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Describe how the lungs adjust to extrauterine life
- About 30ml of amniotic fluid is forced out of the lungs during the birthing process and the rest is absorbed within the next 12-24 hrs
- Air then fills the lungs instead of fluid
- Pressures in the lungs change the pressures in the heart, leading to blood going into the pulmonary arteries to be oxygenated
What are the triggers for newborn respiration?
- Mechanical stimulus: of being pushed thru the birth canal and compression of the chest
- Chemical stimuli: mild hypoxia, hypercapnia, and resp acidosis stimulates the medulla to stimulate respirations
- Thermal stimui: drop in temp promotes resp
- Sensory stimuli: experiencing light, touch, sound, and gravity for the first time promotes resp
How can you test for surfactant production prior to birth? What do you use if you know the baby is going to be preterm? In what gestational week is surfactant produced and at what week is it sufficient (surge of surfactant)?
- L/S ratio during amniocentesis: a ratio of 2:1 denotes matured lungs with reduced risk of RDS
- If you know the baby is going to be preterm, mom will be given corticosteroids IM, such as betamethasone, to promote lung maturation and surfactant production
- Surfactant begins production from type 2 cells at 24 wks gestation, but it does not surge until 36 wks gestation
What are signs of respiratory distress in the newborn?
- Apnea >15 sec
- Tachypnea (normal is 30-60 rpm)
- Nasal Flaring
What cardiovascular adaptations are made after birth?
- Pressures in the resp system are connected to pressure changes in the cardiovascular system
- Decreased pulmonary vascular resistance leas to increased pulmonary blood flow
- Increased systemic vascular resistance leads to cardiovascular changes (such as the closing of the foramen ovale and the ductus arteriosis)
- Foramen venosis functionally closes with the clamping of the umbilical cord
Why is thermoregulation so important in the newborn?
- Newborns lose about 4x the amount of heat as an adult, esp thru their head
- A balance needs to be made between heat production and heat loss (this is a narrow range of balance)
- Baby's have less fat and burn brown fat in the response to cold (babys do not have the shiver reflex)
- Requires more 02 and increased metabolic rate in order to thermoregulate
- Keeping the baby in a flexed position helps decrease heat loss
How do newborn's lose heat?
- Convection: heat loss due to cooler air currents
- Evaporation: heat loss as fluid leaves the skin
- Radiation: heat transfer to cooler surfaces and objects not in contact with the baby
- Conduction: heat transfer to cooler surfaces and objects in contact with the baby
Why are newborns unable to thermoregulate?
- Non-shivering thermogenesis uses Brown Adipose Tissue to produce heat
- BAT midscapular, neck, axillaries, trachea, esophagus, abdominal aorta, kidneys, adrenal glands
- If a baby shivers, it is severely compromised
Describe cold stress
- Excessive heat loss leading to hypothermia
- Increased heart and respiratory rate leads to an increase O2 consumption, depletion of glucose and decrease in surfactant
- This leads to respiratory distress and hypoglycemia
What are some nursing interventions to prevent cold stress and promote thermoregulation?
- Prevent heat loss by clothing, swaddling, hats, keeping baby bed warm, decrease drafts, and keep a warm air temp
- Reverse heat loss by skin to skin contact, feeding to keep glucose up, minimizing skin exposure, and maintaining a thermoregulating bed
What hematology adaptations occur in the newborn?
- Infant Hemoglobin is 14-20 gm/dL
- Infant Hematocrit is 43-63%
- Term infant has about 80ml/kg, or a little more than a cup of blood
- Delaying cord clamping, milking the cord, or decreasing neonatal height from the placenta can all lead to more blood going into the newborn
Describe the changes in the metabolic system in the newborn
- Large amounts of glucose is stored by the fetus before birth
- Glucose value decreases during within the first hours of life
- Glucose levels stabilize within 2-3 hrs from birth
- Optimal Range: 70-100 mg/dL
- Hypoglycemia: <40 mg/dL
How does the hepatic system adjust to extrauterine life?
- Liver occupies about 40% of the abdomen, but the liver is immature
- Liver cannot completely conjugate bilirubin
- Blood coagulation is limited due to lack of enzymes produced by bacteria in the gut, therefore we give vitamin K within an hour from birth
- Phagocytosis occurs in Kupffer cells
- ADEK and iron are stored in liver
- Glycogen storage to be converted to glucose when needed
- Liver metabolizes amino acids and lipids
How does the GI system adapt after birth?
- Pancreatic amylase lacks for the first few months, therefore they cannot process starch
- Proteins are digested easier than fats r/t poor activity of pancreatic lipase
- GI system matures around 36-38 weeks gestation
- Anoxia can stimulate peristalsis of the intestines and lead to meconium staining
What is the usual stomach capacity of the newborn? How much should a baby eat per day?
- Stomach capacity is 5-10ml initially, then 60ml by day 7
- The cardiac sphincter is immature, leading to the need to burp frequently
- Bowel Sounds present within 30-60 min after birth
- Babies should eat 120 kcal/kg/day to gain weight
- 5-10% weight loss in the first few days is normal
Describe the genitourinary system after birth
- Decreased GFR leads to the decreased ability to concentrate urine
- The baby is at risk for both over-hydration and dehydration as well as electrolyte imbalance
- Most infants void within the first 24 hrs
- Pseudomenstration in females is related to the withdrawal of maternal hormones from the fetus
How does the immune system function in the newborn?
- Baby gets passive immunity from mother thru placenta (IgG)
- Baby also gets active immunity as it is exposed (IgM)
- Baby gets passive immunity from breast milk, since colostrum is high in IgA
- *the newborn is highly susceptible to sepsis, esp thru the umbilical stump. S/S of infection may be subtle and newborns do not always run a fever (may be hypothermic)
Describe a newborn's senses
- Eye movement is present at birth, but is not coordinated
- Can see about 10-12 inches and prefers black and white
- Able to hear
- Able to feel pain
- Taste differentiates within the first 1-2 days of life
- Can pick out mom by smell withint 1 week
What reflexes are present at birth?
- Tonic Neck
What are some newborn skin characteristics?
- Vernix Caseosa
- Mongolian Spots
- Stork bites
- Port-wine stains
- Strawberry marks
- Erythema toxicum
Describe two kinds of molding of the newborn head
- Caput succedaneum: swelling of the soft tissue of the scalp that crosses the suture lines
- Cephalhematoma: a collection of blood beneath the periosteum of the cranial bone that does not cross the suture lines
How is a gestational age assessment performed?
Ballard scale is performed to determine gestational age
What are the advantages and disadvantages of circumcision?
- Advantage: possible prevention of cancer, fewer UTIs and STDs
- Disadvantage: infection, hemorrhage
What equipment is commonly used in circumcision?
- Gomco Clamp: clamp is on for procedure and foreskin is removed, clamp stays on for a few min to prevent hemorrhage
- Plastibell Clamp: foreskin is tied over a fitted plastic ring and the ring falls off withint 5-8 days
- Mogen Clamp: used by a trained rabbi
Describe common discharge teaching for mom and baby
- Hearing test done prior to discharge along with newborn and bilirubin screening
- Shaken baby teaching
- Car seat safety education
- Feeding teaching
- Education on bathing/dressing
What can be screened for in newborn blood screening?
- Sickle Cell Anemia
- Cystic Fibrosis
- Congenital hypothyroidism
- *The main goal is to prevent disabilities that may result if left untreated
Name 3 medications commonly given to the newborn
- Phytonadione (Vitamin K)
- Erythromycin Opthalmic Ointment
- Hepatitis B Vaccine (if exposed, immunoglobulins within 12 hrs from birth. Otherwise, first dose given prior to discharge)