Chapter 9 Physiologic Adaptation of the Newborn and

Adjustment to Extrauterine Life Copyright © 2012, 2008 by Saunders, an imprint of Elsevier

Objectives Define key terms listed. Describe four important neonatal adaptations to extrauterine life. Explain how fluid in the lungs is replaced with air. Relate how the neonate’s pulmonary circulation is established. Differentiate among the three fetal circulatory shunts, including their reasons for closure. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 3

Adjustment to Extrauterine Life Quickly breathe and maintain respiration rate Replace fluid in the lungs with air Open up the pulmonary circulation and close the fetal shunts Allow pulmonary blood flow to increase and cardiac output to be redistributed Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 4

Adjustment to Extrauterine Life (cont. ) Provide energy to maintain body temperature and support metabolic processes Dispose of waste products produced by food absorption and metabolic processes Detoxify substances entering from external environment Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 5

Respiratory and Circulatory Function Copyright © 2012, 2008 by Saunders, an imprint of Elsevier

Preparatory Events to Breathing In utero, lungs are filled with fluid Ø Secretions of alveolar cells of lungs with some amniotic fluid Surfactant produced by mature lungs in fullterm fetus Reduces force between moist surfaces of alveoli Ø Prevents collapse with expiration Ø Promotes lung expansion Ø Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 7

Onset of Breathing First breath of healthy term infant occurs within seconds of birth Stimuli to respiratory center Neonate’s brain: sensory, chemical, thermal, mechanical Ø External environment: cold, touch, movement, light, sound Ø Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 8

Chemical Stimulus Once cord is clamped Decreased blood oxygen level Ø Increased blood carbon dioxide level Ø Decreased p. H Ø Acidosis results • Activates respiratory center in medulla to initiate Ø respirations Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 9

Changing from Fluid-Filled to Air-Filled Lungs Copyright © 2012, 2008 by Saunders, an imprint

Comparison of Vaginal Delivery and Cesarean Delivery Vaginal Ø Chest is compressed as the fetus is delivered • Promotes fluid drainage from lungs • Before chest is delivered, almost half of fluid is forced out Ø Chest recoils, and infant sucks in 20 to 40 m. L of air • Creates negative intrapleural pressure Cesarean Chest does not have the compression, recoil, expansion Ø Increases risk of respiratory distress Ø Some fluid is absorbed by lymphatic vessels Ø The rest is removed by the pulmonary capillaries Ø Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 11

Functional Residual Capacity Established with first breath Means there is a small amount of air left in alveoli; allows lungs to stay partially open during expiration With the second and third breath, not as much pressure is needed, and as newborn continues to breathe, respirations should become easier Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 12

Respiratory Rate Normal newborn rate is 30 to 60 breaths/min Pattern includes 5 - to 15 -second pauses, called periodic breathing, and is normal Cessation of breathing for more than 20 seconds is called apnea and is abnormal Obligate nose breather Ø Any nasal obstruction cause respiratory distress Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 13

Closing Down the Fetal Structures (Shunts) Fetus: blood flow bypasses nonfunctional lungs and liver Newborn: blood must circulate to lungs for oxygenation and to liver for filtration Shunts close as a result of Shifts in heart pressure Ø Increase in blood oxygenation Ø Clamping of umbilical cord Ø Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 14

Major Shunts of Fetal Circulation Copyright © 2012, 2008 by Saunders, an imprint of

Foramen Ovale Fetal Opening between right and left atria Ø Blood flow and pressure greater in right atrium Ø Functions like oneway valve Ø Shunts blood away from lungs to aorta Ø Cord clamped on delivery Ø Newborn Clamping cord causes blood from placenta to stop Ø Pressure on left side of heart becomes greater than on right Ø Closes about 1 minute after birth Ø Takes about 2 weeks for complete anatomic closure Ø Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 16

Ductus Arteriosus Fetal Shunts blood from pulmonary artery to aorta Ø Bypasses lungs Ø Pulmonary arterioles dilate in response to increased oxygen needs of lungs at birth Ø Newborn Constricts and completely closes between 15 and 24 hours after birth Ø Anatomic closure takes about 3 to 4 weeks after delivery Ø Can reopen (dilate) if newborn has a decrease in blood pressure or oxygen saturation Ø Referred to as patent ductus arteriosus (PDA) Ø Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 17

Patent Ductus Arteriosus Can lead to right-sided heart failure and pulmonary congestion If it does reopen, unoxygenated blood will bypass lungs and go through the pulmonary artery into aorta and general circulation Newborn becomes hypoxic and can die Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 18

Ductus Venosus Fetal Allows most oxygenated blood to bypass liver and enter inferior vena cava Ø Clamping of cord at birth cuts off venous blood flow Ø Newborn Blood redistributed on clamping of cord Ø Reduced blood flow through shunt • Constricts, closes anatomically Ø about 2 weeks after birth • Eventually becomes a ligament Forces blood perfusion in the liver Ø Mechanism for is closure is unknown Ø Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 19

Audience Response System Question 1 Once the umbilical cord is clamped, what type of stimulus is needed to cause the newborn to breathe on its own? A. B. C. D. Thermal Chemical Mechanical Sensory Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 20

Body Adaptation Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 21

Objectives Recall the location of brown fat and how it is used in infant heat production. Explain three reasons why the newborn should not be allowed to chill or experience cold stress. Explain four ways to prevent heat loss in the newborn. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 22

Body System Adaptations and Functions Copyright © 2012, 2008 by Saunders, an imprint of

Thermoregulation Ability to produce heat and maintain a normal body temperature Newborn maintains body heat by flexing extremities (if good muscle tone) Minimizes exposure of body surface area Ø Decreases risk of cold stress Ø Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 24

Nursing Responsibility Maintain neutral thermal environment Ø Room temperature 25° C (77° F) Makes minimal demands on newborn’s energy reserves Abdominal skin temperature of 36. 5° C (97. 7° F) Allows for Minimal oxygen consumption Ø Conservation of energy Ø Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 25

Cold Stress Newborn responds by increasing basal metabolic rate and oxygen consumption Depletes glycogen stores Ø Results in acidosis Ø Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 26

Factors Contributing to Heat Loss Skin is thin Blood vessels are close to surface Little subcutaneous fat for insulation A greater transfer of heat to the external environment compared with adults Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 27

Heat Loss to Environment Evaporation – Wet surface exposed to air Conduction – Loss of heat to a cooler surface by direct skin contact Convection – Loss of heat from warm body surface to moving cooler air Radiation – Loss of heat from warm object to cooler one when objects are not in contact with one another Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 28

Nonshivering Thermogenesis Newborn cannot use muscle activity (shivering) to produce heat Has difficulty conserving and dissipating heat to maintain optimum temperature Ø Relies on nonshivering thermogenesis Ø Uses brown fat stores Vasoconstriction in cold environments Vasodilation in warm environments Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 29

Newborn Produces Heat By physiologic mechanisms or thermogenesis Includes Increased basal metabolic rate Ø Muscular activity Ø Chemical thermogenesis (nonshivering thermogenesis) • Primary method of heat production Ø Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 30

Brown Adipose Tissue (BAT) Cells contains fat vacuoles Abundant blood and nerve supply As it is metabolized, heat produced warms vital areas of body Can be depleted in newborns who are exposed to prolonged periods of cold stress Thermogenesis can be impaired Typically disappears by 3 months of age Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 31

Brown Fat Locations Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Nonshivering Thermogenesis Nonshivering thermogenesis causes vasoconstriction in cold environments and vasodilation in warm environments. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 33

Newborn Assessment Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 34

Objectives Recognize the normal range of neonatal vital signs. Differentiate among molding, cephalohematoma and caput succedaneum. Describe the assessment of the anterior and posterior fontanelles. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 35

Nursing Assessment of the Newborn Includes Observation Ø Inspection Ø Auscultation Ø Palpation Ø Percussion Ø Phase 1 begins in the delivery room Phase 2 begins upon admission to nursery Ø 1 -4 hours of age Phase 3 is from 4 hours of age until discharge Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 36

Assessment Not performed at one time Series of examinations Detailed evaluation of all body parts Includes Skin color Ø Type of respirations Ø Temperature Ø Activity Ø Feeding behavior Ø Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 37

General Appearance Before disturbing infant, evaluate Resting posture Ø Spontaneous movements Ø Flexion and symmetry • Term infant able to hold flexion while resting • Preterm infant may not be able to maintain flexion Ø Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 38

Central Nervous System (CNS) Extension of neck with arched back is opisthotonos, associated with CNS problems Spontaneous movements potential clues to CNS problems Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 39

Newborn’s Cry Means by which newborns communicate with those around them Strong and lusty High-pitched: may indicate neurologic disorder, hypoglycemia, or drug withdrawal Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 40

Vital Signs Best if taken while newborn is quiet or resting Measure at 15 - and 30 -minute intervals for first hour after birth, then Ø Every 4 to 8 hours thereafter Ø Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 41

Heart Rate Apical rate Listen for 1 full minute Note Rate, rhythm, intensity Ø

Variations in Heart Rate In newborns Normal rate is between 110 and 160 beats/min Ø Bradycardia is heart rate less than 110 beats/min Ø Tachycardia is heart rate greater than 160 beats/min Ø Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 43

Femoral Pulse Evaluate two pulses (in groin region) A weak or slow pulse suggests

Respirations Count for 1 full minute Observe abdominal movement Ø Movement of the chest and abdomen should be synchronized Rate is 30 to 60 breaths/min Intermittent cessation of respirations for less than 15 seconds is normal Ø Apnea—respirations that cease for more than 20 seconds—must be reported to the health care provider Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 45

Symptoms of Respiratory Distress Nasal flaring Costal or substernal retractions (sucking in of chest wall with sternum moving inward with inspiration) Grunting sound on expiration Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 46

Breath Sounds Should be clear over most of area; may hear some moisture in lungs during first few hours after birth Rales—rush of air through fluid Ø Resembles rubbing hair together Rhonchi—coarse sounds Ø Resembles snoring Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 47

Temperature Drops immediately after birth Internal organs poorly insulated Skin relatively thin Heat-regulating center not yet mature Rapidly reflects temperature of environment Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 48

Maintaining Temperature Newborns cannot shiver Use brown fat Skin temperature will drop before core will Allows for early interventions to prevent core hypothermia Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 49

Methods for Temperature Measurement Stable measurement is 36. 5° C (97. 7° F) Take every 30 minutes until stable Each hour for 4 hours Every 8 hours in normal term newborn Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 50

Elevated Temperature Dehydration Too much clothing Infection Environment too hot Can cause infant to break out in a pinpoint red rash called prickly heat or miliaria Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 51

Blood Pressure At birth 60 to 80 mm Hg systolic Ø 40 to 50 mm Hg diastolic Ø If newborn is crying, can increase by 10 to 20 mm Hg If cardiac anomaly suspected, check blood pressure in all four extremities Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 52

Assessment of Physical Characteristics Copyright © 2012, 2008 by Saunders, an imprint of Elsevier

Skin Provides visible record of health status Inspect for characteristics related to preterm, postterm Greenish-brown discoloration (meconium stain) of skin, nails, and cord can result if meconium passed before birth Peeling or excessive cracking of skin associated with postterm Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 54

Head If born head-first and vaginally Often elongated Ø Called molding Ø Usually resolves in a few days Ø Cesarean or breech delivery Normally round Ø No pressure exerted on head during delivery process Ø Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 55

Head Circumference Large surface area compared with body Average 33 to 35. 5 cm (13 to 14 inches) Ø Either equals or exceeds by about 2. 5 cm (1 inch) the circumference of the chest Ø If head is more than 4 cm greater than chest size, serial assessment for increased ICP or hydrocephalus is indicated Small head, microcephaly, may be caused by rubella or toxoplasmosis exposure in utero Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 56

Molding Overlapping of bones of head Result of head compression during birth process Usually

Caput Succedaneum Localized swelling of soft tissues of scalp caused by pressure on head during labor Palpated as soft, fluctuant mass May cross over suture lines Absorbed within a few days No intervention needed Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 58

Cephalohematoma Collection of blood between periosteum and bones of skull May be unilateral or bilateral Ø Does not cross suture line Ø Emerges first or second day after delivery May take as long as 3 weeks to be absorbed Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 59

Fontanelles “Soft spots” Covered with sturdy membranes Openings in skull allow fetal head to mold to fit through birth canal Should be level with cranial bones in a quiet infant, not elevated or depressed Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 60

Fontanelle Assessment Bulging may occur when infant cries, coughs, or vomits If bulging at rest, may indicate hydrocephalus Depressed fontanelle may occur with dehydration and is a late sign Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 61

Large or Delayed Closure of Fontanelles May indicate Congenital hypothyroidism Ø Down syndrome Ø Congenital rubella or syphilis Ø Increased intracranial pressure Ø Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 62

Anterior Fontanelle At birth is between 3. 6 and 6 cm (1. 4 and 2. 4 inches) Usually closed by 18 months of age Small fontanelle or early closure is called craniosynostosis Associated with abnormal brain development Ø Caused by chromosomal anomalies, fetal hypoxia, or fetal alcohol syndrome Ø Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 63

Posterior Fontanelle Triangle-shaped Located between occipital and parietal bones Smaller than anterior Closes between 2 and 3 months of age Late closure may indicate hydrocephalus Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 64

Face Somewhat recessed Nose often flat Cheeks full due to accumulation of fat Makes up the “sucking pads” Ø Allows for strong sucking reflex in the newborn Ø Movements should be symmetric Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 65

Eyes Assess placement, space between, symmetry, blink reflex Iris of light-skinned newborns typically slate blue or gray Permanent color established around 3 to 6 months of age, or later Ø Scleral colors blue-white due to relative thinness Ø Dark-skinned newborns may have dark eyes at birth Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 66

Vision Myopic See best at 7 to 10 inches Ø Can follow or track objects Ø Can focus on an object for about 10 seconds Ø Can discriminate between simple and complex patterns Ø Prefer simple patterns Ø High-contrast colors, such as black and white Ø Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 67

Nose Usually flat due to passing through birth canal Obstruction cause various degrees of respiratory distress, since newborns are obligate nose breathers Ø Flaring nostrils is one sign of distress Sneezing common Ø Helps clear nasal passages Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 68

Mouth Assess Palate for closure Ø Presence of teeth • If present, usually removed to prevent aspiration Ø Excessive salivation • May indicate tracheoesophageal fistula or atresia Ø Tongue • Large, protruding may indicate Down syndrome Ø Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 69

Sucking Reflex present at birth Sucking stimulated when lips touched Ø Depends on state of wakefulness and hunger Ø Weak reflex may result from • Respiratory depression • CNS damage • Drug exposure • Prematurity Ø Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 70

Rooting Reflex present at birth Elicited by stroking mouth or cheek Ø Normal newborn should turn head toward stimulated side (positive rooting reflex) Ø Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 71

Extrusion Reflex present at birth Tongue pushes outward after it has been touched Present until 4 months of age May be mistaken as a refusal to eat or spitting out Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 72

Ears Placement Ø Formation Amount of cartilage Ø Low-set may indicate chromosomal or kidney problem Term newborn—firm Hearing test Hearing established after first sneeze Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 73

Nurse’s Role in Hearing Tests Copyright © 2012, 2008 by Saunders, an imprint of

Neck Short, creased with folds Cannot support full weight of head Ø Lags when pulled from a supine to sitting position Ø Palpate for masses or injury to large muscles Assess Clavicles for symmetry and smoothness Ø Range of motion and neck muscle function with head movement Ø Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 75

Chest Normally round, symmetric, slightly smaller than head Protrusion of lower part of sternum, called xiphoid cartilage, common Measure at nipple line 30. 5 to 33 cm (12 to 13 inches) Ø Approximately 2. 5 cm (1 inch) less than head size Ø Assess breath sounds Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 76

Nipples Distance between is about 8 cm (3 inches) Ø Wide distance may indicate congenital defect Breast engorgement common in both sexes due to maternal hormones Nipples may secrete milklike substance called “witch’s milk” for a few weeks Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 77

Abdomen Slightly protuberant and symmetric Moves with chest during respiration No masses should be

Umbilicus Umbilical stump assessed for two arteries, one vein Ø Single artery associated with congenital anomalies Stump falls off around 7 to 9 days after delivery Assess for signs of bleeding, discharge, or infection May appear as if it is a hernia Will slowly disappear or invaginate Primary site of infection is the umbilical stump Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 79

Bladder Document when first void occurs Urine should not have an odor Ø Typically dark amber due to uric acid crystals • May cause pink stain on diaper Ø With fluid increases, urine lightens in color Ø Monitor number of wet diapers per day Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 80

Female Genitalia Should be clearly differentiated Labia majora cover labia minora in term infant Hymenal tags—small tags of tissue protruding from vaginal opening—disappear in a few weeks May have milky white, mucoid discharge due to withdrawal of maternal hormones Ø Can be pink; called pseudomenstruation Smegma often seen on labia minora Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 81

Male Genitalia Urethral meatus should be on the tip of penis If on undersurface—hypospadias Ø If on upper surface—epispadias Ø Foreskin adhered to glans penis—phimosis Testes usually descended in term newborn Palpated bilaterally in scrotum Ø If not palpated, observe for inguinal hernia Ø Rugae present on scrotum of term newborn Ø Preterm lacks rugae Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 82

Anus Assess if open and if anal sphincter has good muscle tone Open anus allows for passage of meconium stool If no stool is passed within first 24 hours after birth, newborn must be assessed for bowel obstruction Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 83

Stools GI tract begins to function at birth Ø Breastfed—may have more than three a day Ø Stools change color over a few days Should not be watery Bottle-fed—may have less than three a day Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 84

Normal Newborn Stool Cycle Copyright © 2012, 2008 by Saunders, an imprint of Elsevier

Back Should be straight and flat Lumbar and sacral curves do not develop until baby begins to sit up Assess for dimples, masses, hair tufts, spinal curvatures Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 86

Spinal Reflex If one side of back is stroked or stimulated, the spine should

Ortolani Maneuver Hips are examined for dislocation Assess gluteal and popliteal folds Should be symmetric Ø If asymmetric and limited abduction, requires further evaluation Ø Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 88

Ortolani Maneuver (cont. ) Copyright © 2012, 2008 by Saunders, an imprint of Elsevier

Extremities Assess for extra or missing digits, deformities, palmar creases, and diminished femoral pulses Extra digits: polydactyly Ø Webbing of digits: syndactyly Ø Hands should have three creases Ø Assess location of feet Ø If not in normal position, may be clubfoot Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 90

Erb-Duchenne Paralysis Also called Erb’s palsy Arm lies limply at side or newborn unable to elevate arm Orthopedic care needs to implemented immediately Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 91

Femoral Pulses Palpate at same time Diminished or unequal may indicate heart defect Copyright

Audience Response System Question 2 A white- to pink-tinged mucoid discharge from the vagina is noted during the nursing assessment of a female newborn. The nurse knows this is not an unusual finding as it is likely due to: A. B. C. D. Withdrawal of maternal hormones. Blood not completely removed during the bath. Rust-colored uric acid crystals in the diaper. Residual amniotic fluid. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 94

Neurological and Behavioral Assessment Copyright © 2012, 2008 by Saunders, an imprint of Elsevier

Objectives Review key physical and behavioral assessments of the newborn. Discuss normal newborn reflexes. State the purpose of newborn screening test. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 96

Neurologic Assessment Noticeable jerky or jittery movements Excessive electrical discharge from neurons or metabolic disorder such as Hypoglycemia, hypocalcemia, hypoxia Ø Neurologic damage Ø Drug withdrawal Ø Repetitive blinking or pedaling movements of lower extremities may represent seizure activity Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 97

Estimation of Gestational Age Ballard scoring system 12 scores are totaled and maturity rating is expressed in weeks of gestation Ø Performed within first few hours of birth and repeated again at 24 hours Ø Preterm born at less than 38 weeks Term is 38 to 42 weeks Postterm is born after 42 weeks Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 98

Fetal Size Small for gestational age (SGA): weight less than 10 th percentile Large for gestational age (LGA): weight greater than 90 th percentile Weight alone does not determine prematurity or maturity level of newborn Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 99

Behavioral Assessment Phases of reactivity newborn passes through during first 6 to 8 hours

First Period of Reactivity At birth—quiet alertness Followed by phase of active alertness Demonstrates strong sucking reflex; may appear hungry Ø Facilitates bonding and attachment Ø Eye-to-eye contact Ø After 30 minutes to 1 hour becomes drowsy and falls asleep; lasts about 2 to 4 hours Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 101

Second Period of Reactivity May last 4 to 6 hours Awake, alert, and may cry Shows activities such as rooting, sucking, swallowing May respond to eye-to-eye contact Bonding promoted Feeding initiated if not done in first period Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 102

Understanding Newborn Cues Newborn Desires Interaction Focuses on face of parent Ceases random body movement Reaches out Newborn Is Hungry Places hand at mouth Sucking, rooting are evident Flexes arm and clenches fist over body Newborn Desires to End Interaction Turns head away Fussy Yawns Squirms Newborn Is Not Hungry Arches back Falls asleep Relaxes arms at sides Turns head away from nipple Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 103

Behavioral States Sleep states Quiet sleep Ø Active sleep Ø Transitional state Ø Drowsiness Awake state Quiet alert Ø Active alert Ø Crying Ø Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 104

Screening Procedure used to detect abnormal condition before symptoms appear Not diagnostic Enables early interventions Most are state-funded Screening for PKU mandatory in all states Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 105

Screening (cont. ) Screening may include Endocrine conditions Ø Organic acid metabolism Ø Fatty acid metabolism Ø Amino acid metabolism Ø Hearing Ø Cystic fibrosis Ø Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 106

Audience Response System Question 3 What does it mean when a newborn turns its eyes away, is fussy, yawns, and squirms? A. The newborn wants some form of interaction with others. B. The newborn is hungry. C. The newborn wants to be left alone. D. The newborn no longer is hungry. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 107