OB Exam 5 Review (3 Math; 5 SATA; 5 Priority)
Part 1 (Ch. 23 & 24)
1-Expected Transition Vital Signs and Assessment Norms; When to Report Concerns
Neonatal Period -> from birth to 28th day of life
Transition -> physiologic adaptations to extrauterine life after delivery; umbilical cord is
clamped
Normal NB Respiratory Findings
-periods of breathing that include pauses (periodic breathing); on auscultation (clear breath
sounds; transient rales for the first few hrs)
-nose breathers; abdominal breathing (chest and abdomen rise simultaneously)
**Normal Neonate RR = 30-60 breaths/min
**1-Acrocyanosis -> NORMAL finding in the first 24hrs after birth
Concerning NB Respiratory Findings
-nasal flaring, intercostal/subcostal restrictions, grunting; apneic periods >20 seconds; RR <30
or >60 at rest; central cyanosis
Normal NB Circulatory Findings
1-Heart Rate/Sounds -> **normal Neonate HR (120-160bpm; fluctuates w/ sleep/wake); clear
S1, S2; murmurs (turbulent flow; **d/t ductus arteriosus or foramen ovale)
2-BP -> lower in neonates than adults; vessels are shorter, narrower; HR (faster to allow for
lower BP); **normal Neonate BP range = *SBP (80/50) -* DBP (60/40)
Concerning NB Circulatory Findings
-persistent tachycardia (>160bpm) and bradycardia (<100bpm at rest but not sleeping); unequal
or absent pulses; abnormal skin color (pallor, circumoral, central or prolonged cyanosis)
-murmur + poor feeding, apnea, cyanosis, or pallor
Central Cyanosis -> abnormal indicates hypoxemia (potential causes = RDS, meconium
aspiration, PPHN, and pneumonia)
Pallor on NB Skin -> indicates potential sepsis or anemia
Mx of Concerning NB Circulatory Findings
-check pulse ox; 02 for central/circumoral cyanosis; take BP on 4 extremities; transfer to NICU
Normal NB Hematologic System Findings
RBCs At Birth -> fetal circulation is less efficient at 02 exchange than the lungs; fetus needs
additional RBCs for transport of oxygen in uterus
-RBC levels are higher in newborns compared to adults; RBCs falls slowly over the first month
**Normal NB Hct and Hgb Level -> *Hct (51-56%) and *Hgb (14-24-g/dL)
**WBCs At Birth -> 18,000/mm3 (at birth) , increase to 23-24000/mm3 (24hrs old)
**Platelets at Birth -> 150-300/mm3
NB Renal System (Normal Findings) = General
-**initial bladder volume (6-44mL of urine); ability to concentrate urine and excrete excess
solutes is limited until 3 months old; 90% of infants void in first 24hrs, 99% void by 48hrs
1-Normal NB Void Pattern Characteristics
-90% of infants void in first 24hrs, 99% void by 48hrs; first void at birth may be missed; 1st and
2nd day-of-life voids 2-6 times daily; by day 4, voids 6-8 times daily;
2-Normal NB Urine Characteristics
-urine (straw colored, odorless); *uric acid crystal stains (brick dust) can be seen on diaper =
signs of poor intake
Normal NB GI Findings
-neonate can suck/swallow; feedings should be q2-3h; NB can digest carbs/proteins/fats
-NB can’t digest starches (**NO SOLIDS for until 6 MONTHS); bowel sounds should be present
w/in 30-60min after birth; LES immature (spitting/vomiting/regurgitation/acid reflux common)
-weight loss of <10% is common; neonates should regain BW by 2wks;
NB Feces
-meconium seen during first 12-24wks; transition stool (greenish-yellowish-brown) present
during day 3;
-milk or mature stool appears gold, pea-soup, light brown in color appears during day 4
Concerning NB GI Findings
1-Failure to Pass Meconium in 1st 24-48hrs = indicates bowel obstruction
2-Abdominal Distention at Birth = tumor
3-Scaphoid Abd = diaphragmatic hernia
4-Projectile Vomiting -> immature esophageal sphincter
Normal NB Hepatic Findings
-**normal fetal BG (70-90); at birth, newborn is removed from the mother’s glucose supply
(which causes the newborn BG to drop to 55-60mg/dL w/in the first 90 min of life)
-during birth glucagon levels are high and insulin levels are low; glucose levels stabilize 2-3
days of life
Concerning NB Immune System Findings *Infection is the most leading cause of NB
death
**Signs of Infection -> temp instability, respiratory sx, lethargy, poor feedings, and mottled skin
Normal NB Neuromuscular Findings
-almost completely developed at birth; normal tremors, **tremors (jitteriness) of hypoglycemia,
and seizure activity must be differentiated
Assessment Findings (There's a Bunch)
Common NB Skin Findings
1-Erythema Toxicum/Neotatorum -> papular rash that surrounds hair follicles; present
24-72hrs after birth; clears w/o tx
2-Milia -> keratin-filled cysts that resolve spontaneously w/in the first; usually seen on face of
newborn
3-Vernix Caseosa -> cheese-like substance; lubricates skin in utero
4-Jaundice -> yellow discoloration of skin
5-Other -> take note of any marks of instrumentation, bruising, or trauma; vacuum/forcep marks
NB Assessment: Face -> color of face (pink; bluish discoloration may denote bruising from
delivery); facial asymmetry may mean facial nerve swelling or damage; assess eyes/lips for
symmetry
NB Assessment: Eyes-> small subconjunctival hemorrhages are common and resolve in
weeks; + red eye reflex w/ ophthalmoscopic exam
NB Assessment: Nose ->nasal flaring = respiratory distress;sneezing common
NB Assessment: Mouth -> examine gums (Epstein’s pearls [keartine cysts] -> normal and clear
in few wks w/o tx)
NB Assessment: Tongue Tie
Frenulum -> should be able to extend tongue over lower lip, if not suspect a short frenulum
(tongue tie); may cause feeding difficulties
NB Assessment: Ear
Visual Inspection of Tympanic Membrane -> usually a day after birth; hearing screen should
be one 12hrs after birth (water & debris in ear canal can cause obstruction)
NB Assessment: Neck and Chest ->neck should be supple and w/o palpable masses
Breast Bud Assessment -> normal is raised fat tissue w/ full-term infant males/females
(measured on Ballard Exam
NB Assessment: Respiratory
-auscultate for 1min; irregular respiratory pattern is normal in NB (period breathing); abdominal
or diaphragmatic breathing is normal; rales and “wet” sounds are common and will be cleared
Signs of Respiratory Distress -> nasal flaring, grunting, tachypnea
NB Assessment: Cardiac -> murmurs are common d/t open fetal fractures
NB Assessment: Abdomen -> usually can’t assess 4 quadrants like adults (too small); liver
should be palpable
NB Assessment: Male Genitalia -> *Abnormalities
1-Hypospadias or Epispadias -> urethral opening located in abnormal position
2-Cryptorchidism -> undescended testes (usually in inguinal canal)
3-Hydrocele or Scrotal Swelling -> accumulation of fluid around testes (common in breech
birth)
NB Assessment: Female Genitalia ->vaginal tags common and resolve in few weeks
-void w/in 24hrs; labia majora covers minora (in term); discharge of white mucus (normal);
pseudo-menstruation present (discharge d/t withdrawal of mother’s hormones)
-swelling and redness to vulva (common in breech birth)
NB Assessment: Extremities ->
Brachial Plexus Injury (Erb’s Palsy) -> NB is unable to elevate affected arm
-X-ray will be done; physical therapy consult; most recover completely’ moderate to severe
trauma may result in permanent paralysis
Simian Crease (single palmar crease; indicates trisomy 21 or fetal alcohol syndrome); legs of
breech baby remain extended
Club Foot -> abnormal; true clubfoot will feel resistance when moving foot to midline
NB Assessment: Back ->
1-Galant Reflex/Incurvation Reflex -> run finger along one side of infant’s back; infant’s spine
should curve like a “c” toward stimulus
2-Check for Sacral Dimpling -> ***Important*** dimples w/ tufts of hair significant finding and
are associated w/ spina bifida occulta
2-Hypoglycemia and Monitoring
Newborn Rx for Hypoglycemia
1-LGA -> indicates that mother was diabetic
2-Preterm -> baby will have immature glucose d/t being born too soon
3-IDM (Infant of Diabetic Mother) -> mother’s BG levels cross over to the baby -> baby has to
make insulin to combat mother’s diabetes -> baby is born and no longer has BG as a result of
making too much insulin
4-Cold Stress -> NB will use up all their glucose to try and stay warm if hypothermic
Other Rx Factors for Neonatal Hypoglycemia -> respiratory distress, premature or
post-mature infant, IUGR
How to Monitor Hypoglycemia? -> ***HEEL STICK
Maintaining NB BG -> first feedings help stabilize BG levels; hypoglycemia is corrected w/
feedings and its normal
When do I Need to Intervene? = <40mg/dL or frequent BG drops = glucose monitoring,
feeding, and meds
3-Circumcision Care and Recovery
Circumcision -> different ways it can be preformed (circ board, yellen [Gomco] clamp,
PlastiBell device, Morgen clamp])
Pain Mx for Circumcision -> EMLA cream, Dorsal Penile block, sucrose, and swaddling
Care of the Newly Circumcised Infant (GO BACK TO BOOK)
-check for bleeding at site w/ each diaper change (apply gentle pressure w/ gauze if bleeding
changes; notify hcp -> if continues)
-NB should have a wet diaper 2-5 times/day first 1-2 days after birth; clean site w/ water only
during first 3-4 days; during 4-7days clean w/ petrolatum; sponge bath for first week
Normal Findings -> yellow exudate 24-48hrs after for 2-3 days; redness/swelling = infection
4-Physiologic and Pathologic Jaundice
Hyperbilirubinemia -> elevated levels of unconjugated bilirubin in plasma
Assessment and Screening -> universal predischarge bilirubin screening (AAP), TcB
(transcutaneous bilirubin level), TSN (total serum bilirubin level)
Mx of Hyperbilirubinemia -> phototherapy, eye protection, IVF, and exchange transfusion
Phototherapy -> used to conjugate hyperbilirubinemia; provide eye protection; administer
fluids; no clothes; diaper on baby
Pathologic Jaundice (CONCERNING) -> *appears win 24hrs of life; causes the hemolysis of
RBCs; serum bili level >95% for age; mainly caused by *ABO incompatibility;
***NEUROTOXICITY CAN OCCUR
Other Causes of Pathologic Jaundice -> liver disease, bile duct obstruction, enclosed
hemorrhage
S/S of Pathologic Jaundice -> lethargy, hypotonia, irritability, s/c/d; **acute bilirubin
encephalopathy (acute); **kernicterus (long-term damage)
Physiologic Jaundice (EXPECTED) -> *appears after 24hrs of life; occurs in 60% of term NBs;
resolves w/o intervention; *serum bili (5-6mg/dL by 72-96hrs); *”manila envelope” skin
A-Breastfeeding Associated Jaundice -> non-pathologic, usually d/t insufficient intake, con
feedings = encourage feedings
How to tx physiologic jaundice? -> breastfeeding
5-CCHD Screening (When and What to Watch)
CCHD (Critical Congenital Heart Defects) -> group of heart defects that cause serious,
life-threatening sx
Mx of CCHD -> intervention w/in first days or first year of life
***TOF (Tetralogy of Fallot) Four Features (WHAT TO WATCH OUT FOR)
-VSD, pulmonary valve stenosis, right ventricular hypertrophy, and overriding aorta
Nursing Care for CCHD -> assess infants for abnormalities; report sx immediately for tx
Mx of CCDH -> administer cardiotonic meds and diuretics; provide neutral thermal environment;
gavage feeding; prevent crying if it causes cyanosis
***(WHEN) Tests -> CCHD prior to discharge, ECHO, and cardiac cath
Types of CCHD
1-PDA (patent ductus arteriosus) and ASD (arterial septal defect) -> increase pulmonary
flow
2-COA (aorta coarctation) -> obstructive defects
3-TOF (tetralogy of fallot) -> decreases pulmonary blood flow
4-TGV (transposition of the great vessels) -> mixed defects
CCHD Screening -> occurs between 24-48hrs of birth; place pulse-ox on right hand or foot
Child Passes CCHD Test If -> sp02 >97%; difference between two readings is <3%
6-Shoulder Dystocia (should be review but, realistically, no)
Shoulder Dystocia -> condition in which the head is delivered, but the anterior shoulder cannot
pass under the pubic arch’ cause (large fetus [>4kg])
Signs of Shoulder Dystocia
-slow progress of 2nd stage of labor; large caput; +turtle sign (retraction of fetal head against
perineum)
Complications of Dystocia
-fetal (skeletal and nerve injury); maternal (laceration and hemorrhage)
Management of Shoulder Dystocia -> McRoberts Maneuver and Suprapubic Pressure
7-Transient Tachypnea of the NB
Transient Tachypnea of the Newborn (TTN)
-progressive, transient respiratory distress during the transition phase; occurs 1-2hrs after birth
Cause of TTN -> delayed clearance of fetal lung fluid; usually resolves in 48-72hrs
Rx Factors for TTN -> maternal diabetes, asthma, male baby; macrosomia, c/s, maternal
sedation; poor uterine perfusion, and debris in trachea (meconium)
Presentation of TTN (S/S) -> tachypnea, mild cyanosis on room air, grunting/nasal flaring, mild
retractions
Mx of TTN -> apply pulse oximetry; administer 02 via blow-by; hold feeds; chest x-ray
8-Types of Heat Loss
Thermoregulation -> balance between heat loss and heat production; *3rd most critical to NB
survival
**During the First 12hrs -> neonate works to achieve thermal balance while adjusting to
extrauterine life; hypothermia is the most common and dangerous problem
Hypothermia -> excessive heat loss (common and potentially serious problem for neonate);
**hypothermia temp = <96.7
Reasons why Newborns are at Rx for Heat Loss
1-thin layer of SQ fat (less fat, greater heat loss)
2-vessels close to the surface of the skin
3-larger body surface-to-body weight (mass) ration than children and adults
***Neutral Thermal Environment -> ideal temp environment that allows the NB to maintain a
normal body temp to minimize 02 and glucose consumption
***Goal of Care -> maintain thermoneutral environment for the newborn
Different Types of Heat Loss
1-Conduction -> loss of heat from body surface to cooler surface in direct contact
**EX = **baby on warm surface after delivery (*place baby on SSC or radiant warmer after
delivery)
2-Convection -> loss of body heat to cooler outside air
**EX = baby getting hit cold air (*keep unit warm, swaddle, and apply NB hat)
3-Evaporation -> moisture vaporization from the skin
**Ex = baby’s body heat leaving their body (*dry NB after birth/bath)
4-Radiation -> loss of heat to a cooler surface not in direct contact
**EX = sunlight on NB (**move cribs/exam tables away from windows, avoid drafts)
9-Signs of Resp Distress
-***ANSWERED ABOVE IN ASSESSMENT***
10-Initiation of Breathing
Chemical Factors that Initiate Breathing (anatomy)
-chemical receptors detect low 02, high C02, and decreased BF -> decreased BF to fetus ->
stimulates uterine cont. -> respiratory center stimulated
Important Consideration -> clamping of cord lowers prostaglandins -> initiates respiration
Mechanical Factors that Initiate Breathing
-vaginal squeeze of fetal ribcage (releases negative pressure in lungs to inflate) and crying
(promotes positive air pressure in alveoli = holds it up)
Thermal Factors that Initiate Breathing
-temp change -> skin receptors activate respiratory system f
Sensory Factors that Initiate Breathing -> sensory input (ex = handling, pain etc) stimulate
breath
11-Caput Succedaneum v Cephalohematoma
1-Caput Succedaneum -> edematous area on scalp; present at birth; **crosses suture line;
result of labor (pressure of presenting part on the cervix and vacuum extraction deliveries =
caput)
-absorbs w/in 24hrs to a few days
2-Caput Cephalohematoma -> collection of blood between skull bone and periosteum; **does
not cross the suture line; located on parietal bone; firmer than catput; painful to touch; resolves
2-3wks to 3 months after birth
12-Congenital Hip Dysplasia (aka: Development Dysplasia of the Hip)
NB Assessment: Maneuvers for Hip Dysplasia
1-Barlow Maneuver -> abduction of hips w/ gentle downward pressure to feel for displacement
of acetabulum
2-Ortolani’s Maneuver -> downward hip pressure w/ gentle abduction; listen and feel for “click”
w/ hip dislocation
What indicates hip dislocation? -> asymmetrical thigh/gluteal folds; shortened thigh
Tx of Hip Dysplasia -> Pavlik Harness -> applied by PT/OT (soft splint)
13-Initial Meds for NBs
Eye Prophylaxis -> erythromycin ophthalmic ointment, 0.5% (apply ribbon on eye); prevents
ophthalmia neonatorum or neonatal conjunctivitis
Vit K Administration -> 1mg dose (>1500g newborn), IM; site (vastus lateralis); coagulation
factor for NBs that are given *immediately after birth to counteract potential bleeding;
administered b/c vit k synthesis is temp deficient in NBs
14-Fetal Heart Adaptations and NB Flow
Fetal Circulation -> cord clamping inc SVR; gas exchange done by the placenta; blood from
placenta flows through umbilical vein approaches liver and mixes w/ portal circulation
-flows from ductus venosus and enters inferior vena cava
1-Fetal Circulation Flow (heart)
R. Atrium -> foramen ovale -> L atrium -> L ventricle -> aorta -> body
2-Fetal Circulation (heart pt.2)
SVC -> R atrium -> R ventricle -> pulmonary artery -> ductus arteriosus -> descending aorta
(bypasses the lungs)
At the End -> blood returns to the placenta via umbilical arteries
Five Major Circulation Adaptations After Birth
Umbilical Vein -> if cord is clamped = ceases umbilical vein circulation
Ductus Venosus -> fetal blood vessels connecting umbilical vein from placenta to inferior vena
cava; *bypasses the liver and carries 02 blood; becomes ligament/functionally closes in 2-3mon
Foramen Ovale -> shunts 02 blood from right atrium to left atrium to left ventricle; functional
closure 1-2hrs after birth (d/t inc arterial pressure), anatomical closure w/in 30min
Ductus Arteriosus -> connection between pulmonary artery and descending aorta which
bypasses the lungs; protects the lungs against circulatory overload
-carries 02 blood to 02-poor blood; functional closure w/in 24hrs after birth, anatomical closure
w/in 3-4wks after birth
Two BIG Changes After Birth -> placenta is removed from the circulation; lungs take in air
15-Infant Abduction
Teaching about NB Abduction
-teach mothers to identify hospital personnel; never leave baby alone in the room; request 2nd
staff member to verify identity of anyone who wants to take baby out of the room
-exert caution when posting photos of newborn online
16-Discharge Teaching
-educate on diaper rashes and other (rash on cheeks = erythema toxicum); clothing; car seat
safety; safe sleep; bathing; cord care
Cord Care -> should be able to visualize 2 arteries & 1 vein; cord will dry and fall off w/in 7-10
days; diaper should be folded under the umbilical cord
17-Reflexes
Moro (startle) Reflex (How to Test?)
-hold infant in semi sitting position and allow head/trunk to fall backwards or place infant in
supine position and clap
Positive Moro Reflex -> NB gets scared (symmetric abduction and extension of arms; cry may
follow or motor movement); *preterm infants fall backward b/c of weakness
Palmar Reflex -> place finger in palm of hand; + = (NB’s fingers curl around finger)
Plantar Reflex -> place finger at base of toes; + = (toes curl toward around finger)
Babinski Reflex -> stroke foot upwards w/ finger; + = (all toes hyperextend)
Steeping (“Walking) Reflex -> hold infant vertically under arms and allow one toot to touch
table surface; + = (infant will start walking); *positive signs of a healthy baby
Rooting and Sucking Reflex -> touch infant’s lip, cheek, or corners of mouth w/ nipple or
finger; + = (infant turns head towards stimulus and opens mouth)
Swallowing Reflex -> feed infant; + = (swallowing present)
Extrusion Reflex -> newborn forces tongue outwards when the tip of the tongue is touched
Extra Notes (From Lecture)
Thermogenesis (Babies Can’t Shiver)
-neonates generate heat by increasing muscle activity (restlessness, crying) or flexion to
decrease heat loss
-internal heat loss reduced via constriction of blood vessels; increase in BMR in major organs ->
increases 02 and glucose consumption
Non-Shivering Thermogenesis
-involves the use of **Brown Fat which has a richer vascular/nerve supply than ordinary fat
-intense lipid activity in brown fat warms the newborn by increasing heat production
Distribution of Brown Fat
-the amount of brown fat reserve increases w/ gestational age; preemies are more at rx for cold
stress
Hypo/Hyperthermia and Cold Stress
When NB Temp Drops -> vasoconstriction occurs to conserve heat, resulting in hypothermia
-infant presents w/ pale, mottled, cool skin
***If Hypothermia is Not Corrected = COLD STRESS
S/S of Cold Stress
1-RR increases (increased need for 02) oxygen consumption is double leading to hypoxia and
intracranial hemorrhage)
2-BMR increases (glucose/glycogen stores consumeD)
3-Both Metabolic/Respiratory Acidosis Occurs
Hyperthermia -> less common than hypothermia; *temp >99.5
Important Consideration for Thermoregulation
-the best place for a stable baby is skin-to-skin = mom’s temp increases/decreases according to
the baby
Thermogenesis Extra -> in response to cold, the neonate attempts to generate heat by inc
muscle activity (cry, appears restless; unable to shiver);vasoconstriction occurs to conserve heat
(finant pale/mottled);
***Signs of Hepatic System Problems -> hypoglycemia, hyperbilirubinemia, and prolonged
bleeding
Bruising during Birth -> increases the NB’s rx for hyperbilirubinemia
Erythema Toxicum -> appears first 24-72hrs; lasts up to 3wks
Molding -> shaping of fetal head by overlapping of the cranial bones; facilitates movement
through birth canal during labor
Extra Notes Pt.2
Initiation of Breathing Matching
Chemical -> receptors are activated by decreased 02; increased C02 and decreased pH
Mechanical -> vaginal squeeze of the rib cage; crying promotes positive pressure on the alveoli
Thermal -> drastic temp change
Sensory -> handling, suctioning, drying, and pain associated w/ birth
*Always clear the baby’s nose b/c stuffy nose obstructs breathing since NBs are nose breathers
When is acrocyanosis concerning? -> when it becomes central cyanosis
What is abd breathing in NBs? -> breathing in which the chest and abd rise simultaneously
S/S of Poor Cardio Transition -> murmur + poor feeding; persistent brady/tachycardia, central
cyanosis, unequal/absent pulses
RR/HR -> take it for the full 1-min
How can babies generate heat? -> crying, vasoconstriction, muscle abduction
WBCs -> increase in both the baby and mother (23-24k)
*RBCs decrease during the first month -> puts the pt at-rx for hyperbilirubinemia
S/S of Hypoglycemia -> jittery, asymptomatic, seizures, apnea, and lethargy
Desquamation -> peeling of the skin that occurs a few days after birth
Mongolian Spots -> blue-black areas of pigmentation, common on the back/buttocks (will fade
gradually)
Nevi -> superficial capillary defect; they are small, flat, pink, and blanchable (fade over time)
Nevus Flammeus -> port-wine stain
Molding -> crossing over of the parietal bones; helps fetal head get through birth canal
Subgaleal Hemorrhage -> bleeding in the subgaleal compartment; common in vacuum births;
life-threatening blood loss
How is it detected? -> boggy head on palpation
Mx of Subgaleal Hemorrhage -> blood transfusion and administer clotting factors (vit K?)
Sensory Behaviors (Normal Findings)
-visual acuity is low but the NB will fixate on faces/close objects; can follow stimulus side-to-side
-acute hearing after birth (able to recognize/prefer human voices); olfactory sense becomes
more refined over first week (NB can smell breast milk after birth and may recognize parents by
smell)
-rooting, suck, and swallow present at birth; tactile stimulation results in infant response
Hospital Safety and Abduction
-always ask who a hospital personnel is before going into pt room (even if their wearing scrubs)
Circumcision -> REQUIRES PARENTAL CONSENT; do NOT remove yellow exudate on
baby’s penis (granular tissue = indicates healing)
Non-Pharmacological Mx of Circumcision Pain -> swaddle/breastfeeding
Part 2 (Ch.34)
1-Respiratory Distress
RDS (Respiratory Distress Syndrome) -> lack of surfactant which causes progressive
atelectasis; life-threatening (affects 90-98% of premature infants)
Clinical Manifestations of RDS -> signs of respiratory distress
**Nursing Mx of RDS -> provide respiratory support, ventilation/oxygenation, and surfactant
Respiratory Function -> lung of preterm infants (more than 6wks early) lack adequate
surfactant; lungs are noncompliant (don’t expand easily; hard to breathe in)
-preterm infants are prone to atelectasis; inc energy required to breathe (breathing is hard);
baby breathes shallowly and rapidly
Signs of Respiratory Distress in Infants -> poor cough/gag reflex; narrow respiratory
passages; weak respiratory muscles
2-Preemie Priority Care
Important Terms to Understand Questions
High-Rx Newborn -> classified based on the following factors -> birth weight (BW), gestational
age, predominant pathophysiologic problems
Preterm Infants -> majority of high-rx infants are those born at <37wks gestation; organ
systems are immature and lack adequate bodily nutrients
-potential problems and care needs of a preterm infant weighing 4.4lbs (2000gms) differ from
those of a term or post-term (post dates) infants
Classification of High Rx Infants (damn)
1-***Size Values*** -> LBW (<2500gm); VLBW (<1500gm); ELBW (<1000gm)
AGA (appropriate for gestational age) = BW btwn 10th and 90th percentile
SFD/SGA (small for gestational age) = IUGR
LGA (low gestational age) = falls >90th percentile (8.8lbs [4000g]) at birth or more)
Preterm -> birth before 37wks
Late Preterm -> 34wks through 36wks and 6 days
Early Term -> 37wks through 38wks and 6 days
Full Term -> 39 wks through 40 wks and 6 days
Late Term -> 41wks through 41wks and 6 days
Post-Dates -> born after 42wks
Extremely LBW (ELBW) -> BW <1000grams; practical and ethical dimensions of resuscitation
Preterm Respiratory Care
1-Respiratory Assessment -> identify if NB requires resuscitation; find gestational age; pay
attention to characteristics of amniotic fluid; NB status (crying, tone of muscle)
2-Neonatal Resuscitation -> infants that don’t respond to initial steps taken at birth will require
active resuscitation (NRP)
-provide warmth/ventilation; open airway by positioning head; clear airway; start chest
compressions; administer epinephrine or volume expansion
3-Oxygen Therapy -> given warm and humidified; proceed to resuscitation only if needed;
**Nasal Cannula (for infants who require low-flow amounts of 02)
4-CPAP -> noninvasive ventilation that reduces the need for mechanical ventilation; used in
infants that cannot maintain adequate partial 02 despite administration of 02
5-Mechanical Ventilation -> used when other means of therapy have failed to maintain
oxygenation; used for pts w/ severe hypoxemia/hypercapnia and respiratory distress
6-Pharmacological Interventions
A-Surfactant -> maintains lung expansion in preterm <34wk infants; given in adjunct to 02 and
ventilation therapy; administer via endotracheal tube
B-Nitric Oxide -> gas that causes sustained pulmonary vasodilation pulmonary circulation; can
be used in conjunction w/ surfactant therapy, ventilation, and ECMO
C-ECMO (extracorporeal membrane oxygenation) -> used to sustain life secondary to
respiratory and cardiac failure; not used in infants <34wks
-it is a heart-lung machine supplies blood to circulation allowing the lungs to rest
Weaning from Respiratory Substance -> weaning is gradual; spontaneous respiratory effort
must be present to wean; pt is extubate then placed on CPAP
-weaned to 02 using hood or nasal cannula; monitor pt’s 02 levels and blood gas levels’ observe
for s/s of poor tolerance (inc HR, respiratory distress, and cyanosis)
-inc oxygen if poor tolerance and proceed slower w/ weaning
Weight and Fluid Loss or Gain in Preterm Infants -> take daily weights; look for insensible
water loss (IWL) -> evaporative water loss through skin and resp tract
Nursing Actions -> correct fluids; weigh pt and document after each void/stool; tx underlying
cause; adjust incubator temp
Feeding Methods for Preterm Infants
1-Oral Feeding -> human milk (preferred) or formula
2-Gavage Feeding -> breast milk or formula via orogastric (preferred) or NG tube
3-Gastronomy Feeding -> surgical placement of feeding tube through and into stomach
4-Parenteral Nutrition -> supplemental feeding to infants that cannot tolerate neutral
-**feedings are inc in quantity/frequency based on daily assessment (weight gain/loss, ability to
tolerate feeding, and sucking pattern)
Non-nutritive Sucking -> pacifiers are offered while infant is having TPN, gavage feeding, or
between oral feeds
**Benefits of Non-Nutritive Sucking -> improves oxygenation; reduces restlessness and inc
weight gain; improves sucking skills; eases transition from gavage feeding to bottle feeding
Developmental Care for the Preterm Infant
-positioning (keep side-lying or prone; use blanket rolls/swaddle infants; keep extremities close
to the body); reduce stimuli (decrease noise and dim lights)
-communication (observe behavioral cues; infants on ventilator will display change in posture
[cannot cry]); kangaroo care benefits (02 maintenance, bonding/comfort, decreased pain)
Pain Mx of Preterm Infant
-assess for pain at the start of every shift and as per unit’s policy; apply unit’s pain assessment
tool; assess behavioral signs of pain (posture/tone, sleep pattern, facial expression, color/cry)
-assess physiological sx of pain (changes in VS and 02 sat)
Nonpharmacologic Tx for Preterm Infant Pain -> resposition, swaddle, cuddle, light reduction
Pharmacologic Tx for Preterm Infant Pain -> morphine
3-NICU III Parent Teaching - Transport
Reasons for Transporting-> decreases neonatal morbidity/mortality; promotes attachment;
provides efficient care to high-rx woman & fetus; maintains health infant fetus
4-IVH Care
IVH (intraventricular Hemorrhage) -> most common intracranial bleeding in preterm infants
mainly those <34wks; can have severe, long-term outcomes
Clinical Manifestations of IVH -> signs of shock, RDS, lethargy
**Nursing Care of IVH -> monitor at-rx infants, observe for changes, *administer 02 and fluids,
support to parents
5-Surfactant
-***ANSWERED ABOVE IN PHARMACOLOGICAL INTERVENTIONS***
6-SGA Risks
SGA -> small for gestational age (<10th percentile weight for gestational age)
Rx of SGA/IUGR -> infections, teratogens, chromosomal abnormalities, maternal/placental
factors
Complications of SGA/IUGR -> perinatal asphyxia, hypoglycemia, polycythemia, and heat loss
7-ROP
ROP (Retinopathy of Prematurity) -> occurs b/c retina is not fully vascularized and is
susceptible to stress or injury; causes abnormal blood vessel growth on the retina and can lead
to blindness
**Nursing Mx of ROP** -> reduce rx of ROP (*administer correct dose02, *keep lighting at a
minimum, assist w/ eye checks) ; ensure pt has a follow-up w/ ophthalmologist before discharge
ROP -> “spaghetti bowl” blood vessel growth can lead to poor oxygenation; rx factor = *lack of
oxygenation
Extra Notes
SIDS (Safe v Unsafe Sleep)
Safe Sleep -> baby should sleep on their back (prone); baby should sleep in crib (both
naps/normal); firm mattress w/ no blankets, pillows, and plushies; no co-sleeping
Premature CNS -> prone to cerebral palsy; vision and hearing
Sepsis -> systemic inflammatory response syndrome d/t secondary infection; early onset (first 7
days of life); late onset (after first 7 days of life)f
Mx of Sepsis -> assess all systems
TOC for Sepsis -> abx, fluids, and antivirals; encourage breastfeeding (has antibodies)
Dx of Sepsis -> peripheral vein blood culture taken from 2 sites; lumbar puncture to test CSF;
perform UA
Part 3 (Ch.35)
1-Maternal Substance Abuse
Neonatal Abstinence Syndrome (NAS) -> signs and neurological behaviors exhibited by
neonates resulting from the abrupt discontinuation of intrauterine exposure to various
substances
Effects of Drugs on Infant
Tobacco -> LBW; perinatal outcomes (miscarriage, placental abruption, preterm birth)
Second-Hand Smoke -> ear infections, asthma, bronchitis, and SIDS
Alcohol -> craniofacial anomalies, microcephaly, mental retardation, FAS (fetal alcohol
syndrome)
Fetal Alcohol Syndrome -> can result in fetal death; causes dysmorphic facial features, growth
deficiency, and CNS abnormalities
Opioids -> prematurity, miscarriage, preterm labor, IUGR, microcephaly, inc rx for SIDS
Marijuana -> social interaction problems, attention deficit disorder
Cocaine -> congenital anomalies, prematurity
Important Consideration -> **a common effect of substance abuse on all infants is IUGR
Withdrawal Sx will be Based on -> timing of last exposure, type of substance, half life of the
substance
Approximate Timing of Withdrawal Sx -> alcohol in utero (w/in 3-12hrs after birth); narcotics
in utero (48-72hrs after birth); barbiturates in utero (between days 1 and 14)
Nursing Interventions for Withdrawal -> review maternal hx; assess neonate (gestational
age, signs of withdrawal); obtain specimen for toxicology screening (urine, meconium)
-use NAS screening tool to assess for signs of withdrawal; IV fluids for nutrition; swaddle w/
positioning that encourages flexion vs extension
-provide a quiet environment w/ dim lights to minimize stimuli; provide nonjudgmental, honest,
supportive care to mother
NAS S/S
1-S/S that Persist for 4 to 6 Months
-sleep disturbance, hyperactivity, feeding problems, hypertonia
2-Withdrawal S/S are Based on
-time of last exposure, type of substance, and half-life
NAS Scale Score that Indicates Tx -> greater than 8
2-IDM - Rx Associated
IDM (Infant of Diabetic Mother) -> inadequate release of maternal insulin that leads to
hyperglycemia; large amounts of glucose crosses placenta to fetus causing fetal pancreas to
release insulin; high levels of maternal glucose and nutrients in addition to fetal insulin leads to
inc fetal growth (macrosomia)
When Ketoacidosis Occurs -> maternal blood becomes acidotic; exchange of gasses is
minimal leading to fetal death (still birth)
Rx and Anomalies R/T IDM -> anomalies higher in type ½ diabetics w/ elevated FBS levels;
anomalies occur in early in preg d/t high levels of glucose or Hgb A1c
-women w/ pre-pregnancy obesity at-rx of anomalies; congenital anomalies occur between
week 5 and 8 of pregnancy (affects cardiac, renal, musculoskeletal, and CNS)
3-NAS Symptoms
Clinical Manifestations of NAS (Neonatal Abstinence Syndrome)
-respiratory (signs of RDS); neurologic (irritability, tremors, high-pitched cry, hyperactivity,
seizures, exaggerated moro reflex); autonomic dysfunction (frequent yawning & sneezing)
-GI (abnormal feeding pattern, disorganized suck)
Box 35.2 (Signs of Neonatal Abstinence Syndrome)
Acute S/S of NAS ->tremors, high-pitched cry, increased muscular tone/DTR, exaggerated
moro reflex
Subacute S/S of NAS -> irritability, disturbed sleep pattern, hyperactivity, feeding problems,
hypertonia
4-Candidiasis Care
Candidiasis -> white patches in mouth
Nursing Care for Candidiasis -> nystatin (antifungal ointment; applied TID for 7-10 days);
hand hygiene (duh); Amph B (Fungizone) or Fluconazole (Diflucan) -> for NBs w/ indwelling
cath or LBW; avoid breastfeeding to unless mother is on antifungals
Candidal Diaper Dermatitis -> reddened perineal area w/ edema
Care of Candidal Diaper Dermatitis -> cleanse site w/ soap & water; plastic pants to cover the
diaper; ointment application (clotrimazole, miconazole) w/ each diaper change
5-Acquired Viral Infection
CMV -> viral infection that can lead to microcephaly and cause intellectual disabilities
GBS -> can cause group-B strep infection; causes neonatal pneumonia, meningitis, and sepsis
Chlamydia/Gonorrhea -> bacterial infections that cause eye infections; tx w/ erythromycin
Rubella -> causes vision and hearing problems if exposed in utero
Tx of HSV -> acyclovir
E.Coli -> gastroenteritis and septicemia
Listeriosis -> causes meningitis
Toxoplasmosis -> can cause hydrocephalus, rash, preterm birth, and IUGR
Pt 4 (Ch.36)
1-NEC (Necrotizing Enterocolitis) -> acute inflammation and necrosis of the GI mucosa
Acute S/S of NEC -> RDS, unstable temp, pallor, signs of shock, and abd distention
**Nursing Mx of NEC ->* tx goal (prevent progression of NEC); *no oral or tube feedings; IVF;
support the family
Dx of NEC -> abd. X-ray confirms dx of NEC
Causes/Rx Factors of NEC -> preterm, intestinal ischemia, bacteria, and enteral feedings;
*formula feedings
2-Gastroschisis Care
Gastroschisis -> herniation of bowels through defect in abd wall w/ no membranes covering
contents; not associated w/ other anomalies; incidence higher among teen mothers (<20yrs)
Mx of Gastroschisis -> protect abd contents (place neonate torso in bowel bag to decrease
insensible water loss), positioning (side-lying position w/ viscera supported using a blanket roll),
I&Os (Replogle tube to prevent aspiration)
Tx of Gastroschisis -> surgical repair (cover exposed viscera w/ sterile gauze and wrap prior
to surgery)
3-Hydrocephalus -> overproduction of CSF or decrease in absorption; common cause is too
much CSF in ventricle d/t aqueductal flow obstruction
Clinical Manifestations of Hydrocephalus-> larger head, increased FOC (fronto-occipital
circumference), larger fontanelles (full or bulging)
Mx of Hydrocephalus -> serial FOCs, surgery to insert shunts may be performed; nurse in
quiet room, head positioning (reposition the head q4h; do NOT position the head on shunt side)
Anencephaly -> absence of cerebral hemispheres
Microcephaly -> small skull/brain
Encephalocele -> herniation of brain/meninges; found in occiput; causes the failure of the end
of the cranial tube to close
4-Diaphragmatic Hernia -> defect in diaphragm, abd organs in thoracic cavity, and poor
development of the lungs
Clinical Manifestations -> resp distress; HR shifted to right; scaphoid abdomen & barrel-chest
Important Finding -> **you will hear bowel sounds over the lungs
Mx of Congenital Diaphragmatic Hernias -> surgery, suction to decompress GI tract, ECMO
5-Cleft Lip/Cleft Palate -> causes are genetic and environmental (infection, DM, and drugs)
Mx of Cleft Lip/Palate -> surgical repair of cleft lip (6mon old) and cleft palate (9-12mon old)
Concerns for Cleft Lip/Palate -> airway mx, **feeding difficulties, and rx for aspiration
Tx of Cleft Lip/Palate -> special feeding bottle for cleft palate (Haberman/Pigeon Feeder);
ongoing emotional support to family
6-Spina Bifida -> failure of neural tube to close sheath that closes to form brain/spinal cord
2 Categories Spina Bifida -> spina bifida occulta (milder) and spina bifida manifesta (could be
meningocele or myelomeningocele)
1-Meningocele -> meninges and spinal fluid that extend through an irregular vertebral opening;
**covered w/ layer of skin
Clinical Manifestations -> paralysis w/ BM & bladder function affected
2-Myelomeningocele -> herniation of spinal cord and neural elements through an opening in
the spine *w/ or *w/o skin or vertebral opening
Clinical Manifestations -> as above, sac can tear w/ leakage of CSF (**TEARS EASILY);
Spina Bifida Occulta -> milder form of spina bifida that presents w/ a hair tuft
Nursing Mx of Meningocele/Myelomeningocele -> prone-kneeling position, protect sac
(moist, sterile procedure, non-adherent dressing; drape over buttocks for protection), skin care;
encourage ingestion of folic acid to prevent
Tx of Meningocele/Myelomeningocele -> surgery to close the defect; neurology and urology
consults; position the baby prone
7-Choanal Atresia -> *congenital atresia of posterior nares by bony or soft tissue obstruction
Clinical Manifestations of Choanal Atresia -> respiratory issues w/ rest; 02 levels rise w/
crying; NGT to check for obstruction
Mx of Choanal Atresia -> oral airway, prone position; testing (CT scan); assess the patency of
nares; sneezing common from clearing fluid out of their system;remove visible secretions w/
bulb suction; *nasal flaring indicates distress look for it
-dangerous, at-rx for aspiration
8-TEF -> abnormal connection between the esophagus and trachea
Nursing Mx of TEF -> care of resp problems (orogastric tube [Replogle Tube] placed to remove
secretions and dec rx for aspiration), maintain position (keep infant in supine position w/ HOB
30-degrees); antireflux/antacids given
Tx of TEF -> surgical intervention, 1 wk of life