1. Chapter 13 Nursing Assessment of Newborn Transition

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

3. 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

4. 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

5. 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

6. 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

7. 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

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

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

10. 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.

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

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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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.

24. 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

25. 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

26. 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)

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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.

35. 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

36. 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

37. 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

38. 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

39. 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

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

41. 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

42. 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

43. 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

44. 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)

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