OB Exam 4
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What do you document about a mole at birth?
*take a pic for comparison later if changes occur*
Normal color of...
pre term baby
pre term=dark pink/red
Skin assessment at delivery can tell you what? By noting for the presence of what?
if the baby is pre term, on time or post term
thick white cheesy substance that is absorbed by the skin the closer the fetus gets to term
- skin sloughing/peeling
- usually seen on hands/feed of post term babies
soft downy like hair that appears after 20 weeks gestation and covers the entire body. Begins to vanish as fetus ages....sign of premie
What is the significance of petechiae on the head/neck/face vs. seen all over the body?
head/neck/face...small capillaries ruptured from pressure during birth
all over body can be an indication of low platelet count or an infection in the newborn
Central cyanosis/blue lips means
baby had elevated bilirubin levels in utero
Green tinged vernix
caused by mec staining
Ruddy skin color.....sign of?
deep purple/red from increased circulating RBC's (polycythemia)
sign of hemolysis and baby is at risk for jaundice
What is the problem when the skin blanches when you press on it?
What is typically the problem when you see pallor?
hypoxia or anemia
When you see acrocyanosis after the normal findings of it from birth....what is usually the issue?
poor circulation....can be cold too
What does mottling indicate?
the infant is cold, stressed or overstimulated
What is Harlequin color change and what does it mean?
it is a distinct color division with one side of the body deep pink or red and the other half is pale.
Seen in low birth weight infants, is transient and benign. Caused by an imbalance of autonomic regulation of vessels.
Nervus Simplex (Stork Bite)
- flat, hemangioma (from dilated capillaries)
- blanching with pressure
- become more prominent when baby cries
- fade with time
Nevus Flammeus (Port Wine Stain)
- Purple/dark red lesion
- No blanching
- Don't fade with time...remove with laser
IF an infant has a Nevus Flammeus (port wine stain) on his face then
he needs to see an opthamologist
Nevus Vasculosus (Strawberry Hemangioma)
- red elevated area
- will get bigger over the first year of life
- will gradually fade and disappear by 10yo
Funny thing about Nevus Vasculosus
estrogen driven so seen mainly in girls
Café au Lait spots
PERMANENT light brown areas
What could be a complication if a person has many or a very large café au lait spot?
Neurofibromatosis-a genetic neural tissue condition that will cause tumors to develop on spinal nerves
- birthmarks that are bluish/grey that resemble bruises.
- they will disappear after a few years of life, but can stay in to adulthood.
Who will you see Mongolian spots on?
dark skinned people
When is jaundice commonly seen?
First week of life....usually with blanching of the skin over the nose or chest
Greenish/brown discoloration of the skin, nail and cord is from.....watch for?
meconium and stress before birth
watch for respiratory difficulty
small white cysts due to sebaceous glands not functioning yet. Will disappear within a few months....don't pop
small raised red papules from sweat retention...unbundle the baby!! He is too warm
red blotchy areas with a white center that looks like a flea bite or acne
Seen anywhere but palms and soles of feet
Will disappear within hours/days
Normal RR for first 2 hrs of life....normal after
60-70 breaths per min
then...30-60 with transient tachypnea
Describe the newborns breathing
What two things move together when an infant breathes?
abdomen and chest
A newborn breathes through his....
What types of cyanosis are normal for the first few hourse of life?
circumoral and acrocyanosis
Normal HR for a new born
sleeping can get as low as 100 and crying as high as 180/200
Describe where the apical pulse is taken on an infant
Point of Maximal Impulse
- 3rd/4th intercostal space
- lateral to the midclavicular line
How and where is cap refill checked? What is normal?
depression of the skin over the chest, abdomen or extremity until the area blanches
color should return in 3-4 seconds
a blockage/narrowing of one or both nasal passages
How do you check for Choanal Artesia?
- Close the infants mouth and occlude one nostril at a time
- observe for breathing and auscultate breath sounds
- a blue tint to the skin SURROUNDING the lips
Central Cyanosis definition and problem
bluish coloration of the tongue, lips, mucus membranes and skin
sign of arterial oxygen desaturation
blueish color to the lips-HYPOXIA
If I see pallor in an infant what should I do?
get a CBC or Hgb/Hct done and give O2
What is the problem if the heart is not positioned at the PMI?
- can indicate a pneumothorax or dextrocardia
- (heart position is reversed from normal)
If the brachial and femoral pulses are not equal bilaterally this is a sign of
coarctation of the aorta
IUGR is indicated when the baby is
<10% in weight
If a baby is <10% in weight and has symmetrical proportional body parts the problem is caused by
fetal factors early in pregnancy
Name the fetal factors early in pregnancy which can cause IUGR
- Genetic anomalies
- Congenital malformation
- Congenital infections (Rubella/Cytomegalovirus)
- Fetal Infections
- Drug Exposure
- Multiple Gestation
If a baby is <10% in weight and has asymmetrical proportional body parts the problem is caused by
maternal factors....usually UPI in 3rd trimester
Describe asymmetric shape of baby
head circ is larger than expected for birth weight and length
Name the maternal factors that can cause IUGR
- Advanced maternal age
- Drugs/Alcohol/Toxins ingested
- Chronic or pregnancy induced illnesses
- Poor nutrition/malnutrition
- Young maternal age
- Structural Placental Abnormalities
Name 3 chronic maternal problems which will impair uterine and placental blood flow.
- Chronic Renal Disease
- Chronic Heart Disease
- Diabetes Mellitus
IUGR- causing increase in morbidity and mortality of infant
IUGR is common in with poor nutrition/malnutrition....commonly known as the
IUGR can be from fetal or maternal factors....however it is also seen due to
problems intrinsic to the fetus itself
Definition of Asymmetrically growth retarded
infants who had growth restriction due to factors influencing the LAST part of the pregnancy will have a
- normal head circumference
- some reduction in length
- big reduction in weight
Definition of Symmetrical growth retarded
this occurs when IUGR begins early in pregnancy.
Head circumference, length and weight may ALL decrease proportionately.
Who is more likely to have significant intrinsic fetal problems...asymmetrically or symmetrically growth retarded infants?
Potential problems faced by IUGR infants
- Meconium aspiration
- Low body temp
- Low sugar levels
- Low calcium levels
- Pulmonary Hemorrhage
- Persistent HTN
Why is a baby with IUGR at risk for low body temp?
No subcutaneous brown fat for insulation to preserve body heat
Why is a baby with IUGR at risk for low blood sugar levels?
haven't stored much glycogen in the liver
What is the problem that can happen if a baby with IUGR is born with low calcium levels?
risk for convulsions
What is the baby with IUGR born with polycythemia at risk for?
Sign that a newborn is cold
- increased flexion
- increased activity
What is the infants primary method of heat production?
- Non shivering thermogenesis....
- metabolism of brown fat produces heat
Cold stress can cause an increase in fatty acids which can interfere with the transport of bilirubin to the liver, increasing the risk for
2 ways the body will try to conserve heat
- vasoconstriction of peripheral vessels (Acrocyanosis)
- vasoconstriction of pulmonary vessels (RDS)
Blood pressures of a newborn
highest right after birth, then lowest at 3 hrs of age
Weight and the newborn/baby
- loses 5-10% first few days....should regain by 2 weeks
- double birth weight at 6 months
- triple birth weight at 1 yr.
Avg. length of a baby
Avg. Head Circumference
1-2 cm smaller than the head
Molding of the head
an overlapping of the suture lines during delivery, resolves in first few days of life to 1 week
boggy and indistinct swelling in scalp tissue usually over the vertex of the head.
*Crosses suture line, is soft and resolves in 12 hrs to a few days
bleeding between the periodsteum and the skull from pressure during birth.
*ends at suture lines, firm swelling and is NOT present at birth (takes 1-2 days to develop) and takes a few weeks to resolve
Which head injury from birth increases a baby's risk for jaundice?
When are circumcisions done?
12-24 hours after birth...not till newborn is stable
Difference between Gomco and Plastibell circumcision
Gomco (saw)-blood supply is decreased prior to cutting skin, put Vaseline on after
Plastibell-plastic ring covers glans, sutured on and will fall off in 5-8 days, NO vaseline
Care of penis after circumcision
- urinate within 6-8 hrs
- monitor for bleeding/infection
- few drops of blood ok
- yellow exudate ok, don't pick off
If mom has poorly controlled GDM and hyperglycemia in the 3rd trimester baby is at risk for
- fetal macrosomia (large baby)
- neonatal hypoglycemia
Why is a baby who was born to a mom with GDM at risk for hypoglycemia?
baby has been making a lot of insulin to combat moms hyperglycemia. Once he is born, that extra glucose isn't there, but he is still making the same amount of insulin
Assessment of reflexes by nurse....notes
- diminished means preterm or ill infant
- absence means neurologic problem
- asymmetric means trauma during birth that caused nerve injury, paralysis or fracture
When will rooting reflex disappear?
When will stepping reflex disappear?
When will Moro Reflex disappear?
When will Babinski reflex disappear?
What's moro reflex
sudden head extension produced by a light drop of the head
when an infant hears a sudden noise, he flings out his arms and arches his back and spreads his fingers
With post term pregnancys baby's are at risk for
- Placental insufficiency and decreased amniotic fluid.....
- leading to umbilical cord compression=variable decels
How is a post term baby able to small for gestational age?
cuz the placenta is old and he didn't receive enough o2 and nutrients.....so started to use current fat as nourishment.
What will a post term baby look like when born?
- apprehensive face, hypoxic, hyper alert, wide eyed
- thin with loose skin
- little or no vernix
- lots of hair and long nails
- winkled, cracked and peeling skin
- meconium passage
What should a post term infant be assessed for? How compensate?
feed him early and frequently to compensate for the period of poor nutrition before birth
What will a post term newborn temp be like?
- extra blankets
- frequent temps
- teach parents about prevention of cold stress
Birth trauma for LGA infant
- breech/shoulder dystocia
- fractured clavicle
- brachial palsy
- facial paralysis
- phrenic nerve damage
- skull fracture/hematoma
- *increased risk for c section
The GI system and newborn
immature at birth, and reaches maturity at 2-3 years old
How much will the newborns stomach hold?
5-7mL....so abdomen becomes distended easily
Where do you place food/nipple on an infant?
at the back of the tongue
When does sucking typically become coordinated?
A baby has very little saliva until he is
3 months old
When will I hear bowel sounds?
1 hour after birth
Why doesn't a baby have v. K at birth?
cuz the bowel is sterile and there is no normal flor in the GI system to make it
Rule on cereal and cows milk
- cereal at 6 months
- cows milk at 1 year
How long will the newborn live off of mom's iron stores?
4-6 months....if she took in adequate amounts while prego
Size of a babys stomach....
- ping pong ball
- extra large chicken egg
Why shouldn't newborns eat cereal?
cuz amylase and lipase aren't present till 3-6 months and this is needed to break down cereal
When will first BM occur?
- tar black/green sticky
- within 24 hours
- none 36-48 hours...possible obstruction
- breast=yellow/seedy....3-10/day, more than formula babies
- formula=pale yellow/brown, firmer
If you see a large protruding tongue this is a sign of
Downs and hypothyroidism
When is it common to see candidiasis in an infant
not at birth....but 1-2 days later
When's a good time to inspect an infants palate
when they cry
First formula feed should be this amount....cuz don't want to overdistend stomach or cause regurgitation
What does Coombs test look for?
Rh antibodies and incompatibilities
Indirect Coombs vs. Direct Coombs
Indirect-done on maternal serum at 27 weeks, if negative give rhogam, if positive repeat testing to monitor titer
Direct-done on cord blood-tests for maternal antibodies in fetal blood
Metabolic disorders come from what type of disorder?
recessive...one defective gene from EACH parent
If baby has PKU s/s and treatment
digestive problems, V, seizures, musty odor of urine, mental retardation, behavior disorders, seizures
strict diet low in phenylalanine, may breast feed or partial breast feed with close monitoring
If baby has galactosemia s/s and treatment
decreased feedings, lethargy, seizures, mental retardation, death
eliminate galactose from diet....give rice or soy milk
Problem with galactosemia
a decrease in the enzyme that converts galactose to glucose
If baby has a congenital hypothyroid s/s and treatment
mental and motor retardation, short, coarse dry skin/hair, hoarse cry, constipation
Why is the PKU test not done until discharge?
cuz it isn't reliable until an ample amount of amino acid is ingested, which takes 24-48 hours.
Perform test as close to discharge as possible, but no later than 1 week after birth
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