OB Unit 4
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OB Unit 4 Care of the Newborn Rev. 2015 Neonate Term used for a child in the first 4 weeks of life Initial Care & Assessment of the Newborn Immediately After Birth Assess: Respirations Heart Rate Temp APGAR Warmth Identification Done in delivery room 2 ID bands (ankle & wrist) on newborn 1 ID band on mother Footprinting & fingerprinting Protection of Disease Eye prophylaxis w/ Erythromycin Vitamin K injection Spine & Extremities Straight without curves Dimples, tufts of hair and masses Syndactyly/Polydactyly Single crease Equal leg length Simian Crease Bonding Promotion of attachment between neonate & family Should begin immediately Characteristics of the Normal Newborn A. Weight & Length Weight ranges from 5.5-10 lbs. Loses 5-10% during the 1st few days after birth Length ranges from 18-22 inches B. Head & Body Lg. Head (13-14”) Short neck Chest smaller than head (12-13”) Large protruding abdomen Head irregularly shaped “molded” Caput succedaneum Cephalhematoma Both resolve on their own Reassure parents C. Fontanels Soft spots Anteriorabove forehead, diamond shaped,closes bet. 18 mos. Posterior@ crown of head, Triangular, closes at 2nd mo. D. • Blue Eyes or gray @ birth • Appear cross-eyed, unable to focus • Eyelids red/edematous • No tears E. Ears Positioned with outer canthus of the eye High pitched sounds Mothers voice F. Skin • Rashes are common • By 3rd day, more natural tone • Acrocyanosis • Harlequin sign G. Jaundice • Pathological occurs w/i 24 hrs Abnormal • Physiologic May occur in 2-3 days Normal • Immature liver • Elevated bilirubin Treatment Freq. Feeding q 2-3 hrs Sunlight Phototherapy Monitor temp Allow for bonding Influences of Maternal Hormones on Neonate gynecomastia Edematous labia in females Pseudomenstruation Large scrotum Common Skin Observations IN THE NEWBORN….. Milia Erythema toxicum Stork bites Mongolian spots Port wine stain Epsteins pearls Various birthmarks Petechiae Lanugo Vernix caseosa Harlequin sign Mongolian spots Normal Activities and Reflexes Of the Neonate…. Rest & Sleep Sleeps ~ 17 hrs/day Awakens easily Cries when hungry or uncomfortable Arms & legs move freely & symmetrically Reflexes Rooting Reflex Sucking Reflex Dance or Step Grasp Moro or Startle Tonic neck reflex Babinski reflex Newborn movements are jerky due to immature nervous system Senses • Sight • Hearing • Touch • Smell & Taste Protection of the Newborn Preventing Infant Abduction Essential role of nurse Proper ID w/ badge Visitors required to check in Sensors, alarms, exits lock automatically Daily Newborn Care Nursing Assessment Every day, assess : Vital Signs Weight Eyes, Nose & Ears Elimination (Urine & Stools) Umbilical Cord Urination Usually 4-8 hrs fol. delivery Be sure baby voids & document Should have 6-8 wet diapers/day STOOLS Meconium1st stool Transitional stool Milk stool Meconium stools MILK STOOLS Hypothermia Caps Clothing Blankets Warmer/isolette Incubator Cleansing the Newborn 1st bath after Temp = 98.6 Assess skin color; assess for blemishes, rash,abnormal jerking, twitching, bleeding, or congenital abnormalities during bathing Use mild soap sparingly Special attention to skin folds Observe for bleeding at circumcision site first 12 hrs. Circumcision Part or all of foreskin is removed Ritual for all Jewish babies Must be kept clean Assess for bleeding, swelling, & voiding Normal Anatomy Gomco Clamp Plastibell Hollister Plastibell Technique Pros & Cons of Circumcision…Check it out ! http://www.everydayhealth.com/kids- health/the-pros-and-cons-ofcircumcision.aspx Critical Thinking Scenerio The nurse enters the room of a postpartum female who is crying. This woman is in her second day PP and is due to go home this afternoon. The nurse asks why the patient is crying. The patient informs the nurse she is afraid of harming her baby; she is not sure how to bathe him, how to care for his circumcision or how to determine his needs once she is home. How can the nurse respond? Infant Feeding Suck & swallow reflexes are present at birth Feed on “demand” Every 3-4 hrs Advantages of Breastfeeding Colostrum decreases allergies Superior nutrition Economical Readily available Promotes transfer of maternal antibodies Breast feeding tips for success Tickle mouth to trigger rooting reflex Entire areola in mouth not just nipple Place finger in mouth to break suction Diet when breastfeeding Inc. calories by 500/day Inc. Milk (1qt./day) Inc. fluids ETOH inhibits let-down reflex & found in breastmilk Caffeine is transferred Consult MD re: medications Bottlefeeding 1-3 oz per feeding1st wk Total of 15 oz in 24 hrs Intake increases rapidly after 3 wk Always hold infant when feeding Do NOT prop bottle Wash hands before & after Right side-lying to prevent regurgitation Burping During and after each feeding Done whether breast or bottle feeding Hold upright on knee or against shoulder DISORDERS OF THE NEONATE Group B Strep ( GBS) Life threatening infection Caused by bacterium Common cause of sepsis and meningitis and pneumonia in newborns Diagnosis & Treatment Vaginal swab at 35-37 wks Women with +GBS are given antibiotics at time of labor PCN is safe and effective Mom PCN or Ampicillin newborns Gestational Age • Preterm • Term • Post term Gestational Size A.G.A. S.G.A. L.G.A. L.B.W. Nursing Considerations With Preterm Neonates Conserve Energy Handle as little as possible Delay bathing Special care to keep warm Feeding No food for 36 hrs Very small amounts on a 2-3 hr Reflexes may be weak or absent Gavage (NG) or expressed milk using a nipple Elimination Kidneys not fully developed Weigh diaper before & after they urinate Color and Skin ruddy Cyanotic Very skin thin, translucent Respiratory Status Nasal flaring Retractions of sternum and incostal muscles Grunting Air hunger Infection Prevention Good handwashing Contacts with people other than parents is limited Special Care Nursery Respiratory Distress Syndrome (RDS) Leading cause of death Inadequate oxygenation Cause of RDS is unknown Deficiency in pulmonary surfactant Atelectasis is common Symptoms Dyspnea Cyanosis tachypnea Flaring nares Chest retractions Treatment Oxygen & humidity Antibiotics Exogenous pulmonary surfactant Corticosteroids Minimal handling Retrolental Fibroplasia Often led to blindness in preterm newborns Occurs when oxygen concentration is > 40 % for long periods of time Monitor Oxygen bld levels http://www.wisegeek.com/what-is- retrolental-fibroplasia.htm What is Retrolental Fibroplasia? High Risk Newborns are at risk for the following: Meconium Aspiration & Cyanosis…. Meconium/Amniotic Fluid Aspiration Anal sphincter relaxes meconium passes into amniotic fluid Can occur in utero or @birth If first breath is taken prior to suctioning aspiration Cyanosis Blue or dusky color Caused by: Prolapsed cord during delivery Congenital heart defect Medications (analgesics) GI Disturbances of High Risk Neonate Vomiting, Diarrhea Dehydration Vomiting Congenital Birth defects injury Infection Distinct difference between Vomiting & spitting up Diarrhea Most commonly caused by bacteria May be formula or an allergy Stool is formless, greenishyellow & foul smelling Necrotizing Enterocolitis Bowel wall necrose & die Common in preterm babies SX: lethargy, abd. Distention, hypothermia, apnea & irritability Treatment NG tube to suction IV fluids TPN Antibiotics Surgical resection PRN Hypoglycemia Blood sugar < 40mg/100ml S/S : tremors, irritability, jittery, apnea & tachycardia Tx 10-15% glucose water Erythroblastosis Fetalis Occurs when Rh- mother has an Rh+ feturs Condition is uncommon today Preventable with RhoGAM Birth Injuries Fractures Fractured clavicle most common Sx: asymetrical Moro reflex and crying when affected arm is moved Fx will heal w/o difficulties Intracranial Hemorrhage Primarily problem of preterm newborns Other causes: dystocia, precipitate labor & delivery or prolonged labor Symptoms Seizures Respiratory distress Cyanosis Shrill cry Muscle weakness Treatment HOB slightly elevated Oxygen Vitamin K Antibiotics Anticonvulsive meds sedatives Brachial Plexus Injury Results from trauma during a difficult delivery SX: unable to elevate arm, hand or forearm TX: ROM, splinting Toddler with positional deformity of hand and arm (birth-Erb's palsy) Facial Paralysis Bell’s Palsy Result of forceps delivery One side of face affected Sucking reflex impaired Most cases are temporary Congenital Disorders Abnormality that exists at birth MUSCULOSKE LETAL Congenital Disorders Talipes ( Clubfoot ) One or both feet turn out of normal position Occurs more often in boys Excellent prognosis Tx: braces, casts, special shoes Congenital Dislocated Hip More frequently in girls Treat early to prevent permanent damage Limitation of abduction is 1st sign One leg shorter than other Skin folds are asymmetrical X-ray needed to confirm TX: stabilizing head of femur Polydactylism & Syndactylism PolyExtra finger or toe Suture used to tie off appendage Occ. Surgery is necessary SynFusing together of Polydactyly Syndactyly Nervous System Disorders That would make an Infant “High Risk” Hydrocephalus Overabundance of CSF Enlarged head,bulging fontanels, irritability TX: VP shunts inserted into ventricles to drain Measure head circumference daily Spina Bifida Vertebral spaces fail to close Spinal contents herniate into a sac Meningocele Myelomeningocele Spina Bifida is a condition caused by a neural tube defect. Surgery to correct Prognosis depends on deformity’s extent Folate(Folic Acid) reduces the risk for neural tube defects Down Syndrome Trisomy 21 Physical and mental manifestations range from mild to severe Mental retardation & heart defects also exist Trisotomy 21 Anencephally Part or all of the brain is missing Skull is flat Newborn will live for only a short time Infants born with anenceph aly have either a severely underdevel oped brain or total brain absence. A portion of the brain stem usually protrudes through the skull, which also fails to develop properly. (Gale Group.) Microcephaly Abnormally small head Brain does not develop normally Almost always mentally retarded Cardiovascul ar Disorders That would make an infant “High Risk” Review : PDA ASD & VSD Tetrology of Fallot Coarctation of Aorta Respiratory Disorders That would make an infant “High Risk” Choanal Atresia Nostrils are closed at the throat entrance Quickly corrected w/ surgery G.I. Disturbances That would make an infant “High Risk” Esophageal Atresia Esophagus ends in a blind pouch Immediate surgery TPN in interim for nutrition Tracheoesophageal Fistula Opening between esophagus & trachea 1st sign Choking with first feed Life threatening Emergency surgery Tracheoesophageal Fistula Pyloric Stenosis Pyloric opening constricts Food cannot pass through into intestines Projectile vomiting classic symptom Surgical correction is Infant abdominal hernia (gastroschisis) Imperforate Anus Rectum ends in a blind pouch Suspect, if newborn does not pass a stool within 24 hours of delivery Surgery to correct Imperforate Anus PKU(Phenylketonuria) Baby cannot use the protein, phenylalanine Substance builds in blood Can cause brain damage & mental retardation Symptoms intellectual disabilities or mental retardation seizures tremors or jerky hand and leg movements hyperactivity stunted growth eczema a distinct odor in breath, skin, or urine that is often described as musty lighter skin, hair, and eye color than their family members No cure exists All newborns are tested prior to discharge and at 6 wk Testing is mandatory Galactosemia Cannot digest galactose Galactose builds up & damages brain, liver & eyes SX:vomiting,poor weight gain, yellow color to skin TX: lactose free diet Maternal Conditions Affecting the Neonate TORCH Substance Abuse in Pregnancy Drugs reach fetus through placenta Newborn experiences withdrawal symptoms Newborn is likely to be preterm or LBW Neonatal Abstinence Syndrome Generalized disorder Signs appear w/i 72 hours after birth Lasts from 8-16 wks or longer
