1. Fall 2011
Normal Newborn

2. Surfactant- What is this? Why is it necessary? When is it formed?
What is the function of surfactant? When is it produced and when it is sufficient to support extrauterine life?
-Surfactant actives phospholipids (lecithin & sphingomyelin)
-alveolar stability
-begins to develop weeks gestation

3. Respiratory Changes Mechanical Chemical Initiation of Breathing
Thermal
Chest recoil
Increase partial CO2 leads to decreased pH & PO2 stimulates aortic & carotid chemoreceptors to initiate/activate brain response center
(What med/surg patients suffer from this chronic condition? COPD
3. Decreased environmental temperature (increases respiratory rate – work of breathing increases metabolic rate)
Sensory

4. 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
2.What part does each of these factors play in initiation of respirations in the neonate?
Mechanical -
Chemical-
Thermal-
Sensory-

5. Fetal Circulation
3. Trace the circulatory system of the fetus from the umbilical vein to the umbilical arteries. (p. 246)

6. Fetal Circulation (p246-247)
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
3a. Describe the function of each of the 3 structures unique to fetal circulation:

7. (transient murmurs normal in first 24 hours)
Neonatal Circulation
Ductus arteriosus- closes after birth triggered by pressure changes and pO2
(transient murmurs normal in first 24 hours)
Ductus venosus- closes at clamping of umbilical cord
Foramen ovale- closes at first breath
3b. How do these structures change after birth? What process causes these changes?

8. 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)

9. Thermoregulation

10. Thermoregulation Contributing factors to neonatal heat loss Size
Loss of heat source
Loss of glucose supply
Metabolic rate
4 . What characteristics predispose newborns to heat loss?

11. Temperature Regulation
Convection
Radiation
Evaporation
Conduction
How does the NB maintain body temperature?
4a. What are the four avenues by which newborns loose heat? Provide nursing interventions to alleviate each:

12. Neonatal methods of producing heat
Basal metabolic rate
Muscular activity
Non-shivering thermogenesis (NST)
Why is heat regulation vital to the neonate’s survival?
4b. What physiologic methods are available to the neonate for heat production? Discuss the process of non-shivering thermogenesis.

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

14. 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

15. Neonatal Lab Values (p498)
Hemoglobin g/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
5. What are the hemoglobin and hematocrit levels in the newborn?

16. Why is Vitamin K AquaMEPHYTON ® administered to the newborn?
Clinical judgment:
Why is Vitamin K AquaMEPHYTON ® administered to the newborn?
6. Why is Vitamin K given to the newborn?

17. 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
7. What is meconium and what is the significance of this for GI system?
8. What kind of stools follow meconium?

18. 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?
9. What are the five functions of the liver in the neonate?
In what form is glucose stored in the liver?
11. What does it mean to conjugate bilirubin? How does this happen?
12. Why is it important to conjugate bilirubin?
13. What are the factors that increase the risk for jaundice in the first week of life?

19. 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
13. What is physiologic jaundice?
14. At what bilirubin level does jaundice become visible? When does the bilirubin level peak?

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

21. 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?
15. An infant should void within how many hours after birth?

22. Immunologic Adaptations:
Active acquired immunity- the mother forms antibodies in response to illness or immunization
Passive acquired immunity- transfer of immunoglobulins to the fetus in utero (IgG production begins at 20 weeks gestation) or to the infant via breastmilk
16. To what pathogens are newborns particularly susceptible?
17. When does passive immunity received from the mother disappear?

23. 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
18. Describe the 6 behavior states in the newborn.
19. Which of the sleep/awake states is optimal for parental-infant interaction?

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

25. Senses in the Neonate:
Visual
Auditory
Olfactory
Taste
Tactile

26. Apgar Scoring Sign 1 2 Heart rate Absent Above 100 Respiratory effort1 2
Heart rate
Absent
Slow-below 100
Above 100
Respiratory effort
Slow- irregular
Good Crying
Muscle tone
Flaccid
Some flexion of extremities
Active motion
Reflex irritability
None
Grimace
Vigorous cry
Color
Pale blue
Body pink, blue extremities
Completely pink
20. Explain the criteria for assigning an Apgar Score. (p. 377)

27. Apgar Score: assigned at 1 & 5 minutes
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)
21. What Apgar scores require further intervention?

28. 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)

29. Assessment of the Neonate

30. Vital Signs: Pulse Respirations Temperature Blood pressure
Signs of Respiratory Distress
Temperature
Blood pressure
22. What are the normal vital signs of the neonate?
a. Pulse (which additional pulses should be included?)
b. Respirations
c. Temperature
d. Blood pressure
What are the signs of respiratory distress in the newborn?

31. Average size for term Weight Length FOC
30. What is the average assessment finding for each of the following?
Weight
Length
Head Circumference

32. Assessment of NB skull/scalp
Fontanells
Anterior
Posterior
Suture lines
Frontal
Coronal
Sagittal
Lamdoidal
24. Describe assessment of the fontanels and sutures present on newborn’s head.

33. Assessing the Head:
Molding
Caput succedaneum
Cephalhematoma

34. 25. What is molding of the head?
26. Differentiate between caput succedaneum and cephalhematoma.

35. Eyes Ears Mouth Assessing the Face:
What is the significance of variations? (nursing interventions)
32. What is the significance of a shrill or high-pitched cry?

36. Assessment of the NB’s Eyes:
Color
Size
Reaction to light/blink
Conjunctival hemorrhages
Transient strabismus or nystagmus
33. What is included in assessment of the newborn’s eyes?

37. Assessment of the NB’s ears:
Level
Shape/ malformation
Flexibility
What body system must the nurse carefully monitor if anomalies occur with the ears?
34. What do malformation or low-set ears indicate?

38. Assessment of the NB’s mouth:
Lips
Palate
Hydration
Reflexes
Additional normal findings:
Epstein’s pearls
Precocious teeth
Short fernulum of tongue
35. What should the nurse include when assessing the infant’s mouth?

39. 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)
27. What assessment findings must the nurse note regarding the umbilical stump?
Number of arteries=___
Number of veins=___
What is Wharton’s jelly? What is the purpose?

40. 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?

41. Extremities: Upper Hands Lower Hips Feet
28. What maneuvers are employed to assess the hips of a newborn?
29. What is the significance of a simian crease?

42. Neurological Assessment/ Reflexes
Moro or Startle
Palmer grasp
Rooting
Sucking
Step
Babinski
Plantar grasp
Tonic neck
31. Describe neurologic reflexes present in the newborn. What represents normal and abnormal findings?

43. Assessing the genitalia of the NB:
Female
Labia
Clitoris
Vaginal opening
Hymeneal tag
Secretions
Anal opening
Male
Penis
Penial raphe
Urethral meatus
Scrotum
Testes
Rugae
36. Describe the normal genitalia of a newborn:
a. What nursing technique must the nurse include when assessing the male neonate and expected normal findings and variations?
b. What nursing technique must the nurse include when assessing the female neonate and expected normal findings and variations?

44. Skin Assessment: Color and thickness Birthmarks Harlequin sign
Jaundice
37. Describe common assessment findings related to the skin of the newborn.

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

46. Gestational Age: Neuromuscular and physical maturity
Newborn Maturity Rating & Classification (P )
Dubowitz tool
Ballard Score
Posture, reflexes, size,
skin characteristics
and fat distribution
38. What characteristics of the newborn does the nurse assess to determine gestational age?

47. Neonatal Medications Administered within 1 to 2 hours of birth
AquaMEPHYTON ®- vitamin K
Erythromycin ointment
When is best time to administer?
39. What is the rationale for administration of medications to the newborn? Provide specific nursing interventions related to:
AquaMEPHYTON ® -
Erythromycin ointment-

48. Newborn Identification
Footprints
Identification bands
Newborn
Mother
Designated “other”
40. What are the legal implications and methods for newborn identification? (p. 546)

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

50. 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

51. Circumcision: (p 549)
What factors are involved in the parent’s decision to have their male newborn circumcised?
What methods of pain relief may be implemented?
What assessments must the nurse include after circumcision?
41. What factors are involved in the parents’ decision to have their male newborn circumcised?
42. What methods of pain relief may be used for newborn circumcision?
43. What assessments must the nurse include after the circumcision?

52. Circumcision Instruments
44. What are the specific nursing interventions for the two (2) types of circumcision? (including parent teaching)

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

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

55. Required Newborn Screening for Texas: www. dshs. state. tx
Required Newborn Screening for Texas:
Early detection and treatment of inborn metabolic disorders (29 conditions)
Two screening times
24-48 hours after birth
1-2 weeks of age
Hearing screening

56. Nursing interventions for screening the neonate:
Obtain specimen
Preparation of neonate
Comfort measures
Inform parents
Provide information for obtaining results