Chapter 21 The Normal Newborn Adaptation and Assessment

Development of the Lungs Surfactant lines the alveoli and reduces surface tension to keep the alveoli open. Fetal lung fluid moves into the interstitial spaces before, during, and after birth. Lung fluid is absorbed by the lymphatic and vascular systems. Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 2

Initiation of Respirations A number of factors combine to stimulate the respiratory center in the brain and initiate respirations at birth. Chemical Ø Mechanical Ø Thermal Ø Sensory Ø Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 3

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Cardiovascular Adaptation Transition from fetal to neonatal circulation Increases in blood oxygen level Ø Shifts in pressure in the heart and lung Ø Closing of the umbilical vessels Ø Closing of the ductus arteriosus, foramen ovale, and the ductus venosis at birth Ø Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 5

Thermoregulation Newborn characteristics leading to heat loss Skin with little subcutaneous (white) fat Ø Blood vessels close to the surface Ø Large skin surface Ø Methods of heat loss Evaporation Ø Conduction Ø Convection Ø Radiation Ø Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 6

Thermogenesis Methods of heat production Increase activity Ø Flexion Ø Metabolism Ø Vasoconstriction Ø Nonshivering thermogenesis (brown fat) Ø These factors increase oxygen and glucose consumption and may cause respiratory distress, hypoglycemia, and jaundice. Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 8

Effects of Cold Stress Increased oxygen need Decreased surfactant production Respiratory distress Hypoglycemia Metabolic acidosis Jaundice Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 10

Question A newborn is placed under a radiant heat warmer. The nurse knows that thermoregulation presents a problem for newborns because _____. their renal function is not fully developed, and heat is lost in the urine B. their small body surface area favors more rapid heat loss than does an adult's body surface area C. they have a relatively thin layer of subcutaneous fat that provides poor insulation D. their normal flexed posture favors heat loss through perspiration A. Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 12

Hematologic Adaptation Erythrocytes, hemoglobin, and hematocrit Ø Leukocytes Ø Higher for newborns than for adults because less oxygen was available in fetal life than after birth Elevated white blood count Clotting Ø Newborns are given helpful levels of vitamin K, which is necessary to activate clotting factors. Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 13

Gastrointestinal System Stomach Intestines Enzymes Stools Progress from thick, greenish black meconium to loose, greenish brown transitional stools to milk stools Ø Stools of breastfed infants are frequent, seedy, and mustard-colored. Ø Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 14

Blood Glucose Maintenance The neonate uses glucose rapidly and is at risk for hypoglycemia. Infants at risk for hypoglycemia include: Preterm and late preterm Ø Small for gestational age Ø Large for gestational age Ø Born to diabetic mothers Ø Exposed to stressors Ø Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 15

Hyperbilirubinemia Physiologic jaundice Ø Pathologic jaundice Ø Occurs after the first 24 hours of life as a result of hemolysis of red blood cells and immaturity of the liver Begins in the first 24 hours and may require treatment with phototherapy Breast milk jaundice Ø Often caused by a lack of sufficient intake Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 16

Factors that Increase Hyperbilirubinemia Hemolysis of excessive erythrocytes Short red blood cell life Lack of albumin-binding sites Liver immaturity Preterm and late preterm infants Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 18

Factors that Increase Hyperbilirubinemia (cont. ) Lack of intestinal flora Delayed feeding Trauma resulting in bruising or cephalhematoma Fatty acids from cold stress or asphyxia Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 19

Urinary System Kidney function Ø The ability of the newborn kidneys to filter, reabsorb and maintain fluid and electrolyte balance is less than that of the adult kidney. Fluid balance The newborn body is composed of a greater percentage of water. Ø The first void should occur within 24 hours. Ø Absence of stool or urine for 48 hours may signify an abnormality. Ø Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 20

Immune System Neonates are less effective at fighting off infection than the older child or adult. Ig. G crosses the placenta in utero and provides a newborn with passive immunity. Ø Ig. M and Ig. G are produced to protect against infection. Ø Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 21

Psychosocial Adaptation First period of reactivity Wide awake, alert, and seems interested in their surroundings Ø Temperature may be decreased and heart rate may be elevated Ø Period of sleep or decreased activity Ø Falls into a deep sleep Second period of reactivity Ø Become interested in feeding Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 22

Behavioral States Deeper quiet sleep Light or active sleep Drowsy Quiet alert Active alert

Assessment Assess immediately after birth to detect abnormalities. Cardiorespiratory status History, airway, color, heart sounds, pulses, and blood pressure Ø Cyanosis, acrocyanosis Ø Thermoregulation Ø Axillary temperatures are preferred over rectal temperatures. Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 24

Normal Vital Signs in the Newborn Temperature Axillary • 36. 5 -37. 3° C • 97. 7 -99. 1° F Ø Rectal • 36. 5 -37. 7° C • 97. 7 -99. 8° F Ø Skin • 35. 5 -36. 5° C • 95. 9 - 97. 7° F Ø Apical pulse: 120 -160 beats per minute (bpm) Ø (100 sleeping, 180 crying) Respirations: 30 -60 breaths per minute Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 27

Assessing for Anomalies Head Molding Ø Fontanels Ø Caput Ø Cephalhematoma Ø Facial symmetry

Assessing for Anomalies (cont. ) Neck Clavicles Cord Extremities Hands and feet Ø Hips

Measurements An important way to learn about growth prior to birth Weight Ø Length Ø Head and chest circumference Ø Eyes and ears Ø Reflexes Ø Abnormal measurements alert the nurse that complications may occur. Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 35

Signs of Hypoglycemia Jitteriness, tremors Poor muscle tone Sweating Tachypnea Grunting Cyanosis Apnea Diaphoresis Low temperature Poor suck High-pitched cry Lethargy Irritability Seizures, coma NOTE: Some infants may be asymptomatic. Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 39

Gastrointestinal System Initial feeding provides information about the ability to coordinate: Sucking Ø Swallowing Ø Breathing Ø Tolerance to feedings Ø Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 40

Genitalia Female Labia majora should be large and completely covered the clitoris and labia minora. Ø Genitalia may be darker than the surrounding skin. Ø A small amount of vaginal discharge is normal. Ø Male At term the scrotum should be pendulous. Ø Genitalia may be dark brown. Ø Palpation of the scrotum determines if the testes have descended. Ø Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 41

Integumentary System Marks on the skin should be documented, including location, size, and a general description. Vernix Ø Lanugo Ø Milia Ø Erythema toxicum Ø Birthmarks Ø Marks from delivery Ø Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 43

Gestational Age Assessment Neuromuscular characteristics Posture Ø Square window Ø Arm recoil Ø Popliteal angle Ø Scar sign Ø Heel to ear Ø Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 50

Gestational Age Assessment (cont. ) Physical characteristics Skin Ø Lanugo Ø Plantar surface Ø Breasts Ø Eyes and ears Ø Genitals Ø Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 58