Chapter 13 Nursing Assessment of Newborn Transition

Physiologic Adaptation Respiratory system Birth process Helps expel fetal lung fluid Stimulates lung inflation Stimulates surfactant production Surfactant keeps alveoli from collapsing after expansion

Physiologic Adaptation (cont.) Circulation through the heart Fetal circulation High pressure in the lungs causes pressure in right atrium > left atrium Pressure differences help route blood Through the foramen ovale, ductus arteriosus Away from nonfunctioning lungs Back into general circulation Ductus venosus shunts fetal blood away from the liver

Physiologic Adaptation (cont.) Circulation through the heart (cont.) Birth means fetal shunts must close First breath reverses pressure in atria causing foreman ovale to close Redirects blood to the lungs Increase in oxygen aids in closing ductus arteriosus Ductus venosus closes and blood flows through liver Newborn circulation similar to adult circulation

Physiologic Adaptation (cont.) Thermoregulatory adaptation Thermoregulation is the physiologic process of balancing heat production with heat loss to maintain adequate body temperature Newborn thermoregulation difficulties Prone to heat loss due to lower proportion of heat- producing tissue Not readily able to produce heat Vulnerable to cold stress

Physiologic Adaptation (cont.) Thermoregulatory adaptation (cont.) Newborn loses heat in four ways Conduction Convection Evaporation Radiation Newborn compensation Flexed posture conserves heat Burning brown fat produces heat

Physiologic Adaptation (cont.) Metabolic adaptation Neonatal hypoglycemia: Blood glucose falls to ≤50 mg/dL Prebirth risk factors Inadequate fetal blood flow to placenta during pregnancy Maternal diabetes Medications increasing maternal blood sugar Prolonged labor; maternal infection Postbirth risk factors Respiratory distress; cold stress

Physiologic Adaptation (cont.) Neonatal hypoglycemia (cont.) Early signs and symptoms Jitteriness Poor feeding Listlessness Irritability Low temperature Weak or high-pitched cry Hypotonia

Physiologic Adaptation (cont.) Neonatal hypoglycemia (cont.) Late signs and symptoms Respiratory distress Apnea Seizures Coma

Question Tell whether the following statement is true or false. Neonatal hypoglycemia is defined as a blood glucose level of 50 mg/dL or lower.

Answer True Rationale: Neonatal hypoglycemia occurs when blood glucose levels drop to 50 mg/dL or lower.

Physiologic Adaptation (cont.) Hepatic adaptation Liver immature at birth Bilirubin Conjugated Water-soluble Excreted in feces Unconjugated Fat-soluble Enters cells causing jaundice

Physiologic Adaptation (cont.) Bilirubin (cont.) Hyperbilirubinemia High levels of unconjugated bilirubin in the bloodstream (serum levels ≥4 to 6 mg/dL) Physiologic jaundice First appears on head Progresses in a cephalocaudal manner

Physiologic Adaptation (cont.) Physiologic jaundice (cont.) Jaundice that occurs after first 24 hours of life (usually on days 2 or 3 after birth) Bilirubin levels that peak between days 3 and 5 Bilirubin levels that do not rise rapidly (no greater than 5 mg/dL per day) Jaundice occurring within the first 24 hours of birth considered pathologic

Physiologic Adaptation (cont.) Hepatic adaptation (cont.) Newborn cannot produce vitamin K due to lack of gastrointestinal flora Liver unable to produce some clotting factors Newborns receive vitamin K (AquaMEPHYTON) intramuscularly Prevent hemorrhage

Physiologic Adaptation (cont.) Behavioral and social adaptation Brazelton’s Neonatal Behavioral Assessment Scale Six sleep and activity patterns Deep sleep Light sleep Drowsy Quiet alert Active alert Crying

Nursing Assessment of the Normal Newborn Initial assessments at birth Success of cardiopulmonary adaptation (assess immediately) Vigorous or lusty cry Heart rate greater than 100 bpm Pink color Assessment by RN

Nursing Assessment of the Normal Newborn (cont.) Initial assessments at birth (cont.) Apgar score Not a guide for newborn resuscitation Useful to evaluate resuscitation efforts Helps determine intensity of care newborn needs

Nursing Assessment of the Normal Newborn (cont.) Apgar score (cont.) Five parameters Heart rate Respiratory effort Muscle tone Reflex irritability Color Scored 0 to 2 points each

Nursing Assessment of the Normal Newborn (cont.) Apgar score (cont.) Assessed at one and five minutes of life Score of less than 7 at five minutes RN scores every five minutes until score is Above 7 Newborn is intubated Newborn is transferred to nursery

Nursing Assessment of the Normal Newborn (cont.) Apgar score (cont.) Scores 7 to 10 at five minutes: Doing well Scores 4 to 6 at five minutes: Needs close observation Score 0 to 3 at five minutes: In severe distress

Question The Apgar score, given at one and five minutes of life, is an important assessment tool for the newborn. What information is this assessment used for? a. Guides resuscitation efforts b. Helps determine intensity of newborn needs c. Indicates whether newborn is “normal” d. Used to evaluate resuscitation efforts

Answer b. Helps determine intensity of newborn needs Rationale: The Apgar score is useful in determining the intensity of the needs of the newborn for the first few days of life.

Nursing Assessment of the Normal Newborn (cont.) Continuing assessments throughout newborn transition First two hours: Measure heart and respiratory rates every 30 minutes Measure temperature every 30 minutes until stabilized above 97.6°F Observe for hypoglycemia

Nursing Assessment of the Normal Newborn (cont.) Initial admitting assessment Review mother’s history General observations of specific measurements Head-to-toe approach General appearance, body proportions, and posture Symmetrical Well nourished Without cyanosis

Nursing Assessment of the Normal Newborn (cont.) Vital signs Respiratory rate – 30 to 60 breaths per minute B/P low – 60 to 80/40 to 45 mm Hg Heart rate high – 110 to 160 bpm Axillary temperature – 97.7°F to 99.5°F (36.5°C to 37.5°C)

Nursing Assessment of the Normal Newborn (cont.) Physical measurements Weight 2500 to 4000 g Length (head-to-heel) 48 to 53 cm Head circumference 33 to 35.5 cm Chest circumference 30.5 to 33 cm

Nursing Assessment of the Normal Newborn (cont.) Head-to-toe assessment Skin, hair, and nails Vernix caseosa White, cheese-like substance covering fetal body during second trimester to protect against skin dryness Lanugo Fine, downy hair present in abundance on preterm infant but found in thinning patches on shoulders, arms, and back of term newborns

Nursing Assessment of the Normal Newborn (cont.) Skin, hair, and nails (cont.) Common skin manifestations of the normal newborn Milia Tiny, white papules resembling pimples Acrocyanosis Bluish color to hands and feet of newborns; normal in first six to 12 hours after birth

Nursing Assessment of the Normal Newborn (cont.) Skin, hair, and nails (cont.) Common skin manifestations of the normal newborn (cont.) Mottling: Characterized by red and white, lacy pattern sometimes seen on fair-complexioned newborns Harlequin sign: Characterized by a clown suit- like appearance of the newborn Caused by constriction and dilation of blood vessels

Nursing Assessment of the Normal Newborn (cont.) Skin, hair, and nails (cont.) Common skin manifestations of the normal newborn (cont.) Mongolian spot Bluish-black areas of discoloration on the back, buttocks, or extremities of dark- skinned newborns Telangiectatic nevi (“stork bites”) Pale pink or red marks found on the nape of the neck, eyelids, or nose of fair-skinned newborns

Nursing Assessment of the Normal Newborn (cont.) Skin, hair, and nails (cont.) Common skin manifestations of the normal newborn (cont.) Nevus flammeus or port-wine stain Dark reddish purple birthmark that most commonly appears on the face

Question Baby girl Smith, a healthy newborn female weighing 8 lb 2 oz, was born two hours ago. You note that her hands and feet are blue in color and her trunk is pink. What would you document? a. Mongolian spots noted on extremities b. Telangiectatic nevi noted on extremities c. Acrocyanosis present d. Milia present

Answer c. Acrocyanosis present Rationale: Acrocyanosis, blue hands and feet with a pink trunk, results from poor peripheral circulation and is not a good indicator of oxygenation status.

Nursing Assessment of the Normal Newborn (cont.) Head-to-toe assessment (cont.) Head and face Molding Elongated head shape Caput succedaneum Swelling of the soft tissue of the scalp Cephalhematoma Swelling that occurs from bleeding under the periosteum of the skull

Nursing Assessment of the Normal Newborn (cont.) Head-to-toe assessment (cont.) Head and face (cont.) Sutures palpable; fontanels open Facial movements symmetrical Eyes Movement usually uncoordinated Strabismus “Doll’s eye” reflex Nose

Nursing Assessment of the Normal Newborn (cont.) Head-to-toe assessment (cont.) Head and face (cont.) Mouth Pink and moist Strong suck reflex Epstein pearls Abnormal Thrush; cleft lip/palate

Nursing Assessment of the Normal Newborn (cont.) Head-to-toe assessment (cont.) Ears: Even and symmetrical Neck: Short and thick without webbing Chest: Barrel-shaped, movements equal bilaterally Abdomen: Dome-shaped, protuberant Umbilical cord: Without redness, drainage

Nursing Assessment of the Normal Newborn (cont.) Head-to-toe assessment (cont.) Genitourinary Void within first 24 hours Light in color, without odor Genitalia may be swollen Smegma: Cheesy white substance, allow to wear away gradually without scrubbing Report ambiguous genitalia immediately

Nursing Assessment of the Normal Newborn (cont.) Head-to-toe assessment (cont.) Genitourinary (cont.) Female Hymenal tag may be present Imperforate hymen: Report Pseudomenstruation

Nursing Assessment of the Normal Newborn (cont.) Head-to-toe assessment (cont.) Genitourinary (cont.) Male Epispadias Urinary meatus is located abnormally on dorsal (upper) surface of glans penis Hypospadias Urinary meatus is located abnormally on the ventral (under) surface of glans penis

Nursing Assessment of the Normal Newborn (cont.) Head-to-toe assessment (cont.) Genitourinary (cont.) Male (cont.) Phimosis: Tightly adherent foreskin A normal condition in the term newborn Cryptorchidism: Undescended testicles Hydrocele: Fluid within the scrotal sac

Nursing Assessment of the Normal Newborn (cont.) Head-to-toe assessment (cont.) Extremities Flexed position Simian crease: Down syndrome Ortolani maneuver; Barlow sign Back and rectum Spine: Straight and flat Anus should be patent

Nursing Assessment of the Normal Newborn (cont.) Neurologic assessment Reflexes Rooting reflex Suck reflex Palmar, plantar grasp Stepping reflex Moro (startle) reflex Tonic neck reflex (fencer’s position)

Nursing Assessment of the Normal Newborn (cont.) Behavioral assessment Assess bonding Gestational age assessment Critical evaluation