The Normal Newborn Neonatal time period – birth to 28 days Transition period – First and second periods of reactivity First period-Birth to 30 minutes Unresponsive period lasts minutes Second period-occurs b/t 4-8 hrs; lasts 10 mins to several hours

Objectives Discuss physiologic & behavioral adaptations the newborn must make in the transition from intrauterine to extrauterine life Recognize newborn reflexes Describe normal physiologic findings Describe common deviations from normal physiologic findings Discuss nursing care of the normal newborn

Initial Care and Assessment at Birth Airway maintenance; resuscitation Maintain warmth VS APGAR

Vital Sign Norms Temperature C Heart rate bpm Respirations breaths/min B/P-80’s-90’s/40’s-50’s

APGAR Appearance or color Pulse or heart rate Grimace or reflex irritability Activity or muscle tone Respirations

APGAR…

Initial Care continued Medication guides Eye prophylaxis-EES Vitamin K administration Triple dye to cord Signs of potential complications Assess blood glucose levels

Initial Care continued Physical exam Gestational age assess within 48 hours of birth Measurements Promote bonding Initiate breast feeding Umbilical cord-assess for 3 vessels

Biologic/Physiologic Adaptations Respiratory System Respiratory: initial respirations triggered by mechanical, sensory, thermal & chemical factors Mechanical: chest compression during labor removes fluid from lungs; first breath decreases pulmonary resistance

Respiratory System con’t. Sensory: light, noise, sound Thermal: chill stimulates nerve endings causing rhythmic respirations Chemical: changes in blood (increased CO2, decreased pH, decreased 02) from transitory asphyxia during delivery initiates medulla’s respiratory ctr.

Respiratory System con’t. The newborn is an obligatory nose breather ~ any obstruction will cause respiratory distress; the newborn’s ability to maintain respiratory function is influenced by his large heart that reduces lung space and weak intercostals muscles, and horizontal ribs and high diaphragm, which restrict the space available for lung expansion

Cardiovascular System Cardiovascular: expansion of lungs with first breath increases pulmonary blood flow & decreases pulmonary vascular resistance (converts circ.) Increased aortic pressure and decreased venous pressure: clamping of the umbilical cord increases vascular resistance, and aortic blood pressure increases

Signs of Cold Stress Skin temp decreases Resp rate increases 1 st, then apneic spells Heart rate increases 1 st, then bradycardia begins Skin is mottled & acrocyanosis Physical activity decreases

Care for NB with Cold Stress Prevention first Warm gradually

Fetal to Newborn CV Transition The foramen ovale (an opening that previously connected the right and left atria), functionally closes in about 1 to 2 hours, and anatomically closes in a few weeks to 1 year, increasing the left atrial pressure; some shunting may occur early in transition and with crying; murmur may be heard over R & L atria

Fetal to Newborn CV Transition con’t. The ductus arteriosus (in fetal circulation, an anatomic shunt between the pulmonary artery and arch of the aorta) closes, reversing the blood flow, so now blood flows from the aorta to the pulmonary artery because of the increased left arterial pressure

Fetal to Newborn CV Transition con’t. The ductus venosus closes (in fetal circulation, shunts arterial blood into inferior vena cava) thought to be related to severance of the cord, results in redistribution of blood and cardiac output; closure forces perfusion of the liver

Thermogenic Poor thermogenesis - cannot shiver; decreased brown fat; large surface to body area Forms of heat loss (p 533) Convection Radiation Evaporation Conduction

Renal System Minimal range of chemical balance and safety Diarrhea, infection and improper feeding leads to acidosis and fluid imbalances (dehydration & edema) Limited ability to excrete drugs First void within 24 hours Brick dust – pink-tinged stains appearing on diaper; caused by uric acid crystals and normal in first few days of life. Later, may be a sign of dehydration.

GI System Fat & starch digestion poorer d/t decreased pancreatic amylase & lipase First stool within 48 hours Hypoglycemia possible Weight loss-5-10% normal

Transition of Stool Meconium-thick, greenish-black, tarry X 1-2 days Transitional-thinner, brown to greenish by 3 rd day Milk stools-Breast: yellow-gold, soft, mushy; Bottle: pale yellow to brown, firmer, more odorous

Hepatic System Iron stores from mother last until 5th month Liver immature at birth – susceptible to hypoglycemia (cannot form glucose from protein) & hyperbilirubinemia (limited ability to metabolize bilirubin) Early feeding facilitates a decrease in bilirubin through stimulation of intestinal activity & passage of meconium

Hepatic System con’t Physiologic jaundice Pathologic jaundice Lack of intestinal bacteria to synthesize vitamin K leads to clotting problems (inject vitamin K at birth)

Integumentary System Acrocyanosis Erythema toxicum Lanugo Milia Mongolian spats Nevi Vernix caseosa Epstein’s pearls

Reproductive System Breast tissue swells in both sexes due to increased estrogen levels of the pregnancy Witches milk Female pseudomenstruation

Neurological System/Senses Reflexes (except extrusion, Glabellar & deep tendon) Distinguishes patterns at 2 weeks Hears, tastes, smells, feeds, feels pain (hearing screening before d/c) Sleeps ~ 17 hrs/day

Musculoskeletal System Ortolani’s maneuver (click) Asymmetrical gluteal folds

Immune System Only IgG crosses the placenta- passive acquired immunity NBs begin producing antibodies at 3 mos IgA absent in resp, urinary & GI tract until ~4-6 mo unless breast fed Signs/sxs infection

Terms to Know Microcephaly Hydrocephaly Doll’s eyes Sunset sign (eyes) Thrush Syndactyly Polydactyly

Newborn Lab Values Hgb-14-24g/dl Hct-44-64% RBCs WBCs-9,000-30,000 Bilirubin, direct-0-1mg/dl Bilirubin, total-1-2 days-6mg/dl; 2-5 days-12mg/dl Serum glucose-50 or >mg/dl

Care of the Normal Newborn Care Path, know 1 st hr hr, 24 hr, hr information Airway maintenance-suction, position; signs of resp distress Temperature maintenance Cord care Circumcision care

Care continued Phototherapy Collection of urine specimen Newborn analgesics – “sugar” (glucose) water; EMLA cream; penile blocks HBV within 12 hrs of birth Signs of infection Safety

Care continued Feeding Nonnutritive sucking Infant massage Bonding Handwashing!! Teaching