FF Exam 4 PDF

FF Exam 4 Explain the common physiological and behavioral adaptations the newborn makes during the transition from intrauterine to extrauterine life (3 Q) 3 stages of transition: 1. First period of reactivity → up to 30 min after birth + HR increases to 160-180 but fa...

FF Exam 4 Explain the common physiological and behavioral adaptations the newborn makes during the transition from intrauterine to extrauterine life (3 Q) 3 stages of transition: 1. First period of reactivity → up to 30 min after birth + HR increases to 160-180 but falls to baseline 100-120 after 30 min + RR 60-80, irregular respirations + Fine crackles, nasal flaring, grunting, chest retractions should cease after 1st hour of life + Alert; startled, cries, tremors, moves head side to side + Bowel sounds audible and meconium may be passed 2. Period of decreased responsiveness → 60-100 minutes + Infant is pink + RR rapid at 60; shallow but unlabored + Peristaltic waves over rounded abdomen + Sleeps or has marked decrease in motor activity 3. Second period of reactivity → occurs 2-8 hours after birth; lasts 10 min-several hours + Brief periods of tachycardia/tachypnea + Increased muscle tone, skin color changes, mucous production + Meconium commonly passed + Healthy infants experience this no matter gestational age/birth type…. Very preterm infants do not due to immaturity Do not take baby to warmer unless they absolutely need it!!! Baby does best on mom!! Respiratory adjustments + Initiation of breathing: increase in systemic resistance due to cord clamping → rise in BP → shunts to lungs to do the work - Crying increases distribution of air to lungs and keeps alveoli open + Chemical factors → activation of chemoreceptors in carotid artery and aorta result from relative state of hypoxia associated with labor + Mechanical factors → squeeze when passing through birth canal(watch c/s babies closely; they did not get this squeeze) + Thermal factors → colder temp stimulates receptors on the skin, which stimulates the respiratory center in the medulla + Sensory factors → suctioning mouth/nose, drying baby, and environmental factors (light, smell, sounds) stimulate respiratory center + Obligate nose breathers and will NOT instinctively open mouths if they can’t breathe through their nose Signs of respiratory distress → nasal flaring, retractions, grunting, seesaw respirations, RR under 30 or over 60 per minute + Central (circumoral) cyanosis = respiratory distress + Acrocyanosis = normal! Cardiovascular system adjustments  + Increased pulmonary blood flow from left side increases pressure in left atrium → closure of foramen ovale + In 1st few days of life, crying can temporarily reverse flow through the foramen ovale → mild cyanosis + In utero Po2 → 20-30 + After birth Po2 → 50 → ductus arteriosus constricts from increased oxygen - Circulating PGE2 also helps close this - Closes within 24 hours; permanent closure in 2-3 months and becomes a ligament - Can reopen in response to low O2 - Patent ductus arteriosus can be detected as a murmur + Umbilical arteries, umbilical vein, and ductus venosus → close and become ligaments in 2-3 months + Heart rate - 120-160 BPM (brief fluctuations based on activity) - If it is high or low, reevaluate 30 min-1 hour later or when infant activity changes - Apical impulse → “point of maximum impulse (PMI)” → 4th intercostal space to the left of midclavicular line; also called precordial activity + Heart sounds - Irregular rhythm first few hours is fine, but is abnormal after this time - Sounds are high pitch, short, and intense - S1 louder and more dull than S2; 3rd/4th sounds can’t be heard on baby - Most murmurs are harmless but should resolve in 6 months; concern only if followed by poor feeding, cyanosis, apnea, or pallor + Blood pressure → not routinely assessed on newborn - MAP should be nearly equivalent to weeks of gestation - Increases over first few months then levels off - Drop in systolic BP during first hour of life common + Blood volume - 80-100 mL/kg body weight; preterm infant is more - Delayed clamping → reduced risk for intraventricular hemorrhage and necrotizing enterocolitis; also increases BP and blood volume to baby Hematologic system adjustments + High amounts of RBC needed in utero for O2 transmission; high at birth + Platelets activated at birth and have improved aggregation in first few hours of life Thermogenic system adjustments + During first 12 hours of life neonate attempts to achieve thermal balance + Thermoregulation → maintenance of heat loss and heat production + Risks of heat loss → thin subq fat, blood vessels close to skin surface, larger body surface to body weight ratio + 4 modes of heat loss: 1. Convection → flow of heat from body surface to cooler ambient air + Wrap baby and put hat on them  2. Radiation → loss of heat from body surface to a cooler solid surface not in direct contact but in proximity + Place bassinets and examining tables away from windows; avoid air drafts 3. Evaporation → liquid to vapor + Dry after birth and keep dry 4. Conduction → loss of heat from body surface to cooler surfaces in direct contact + Prewarmed bed under radiant warmer when born + Infant takes on position of flexion to keep warm + Produce heat through nonshivering thermogenesis; triggered when skin temp down to 95-96.8 F → accomplished by metabolism of brown fat + increased metabolic activity in brain/heart/liver → rapid depletion of brown fat store = cold stress - Brown fat has richer vascular/nerve supply than regular fat; warms baby by increasing heat production by up to 100%; present for several weeks after birth and rapidly depleted by cold stress Renal system adjustments + Kidneys occupy large portion of posterior abdominal wall + Almost all palpable masses in abdomen are renal in origin + At birth small quantity of urine in bladder (40 mL); usually void at birth but it may be missed and not recorded + First few days → 15-60 mL/kg/day UO + After day 4 → voids 6-8 times; pale straw-color indicates hydration + No voiding after 24 hours → notify neonatal HCP; assess for fluid intake, bladder distention, restlessness, signs of discomfort + Uric acid crystals “brick dust” normal in first week; s/s of inadequate intake after + Fluid excretion = 5=10% weight loss in first 3-5 days of life; should regain in 10-14 days Fluid/electrolyte adjustments + Baby is 75% water at birth; reduction in this extracellular fluid with diuresis in first days of life + At birth GFR is low → reduced ability to remove waste from blood GI system adjustments + 32-34 weeks → baby can coordinate sucking, swallowing, and breathing + Baby cannot move food from lips to pharynx, so placing nipple (breast/bottle) well inside mouth is needed + If the neonate has teeth at birth they are often extracted → risk for aspiration due to poorly formed roots/looseness + Mucosal barrier in intestines not developed til 4-6 mo → risk for allergies/infection + Intestinal flora/gut microbiota → synthesize vitamin K, folate, and biotin - Breast milk helps this flora develop → oligosaccharides have prebiotic function + Newborns prone to GER → involuntary backflow of stomach contents  - GER can cause dysphagia, esophagitis, and aspiration (GERD) + All digestive enzymes present but amylase and lipase + Limited ability to digest fats! Can digest protein and carbs + Lactase high in baby → helps digest lactose in moms milk/formula + Meconium → green/black with occult blood; usually pass in first 12-24 hours of life but some in 48 hours + Transitional stools → green brown/yellow brown, curds of milk, thinner than meconium + Milk stool → breast milk stool will be yellow/gold, pasty, odor like sour milk, looks like cottage cheese + mustard; formula stool will be pale yellow/light brown, firmer, and stronger odor + Active rectal “wink” reflex → contraction in response to touch → good sphincter tone Hepatic system adjustments + Liver palpated 1-2 cm below right costal margin + Liver important for iron storage, glucose and fatty acid metabolism, bilirubin synthesis, and coagulation + Begins storing iron in utero → store is equal to total hgb and length of gestation + Newborn removed from maternal glucose supply → sudden drop in glucose - Feeding helps stabilize them - Levels not routinely assessed unless hypoglycemic s/s or risks - Hypoglycemia risks → large for age, preterm, diabetic mom + Breakdown of RBC → unconjugated bilirubin → binds to glucuronic acid to become conjugated → excreted via GI/GU - Urobilinogen → excreted via urine and feces - Stercobilogen → excreted via feces + Feeding reduces serum bilirubin levels → stimulates peristalsis and produces more rapid passage of meconium, diminishing amount of reabsorbed unconjugated bilirubin + Coagulation factors activated by vit K → low clotting factors, increase by 9 months; vit K shots given to prevent vit k deficiency bleeding Immune system adjustments + Passive immunity of IgG provides antimicrobial protection for first 3 mo + Produces IgM by 8 weeks → immunity for blood-borne pathogens + IgA missing from resp/urinary tracts, breastfeeding gives it to intestinal tract → acts in intestines to neutralize bacteria and viral pathogens + Breastfed infants have enhanced response to vaccines; lower risk for allergies, inflam bowel disease, and T1DM Integumentary system + All skin structures present at birth!! + After 35 weeks gestation, vernix caseosa (cheese-like) fused w epidermis for protection; prevents fluid loss through skin + Few hours after birth skin is erythematous then fades to normal color + Skin mottled/blotchy in extremities  + Acrocyanosis → cyanosis in hands/feet common in first 48 hours and intermittently appears over next 7-10 days; this is normal! + Simian line → single palmar crease seen in asian infants w down syndrome + Milia → distended, small, white sebaceous glands + Wont sweat for 1st 24 hours; starts after 3 days + Desquamation → peeling of skin few days after birth; large areas of this at birth can indicate postmaturity + Congenital dermal melanocytosis (slate gray nevi) → bluish/black pigmentation spots common on back and buttocks; fade gradually over months or years Reproductive system adjustments + Increase in estrogen may cause girl newborn to have mucoid vaginal discharge or slight bloody spotting + Vaginal or hymenal tags common and no clinical significance + Vernix caseosa between labia should NOT be forcefully removed during bathing + Breech position → labia may be bruised; no clinical significance + Epithelial pearls → common in males; small, white, firm lesions at tip of prepuce + 28-36 weeks → testes palpate in scrotum and rugae cover scrotal sac + Swelling of breast tissue “hyperestrogenism”; some infants have thin discharge “witch’s milk”; no significance + Scrotum darker than everything else Skeletal system adjustments + More cartilage than bone at birth + Cranial shape may be distorted due to molding → shaping of fetal head by overlapping of cranial bones to facilitate movement through birth canal during labor Neuromuscular adjustments + Almost completely developed at birth + Tremors should not occur when infant is quiet and shouldn’t exceed 1 year Behavioral adjustments + 3 adaptations: 1. Physiologic and autonomic system 2. Motor organization 3. State regulation → ability to modulate state of consciousness + Sleep/wake states → 2 sleep states and 4 wake states - State modulation → ability to smoothly transition states - Newborn sleeps 16-19 hours a day Sensory adjustments + Vision → can see clearly 17-20 cm (8-12 in), enough to see mom during feeding/cuddling; have face preferences and it is usually mom they prefer; engage w eye contact; can imitate facial expressions and motions like sticking tongue out; prefer black/white, color discrimination at 2-3 mo + Hearing → responds/recognize moms voice; comforted by moms heartbeat in utero, place heartbeat simulator nearby or sing lullaby  + Smell → strong sense of smell; recognize moms smell by 5 days; can smell difference in moms milk and other milk + Taste → prefers sweeter solutions + Touch → face, hands, soles of feet most sensitive Describe the assessment of the newborn immediately following delivery and in the first few days of life, common complications, related nursing considerations, interventions, and documentation (6 Q) Birth-First 2 Hours of Life Syringe used ONLY if infant has difficulty clearing airway Baby not term, poor muscle tone, no crying/breathing → place under warmer and complete assessments there After ensuring infant is breathing, assess HR by grasping base of cord or auscultating chest w stethoscope Identically numbered bands on newborn wrist/ankles, mom, and possibly father ASAP and before taking baby out of moms room Infant footprint w ink within 2 hours of birth Initial exam can be done on moms chest or in her arms OR in radiant warmer APGAR score + HR, resp effort, muscle tone, reflex irritability, color (all scored 0, 1, or 2) + Color: buccal mucosa, conjunctiva, nail beds, lips, ears, soles of feet + Color in darker skin: buccal mucosa + 0-3 → severe distress + 4-6 → moderate difficulty + 7-10 → minimal to no difficulty adjusting to extrauterine life + Assigned at 1 and 5 min after birth; 160) → anemia, hypovolemia, hyperthermia, sepsis + Persistent bradycardia (