extension of the posterior pelvic girdle flexors and notes the location of the heel where significant resistance is appreciated. Landmarks noted in order of increasing maturity include resistance felt when the heel is at or near the: ear (-1); nose (0); chin level (1); nipple line (2); umbilical area (3); and femoral crease (4).
ballardscore.com

48. Physical Maturity

49. Skin
“Maturation of fetal skin involves the development of its intrinsic structures concurrent with the gradual loss of its protective coating, the vernix caseosa. Hence, it thickens, dries and becomes wrinkled and/or peels, and may develop a rash as fetal maturation progresses. These phenomena may occur at varying paces in individual fetuses depending in part upon the maternal condition and the intrauterine environment.
Before the development of the epidermis with its stratum corneum, the skin is transparent and adheres somewhat to the examiner's finger. Later it smoothes, thickens and produces a lubricant, the vernix, that dissipates toward the end of gestation.
At term and post-term, the fetus may expel meconium into the amniotic fluid. This may add an accelerating effect to the drying process, causing peeling, cracking, dehydration, and imparting a parchment, then leathery, appearance to the skin. For scoring purposes, the square which describes the infant's skin the most closely should be selected.”
gregorygordonmd.com

50. Lanugo ballardscore.com
“In extreme immaturity, the skin lacks lanugo. It begins to appear at the 24th to 25th week and is usually abundant, especially across the shoulders and upper back, by the 28th week of gestation.
At term, most of the fetal back is devoid of lanugo, i.e., the back is mostly bald.
Variability in amount and location of lanugo at a given gestational age may be attributed in part to familial or national traits and to certain hormonal, metabolic, and nutritional influences. For example, infants of diabetic mothers characteristically have abundant lanugo on their pinnae and upper back until close to or beyond full-term gestation. When scoring for lanugo, the examiner selects the square that most closely describes the relative amounts of lanugo on the upper and lower areas of the infant's back”.
ballardscore.com

51. Plantar Surface
Very premature and extremely immature infants have no detectable foot creases. To further help define the gestational age of these infants, measuring the foot length or heel-toe distance is helpful. (ref 10,12) This is done by placing the infant's foot on a metric tape measure and noting the distance from the back of the heel to the tip of the great toe. For heel-toe distances less than 40 mm, a minus two score (-2) is assigned; for those between 40 and 50 mm, a minus one score (-1) is assigned.
ballardscore.com

52. Breast
“The breast bud consists of breast tissue that is stimulated to grow by maternal estrogens and fatty tissue which is dependent upon fetal nutritional status. the examiner notes the size of the areola and the presence or absence of stippling (created by the developing papillae of Montgomery). The examiner then palpates the breast tissue beneath the skin by holding it between thumb and forefinger, estimating its diameter in millimeters, and selects the appropriate square on the score sheet.”
ballardscore.com

53. Eyes and Ears neonatalicu.com ballardscore.com
“The pinna of the fetal ear changes it configuration and increases in cartilage content as maturation progresses. Assessment includes palpation for cartilage thickness, then folding the pinna forward toward the face and releasing it. The examiner notes the rapidity with which the folded pinna snaps back away from the face when released, then selects the square that most closely describes the degree of cartilagenous development. In very premature infants, the pinnae may remain folded when released. In such infants, the examiner notes the state of eyelid development as an additional indicator of fetal maturation. (ref 13) The examiner places thumb and forefinger on the upper and lower lids, gently moving them apart to separate them. The extremely immature infant will have tightly fused eyelids, i.e., the examiner will not be able to separate either palpebral fissure with gentle traction. The slightly more mature infant will have one or both eyelids fused but one or both will be partly separable by the light traction of the examiner's fingertips.”
neonatalicu.com
ballardscore.com

54. Genital ballardscore.com
“Concurrently, the scrotal skin thickens and develops deeper and more numerous rugae. Testicles found inside the rugated zone are considered descended. In extreme prematurity the scrotum is flat, smooth and appears sexually undifferentiated. At term to post-term, the scrotum may become pendulous and may actually touch the mattress when the infant lies supine.
In extreme prematurity, the labia are flat and the clitoris is very prominent and may resemble the male phallus. As maturation progresses, the clitoris becomes less prominent and labia minora become more prominent. Nearing term, both clitoris and labia minora recede and are eventually enveloped by the enlarging labia majora.”
ballardscore.com

55. Chapter 22– The Normal Newborn: Nursing Care

56. Early Care Administering Vitamin K injection- Providing eye treatment
Prevents bleeding problems
Given because fetal intestines are sterile, needs food in the gut to synthesize Vitamin K
Providing eye treatment
Erythromycin ointment
Cardiorespiratory status
Positioning infant
Suctioning secretions
Close observation
Cold stress, prematurity, postmaturity, IUGR, LGA or SGA, asphyxia, problems or trauma at birth, maternal diabetes can put the infant at risk for hypoglycemia.

57. Question
The nurse administers vitamin K to the newborn for what reason?
Most mothers have a diet deficient in vitamin K, which results in the infant being deficient.
Vitamin K prevents the synthesis of prothrombin in the liver and must be given by injection.
Bacteria that synthesize vitamin K are not present in the newborn's intestinal tract.
The supply of vitamin K is inadequate for at least 3-4 months, and the newborn must be supplemented

58. Ongoing Nursing Assessments
Bathe
Frequent assessments or VS depending on gestational age
Shift assessments
Cord care –clean with water when visibly soiled
Assist mom/dad with feeding
Position infant on back for sleep
Protection
Identification- ID bands at birth
Prevent abduction-security bands
Prevent infection- handwashing

59. Circumcision Surgical removal of foreskin Advantages/Disadvantages
Parents choice!!! Much controversy.
Provide information, not opinions
Observe for bleeding, infection, irritation
Since the last AAP policy was published, scientific research shows clearer health benefits to the procedure than had previously been demonstrated. According to a systematic and critical review of the scientific literature, the health benefits of circumcision include lower risks of acquiring HIV, genital herpes, human papilloma virus, and syphilis. Circumcision also lowers the risk of penile cancer over a lifetime; reduces the risk of cervical cancer in sexual partners, and lowers the risk of urinary tract infections in the first year of life.  Susan Blank, MD
lozster.wordpress.com
PAIN? NIPS scale

60. Gomco Vaseline gauze applied with each diaper change
pediatricsconsultantlive.com

61. Plastibell Circumcision

64. Newborn Genetic Screening
Immunization for Hepatitis B
Immune globulin if mom tests positive for Hep B
Newborn screening, 52 total diseases screened
after first 24 hours when baby has been fed, and
repeat at days of life
Hypothyroidism, cystic fibrosis
Galactosemia, metabolic disorders
Hemoglobinemia, sickle cell

65. Discharge and Follow-up
Discharge varies according to maternal and neonate’s needs
Most laws allows 48 hours for vaginal delivery and 96 hours for cesarean delivery
Give simple and exact discharge instructions
Follow-up appointment 2-3 days after leaving hospital
Some hospitals don’t offer circumcision so it will have to be done in the pediatrician’s office.

66. allmotivated.com
Newborn Nutrition
Chapter 23

67. Nutritional Needs of the Newborn
39-50 kcal/d of breast milk or formula
Infants lose up to 10% of birth weight during first few days and regains by 2 weeks of age
Neonates digest simple carbs and proteins well; fat less well
Vitamins and minerals present in both
Additional water not necessary

68. Breast milk Composition
Changes are in 3 phases: Lactogenesis
Colostrum – thick yellow fluid higher in proteins, fat-soluble vitamins, minerals; has laxative effect; helps establish intestinal flora; rich in immunoglobulins
Transitional – lactose, fat, and calories increase; vitamin content is that of mature milk
Mature milk – bluish-white and more liquid; sufficient to meet infant’s needs

69. Breast milk Composition (cont)
Proteins – easy to digest; low concentrations of tyrosine and phenylalanine
Carbohydrates from lactose – promotes calcium absorption and normal intestinal flora
Fat is ½ of milk calories – more easily digested than cow’s milk fat
Foremilk is the milk (typically lower in fat) available at the beginning of a feeding; hind milk is milk at the end of a feeding, which has a higher fat content than the foremilk at that feeding.

70. Formula Composition
Unmodified cow’s milk (store bought) not recommended for infants younger than 12 months
Soy or protein formulas for infants with allergies
If allergic to cow’s milk, may also be allergic to soy milk
Special formulas available for infants with special problems like lactase deficiency, galactosemia, or Phenylketonuria (PKU)

71. Breastfeeding Benefits
Baby
Less likely to have allergic reactions
Helps prevent infections
Meets nutritional needs
Easily digested
No possibility of improper dilution
Unlikely to be contaminated
Less likely to result in overfeeding
No constipation
Mother
Enhances uterine involution
More likely to rest while feeding
More likely to eat well
May help weight loss
May enhance bonding
Economical and convenient
Makes travel easier
May reduce risk of some cancers
No equipment to wash

72. Normal Breastfeeding
Milk is synthesized when suckling from nutrients removed from mother’s blood
Prolactin stimulates milk production; suckling continues to increase prolactin release. Oxytocin released to “let-down” milk from milk glands in response to suckling
Causes uterus to contract to prevent hemorrhage
Pain or anxiety can inhibit let-down
Continued milk production requires constant removal
(supply and demand)

73. Prolactin, Oxytocin, and Milk Production

74. Formula Feeding Reasons to select formula
Medical conditions, little experience, lack of knowledge, personal preference, culture, employment, support
Combination feeding delayed until breastfeeding well-established
fearlessformulafeeder.com