PHYSIOLOGIC EXTRAUTERINE ADAPTATION

NORMAL NEWBORN

RESPIRATION
Theories of Respiration 1. Chest recoil after pressure passing through birth canal 2. Chemical increased pCO2, decreased pH & pO2 3. Thermal decreased temperature 4. Sensory over stimulation 5. Increased BP after cord is clamped First breath normally within seconds of birth Newborns are obligatory nose breathers

Increased aortic pressure & decreased venous pressure cord results when cord is cut less blood return to vena cava, (no placental circulation) Increased systemic pressure & decreased pulmonary artery pressure. More pulmonary blood flow

Cardio-Pulmonary CIRCULATION:

lung expansion

Increased blood pO2 vasodilation of pulmonary vessels Less pulmonary artery resistance Less vascular pressure vascular beds open
Foramen ovale closes
(Occurs 1 to 2 hours after birth)
Note: In utero, right atrial pressure is greater After birth, left atrial pressure is greater Some shunting may occur;permanent closure in a few mos.

Cardio-Pulmonary Circulation

Contd: C-P CIRCULATION

Ductus arteriosus closes. (Functionally within 15 hours after birth) Blood flows from aorta into pulmonary artery (Fibrotic in 3 weeks) Ductus Venosus closes. (Fibrosis in 3 7 days) Perfusion of liver occurs.
Note: Fetus needs more RBC for O2 transport than newborn; Hemoglobin drops from 14 gm/dl at 4 weeks to 12 gm/dl.

ELIMINATION - Gastrointestinal
Characteristics: o NB digests CHO and CHON easily o Poor fat digestion & absorption o Meconium usually excreted within 24 hours of birth o Transitional stools passed by 3 6 d o Yellow stools begin at about 6 days o One to two stools QD at 2 weeks after birth

ELIMINATION URINARY

GFR rate is low Acidosis & fluid imbalances can occur rapidly Void within 24 hours & then 5 20 times/day Uric acid crystals may cause brick dust reddish stain on diaper

HEPATIC SYSTEM
Physiologic jaundice (after first 36 h) (r/t
increased load of bilirubin on liver cells & decreased bilirubin clearance from plasma.)

Non-physiologic jaundice
(r/t impaired ability to excrete conjugated bilirubin & high serum levels of conjugated bilirubin)

Breast-feeding jaundice rise in bilirubin

levels from fourth day of life

Unconjugated bilirubin from blood can enter

tissues causing yellow coloring (jaundice).

Clotting factors 2,7,9, 10 are low because

Vit. K not produced, making newborn susceptible to bleeding.

Neurology
Neurologic system not fully developed, Reflexes are indicators of newborns development. (APGARs scoring)

Integumentary
Skin pink to red, Acrocyanosis lasts 2-6 hours after birth, Thin epidermis.

TEMPERATURE REGULATION
1. Large surface area in proportion to mass 2. Less fats =Greater potential for heat loss than adult 3. Heat transfer by:
a.Evaporationnewborn wet with amniotic fluid loses heat. b.Radiationnewborns heat is transferred to cooler objects in envi; heat loss to air, objects. c.Convectionpassage of cool air against skin. d.Conductionthermal conductivity to objects, which are cooler.

HEAT PRODUCTION
Nonshivering thermogenesis metabolizes brown fat Increased muscular activity Flexed posture decreases amount of skin surface exposed to cold Vasomotor controlretains heat by controlling blood flow to the skin.

IMMUNITY
a. Capable of combating some infections b. IgG crosses placenta, fetus synthesizes IgM, IgA is not found at birth, but it is in the breast milk.

REACTIVITY
IST PERIOD OF REACTIVITY (immed. after birth)

1.

2. 3. 4. FIRST

rapid RRup to 80 per minute transient nasal flaring grunting may occur HR= up to 180 BPM SLEEP

1. Occurs within 2 hours after birth 1.

2. 3. 4.

2. Lasts up to several hours SECOND PERIOD OF REACTIVITY

Hyper-response to stimuli skin color slightly cyanotic rapid heart rate oral mucus may cause choking

l. NUTRITION
Weight loss of 5-10% in first 3-4 days ii. Should regain birth weight by two weeks iii.Stomach capacity 3060ml i.

m. WEIGHT
i. Average-3405 gm (7 lb, 8 oz) ii. Range-2500-400gm (5 lb, 8 oz to 8 lb, 13 oz) iii. Lose 10% or less of birth weight

n. MEASUREMENT
i.

Length 1. top of the head to soles of feet 2. average- 50 cm (20 inches) 3. range- 45-55 cm (18-22 inches) ii. head circumference- measurement of occipitofrontal diameter, average 33-35 cm (13-14 inches) iii. chest circumference 1. measurement at nipple line 2. equal to or less than head circumferene

o. VITAL SIGNS
i. Temperature 1. rectal-measures core temperature. Normal range- 36.6-37.2oC (97.8-99oF) 2. axilliary-reflects body temperature. Normal range 36.5-37oC (97.7-98.6oF) ii. pulse 1. normal range-120-160 BPM 2. low normal-90-120 BPM 3. high normal- 160-180 BPM iii. respiration-abdominal-range 30-60 per minute

III. PHYSICAL CHARACTERISTICS (normal and varation)

A. INTEGUMENT

A. INTIGUMENT
a. b. c. d. Acrocyanosis-normal-lasts2-6 hours after birth Circumoral cyanosis-abnormal-bluish around mouth Jaundice-seen first on head, physiological peaks about 5-7 days HARLEQUIN SIGN i. Color discrepancy between 2 longitudinal halves ii. Dependent half dark pink iii. Upper half pale iv. Occurs 48-96 hours ecchymosis-birth trauma

e.

f.

PETECHIAE i. Increased vascular pressure causing rapture capillaries during delivery ii. On upper trunk and face iii. Remain 24-48 hours g. ERYTHEMA TOXICUM i. Pink papular rash ii. May have pustules iii. Occur 24-48 hours after birth iv. Occur in 30-70% of newborns h. MILIA i. Distended sebaceous glands ii. Tiny white papules on face iii. Disappear in few weeks i. VERNIX CASEOSA i. Whitish cheese-like substance ii. Protects skin in utero iii. Covers body up to 38 weeks gestation iv In the creases up to 42 weeks

j. lanugo- fine downy hair over back and shoulders disappear about 38 weeks gestation k. MONGOLIAN SPOTS i. Bluish-black areas of pigmentation over the back and buttocks of dark-skinned infants ii. Fade in the first or second year l. TELANGIECTIC NEVI i. Stork bites ii. Flat, deep pink localized area of capillaries dilation iii. Blanch with pressure iv. On back of neck, occiput eyelids, nose v. Disappear by two years vi. May reappear if child cries

d.

NEVUS FLAMMEUS- port-wine stain; capillary angioma. i. Red-to-purple dense area of capillaries ii. Vary in size iii. Flat iv. Commonly on the face v. Do not blanch with pressure vi. Does not disappear e. NEVUS VASCULOSUS- strawberry mark i. Raised. Sharply outlined, rough ii. Dark red iii. Capillary hemingioma iv. Consists of newly formed and enlarged capillaries in dermal and subdermal layers v. Most in head areas vi. Grow until 8 months vii. Disappear by 7 years

B. HEAD
a. Molding i. Overriding of skull bones ii. Resolves in 2-3 days fontanel i. anterior- diamond shape, closes about 18 months ii. posterior- triangle shape, closes by 2-3 months caput succedaneum i. edematous swelling of scalp from pressure of delivery ii. may cross suture lines iii. present at birth iv. disappears in few days cephalohematoma i. bleeding between cranial bone and periosteal membrane ii. does not cross suture lines iii. may not appear for hours iv. may take months to disappear

b.

c.

d.

C. FACE & D. EYES

C. a. b. D. a. b. c. d. e. f. FACE Symmetrical Sucking pads in cheeks EYES Permanent color by 3 12 months Equal pupils Pupils react to light Blink present Red reflex present Pseudostrabismus i. Poor neuromuscular control ii. Regresses in 23 4 months Sub-conjunctival hemorrhage i. Caused by changes in vascular tension at birth ii. Lasts a few weeks

g.

E. MOUTH & F. EARS

E. MOUTH a. Epsteins pearls small white epithelial cysts on gums, disappear in weeks b. Teeth rare c. Cleft lip or palate abnormal F. a. b. c. d. EARS Top should be at level of inner canthus of eye Pinna is curved & cartilage stands upright Maybe filled with vernix Hearing improves at first cry

G.NECK, H.CHEST & I.ABDOMEN

G. NECK Cannot support head weight, short with many folds H. CHEST a. Retractions abnormal b. Extra nipples maybe present c. Breast buds raised d. Engorgement (from maternal hormones) may last up to 2 weeks e. Heart murmur 90% subside in days I. a. b. c. ABDOMEN Umbilical cord falls off in 7 10 days Bowel sounds heard 1 hour after birth Protrudes

J.BLADDER & K.GENETALIA

J. a.
K. a.

BLADDER Non palpable, voiding within 24 hours

GENITALIA Female i. Pseudomenstruation (from maternal hormones) disappears in 2 4 weeks ii. Labia edematous iii. Hymenal tag disappears in weeks Male i. Foreskin not easily retracted ii. Testes descend at 36 38 weeks of gestation iii. Epispadias urinary meatus on dorsal surface of penis iv. Hypospadias urinary meatus on ventral surface of penis

b.

L.BACK, M.ANUS & N.EXTREMITIES

L. BACK a. Straight spine b. Nevus pilosus (hairy dimple at bese of spine) associated with spina bifida M. ANUS stooling in 24 48 hours N. EXTREMITIES a. Equal movement b. Sole creases i. 2/3 at 36 38 weeks gestation ii. 3/3 at 38 42 weeks gestation c. Polydactyly extra digits d. Syndactyly webbing of digits e. Phocomelia absence of portion of limb f. CHD i. Hip click ii. Unequal leg length iii. Unequal gluteal folds g. Club Foot talipes equinovarus will not return to midline

IV. NEUROLOGICAL ASSESSMENT

A. a. b. c. d.

Neuromuscular maturity Arm recoil pull arm straight & release Scarf sign bring elbow to midline Heel to ear bring heel to ear Popliteal angle

i.
abdomen & try to straighten leg ii. back of knee

Press thigh on
Measure angle at

Square window press hand against forearm

B. a.

b. c. d. e.

Neurological Status Moro reflex (startle) i. Suddenly lower head a few centimeters ii. Should abduct & extend arms symmetrically iii. Fingers fan out iv. Thumb & forefinger form C v. Arms adduct, legs extend Pupillary reflex pupil constrict in bright light Blinking reflex eyelids close in bright light Rooting reflex turns head in response to light touch on cheek Sucking reflex sucks on nipple or finger

Grasp reflex fingers close around finger or object placed in hand Babinski reflex i. Upward stroking on lateral surface of foot ii. Hyper extends toes & dorsiflexes great toe h. Plantar reflex toes curl downward when finger is pressed against base of toes i. Tonic-neck reflex (fencing) i. Quickly turn head to one side while lying on back ii. Extremities on side turned to extend while others flex j. Trunk incurvation (Galants) i. Place in prone position & stroke back about 2 inches from spine ii. Curves body to side of stimulus k. Stepping reflex i. Hold infant upright & allow one foot to touch a flat surface Alternately moves feet in stepping motion f. g.

NEWBORN ASSESSMENT
A.
a. b.

GENERAL
Wear gloves Assess under radiant warmer or in skin to skin contact with mother

B. a. b. c. d. e. f.

NORMAL FINDINGS Respirations i. Rate 30 60/min ii. Irregular iii. No retractions iv. No grunting Apical pulse rate 120 160 BPM, irregular Temperature skin 36.5 degrees C (97.8 degrees F) Skin color body pink, bluish extremities Umbilical cord 2 arteries, one vein, clamp present Gestational age basic neuromuscular & physical maturity assessment

g.

Apgar s i. Heart rate 1. 0 absent 2. 1- <100 3. 2 - > 100 ii. Respiratory effort 1. 0 absent 2. 1 slow irregular 3. 2 good crying iii. Muscle tone 1. 0 flaccid 2. 1 some flexion of extremities 3. 2 active motion

iv. Iv. Reflex irritability 1. 0 none 2. 1 grimace 3. 2 vigorous cry v. Color 0 pale blue 1 body pink, extremities blue 2 completely pink

1. 2. 3.

h. Birth defects & anomalies

II. ASSESSMENT DURING FIRST HOURS

A. General
Head to toe Wear gloves Keep infant warm a. b. c.

B.

Posture
Extremities in moderate flexion Spontaneous movement

a. b.

C. D.

Weight balance scale or use electronic scale, use scale paper cover Measurements
a. b. c. d. e. Length HC Chest circumference Abdominal Circumference if abdominal distention suspected Use soft tape measure

E. a.

F. G. H. I. J.

VS Temperature i. Skin 1. Axillary- leave glass thermometer in place for 3 minutes or use electronic thermometer 2. Ear- use electronic thermometer 3. Continuous skin probe ii. Core b. Apical Pulse count one full minute, auscultate for murmurs c. Respirations count 1 full minute, observe rise & fall of abdomen Cry Integument color, turgor, texture, temperature, markings Head shape, fontanels, sutures Face eyes, ears, nose, mouth Neck

 K. Chest appearance, retractions, HR & sounds, lung sounds, RR L. Abdomen appearance, umbilical cord (color & number of vessels), intestines (bowel sounds, rectum stools) M. Genitalia- appearance & sex N. Bladder if palpable, voiding O. Skeletal structure clavicles, extremities, spine L. Gestational age
a. Neuromuscular maturity b. Physical maturity skin, lanugo, plantar creases, breasts, ears genitals

NEWBORN CARE
I. IMMEDIATE CARE A. Maintain Respirations
a. Suction mouth & nose with buld syringe or Dee Lee mucus trap as needed b. Place in trendelenburg position if necessary (can be done on mothers abdomen) c. Suction mouth first then nose. If nose is suctioned while mucus is in airway, infant may make an inspiratory gasp & aspirate mucus

B. Maintain warmth
a. Dry immediately b. Place under warm blankets in skin to skin contact with mothers abdomen c. Place under radiant warmer uncovered

C. Apgar Score at 1 & 5 minutes D. Care for Umbilical cord

a. b. c. Apply cord clamp 0.5 1 inch from abdomen Maintain asep0sis when shortening cord Count vessels in cord & record

E. Evaluate newborn for deviations from normal F. Identify Newborn

a. b. c. Apply arm & leg bracelet on newborn Apply matching bracelet on mother Footprint newborn & fingerprint mother if hospital policy indicates

G. Promote attachment
a. b. c. Allow parents to hold & touch infant Assist with breast feeding if desired Help establish eye- to eye contact

H.

Perform procedures
a. b. Weigh if hospital policy at this time Administer eye prophylaxis if hospital policy at this time

II. CARE DURING THE FIRST FEW HOURS

A. Admission a. Maintain clear airway by suctioning as necessary b. Place under radiant heater or wrapped securely in blankets c. Lie- on- side prop with blanket d. Assess V/S hourly for first few hors e. Weigh & measure f. Perform physical assessment

 g. Prevention of Infection i. Perform scrub prior to entering nursery or rooming-in unit ii. Wash hands between infants iii. Wear gloves until after bath & when handling blood & body fluid iv. Clean stethoscope between infants or use separate stethoscope for each infant v. Apply drying agent to cord after bath vi. Administer prophylactic eye treatment to prevent opthalmia neonatorum (Neisseria G. & Chlamydia trachomatis)
1. 2. 3. Erythromycin, Tetracycline, Penicillin Silver Nitrate sol 1% (not effective against chlamydia) Instill into lower conjunctival sac both eyes

 h. Prevent hemorrhage i. Administer Vit K IM vastus lateralis muscles ii. Provide Vit K until gut can begin synthesizing it i. Assess glucose level if indicated or is hospital policy i. Drop of blood from heel on glucose strip ii. Should be >45 mg/dl j. Bathe infant with warm water & mild soap when temperature is stable k. Provide nutrition i. First feeding per hospital policy breast milk, glucose water, sterile water ii. Glucose water can damage lung tissue if aspirated iii. Do not overfeed l. Facilitate attachment if infant is separated from mother, return infant to mother as soon as policy permits

III. ROUTINE CARE

A. a. b. c. Assess Vital Signs follow hospital policy Temperature Apical pulse Respirations

B. a. b.
C. a. b. c.

Maintain Airway Position on side prop with blankets Keep bulb syringe within reach
Maintain Warmth Dress in shirt & diaper Wrap in blankets Stockinette cap if needed for warmth

 D.

Promotion of Nutrition

A. Breastfeeding i. Put to breast as soon as possible

Feed on demand every 1.5 3 hours iii. Position the i8nfant so that the body faces mothers body iv. Elicit rooting reflex to entice infant to turning toward breast v. Put as much on areola in mouth as possible vi. Direct nipple straight into mouth vii. Hold breast cupped in hand with thumb on top so that nipple protrudes, make sure nose is not blocked by mothers breast viii. Make sure infant has latched on & is sucking properly ix. Do not use a nipple shield ii.

 x. Allow infant to suck on one breast as long as it is sucking correctly & breast has not been emptied xi. Do not set time limits xii. Breast suction by inserting finger into infants mouth next to nipple xiii. Alternate use breast xiv. Burp infant between breasts xv. Burp well at end of feeding xvi. Rotate positions used to hold infant to decrease nipple trauma

 b. Bottle Feeding i. Feed on demand usually every 3 5 hours ii. Cradle infant close to body iii. Elevate head to prevent development of otitis media iv. Never prop bottle v. Check flow of formula from nippleto ensure flow in drops, not a stream vi. Place nipple on top of tongue, pointed toward back of mouth vii. Tilt bottle so that nipple remains full of formula viii. Burp every to 1 ounce ix. Burp before feeding if infant has been crying x. Do not force the infant to drink once it seems disinterested

 E. Provide cleanliness i. Change diapers & clean diaper area as needed ii. Bathe as needed F. Prevent Complications i. Weigh daily & compare to previous weights ii. Apply alcohol to cord with diaper changes iii. Assess for signs of infection iv. Do not cut nails v. Provide circumcision care
1. Assess for swelling or infection 2. Observe & record for fir4st voiding 3. Apply Vaseline, A&D or other ointment to area with diaper changes with all types except Plastibell

vi.

PKU screening test done on second or third day

 H. Document Care Provided I. Provide parent Education i. Suctioning depress buld before inserting ii. Positioning=- right side is optimal iii. Wrapping & Swaddling iv. Dressing do not overdress v. Diapering wash & dry area with each diaper change vi. Holding cradle, upright vii. Umbilical Cord care alcohol after diaper changes viii. Temperature Taking axillary ix. Bathing
1. 2. Sponge bathe until cord falls off Tub bath every other day after cord falls off

x.

Feeding Breast or Bottle feeding

xi.
1. 2. 3.

Burping
Upright on shoulder Sitting on lap Lying face down across lap

xii. xiii. xiv. xv.

1. 2. 3. 4. 5. 6.

Formula Preparation Nail care trim after 2 weeks with infant scissors Travel use car seat Call Physician
Axillary temp >101 degrees F Watery stool persists Vomiting Less than 6 wet diapers per day Refuses 2 feedings in a row Lethargic

vi.
1. 2.

Return appointment date on time

For routine follow-up For PKU testing

GESTATION RELATED CONDITIONS

I.PRETERM NEWBORN
a.
b.

DEFINITION-infant born before 38 weeks gestation

c.

ETIOLOGY AND PATHOPHYSIOLOGY i. Many contributing factors ii. Exhibit immaturity in all body systems ASSESSMENT DATA i. Respiratory distress syndrome- tachypnea, retractions, nasal flaring, expiratory grunt, pallor, cyanosis ii. Bronchopulmonary displaisa iii. Retinopathy iv. Patent ductus arteriosus- continuous murmur, bounding peripheral pulses, wide pulse pressure, persistent respiratory distress, hypoxia v. Intracranial hemorrhage- beginning at 16 hours of life, apnea, dropping hematocrit, bulging fontanel, change in activity

vi. Inadequate temperature regulation- lethargy, fatigue, poor feeding, bradycardia, unstable blood pressure, depressed respiration vii. Immature feeding reflexes viii. Necrotizing enterocolitis (NEC)- abdominal distention, decrease in peristalsis of bowels, occult blood in stool, peritoneal gas, unstable pressure, apnea, bradycadia, sepsis ix. Low hetmatocrit x. Impaired conjugation of bilirubin xi. Infection

d.

TREATMENT i. For RDS- supplemental humidified oxygen via hood, intubation if breathing difficulties, nasotracheal or orotracheal tube, continuous positive airway pressure(CPAP), muscle relaxants if needed, chest percussion, postural drainage, diluretics, temperature controlled environment. ii. Nutrition- IV fluids, nasograstic or ososgrastic feeding, total prenatal nutrition (TPN) if indicated, daily weight iii. For bronchopulmonary dysplasia- broncho dilators, suction iv. For periodic breathing- pneumogram tracing, cardiorespiratory monitoring, theophylline of caffeine v. For retinopathy- ophthalmologic examination

 vi. For patent ductus arteriosus- indomethacin, intake and output, surgical repair vii. For intracranial hermorhage- ultrasound of head, medication for seizures, if needed, serial lumbar punctures viii. For NEC- nasograstic tube, measure abdominal girth, test stools and nasograstic drainage for occult blood, withhold feedings, IV antibiotics, surgical intervention if necessary

e.

NURSING INTERVENTION i. Frequent vital signs ii. Auscultate breath sounds iii. Suction endotracheal tube iv. Give oxygen before suctioning, if needed, and for respiratory distress v. Monitor blood glucose levels vi. Maintain skin temperature at 36.1-36.7oC vii. Minimize heat loss viii. Monitor signs of cold stress ix. Monitor signs of hypoglycemia x. Provide nutrition per physician order

xi. xii.

xvi.

Record intake and output Weigh diapers xiii. Monitor IV site and rate hourly xiv. Begin bottle or breast feeding slowly xv. Monitor weight daily Monitor hematocrit level xvii. Monitor bilirubin levels xviii. Report signs of complications xix. Include parents in planning care xx. Encourage parental visiting and participation xxi. Provide sensory stimulation xxii. Provide emotional support for parents xxiii. Provide discharge instructions

II. POSTMATURE NEWBORN

a. b.
a. b. c.

DEFINITION- newborn born after 42 weeks gestation ETIOLOGY AND PATHOPHYSIOLOGY

Placenta is unable to nourish fetus inadequately Placenta loses its ability for gas and nutrient exchange Newborn loses subcutaneous fat and muscle mass

c.

ASSESSMENT DATA

a. Loss of subcutaneous fat and muscle mass b. Peeling skin c. Long fingernails d. Wide-eyed gaze e. Loigohydramnios f. Asphyxia- cyanosis, limp, weak, unresponsive to simulation, seizures, poor suck g. Meconium staining h. Meconium aspiration syndrome- tachypnea, cyanosis, grunting, nasal flaring, acidosis, retractions, hypoxia, hypercarbia

 d.

TREATMENT

a. Resuscitation if necessary b. Thorough suctioning of mouth and nose after head is born c. Tracheal suctioning before first breath, if possible d. Laryngoscopic examination of airway to visualize vocal cords (to determine if meconium reached that level) e. Oxygen f. Intubation and mechanical ventilation if necessary

 e. a. b. c. d. e. f. g. h.

NURSING INTERVENTIONS Observe cardiopulmonary status Provide warmth Monitor blood glucose frequently Initiate early feeding (usually glucose water) Institute medical management as ordered Assist with resuscitation as needed Monitor seizures and report Monitor intake and output

i. Auscultate breath sounds j. Monitor chest expansion for equality k. Assist with procedures l. Ensure chest physical therapy and postural drainage followed by suctioning m. Include parents in planning care n. Encourage parental visiting and participation o. Provide emotional support for parents p. Provide discharge instructions

NEONATAL CONDITIONS PRESENT AT BIRTH

I. INFANT OF ALCOHOL DEPENDENT MOTHER

a. DEFINITION- infant of mother who ingested alcohol during pregnancy (5 or more drinks on occasion or at least 1.5 drinks/day) b. ETIOLOGY AND PATHOPHYSIOLOGY i. Ethanol freely crosses the placenta ii. Exactly how damage to the fetus is unknown c. ASSESSMENT DATA
a. Identify maternal alcohol use

b. Fetal alcohol syndrome- growth retardation (prenatal and post natal), permanent CNS damage, microcephaly, mental retardation, cranofacial abnormalities, decreased adipose tissue, feeding problems, hyperactivity, anomalies

 d. TREATMENT a. Prevention by elimination of alcohol consumption in pregnancy b. Management of CNS dysfunction and withdrawal c. Treat seizures with Phenobarbital or diazepam e. NURSING INTERVENTION a. Observe for withdrawal symptoms within first three daystremors, seizures, sleeplessness, inconsolable crying, abdominal reflexes, exaggerated mouthing behaviors, abdominal distensions b. Keep warm, avoid heat loss c. Protect from injury d. Monitor seizures e. Administer medications to limit convulsions f. Monitor IV therapy

g. h. i. j. k. l. m.

Reduce stimuli- quiet, dimly lit environment Spend time with feeding Observe for respiratory distress Provide parental support Praise positive parenting efforts Provide discharge instructions Refer to community resources for follow up

II.INFANT OF A DIABETIC MOTHER

a. DEFINITION- infant of mother who has diabetes mellitus b. ETIOLOGY AND PATHOPHYSIOLOGY i. Alterations in glucose metabolism in diabetic mother affect fetus and newborn ii. Maternal hypoglycemia causes fetal hyperglycemia which results in fetal hyperinsulinemia iii. Fetus at high risk for developing anomalities iv. Birth may be difficult- preterm, macrosomic infant v. Infants pancreas continues to produce insulin in large quantities after birth causing hypoglycemia

 c. ASSESSMENT DATA a. Macrosomia- plump, plethoric, puffy, exhausted (from birth) b. May be lethargic or jittery c. If placental insufficiency, may be small for gestational age d. Body organs (except brain) larger e. Respiratory distress syndrome f. Congenital anomalities- transposition of great vessels, ventricular septal defects, patent ductus arteriosus g. Hypoglycemia (serum glucose <35 mg/dl in term meonate) h. Hyperbilirubinemia (total serum bilirubin >12 mg/dl in term neonate) i. Hypocalcemia (<7 mg/dl) j. Polycythemia (venous hemoglobin >22 gm/dl and venous hematocrit >65%)

 e.

NURSING INTERVENTIONS
a. Feeding glucose as necessary b. Administer IV therapy if ordered c. Monitor for hypoglycemia d. Monitor for hyperbilirubinemia e. Assess for anomalities, birth trauma f. Monitor for hypocalcemia g. Monitor for respiratory distress syndrome h. Check hematocrit level i. Check glucose strips frequently (usually hourly) Promote nonnutritive sucking to lower activity levels

III. INFANT OF DRUGDEPENDENT MOTHER

a. DEFINITON- infant of mother who abused drugs during pregnancy b. ETIOLOGY AND PATHOPHYSIOLOGY a. Most common drugs used- cocaine, opiates, marijuana b. Periodic episodes of cerebral anoxia from withdrawal causes permanent fetal brain damage c. Infant may have behavioral and attachment problems d. Infant may have difficulty adjusting to lights and noise

 c. ASSESSMENT DATA a. Identify maternal drug dependency, especially those used before delivery b. Neonatal abstinence syndrome- CNS, GI, respiratory vasomotor c. Irritability d. Tremulousness e. Respiratory distress (heroin)- meconium, aspiration, transient tachypnea f. Jaundice (methadone) g. Congenital anomalities h. Behavioral abnormalities Withdrawal (within first 72 hours)

 d.
a. b. c. d.

TREATMENT
Prevention by eliminating drug dependency in pregnancy Support physical needs Nutritional support Phenobarbital, or other drug, to control withdrawal symptoms

e.

NURSING INTERVENTIONS
a. Decrease environmental stimuli b. provide adequate rest c. provide nutrition to meet needs on demand rather than on schedule d. swaddle infant and support self-comforting e. change positions frequently f. promote parental care giving educate parents about care

IV. INFANT HEMOLYTIC DISEASE

a. DEFINITION- infant with a condition in which red blood cells are destroyed as a result of an antigen-antibody reaction b. ETIOLOGY AND PATHOPHYSIOLOGY
Rh compatibility i. Rh- mother pregnant with Rh+fetus ii. Mother previously exposed to D antigers iii. Fetal antigen stimulate maternal production of antibodies against D antigens iv. Anti D antibodies enter fetal circulation and destroy fetal RBCs v. Fetus increases production of RBCs in liver, spleen and bone marrow vi. Fetal anemia is erythroblastosis fetalis vii. Fetus exhausts ability to produce RBCs (hydrops fetalis) and can have multisystem failure cardiovascular, respiratory, hepatic viii. Rarely in first pregnancies a.

 b. ABO compatibility i. Maternal blood group is incompatible with fetal blood group ii. Most common if mother is type O and fetus is type A or B iii. Maternal antibodies cause agglutination of fetal blood cells and clumping iv. Clumps get caught in small vessels and hemolyze, producing belirubin v. Occurs in any pregnancy

 c. ASSESSMENT DATA a. Rh isoimmunization i. Yellow amniotic fluid ii. Tachycardia progressing to bradycardia iii. Hypotension iv. Respiratory distress v. Jaundice beginning during first day of life b. ABO incompatibility vi. Jaundice in first 24 hours vii. Hyperbilirubinemia viii. Weak to moderate direct Coombs test

 d. TREATMENT 1. Rh isoimmunization
a. b. c. d. e. f. g. prevention with administration of RhoGAM to mother is desired intrauterine transfusions if severe blood studies photo therapy exchange transfusion with Rh- whole blood infusion of albumin drug therapy may need no treatment photo therapy exchange transfusion, rarely

2. ABO incompatibility
a. b. c.

 e. 1. 2.

NURSING INTERVENTIONS Assess jaundice by blanching skin over bony prominence Notify physician to evaluate hyperbilirubinemia
serum bilirubin level birth weight age in hours

a. b. c.

3. 4. 5. 6.

Offer fluids between feedings Avoid cold stress Prevent infection Provide phototherapy
a. b. c. d. Naked infant Cover eyes Reposition every two hours Remove eye patches for feeding

 7.. Monitor exchange transfusion for complications following it 8. Keep umbilical cord moist 9. Encourage parents to hold; feed and talk to the infant 10. Answer parents questions 11. provide emotional support

V. INFANT WITH INFECTION (SEPSIS)

a. DEFINITION- infant who has a generalized infection from pathogenic bacteria in the bloodstream b. ETIOLOGY AND PATHOPYSIOLOGY

a. Risk factors- maternal infection, preterm or low birth weight infant, result of invasive procedures b. Immature immune system

 c.
a. b. c. d. e. f. g. h. i. j.

ASSESSMENT DATA
Maternal history CBC with differential, serum electrolytes, glucose Vital signs Urinalysis Cultures of body fluids, drainage Seizures Bulging fontanels Jaundice Chest x-ray Feeding ability apnea

 d.
a. b. c.

TREATMENT
Identify type and source of infection IV therapy with antibiotics Supportive physiologic care
Prevent further infection Administer antibiotic therapy Monitor for side effects Maintain neutral thermal environment e. Administer oxygen if needed Monitor vital signs g. Monitor caloric and fluid (PO, IV) intake Monitor parental involvement i. Teach parents about the condition J . Monitor weight and output

e.

NURSING INTERVENTIONS

a. b. c. d. b. c. f. d. e. h. f. g.