NORMAL NEWBORN Marlene Meador RN, MSN, CNE

Surfactant- What is this? Why is it necessary? When is it formed?

Respiratory Changes Initiation of of Breathing Breathing Mechanical Chemical Thermal Sensory

Factors in Initial Respiration Mechanical – chest recoil Chemical- respiratory acidosis Thermal- decrease in environmental temp Sensory- tactile, auditory, and visual influences stimulate activation of the first breath

Fetal Circulation (p ) Ductus arteriosus- blood flow from pulmonary artery to aorta Ductus venosus-blood flow from umbilical vein into the inferior vena cava Foramen ovale- blood flow from right atrium to left atrium

Neonatal Circulation Ductus arteriosus- closes after birth triggered by pressure changes and pO 2 (transient murmurs normal in first 24 hours) Ductus venosus- closes at clamping of umbilical cord Foramen ovale- closes at first breath

Cardiovascular/Cardiopulmonary Adaptations Increased aortic pressure and decreased venous pressure (clamping of cord) Systemic pressure and pulmonary artery pressure (expanding of the lungs) Closure of foramen ovale (atrial pressure changes) Closure of ductus arteriosus (PO2 triggers constriction of ductus arteriosus) Closure of ductus venosus (clamping of cord)

Thermoregulation

Contributing factors to neonatal heat loss Size Loss of heat source Loss of glucose supply Metabolic rate

Temperature Regulation Convection Radiation Evaporation Conduction How does the NB maintain body temperature?

Neonatal methods of producing heat Basal metabolic rate Muscular activity Non-shivering thermogenesis (NST) Why is heat regulation vital to the neonate’s survival?

What nursing interventions assist the neonate to maintain adequate thermoregulation? Drying Swaddling (blankets) Cap Skin to skin contact (cuddling)

Hematopoietic System Lifespan of neonatal RBC: days (2/3 lifespan of adult’s RBC) Factors effecting blood volume: Delayed cord clamping Shift of plasma to extra-vascular spaces Gestational age Prenatal or postnatal hemorrhage

Neonatal Lab Values (p498) Hemoglobin 14-20g/dl Hematocrit 48-69% WBC 10,000 – 30,000mm3 Glucose 40-60mg/dl first 24 hr then 50-90mg/dl Low blood sugar 40-45mg/dl requires treatment

Clinical judgment: Why is Vitamin K AquaMEPHYTON ® administered to the newborn?

GI Function: What is the significance of meconium? What is the priority nursing intervention regarding GI assessment? Presence of bowel sounds and patency of the anus

Hepatic Function What is the function of the liver in the neonate? What is physiologic jaundice? What is the difference between conjugated and unconjugated bilirubin? What is the long-term consequence of elevated bilirubin levels?

Normal Lab Values Bilirubin levels for a term NB<3mg/dl Elevated bilirubin levels depend on NB’s age- peak levels reached between day 3 and 5 in the term infant. Toxic levels approximately – 20mg/dl

Nursing Interventions: to decrease physiologic jaundice Maintain NB’s core temperature Monitor stool frequency and characteristics Encourage early feeding Encourage bowel elimination Prevent dehydration

Urinary System of the NB What is the normal number of voids in a 24 hour period? For first 48 hours- 1 or 2 daily Following 48 hours- 6 times daily What is brick-dust staining?

Immunologic Adaptations: Active acquired immunity- the mother forms antibodies in response to illness or immunization – passed through breast milk Passive acquired immunity- transfer of immunoglobulins to the fetus in utero (IgG production begins at 20 weeks gestation)

Behavioral States of the NB p. 665 & 872 CHART Sleep States: Deep or quiet sleep Active or REM sleep Alert States: Drowsy Wide awake Active awake Crying

Critical thinking… Which of the behavioral states is optimal for maternal-infant bonding?

Senses in the Neonate: Visual Auditory Olfactory Taste Tactile

Apgar Scoring Sign012 Heart rateAbsent Slow-below 100 Above 100 Respiratory effort Absent Slow- irregular Good Crying Muscle toneFlaccid Some flexion of extremities Active motion Reflex irritability None Grimace Vigorous cry ColorPale blue Body pink, blue extremities Completely pink

Apgar Score: assigned at 1 & 5 minutes. A score below 8 may require resuscitative efforts. 0-3 poor condition 4-6 fair condition 7-10 positive (good condition)

Quick review! What measures should the nurse take to ensure a patent airway in the NB? Why is it important to maintain a neutral thermal environment? What nursing interventions assist to maintain the NB’s core temp? (prevent cold stress)

Assessment of the Neonate

Vital Signs: Pulse Respirations Temperature Blood pressure

Average size for term Weight Length FOC Which measurement is priority for on- going assessment?

Assessment of NB skull/scalp Fontanelles Anterior Posterior Suturelines Frontal Coronal Sagittal Lambdoidal

Assessing the Head: Molding Caput succedaneum Cephalhematoma

Assessing the Face: Eyes Ears Mouth What is the significance of variations? (nursing interventions)

Assessment of the NB’s Eyes: Color Size Reaction to light/blink Conjunctival hemorrhages Transient strabismus or nystagmus

Assessment of the NB’s ears: Level Shape/ malformation Flexibility What body system must the nurse carefully monitor if anomalies occur with the ears?

Assessment of the NB’s mouth: Lips Palate Hydration Reflexes Additional normal findings: Epstein’s pearls Precocious teeth Short fernulum of tongue

Why is it important to assess the umbilical stump? How many vessels will you find in the umbilical cord? ___ Arteries ___ Veins What is Wharton’s jelly? (p. 246)

Assessment of the Abdomen What is the general shape What is the ratio of FOC to abdominal size? What organs must be assessed in the abdomen?

Extremities: Upper Hands Lower Hips Feet

Neurological Assessment/ Reflexes Moro or Startle Palmer grasp Rooting Sucking Babinski Plantar grasp Tonic neck

Assessing the genitalia of the NB: Female Labia Clitoris Vaginal opening Hymeneal tag Secretions Anal opening Male Penis Penial raphe Urethral meatus Scrotum-testes Anus

Skin Assessment: Color and thickness Birthmarks (telangiectatic nevi, flammeus, Mongolian) Harlequin sign Jaundice

Assessment of NB skin Acrocyonosis Mottling Erythema toxicum Vernix caseosa Telangiectatic nevi Mongolian spots- Why is it important to carefully document these birth marks?

Gestational Age: Neuromuscular and physical maturity Newborn Maturity Rating & Classification (P. 525) Dubowitz tool Ballard Score

Gestational Age Assessment Posture, reflexes, size, skin characteristics and fat distribution (pages ) Dubowitz scale Ballard score Neuromuscular maturity- posture, square window (wrist) arm recoil, popliteal angle, scarf sign, heal to ear maneuver Physical maturity- skin condition, lanugo, plantar surface, breast buds, earl and genital development.

Neonatal Medications Administered within 1 to 2 hours of birth AquaMEPHYTON ®- vitamin K Erythromycin ointment When is best time to administer?

Newborn Identification Footprints Identification bands Newborn Mother Designated “other”

What would you include in a transfer of care report for the neonate to the transition nursery?

Apgar scores Resuscitative efforts Time of birth, weight and length Labor analgesia or anesthetic L&D history Maternal history

Circumcision: (p 549) What factors are involved in the parent’s decision to have their male newborn circumcised? What assessments must the nurse include after circumcision?

Circumcision Care: pre-op & post -op Informed consent Comfort measures Risk of ______? Infection prevention Parent teaching and discharge planning

Discharge teaching for the NB: Safety Elimination Genitalia care General Feeding Signs of illness NB behavior Immunization schedule Return appointment schedule

Please contact me with any questions or concerns. Marlene Meador RN, MSN, CNE