Chapter 23: Care of the Newborn PDF

**Apgar Scoring** +-----------------+-----------------+-----------------+-----------------+ | An Apgar score | | | | | is assigned | | | | | based on a | | |...

**Apgar Scoring** +-----------------+-----------------+-----------------+-----------------+ | An Apgar score | | | | | is assigned | | | | | based on a | | | | | quick review of | | | | | systems that is | | | | | completed at 1 | | | | | and 5 min of | | | | | life. This | | | | | allows the | | | | | nurse to | | | | | rapidly assess | | | | | extrauterine | | | | | adaptation and | | | | | intervene with | | | | | appropriate | | | | | nursing | | | | | actions. | | | | | | | | | | 0 to 3 | | | | | indicates | | | | | severe distress | | | | | | | | | | 4 to 6 | | | | | indicates | | | | | moderate | | | | | difficulty | | | | | | | | | | 7 to 10 | | | | | indicates | | | | | minimal or no | | | | | difficulty | | | | +=================+=================+=================+=================+ | **APGAR SCORE** | **0** | **1** | **2** | +-----------------+-----------------+-----------------+-----------------+ | Heart Rate | Absent | Slow, less than | Greater than | | | | 100/min | 100/min | +-----------------+-----------------+-----------------+-----------------+ | Respiratory | Absent | Slow, weak cry | Good cry | | Rate | | | | +-----------------+-----------------+-----------------+-----------------+ | Muscle Tone | Flaccid | Some flexion of | Well-flexed | | | | extremities | | +-----------------+-----------------+-----------------+-----------------+ | Reflex | None | Grimace | Cry | | Irritability | | | | +-----------------+-----------------+-----------------+-----------------+ | Color | Blue, pale | Pink body, | Completely pink | | | | cyanotic hands | | | | | and feet | | | | | (acrocyanosis) | | +-----------------+-----------------+-----------------+-----------------+ **Section 1: Low-Risk Newborn** **Newborn Assessment Overview** - Understanding the physiologic responses of a newborn to birth is crucial for effective nursing care. - Key areas of focus include Apgar scoring, physical examination, New Ballard Score, vital signs, and complications. - The transition to extrauterine life involves significant adjustments in respiratory and circulatory systems. - The establishment of respiratory function is critical, marked by the first breath and the cutting of the umbilical cord. - Circulatory changes involve the closure of three shunts: ductus arteriosus, ductus venosus, and foramen ovale. - Immediate assessment post-birth is essential to identify any abnormalities or complications. **Apgar Scoring** - The Apgar score is a quick assessment performed at 1 and 5 minutes after birth to evaluate the newborn\'s adaptation. - Scoring ranges from 0 to 10, with lower scores indicating greater distress: 0-3 (severe distress), 4-6 (moderate difficulty), 7-10 (minimal or no difficulty). - The five criteria assessed are heart rate, respiratory rate, muscle tone, reflex irritability, and color. - Each criterion is scored from 0 to 2, with a total score indicating the newborn\'s condition. - Example of scoring: A newborn with a heart rate of 120, good cry, and pink color would score 10. - For color assessment, consider the genetic background of the newborn. **Equipment for Newborn Assessment** - **Bulb Syringe**: Used for suctioning mucus from the mouth and nose. - **Pediatric Stethoscope**: Evaluates heart rate, breath sounds, and bowel sounds. - **Axillary Thermometer**: Monitors temperature to prevent hypothermia; rectal temperatures are avoided. - **Blood Pressure Cuff**: Electronic method for measuring blood pressure in all four extremities if cardiac issues are suspected. - **Scale**: Used for weighing the newborn, ensuring it is at zero before use. - **Tape Measure**: Measures length from crown to heel and head circumference at the greatest diameter. **Initial Assessment Procedures** - Conduct a quick initial assessment to identify life-threatening abnormalities. - **External Assessment**: Observe skin color, peeling, birthmarks, and nasal patency. - **Chest Assessment**: Check for ease of breathing and auscultate heart and lung sounds. - **Abdominal Assessment**: Inspect the umbilical cord and abdomen for normal findings. - **Neurologic Assessment**: Evaluate muscle tone, reflexes, and fontanel size. - Document any gross structural malformations observed during the assessment. **Expected Reference Ranges** **Measurement** **Normal Range** --------------------- ---------------------------------- Weight 2,500 to 4,000 g (5.5 to 8.8 lb) Length 45 to 55 cm (18 to 22 in) Head Circumference 32 to 36.8 cm (12.6 to 14.5 in) Chest Circumference 30 to 33 cm (12 to 13 in) **Section 2: Gestational Age Assessment** **Importance of Gestational Age Assessment** - Gestational age assessment is performed within the first 48 hours after birth. - It is crucial for predicting neonatal morbidity and mortality. - The assessment includes physical measurements and the New Ballard Score. - Accurate gestational age helps in planning appropriate care and interventions. - The New Ballard Score provides a baseline for assessing growth and development. - Understanding gestational age is essential for classifying newborns. **New Ballard Score** - The New Ballard Score assesses neuromuscular and physical maturity of the newborn. - Each parameter is rated on a scale from -1 to 5, with a total score indicating weeks of gestation. - Neuromuscular maturity includes assessments like posture, arm recoil, and heel to ear distance. - Physical maturity assesses skin texture, lanugo, breast tissue, and genitalia development. - Example: A score of 35 indicates a gestational age of approximately 38 weeks. - This scoring system helps in identifying preterm and post-term infants. **Classification of Newborns** - Newborns are classified based on gestational age and birth weight. - **Appropriate for Gestational Age (AGA)**: Weight between the 10th and 90th percentile. - **Small for Gestational Age (SGA)**: Weight less than the 10th percentile. - **Large for Gestational Age (LGA)**: Weight greater than the 90th percentile. - Classification aids in identifying infants at risk for complications. - Understanding these classifications is vital for targeted nursing interventions. **Genitalia Development and Classification** **Genitalia Development** - Male genitalia development ranges from a flat smooth scrotum to pendulous testes with deep rugae, classified on a scale from -1 to 4. - Female genitalia development includes a prominent clitoris with flat labia to labia majora covering the labia minora and clitoris, also classified on a scale from -1 to 4. - These classifications help assess the maturity and development of newborns, providing insight into their gestational age. **Classification of Newborns** - **Appropriate for Gestational Age (AGA)**: Weight between the 10th and 90th percentile, indicating normal growth. - **Small for Gestational Age (SGA)**: Weight less than the 10th percentile, suggesting potential growth issues. - **Large for Gestational Age (LGA)**: Weight greater than the 90th percentile, which may indicate maternal diabetes or other conditions. - **Low Birth Weight (LBW)**: Defined as weight of 2,500 g or less at birth, associated with higher risks of morbidity. - **Intrauterine Growth Restriction (IUGR)**: Growth rate does not meet expected norms, often due to placental insufficiency or maternal health issues. **Gestational Age Definitions** - **Early Term**: 37 0/7 weeks to 38 6/7 weeks. - **Full Term**: 39 0/7 weeks to 40 6/7 weeks. - **Late Term**: 41 0/7 weeks to 41 6/7 weeks. - **Preterm**: Born before 37 0/7 weeks, with increased risk of complications. - **Postterm**: Born after 42 0/7 weeks, with potential risks associated with placental insufficiency. **Vital Signs Assessment** **Sequence of Vital Signs** - Vital signs are assessed in the following order: respirations, heart rate, blood pressure, and temperature. - Normal respiratory rate for newborns is 30 to 60 breaths/min, with brief periods of apnea (less than 15 seconds) being common. - Abnormal findings such as crackles, wheezing, grunting, and nasal flaring indicate respiratory distress. **Heart Rate Assessment** - Normal heart rate ranges from 110 to 160 beats/min, with fluctuations based on activity. - The apical pulse is assessed for one full minute, preferably when the newborn is sleeping. - Heart murmurs should be documented and reported for further evaluation. **Blood Pressure and Temperature** - Normal blood pressure for newborns ranges from 60 to 80 mm Hg systolic and 40 to 50 mm Hg diastolic. - Normal temperature ranges from 36.5° C to 37.5° C (97.7° F to 99.5° F), with 37° C (98.6° F) being average. - Newborns are at risk for hypothermia and hyperthermia until thermoregulation stabilizes. **Physical Examination from Head to Toe** **Posture and Skin Assessment** - Newborns typically lie in a curled-up position with moderate flexion of arms and legs. - Skin color transitions from deep red to purple, with acrocyanosis common in the first few hours. - Jaundice may appear on the third day of life due to increased bilirubin levels, but usually resolves spontaneously. **Normal Deviations in Skin** **Condition** **Description** **Notes** --------------------- ----------------------------------------------------------------------------------- -------------------------------------------- Milia Small raised pearly or white spots on the face. Disappear spontaneously without treatment. Mongolian Spots Blue, gray, brown, or black pigmentation spots, common in darker-skinned infants. Document location and presence. Telangiectatic Nevi Flat pink or red marks that blanch easily, usually fade by age two. Commonly found on the neck and eyelids. Nevus Flammeus Capillary angioma that does not blanch, often seen on the face. Permanent unless treated. Erythema Toxicum Pink rash appearing within the first three weeks, no treatment required. Commonly referred to as newborn rash. **Head Assessment** - The head circumference should be 2 to 3 cm larger than the chest circumference. - A head circumference greater than or equal to 4 cm larger than the chest circumference may indicate hydrocephalus. - Regular monitoring of head size is crucial for assessing neurological development. **Newborn Physical Characteristics** **Head and Circumference** - The head circumference should be 2 to 3 cm larger than the chest circumference, indicating normal growth. - A head circumference greater than or equal to 4 cm larger than the chest circumference may suggest hydrocephalus, a condition characterized by excessive cerebral fluid. - Conversely, a head circumference less than or equal to 32 cm can indicate microcephaly, which is an abnormally small head. - The anterior fontanel is typically palpable, diamond-shaped, and averages about 5 cm, while the posterior fontanel is smaller and triangular. - Bulging fontanels at rest can indicate increased intracranial pressure, infection, or hemorrhage, while depressed fontanels may suggest dehydration. - Sutures should be palpable, separated, and may overlap (molding) due to head compression during labor. **Caput Succedaneum and Cephalohematoma** - **Caput Succedaneum**: This is localized swelling of the soft tissues of the scalp caused by pressure during labor. It can cross suture lines and typically resolves within 3 to 4 days without treatment. - **Cephalohematoma**: This is a collection of blood between the periosteum and the skull bone, which does not cross suture lines. It results from trauma during birth and resolves in 2 to 8 weeks. **Condition** **Description** **Resolution Time** **Treatment Needed** ------------------- ----------------------------------------------- --------------------- ---------------------- Caput Succedaneum Soft edematous mass, crosses suture lines 3 to 4 days No Cephalohematoma Blood collection, does not cross suture lines 2 to 8 weeks No **Sensory Assessment** **Eye Examination** - Assess for symmetry in size and shape; the distance between the inner and outer canthus should equal one-third the distance across both eyes. - Immature lacrimal glands may result in minimal or no tears, and subconjunctival hemorrhages can occur due to birth pressure. - The pupillary and red reflexes should be present, indicating normal eye function. - Eyeball movement may appear random and jerky, which is typical in newborns. **Ear and Nose Assessment** - Ears should be positioned in line with an imaginary line drawn from the inner to outer canthus of the eye; low-set ears may indicate chromosomal abnormalities. - The nose should be midline, flat, and broad, with some mucus present but no drainage. Newborns are obligate nose breathers. - Nasal blockage can lead to flaring of the nares, cyanosis, or asphyxia, as newborns do not develop the reflex to open their mouths until 3 weeks after birth. **Oral and Neck Assessment** **Mouth Examination** - Assess for palate closure and the strength of sucking; lip movements should be symmetrical. - Excessive saliva may indicate a tracheoesophageal fistula, while Epstein's pearls are common and typically resolve within weeks. - The tongue should move freely and be symmetrical; a protruding tongue can indicate Down syndrome. **Neck Characteristics** - The neck should be short, thick, and surrounded by skin folds, with no webbing present. - It should allow for free movement; absence of head control may indicate prematurity or Down syndrome. **Abdomen and Extremities Assessment** **Abdomen Examination** - The umbilical cord should be odorless and show no intestinal structures; the abdomen should be round and nondistended. - Bowel sounds should be present shortly after birth, indicating normal gastrointestinal function. **Extremities Assessment** - Assess for full range of motion and symmetry; extremities should be flexed. - Check for bowed legs and flat feet, which are normal due to muscle development. - Gluteal folds should be symmetrical, and nail beds should be pink with no extra digits present. **Reflexes and Neurological Assessment** **Reflexes** - **Sucking and Rooting Reflex**: Elicited by stroking the cheek; newborn turns head and begins to suck. Expected to disappear by 3-4 months. - **Palmar Grasp**: Elicited by placing a finger in the palm; newborn curls fingers around it. Expected to lessen by 3-4 months. - **Plantar Grasp**: Elicited by placing a finger at the base of toes; newborn curls toes downward. Expected from birth to 8 months. - **Moro Reflex**: Elicited by allowing the head and trunk to fall backward; newborn spreads arms and then retracts them. Expected to be present at birth. **Reflexes in Newborns** **Symmetrical Tonic Neck Reflex** - The newborn will symmetrically extend and abduct the arms at the elbows, with fingers spread to form a \'C\'. - This reflex is expected to be complete until 8 weeks, with body jerk responses observed until 18 weeks, and absent by 6 months. **Moro Reflex** - Elicited by holding the newborn in a semi-sitting position and allowing the head and trunk to fall backward. - Expected age for this reflex is from birth to 3-4 months. **Babinski Reflex** - Elicited by stroking the outer edge of the sole of the foot, moving towards the toes, causing the toes to fan upward and outward. - This reflex is expected from birth to 1 year. **Stepping Reflex** - Elicited by holding the newborn upright with feet touching a flat surface, prompting stepping movements. - Expected age for this reflex is from birth to 4 weeks. **Sensory Development in Newborns** **Vision** - Newborns can focus on objects 8 to 12 inches away, which is the distance from the mother's face during breastfeeding. - They prefer dim lighting and can track high-contrast objects, favoring black and white patterns. **Hearing** - Hearing is similar to that of an adult once amniotic fluid drains from the ears. - Newborns exhibit selective listening to familiar voices and can turn towards sounds. **Touch and Taste** - Newborns respond to tactile messages of pain and touch, with the mouth, hands, and soles of the feet being the most sensitive areas. - They prefer sweet tastes over salty, sour, or bitter. **Smell and Habituation** - Newborns have a highly developed sense of smell and can recognize their mother's scent. - Habituation allows newborns to become accustomed to environmental stimuli, reducing responses to constant stimuli. **Pain Assessment in Newborns** **Pain Measurement Tools** - CRIES scale and Neonatal Infant Pain Scale (NIPS) are commonly used tools for assessing pain in newborns. - Pain assessment combines behavioral observations and physiological findings. **Behavioral Responses to Pain** - Alterations in sleep-wake cycles, feeding, or activity can indicate pain. - Signs include fussiness, irritability, limb withdrawal, and facial grimacing. **Physiological Responses to Pain** - Vital signs may show rapid or shallow respirations, decreased oxygen saturation, and increased heart rate. - Other signs include skin pallor or flushing, hyperglycemia, and increased muscle tone. **Newborn Laboratory Values and Complications** **Expected Laboratory Values** **Test** **Normal Range** ----------- --------------------------- Hgb 14 to 24 g/dL Platelets 150,000 to 300,000/mm³ Hct 44% to 64% Glucose \> 40 to 45 mg/dL RBC count 4.8 x 10⁶ to 7.1 x 10⁶ Bilirubin 24 hr: 2 to 6 mg/dL 48 hr: 6 to 7 mg/dL 3 to 5 days: 4 to 6 mg/dL WBC count 9,000 to 30,000/mm³ **Complications and Nursing Actions** - **Airway Obstruction**: Suction mouth and then nose with a bulb syringe to prevent aspiration. - **Hypothermia**: Monitor axillary temperature and maintain skin temperature through skin-to-skin contact or radiant warmer.