NUR1423 Family with a newborn (nursing care)
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How well a newborn makes adjustments at the time of birth depends on which factors?
- - intrauterine environment
- - care during labor/brith
- -care during newborn/ neonatal period
When and how long is the neonatal period?
birth through first 28 days of life
What does an assessment of a newborn/ neonate include?
- review of mother's pregnancy history
- physical examination of infant
- analysis of laboratory report (e.g. hematocrit, blood type,...)
- assessment of parent and child interaction to ensure the beginning of bonding
When does the assessment of the neonate start?
- Starts immediately after birth
- is continued at each contact
- (hospital, home visits, well-baby visits...)
What are important teaching subject regarding the neonate?
Teaching new mothers and their partners assessments concerning their infants regarding
- respiratory rate
- overall health
is crucial to continue the monitoring at the infant's health at home.
2020 National Health Goals regarding newborn period
- Increase breastfeeding, if possible until 3 months
- increase # of full term babies who sleep on their back
- reduce perinatal mortality rate
- no night time bottles (while falling asleep-> decay)
Which factors should nursing planning take into account?
- newborns needs during transition period
- mother's need for adequate rest
- necessity for parents to become acquainted with new child
- A blue or purple mottled discoloration of the extremities, esp. of the fingers, toes, and/or nose.
- commonly observed in newborns and in others after exposure to cold temperatures
- and in patients with reduced cardiac output.
- In patients with suspected hypoxemia, it is an unreliable sign of diminished oxygenation. (Instead of relying on this sign, pulse oximetry or arterial blood gases should be measured.)
- Diffuse edema of the fetal scalp that crosses the suture lines.
- Head compression against the cervix impedes venous return, forcing serum into the interstitial tissues.
- The swelling reabsorbs within 1 to 3 days.
- A usually benign tumor consisting principally of blood vessels (hemangioma)
- A benign tumor found on the skin or in an internal organ, composed of dilated blood vessels, and often encapsulated within a fibrous shell.
- infantile hemangioma A dull red benign lesion, usually present at birth or appearing within 2 to 3 months thereafter.
- This type of birthmark is usually found on the face or neck and is well demarcated from the surrounding skin.
- It grows rapidly and then regresses. It is caused by a proliferation of immature capillary vessels in active stroma. SYN: strawberry hemangioma; strawberry mark; strawberry nevus
- (2) TREATMENTIf removal is necessary, plastic surgical excision using the carbon dioxide, argon, or potassium titanium oxide phosphate laser is effective in ablating this lesion.The use of laser treatment necessitates observance of all laser safety precautions.
- A bluish discoloration of the mucous membranes in the mouth, indicating hypoxemia and respiratory failure.
- TREATMENT If hypoxemia is confirmed by oximetry or arterial blood gas analysis, supplemental oxygen is provided.
- PATIENT CARE The patient's vital signs, blood gases, and sensorium should be monitored closely, as this sign may indicate hypoxemia accompanying impending respiratory failure.
- A mass composed of clotted blood, located between the periosteum and the skull of a newborn.
- It is confined between suture lines and usually is unilateral.
- The cause is rupture of periosteal bridging veins due to pressure and friction during labor and delivery.
- The blood reabsorbs gradually within a few weeks of birth.
- Incidence is 1.5-2.5% of all deliveries. The overlying scalp is not discolored.
- If the lesion is extensive, hyperbilirubinemia may develop.
erythema toxicum neonatorum
- A benign, self-limited rash marked by firm, yellow-white papules or pustules from 1 to 2 mm in size present in about 50% of full-term infants.
- The cause is unknown, and the lesions disappear without need for treatment.
1. Downy hair covering the body.
- 2. Fine downy hairs that cover the body of the fetus, esp. when premature.
- The presence and amount of lanugo aids in estimating the gestational age of preterm infants.
- The fetus first exhibits lanugo between weeks 13 and 16.
- By gestational week 20, it covers the face and body. The amount of lanugo is greatest between weeks 28 and 30. As the third trimester progresses, lanugo disappears from the face, trunk, and extremities. lanuginous, adj.
- First feces of a newborn infant, made up of salts, amniotic fluid, mucus, bile, and epithelial cells.
- This substance is greenish black, almost odorless, and tarry.
- The first meconium stool should appear during the first 24 hr.
- Meconium should persist for about 3 days.
Blood glucose levels less than 40 mg/dl in infants during the first hours of life.
Approximately 8% of normal term infants who were born vaginally and nearly 16% of those born by cesarean delivery experience one or more episodes of hypoglycemia, usually within the 24 to 72 hr period following birth.
Premature and small-for-gestational-age infants experience an earlier onset (6 hr or so after birth) because of reduced glycogen production by their smaller, immature livers.
Infants of diabetic mothers and those who are small for gestational age exhibit a higher incidence of low blood sugar
safety issues specific to newborns when taking measurements are
- not leaving newborn on a bed or scale
- protection against hypothermia,
what are the baby's vital statistics?
- head circumference
- chest circumference
what is the first measurement that is taken from a newborn
- the weight,
- still nude and without blanket soon after birth in birthing room
- other measurements done when baby is dry
why is the weight of a newborn important?
how often will newborn be weighed?
- baseline for comparison
- helps to determine maturity
first initial weight, then once a day at around the same time
1 minute and 5 minutes after birth
- respiratory effort
- muscle tone
- reflex irritabilty
high correlation between low 5 minute apgar score and neurologic illness
newborn: respiratory evaluation
- 1. chest movement
- 2. intercostal retraction
- 3. xiphoid retraction
- 4. nares dilatation
- 5. expiratory grunt (Grunzen)
- 1.sole creases
- 2.breast nodule diameter
- 3.scalp hair
- 4.ear lobe
- 5.testes and scrotum
- cyanosis of the trunk
- always cause of concern
- indicates decreased oxygen
- normal finding at birth
- lips, hand, feet appear blue
collection of blood under periosteum of the skull bone caused by pressure at birth
risk of developing jaundice
- intestinal obstruction
pallor in newborn
- is potentially serious
- could be a sign of anemia:
- low iron stores
- blood incompetability
- excessive blood loss
- internal bleeding (blood in stool or vomitus?)
- white, cream cheese like substance that serves like a skin lubricant in utero
- document the color (same as amniotic fluid)
- fine, downy hair on shoulders, back, upper arms, forehead, ears
- 37-39 often lots of lanugo
- 42 postterm rarely show lanugo
usually disappears by two weeks of age
- drying of skin after delivery
- often on palms of hand and sole of feet
- (air environment causes the change/ peeling)
pinpoint white papule on cheek, across the bridge of nose
1. hemangiomas -vascular tumors of the skin- (a,b,c)
a,nevus flammeus: port wine stain, lighter = stork beak marks at neck-> can be treated with laser therapie, one level with skin surface
b, strawberry hemangioma: elevated areas: continue to enlarge first up to one year of age, after that shrink, after 10years they should be completely be absorbed
c, cavernous hemangioma: raised and irregular in shape, they will not disappear. goes deep into tissue, so after removal might still be evident after surgical removal
2. Mongolian spots: ccollection of pigment cells (slate grey) disappear by school age
- rash (present in most newborns)
- looks like flea bites
- lack of pattern
- disappears after a few days
- requires no treatment
- disappear within 1-2 days
- closely assess face, especially when crying-> symmetrical or maybe facial nerve injury
- inelastic skin turgor has to be reported, could be a sign of:
- malnutrition in uterus
- difficulty sucking at birth
- metabolic disorder
- -> suggests extremely poor nutrition
- openings where the skull bones join
- a, anterior fontanelle:
- diamond shaped, W 2-3cm w x L 3-4cm
- soft (indented->dehydration, bulging-> increased incranial pressure)
- closes between 12-18 months
- b, posterior fontanelle: triangular shaped,
- L 1-2cm
- edema of scalp
- is going to be reabsorbed
- does not need treatment
- permanent color 3-12 months of age, before blue/grey
- red spot or red ring around cornea (subconjuntival hemorrhage) absorbed within 2-3 weeks
- no treatment necesssary
- slight edema around eyes normal (2-3 days)
- eyes should be round, proportionate in size
hearing test with bell 6 inch way from ear-> baby would blink possibly startle (erschrecken)
newborns: the nose
check for blockage of the rear of the nose-> closing infants mouth by pressing one naris at a time-> note any discomfort or stress with breathing while one side of nose is blocked
newborns: the mouth
- mouth should open evenly
- palate should be intact
- ocssionally showin Epstein pearls-> are going to disappear (no treatment necessary)
- any teeth must be evaluated for stability (loose-> extract, possible aspiration)
- mucus is normal and can be drained by putting newborn on side
- ! too much mucus (bubles)-> possibility of trachea and esophagus connection-> danger of aspiration during feeding !
newborn: the neck
- head should move freely, baby should show effort to try to control head when sitting
- rigidity could be a sign of meningitis or injury of sternocleidomastoid muscle during birth
newborn: the chest
- circumference 2 cm smaller than head
- should be symmetrical
- check for fracture in clavicle during birth (often in large infants),
- supernumerary nipple might be found
- possible fluid in breast should not e expressed-> possible entrance for bacteria
- !retraction (drawing of the chestwall during inspiration) should not be present-> sign of respiratory distress-> immediate help like oxygen therapy
- rhonchi is normal
- grunting-> abnormal. distress-> immediate consultation
newborn: the abdomen
- should be slightly protuberant (erhoben)
- bowelsound within one hour after birth
umbilical cord: one vein, 2 arteries (!only one artery-> close observation regarding anomalies!
!always inspect th cord clamp to see if it is secure (no bleeding..0)
base of cord should not appear wet -> infection?
day 6-10 cord breaks free
- palpation of kidneys in first hours paplable-> do check
- abdominal reflex- umbilicus same direction than stroking finger (sometimes as late as 10th day)
- feet cannot be lined to midline position
- !best when treated in immediate newborn period!
birth record documentation
- 1. time of birth
- 2. time infant breasfed
- 3. respirations spontaneous or aided
- 4. apgar score 1 + 5 minute
- 5. eyeprophylaxis given?
- 6. Vitamin K?
- 7.general condition of infant
- 8. cultures taken ?
- 9. infant voided/stool?
- 10. number of vessels in umbilical cord
- sudden infant death syndrom
- sudden death before age 1
- - place infant on back for sleeping
- use firm sleep surface
- room sharing without bed sharing
- no overheating
- no exposure to tobacco smoke and other drugs
change diaper often
- with each change wash area with clear water
- dry well
- wear gloves is standard precaution
- should be done before discharge or 2-3 days after birth
- check if it was done
Hepatitis B vaccination
- 1. within 12 hours after birth
- 2. one month later
- 3. at 6 months
Vitamin K administration
- at risk for bleeding disorders during first week-> gastrointestinal tract does not have normal flora yet (is sterile) -> not yet able to produce Vitamin K, which is necessary for blood coagulation -> administered IM 0.5-1mg within the first hours
Vitamin K also available in oral form but not that preferred (absorption immature or vomiting)
- check for bleeding every 15 min. for the first hour
- observe closely 2 more hours
- document voiding after procedure
- site appears red, but should not have strong odor or discharge
- -> helps forcing the milk to toward the nipple (let-down-phase)
- -> helps contracting the uterus (smooth muscle contraction: tagging, cramping feeling)
calculating formula's adequacy
total fluid: 75-90 ml (2.5-3oz) per pund of bodyweight (150-200ml per kg)
calories: 50-55 per pound of bodyweigt (100-120 kcal per kg)
- thumb rule
- baby's age + 2-3 in month
- (age: 0 -> 2-3 oz each feeding, age 2 moths-> 4-5 oz per feeding...)
6 feedings per day
how much calories does breast milk/ formula milk have?
4 main reasons for postpartum hemorrhage
- 4 T's
- tone, trauma, tissue, thrombin
- 1. uterine atony
- 2. trauma (lacerations, hematomas, uterine inversion, uterine rupture)
- 3.retained placental fragments
- 4. development of disseminated intravascular coagulation
- AGA appropriate for this age (between 10-90% if children in this range)
- Small for gestational age
- Large for gestational age
- Low birth weight-> below 2500 g
- VLBW -> 100-1500 g
- respiratory distress syndrome
- -preterm infant
- -diabetic mother
- -cesarian birth
- -decreased blood perfusion in lung
- _> hyanlike (fibrous) membrane covering alveoli, preents gasexchange
- -> caused by low level or absence of surfactant
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