Neonatal Assessment Quiz

Normal Newborn

• Physiological adaptation of the newborn from intrauterine to extrauterine is covered.
• Assessment and immediate care of the normal newborn, including Apgar scoring, and birth injuries are also included.
• The first vital task for the newborn is initiating respirations.
• Fetal lung fluid production is 4-5 ml/kg/hr.
• Fetal lung fluid decreases as the fetus nears term, preparing for air breathing.
• Surfactant is a slippery detergent-like combination of lipoproteins and is detectable by 24-25 weeks of gestation.

Initiations of Respirations (Chapter 19, page 517)

• The first vital task of the newborn is initiating respirations.
• During fetal life, alveoli produce fetal lung fluid that expands the alveoli.
• Fetal lung fluid is continuously produced at a rate of 4 to 5 ml/kg/hr.
• As the fetus nears term, the amount of fetal lung fluid decreases in preparation for birth.
• Absorption of fetal lung fluid is accelerated by secretion of fetal epinephrine and corticosteroids but may be delayed by Cesarean birth without labor.
• Fluid removal reduces pulmonary resistance and enhances air breathing.

Initiations of Respirations: Surfactant

• A slippery detergent-like combination of lipoproteins is detectable by 24-25 weeks of gestation.
• Surfactant reduces surface tension within alveoli, allowing them to remain partially open at birth.
• Without surfactant, alveoli collapse when the infant exhales.
• By 34-36 weeks, sufficient surfactant is typically produced to prevent Respiratory Distress Syndrome.
• Increased surfactant secretion occurs during and immediately after labor to aid transition from fetal to neonatal life.
• Steroids may be given to a preterm laboring woman to increase surfactant production and speed lung maturation.

Initiations of Respirations: Causes

• At birth, the infant's first breath forces remaining fetal lung fluid out of the alveoli to allow air to enter the lungs.
• Chemical factors: Chemoreceptors in the aorta and carotid arteries respond to hypoxia, specifically a decrease in the partial PO2, and pH. An increase in PCO2 stimulates respiratory centers in the brain.
• Mechanical factors: Recoil of the chest, when pressure is released at birth, draws air into the lungs and helps remove fluid from the airways..

Initiations of Respirations: Thermal and Sensory Factors

• The infant transitions from a warm, fluid-filled uterus to a cooler environment.
• Skin sensors respond to temperature changes and stimulate respiratory centers in the medulla.
• Auditory, tactile, visual, and other sensory factors stimulate further respiratory responses, including actions from nurses.
• Sensory factors include procedures at birth and the stimulation of light, sound, smell, and pain at delivery.

Initiations of Respirations: Continuation

• Approximately 20-30 ml of air from the first breaths remains in the lungs to become the functional residual capacity (FRC).
• Within the first hour, 80-90% of the FRC is established.
• Subsequent breaths require less effort than the first breath.
• Fluid removal from the lungs through absorption can take multiple hours.

Cardiovascular Adaptation

• Three fetal shunts (ductus venosus, foramen ovale, and ductus arteriosus) carry most blood away from the lungs and liver.
• At birth, the shunts close in response to increased blood oxygen and pressure shifts within the heart, pulmonary, and systemic circulations. Umbilical cord clamping is involved.
• The transition from fetal to neonatal circulation occurs simultaneously within minutes after birth.

Neurological Adaptation: Thermoregulation

• Maintaining body temperature is crucial for newborns.
• A significant drop in temperature (0.2-1°C) occurs within minutes if the infant is not kept warm.
• Neonates need to produce and maintain adequate heat to prevent cold stress that can have severe effects.

Neurological Adaptation: Methods of Heat Loss

• Evaporation: Air drying of the skin cools the infant.
• Conduction: Contact with cold surfaces or objects.
• Convection: Heat transfer from the baby to surrounding air.
• Radiation: Heat transfer to the walls of the incubator (use of radiant warmer).

Hematological Adaptation

• Blood volume in a normal term newborn is 80-100 ml/kg.
• Hemoglobin (Hgb) is higher in infants (15-24 g/dL) compared to adults.
• Hematocrit (Hct) is 44%-70%.
• White blood cell count (WBC) is 15,000/mm³ in a term infant.
• Low vitamin K in infants puts them at risk of bleeding complications, requiring vitamin K supplementation.

Gastrointestinal System

• Newborns' stomach capacity is 6 ml/kg at birth.
• Intestines are longer in newborns to maximize absorption.
• Water loss can be an issue if diarrhea develops.
• Bowel sounds can be heard 15 minutes after birth.
• Pancreatic enzymes, particularly amylase, are deficient in the first 4-6 months after birth.
• Meconium, a greenish-black stool, is the first stool.
• Typically, 99% of newborns have passed meconium within 24 hours of birth
• Breastfed infants' stools are typically seedy, mustard colored, and consistent with four or more stools daily.
• Formula-fed infants usually have pale yellow stools.

Hepatic System

• Glucose, as the primary energy source, is low in concentration in newborns for 60-90 minutes after birth and gradually rises to a stable level within 2-3 hours.
• In term infants, glucose levels should be 40-60 mg/dL during the first day.
• Premature infants, low-birth-weight infants, and those with gestational diabetes are at increased risk for hypoglycemia as they have less developed glycogen stores.

Hepatic System: Conjugation of Bilirubin

• Newborns' livers may not be fully mature to prevent jaundice.
• Hyperbilirubinemia (excessive bilirubin in the blood) is common (60% of term and 80% of preterm infants).
• Factors increasing hyperbilirubinemia risk include: hemolysis of excessive erythrocytes, short red blood cell lifespan, lack of albumin binding sites, and/or liver immaturity.
• Breastfeeding, delayed or inadequate feeding, and blood incompatibility can also raise bilirubin levels
• Infants with gestational diabetes mothers may exhibit elevated bilirubin due to increased insulin production.
• Elevated bilirubin causes jaundice, a yellowish discoloration of the skin, sclerae, mucous membranes, and nails.

Hyperbilirubinemia

• Excessive bilirubin in the blood, causing jaundice.
• Jaundice is yellowish discoloration of skin, sclera, mucous membranes, and nails.

Physiological Jaundice

• Transient hyperbilirubinemia considered normal.
• Jaundice is absent in the first 24 hours.
• In term infants, jaundice peaks on day 2-3 after birth and Maximum intensity by 4th-5th day.
• In preterm infants, the peak may reach the 7th day.
• Jaundice is discernible when bilirubin levels exceed 5 mg/dL
• Normal values of unconjugated bilirubin are 0.2 to 1.4 mg/dL.

Non-Physiological (Pathological) Jaundice

• Jaundice appearing within the first 24 hours or persisting after 14 days, suggests a possible pathology.
• Rapid increase in bilirubin levels (greater than 5 mg/dL/day)
• Clay or white-colored stools indicate a problem.
• Breastfeeding or early-onset jaundice is seen in 13% of breastfed infants by 1 week of age.
• True breast milk jaundice is usually seen after 5 days after birth and can last a couple of months; some infants have levels up to 20-30 mg/dL.

Urinary System

• Kidneys develop fully by 34-36 weeks' gestation.
• Voiding typically occurs within the first 12 hours in 50% of newborns and in 99% within 48 hours after birth.
• Failure to void may be related to fluid intake.
• Normal newborns void frequently (usually 6 times per day for first couple of days following birth.
• Daily fluid intake for the first two-three days post-birth is 60-100 ml. increasing to 150-175 ml by day 5.

Immediate Assessment of the Normal Newborn: Apgar Score

• A standardized method for assessing the newborn's clinical status immediately (1 minute and 5 minutes) after birth.
• Factors include heart rate, respiratory effort, muscle tone, reflex response, and color.

Early Focused Assessment

• Focus on rapid overall assessment to identify any needs for immediate resuscitation or medical intervention.
• Heat loss prevention during and immediately after birth and physical/parental presence during assessment is important.
• Ensure assessment involves a sequence to effectively evaluate the baby's condition

Normal Newborn: Gestational Age

• Neonatal period is the first 28 days of life.
• Early neonate is 0-7 days and late neonate is 8-28 days.
• 2/3 of deaths observed occur during the neonatal period.
• Preterm: < 37 weeks
• Term: 37-41+6 weeks
• Post-term: ≥ 42 weeks

Gestational Age and Risk

• Preterm infants are at higher risk for respiratory distress syndrome, necrotizing enterocolitis, patent ductus arteriosus, and apnea.
• Post-term infants are at higher risk for asphyxia, meconium aspiration, congenital anomalies, like chromosomal issues.

Initial Assessment: Apgar Scoring System

• Score assessment to evaluate the newborns' vital signs immediately after birth.
• Factors and scores used to determined level of care, resuscitation, or additional intervention needed are described.
• Activity (Muscle tone), Pulse, Grimace (reflex irritability), Appearance (skin color), and Respiration are the components used for scoring.

Apgar Score Components

• Heart rate
• Respiratory effort
• Muscle tone
• Reflex response
• Color

Importance of Apgar Score

• Assess newborn condition at birth
• Identify need for resuscitation
• Provide necessary care to baby
• Prevent hypothermia

Care According to Apgar Score

• Apgar score of 1-3: resuscitation is required.
• Apgar score of 4-6: stimulation is required; administer oxygen and Narcan if needed.
• Apgar score of 7-10: no action is required except infant support.

Immediate and Early Care

• Clear airway, clamp umbilical cord, dry and regulate infant temperature, and wrap or put the newborn in a radiant warmer or use blankets.
• Proper identification and record keeping are essential.

Focused Early Assessment: Cardiorespiratory Status

• Respiratory Rate (RR): assessed every 30 minutes then every 2 hours. Normal is 30-60 breaths per minute. Respiratory patterns/quality noted.
• Respiration: Should be normal; not labored; symmetrical chest movement.
• Breath sounds: Clear, crackles (first and second hour after birth) not unusual.
• Color: Assess for pallor (anemia, hypoxia), ruddy color (polycythemia).

Assessments of Respiration

• Pauses in breathing lasting 5 to 10 seconds without other changes followed by rapid respirations for 10 to 15 seconds; this is seen in term infants in the first days after birth
• Apnea (20 second or more pause) is more common and worrisome in preterm infants and requires immediate intervention.

Focused Early Assessment—Assessment of Respiratory Distress

• Tachypnea (> 60 bpm)
• Retractions
• Nasal flaring
• Cyanosis
• Asymmetrical chest expansion
• Potential causes of these issues, such as nasal passage blockage and other relevant issues, are addressed.

Focused Early Assessment—Assessment of Cardiorespiratory Status

• Heart sounds: 120-160 beats per minute (bpm).
• Regular rhythm. Respiration; sleeping=100 bpm, crying=180 bpm.
• Most newborns' murmurs are temporary.
• Blood pressure: Average is 65 – 95 mmHg (systolic) and 30-60 mmHg (diastolic).
• Normal capillary refill time; presence and equal brachial and femoral pulses.

Focused Early Assessment—Assessment of Thermoregulation

• Body temperature is usually taken by axillary method, typically 36.5-37.5 °C.

General Assessment: Head-to-Toe

• Head: symmetric & round; soft tissue.
• Hair: consistent pattern; abnormalities may indicate genetic issues
• Molding: normal changes in head shape due to birth canal passage.
• Fontanels: Normal/symmetrical anterior (diamond shape, 4-6cm, soft/flat) and posterior (triangular, 0.5-1cm, closes within 2 months).
• Face: Symmetrical facial structure.

Face

• Normal: symmetric eyes, nose, nostrils, normal ear configuration, freely moving tongue
• Abnormal: Injuries, facial palsy, asymmetrical eyes, nasal flaring, low-set ears, cleft lip/palate, precocious teeth, tongue tie.

Neck and Clavicles

• Assess neck ROM, no masses or fractures.
• Clavicle fractures are more common in large infants, especially with shoulder dystocia. Clinical signs/physical examination details should be included for detection.

Chest

• Normal: 2 nipples, enlarged breasts; normal breath sounds.
• Abnormal: Extra nipples, apnea, cyanosis, tachypnea or grunting, crackles, wheezes, tachycardia, or bradycardia.

Umbilical Cord

• Contains 3 vessels: 2 arteries, 1 vein.
• Small arteries may stand up at the end.
• Single artery may indicate additional issues.
• Two-vessel cord, associated with kidney or chromosomal issues.
• Yellow/green tinge may indicate meconium staining during birth.

Extremities

• Infants should actively- move extremities (symmetrically).
• Term infants have sharply flexed extremities that resist extension.
• Poor muscle tone associated with inadequate oxygenation during birth.
• Assess for fractures; crepitus, redness, and swelling should be noted.
• Examine hands and feet for symmetry; assess extra digits (polydactyly) or webbing between digits (syndactyly).

Hips

• Examine for developmental dysplasia.
• Assess for instability of hip joint, which is possible to occur in the head of the femur (acetabulum).
• Compare height of knees.
• Check for leg symmetry; shorter leg often indicates dislocation. Barlow and Ortolani tests can be used for hips.

Vertebral Column

• Symmetrical, no masses or deformities.
• Spina bifida (failure of vertebra to close) is a noted abnormality.

Measurements: Weight

• Large for gestational age (LGA), > 4000 g
• Average for gestational age (AGA), 2500-4000 g
• Small for gestational age (SGA), <2500 g
• Normal birth weight is 2500-4000g;
• 5-10% weight loss common in first week from fluid loss associated with birth.
• Regain (or surpass) of birth weight expected by two weeks.
• Daily weight gain of 30g is typical for the neonatal period

Measurements: Length and Circumferences

• Length measured from top of head to outstretched leg, 48-53 cm (19-21 inches).
• Head circumference: Growth is approximately 2.5 cm per month for the first 6 months, is typically 32-38 cm (13-15 inches).
• Chest circumference is usually 2 cm smaller than head circumference, with normal measurement at 30-36 cm (12-14 inches).

Assessment of Body Systems: Neurological Exam

• Reflexes are crucial for evaluating central nervous system (CNS) health.
• Sucking/rooting reflex, Moro reflex, grasp (palmar/plantar) reflex, Babinski reflex, tonic neck reflex, and stepping reflex are included.

Hepatic System (Assessment)

• Newly born blood glucose level should be checked, particularly if the infant is at risk for hypoglycemia.
• Indicators for hypoglycemia in newborns include poor feeding, tremors, or poor suck, low temperature, dyspnea (shortness of breath) or cyanosis, profuse sweating, and a high-pitched cry; some infants will be asymptomatic.
• Assess for jaundice by pressing on the infant's sternum, and noting any yellow skin discoloration; blanching should occur after pressure.

Gastrointestinal/Abdomen Assessment

• Normal: 3 umbilical blood vessels.
• Normal: Liver position 2cm below costal margin.
• Normal: Present bowel sounds, typically within the first 24 hours of birth.

Assessment- Skin

• Normal Color: Bright red, soft texture with good elasticity.
• Potential abnormalities: edema around eyes, face, and genitalia; acrocyanosis, which is cyanosis of hands and/or feet/extremities.
• Erythema toxicum neonatorum: A rash of blotchy, red areas.
• Mongolian spots: Blue-black macules that typically disappear within 2-3 years of age.

Skin Assessment-Additional Points

• Vernix caseosa: Thick whitish substance found on newborn skin, primarily on underlying folds, and is typically present to some degree at birth.
• Lanugo hair: Fine, downy hair found on newborns; typically present at birth.
• Milia: Small white cysts commonly found on the nose and cheeks; typically resolve within a few weeks

Female Genitalia

• Normal: Normal configuration; mucoid discharge; pseudomenstruation
• Abnormal: Abnormal configuration

Male Genitalia

• Normal: Normal configuration, testes in scrotum.
• Abnormal: Hypospadias, epispadias, undescended testes, ambiguous genitalia.

Anus Assessment

• Normal: patent (open), meconium stools (unformed, black, tarry) within 12 hours of birth.
• Abnormal: Imperforate anus; fistula

Cord Care

• Umbilical stump care is important to prevent bleeding and infection.
• Cutting the cord, ligation with a clamp, and keeping the stump exposed and clean with water is critical.

Rooming-In

• Rooming-in is the practice of keeping newborns with their mothers in the same room.
• Advantages: Promotes bonding, facilitates exclusive breastfeeding, early exposure to maternal flora, reduces nosocomial infections, and allows for close maternal observation.

Feeding

• Breastfeeding is the superior method to nourish newborns.
• Breast milk provides balanced nutrients, reduces infection risk, and provides protection against diarrhea, along with promoting mother-child bonding.
• Breast milk is easily available, affordable, and supports child spacing (in families).

Nursing Care and Teaching

• Maintain a patent airway, provide newborn stabilization and life support.
• Provide Early asphyxia identification, management, and prevention or reduction of sudden infant death syndrome (SIDS)
• Positioning infant on their back to sleep
• Avoid placing excessive blankets in their bed to prevent or reduce overheating
• Avoid placing blankets over infant's head or in stroller.
• Keep the infant in a safe and warm environment, but avoid excessive warmth.
• Prohibit smoking around the infant.

Medication and Vitamin K administration

• Vitamin K injection is administered within the first hour to prevent bleeding complications associated with the inability of some newborns to create necessary vitamin K stores without normal intestinal bacteria.

Part III: Birth Injuries

• Common birth injuries, including caput succedaneum, cephalhematoma, and shoulder dystocia, along with associated issues such as brachial plexus injuries and clavicle fractures, are discussed.

Caput Succedaneum

• Localized swelling of soft scalp tissues, appearing over the vertex (top) of the newborn crossing suture lines.
• Results from labor pressures against the cervix.
• Swelling due to pressure interference on blood flow from the area producing local edema. May occur with vacuum extractor use during second stage of labor.
• Soft, fluctuant mass; resolves within 2-3 days; no treatment needed.

Cephalhematoma

• Blood collection between periosteum and skull bone, typically the parietal bone
• Due to trauma to small blood vessels within the periosteum
• Occurs with prolonged or difficult labor
• Develops within the first 24-48 hours, firm swelling over parietal bone, unilateral or bilateral, clear edges ending at suture lines. Resolve slowly, could take 3 months.
• Associated risk for jaundice and anemia

Shoulder dystocia

• Occurs when the infant is too large or mother has diabetes.
• Umbilical cord can be compressed between fetal parts and maternal pelvis during birth;
• "Turtle sign": baby's head is stuck & can't be easily expelled.
• Nurse intervention required; fundal pressure; McRoberts' maneuver; notify physician.

Brachial plexus and clavicle fractures

• Brachial plexus injuries can cause arm paralysis
• Clavicle fractures are common in large infants.
• Immobilization often required based on physician order.

Test your knowledge on neonatal assessment, specifically focusing on the Apgar score and critical considerations for newborn care. This quiz covers important concepts related to neonatal health, including respiratory distress syndrome and the unique needs of preterm infants. Enhance your understanding of immediate newborn evaluations and key nursing practices.