Learning Objectives
1. Describe the respiratory and cardiovascular changes that occur in the newborn during the transition from the fetal to the newborn environment.
2. Identify the four causes of newborn heat loss. State at least one example of each. Identify nursing considerations related to the prevention of cold-stress of the neonate.
3. State the four main goals for immediate care of the newborn.
4. Identify the five components of the Apgar score. Identify nursing considerations related to each component.
5. Discuss the procedure for proper identification of a newborn. State nursing considerations related to safety precautions, prevention of nosocomial infections, and completion of birth documentation.
6. State nursing considerations related to Standard Precautions, eye prophylaxis, vitamin K administration, and parental bonding.
7. Discuss the normal ranges of weight and length of the neonate. State nursing considerations related to molding, caput succedaneum, cephalohematoma, anterior fontanel, and posterior fontanel.
8. Define and discuss the nursing considerations related to the following terms: pseudomenstruation, phimosis, acrocyanosis, milia, Epstein’s pearls, erythema toxicum, petechiae, Mongolian spots, lanugo, and vernix caseosa.
9. Define the following reflexes of the newborn: rooting, palmar grasp, Moro’s, tonic neck, Babinski’s, stepping, and sucking.
10. Identify the important elements of information regarding the process of labor and birth that must be reported to the newborn nursery nurse.
11. Identify the components of the initial assessment of a newborn. Include nursing considerations related to each of the following: the umbilical cord, physical measurements, vital signs, respiratory status, and elimination and meconium. Identify the components of a routine assessment of a newborn. Include nursing considerations related to each of the following: vital signs, weight, urine, and stools.
12. State the important nursing considerations related to each of the following: holding a newborn, dressing a newborn, cord care, circumcision, and sleep.
13. State the main benefits of breastfeeding. Define the following terms: colostrum, foremilk, hindmilk, and LATCH. Identify the nursing considerations for each term. State the nursing considerations related to the following common problems of breastfeeding: sore and cracked nipples, engorgement, plugged ducts, and mastitis.
14. Identify the teaching considerations regarding nutrition for the breastfeeding mother. Identify the teaching considerations for the mother who is bottle feeding.
|
IMPORTANT TERMINOLOGY |
|||
|
acrocyanosis |
epispadias |
lanugo |
phimosis |
|
alveoli |
Epstein’s pearls |
mastitis |
port-wine stain |
|
Apgar |
erythema toxicum |
meconium |
prepuce |
|
bonding |
fontanels |
milia |
pseudomenstruation |
|
brown fat |
foremilk |
molding |
smegma |
|
cephalohematoma |
galactosemia |
Mongolian spots |
stork bite |
|
caput succedaneum |
hindmilk |
neonate |
surfactant |
|
circumcision |
hypospadias |
ophthalmia neonatorum |
vernix caseosa |
|
desquamate |
hypothyroidism |
outer canthus |
|
|
en face position |
inner canthus |
||
Acronyms
G6PD
LATCH
LDR
LDRP
PKU
SIDS
The care babies receive and the bond they form with their parents during the first several weeks of life have many effects. These factors influence the growth and development of healthy infants and the closeness of the entire family. As a nurse, you play a special role as a teacher and advocate for family caregivers and their newborns.
A normal baby is born with the reflexes and body systems needed to live outside the woman’s body. By no means, however, is the baby ready to live on its own. The infant cannot meet its own basic needs without help. In this topic, you will learn to assist neonates (newborns during the first 28 days of life) and teach their new parents how to care for them. You will learn about immediate care for healthy newborns, their physical and behavioral characteristics, and the typical care of the infant from the time of birth until the time of discharge.
IMPORTANT CONCEPTS IN NEWBORN CARE
At the time of birth, the neonate must quickly make four dramatic changes to adapt to the world outside the shelter of the womb. These changes are temperature regulation, circulation, respiration, and source of nourishment.
The neonate must also complete these transitions quickly; the first 24 hours of life are critical for the newborn. In providing initial care, the focus is on monitoring and assessing the newborn’s vital systems and keeping the infant warm. The baby’s well-being depends on having a clear airway and effective respiration. Assessing the respiratory and circulatory systems, checking vital signs, and administering cord care are important skills that you will need to master.
Respiration
The changes in respiration are the greatest challenge for the newborn. The baby must begin breathing immediately after birth. Before birth, all of the fetus’ oxygen had been provided through the placenta, where gases and nutrients from the maternal blood diffused into the fetal blood. As soon as the cord is clamped, however, the infant’s lungs become the organs of gas exchange.
Excess secretions in the airway can block breathing and, if inhaled, can cause aspiration pneumonia. Immediately after delivery of the baby’s head, the birth attendant removes secretions first from the mouth, then the nose with either gloved fingers or with a small, soft-bulb syringe (In Practice: Nursing Procedure 67-1).
The change from being enclosed by the muscular walls of the uterus and the bag of amniotic fluid to an air-filled room with light, noises, and stimulation must be quite a shock. The healthy infant responds to the changes in pressure, temperature, gravity, and stimulation by taking the first breath. When the newborn takes the first breath, he or she usually makes the first sounds.
Although the fetus had some breathing movements in utero, the lungs were filled with fluid, and no gas exchange occurred across the lung sacs (alveoli). The first breath expands the air passages and the alveoli. The healthy newborn has enough surfactant—a chemical that stabilizes the walls of the alveoli—to allow the sacs to remain open, rather than collapsing after each breath. This means that the next breath will not require as much effort.
The first few breaths set into process events that (1) assist with the conversion from fetal to adult type circulation, (2) empty the lungs of liquid, and (3) establish neonatal lung volume and function in the newborn. The baby’s respirations may not stabilize for about 2 hours after birth. During that time, some breaths may sound noisy and wet. However, it is abnormal for the respiratory rate to be greater than 60 breaths per minute at 2 hours of life.
If the mother has been medicated, or has had a long-lasting anesthetic, the newborn may not breathe at once and must be stimulated.
Nursing Alert By 2 hours of life, the baby’s respiratory rate should be less than 60 breaths per minute. Apgar numbers are significant and might also be related to NCLEX questions.
Circulation
The circulatory pathway changes abruptly when the umbilical cord is clamped and then cut. At birth, the fetal circulatory structures (the foramen ovale, ductus arteriosus, and ductus venosus) must close to allow blood to flow to the heart, lungs, and liver. If these circulatory changes do not occur spontaneously, the newborn will have inadequate oxygenation because of persistent fetal circulation. Surgical intervention is required to correct this problem.
Nursing Alert It is important to remember that the changes in the circulatory system happen at the same time as the changes in respiration; the transitions to support life after birth by these two systems are completely interrelated.
Body Temperature
When the fetus was inside the mother’s uterus, the temperature was very stable. The fetus had no need to expend energy to maintain its own temperature. After being born, however, the baby must work to keep warm. The baby loses heat by four mechanisms: conduction, convection, evaporation, and radiation (Fig. 67-1).
To counteract the heat loss, the baby has three ways to maintain its temperature: shivering, which is not very efficient; muscle movements, which have only a little benefit; and the production of heat caused by using a stored fat known as brown fat. Only infants born at term have much brown fat, and after it is used, the baby cannot create more. This is one reason that it is so important for the nurse to take steps to keep the baby warm. If the baby needs to work hard to keep his or her temperature elevated, the baby may become cold-stressed. A chain of events then occurs that can be harmful to the baby’s blood sugar, oxygenation, and acid-base balance.
FIGURE 67-1 · Heat loss in the newborn can be caused by any one, or a combination, of the following factors: (A) Conduction: heat loss due to direct contact with a colder surface. (B) Convection: heat loss due to air movement. (C) Evaporation: heat loss due to the cooling effect of water loss on the skin. (D) Radiation: heat loss via infrared heat rays due to body metabolism.
A newborn’s skin has a bluish or dusky tinge at first. As soon as oxygen enters the circulating blood in quantity, the white newborn’s skin turns lighter and assumes a pink tone. Newborns of other races remain slightly darker.
CARE OF THE NEWBORN IMMEDIATELY AFTER BIRTH
It is important to set goals for the immediate care of the newborn. Without goals, actions become merely routines; but if the goals are clear, then it is possible to make a plan to meet them. The importance of each goal and the way that it is addressed will vary from one place to another. Four goals for immediate management of the newborn are to:
1. Establish and maintain an airway and respirations
2. Provide warmth and prevent hypothermia
3. Provide a safe environment and routine preventive measures
4. Promote maternal-infant attachment
NCLEX Alert Clinical situations may ask you to differentiate between the normal newborn and a newborn who needs nursing interventions. Respirations, body temperature, or reflexes may be described in the scenario. Be sure to know how to use the Apgar scores.
Initial Assessment: Apgar Score
The Apgar score was named for the physician who developed it, Dr. Virginia Apgar. A mnemonic for the five criteria of the Apgar score is appearance, pulse, grimace, activity, respiratory effort. It provides a quick and accurate means to assess the newborn’s physical condition at the time of birth. The score is used to determine whether the baby needs immediate assistance or resuscitation. It should be determined at 1 minute and again at 5 minutes after birth. The 1-minute score is most accurate in predicting immediate survival, whereas the 5-minute score may be better in predicting long-term survival and any neurologic damage. If the Apgar score is less than 7 points at the 5-minute measurement, a third Apgar reading may be obtained at 10 minutes after birth.
Five criteria are assessed each time (Table 67-1). To obtain an Apgar score, give a number from 0 to 2 on each area of the Apgar scoring chart to the infant. Then total all the numbers. Record both the 1- and 5-minute Apgar scores on the newborn’s chart.
TABLE 67-1. The Apgar Score
|
|
SCORE |
|
|
|
|
0 |
1 |
2 |
|
Heart rate |
Absent |
<100 |
>100 |
|
Respiratory effort |
Absent |
Slow, irregular |
Good, crying |
|
Muscle tone |
Flaccid |
Some flexion of extremities |
Active motion |
|
Reflexes, Irritability |
No response |
Weak cry or grimace |
Vigorous cry |
|
Color |
Blue, pale |
Body pink, extremities blue |
Completely pink |
The following list describes the meanings of the Apgar scores:
• If the total score is 10, the newborn is in the best possible condition.
• If the score is 7 to 9, the newborn usually does not need resuscitation.
• If the score is 4 to 6, the newborn is in danger.
• If the score is 0 to 3, the newborn needs emergency resuscitation.
Nursing Alert If the Apgar score is 7 or less, a person who is skilled in neonatal resuscitation should evaluate the infant and provide immediate assistance.
Neonatal Resuscitation
If breathing does not begin either spontaneously or following tactile stimulation, the newborn’s respiratory center is probably depressed. You must take emergency action. The newborn must be resuscitated immediately; permanent brain damage can occur if the newborn is without oxygen for more than approximately 4 minutes.
The purpose of resuscitation is to establish an airway, provide oxygen to the lungs, and stimulate the newborn to breathe. When respiratory difficulties develop in the delivery room, the birth attendant or anesthesiologist assists the newborn. When a baby develops complications in the newborn nursery, however, you may be the person to begin the resuscitation efforts (see In Practice: Nursing Procedure 67-1).
Maintaining Body Temperature
Even with the birthing room temperature set at 75°F (23.9°C), the air is a cold shock to the baby emerging from the warm mother’s body, still wet with amniotic fluid. Lifting the newborn onto the mother’s bare stomach or chest, perhaps even before the cord is clamped or cut, lets the heat of the mother’s body transfer to the newborn. The baby should also be quickly dried, and all wet towels and blankets should be promptly removed and replaced with dry ones. Warm towels or receiving blankets should be placed over mother and newborn. The infant will lose a great deal of heat from its head, so many hospitals and birth centers place a cap on the baby’s head to conserve warmth. When it is time for the infant assessment, using a radiant warmer, a prewarmed mattress, and warm instruments provides a heat-gaining, rather than a heat-losing, environment (Box 67-1). The goal of thermoregulation is to balance heat loss and heat production and create a neutral thermal environment.
Clamping and Cutting the Cord
The birth attendant will decide when to place two Kelly clamps on the umbilical cord. Delaying this procedure allows the infant to receive additional blood from the placenta. Whether or not this is best for the baby depends on the gestational age of the baby, the health of the mother and baby, and other factors. After the cord is clamped, the infant must obtain oxygen through its own respiratory effort. The cord is cut between the two clamps; usually a cord blood sample is obtained from the portion of the cord still attached to the placenta.
BOX 67-1.
Conserving Heat for a Newborn
There are several things you can do to help a newborn maintain its temperature.
In the Delivery or Birth Room
♦ Prewarm any blankets, towels, hats, or clothing before the birth.
♦ Dry the baby immediately
♦ Replace wet blankets or towels after drying the baby.
♦ Prewarm the infant resuscitation area.
♦ Set birth room temperature at 75°F (23.9°C).
♦ Do not lay the baby on wet sheets while being suc-tioned.
In the Nursery
♦ Transport the newborn in an isolette with the portholes closed.
♦ Place newborn care areas away from windows, outside walls, doorways, and drafts.
♦ Keep the newborn’s head covered and the body well wrapped for the first 48 hours.
♦ Postpone the newborn bath until the baby’s temperature has been stable for 2 hours at about 97.6°F-98.6°F (36.5°C-37°C).
♦ Bathe the newborn under a radiant heater:
♦ Do not wash off all vernix (protective material on skin) initially
♦ Cover work table and scales so they are not cold.
♦ Organize work so that the newborn is uncovered only briefly.
♦ Heat any oxygen or humidified air given.
After the baby is dried, he or she is handed either to a nurse or to the mother for skin-to-skin contact. This can be done before the Kelly clamp is replaced with a plastic umbilical cord clamp. When replacing the Kelly clamp with a plastic umbilical cord clamp, be careful to place the clamp 1-2 cm above the umbilicus, taking particular care not to clamp any of the baby’s skin along with the cord. The Kelly clamp is removed only after the plastic clamp is applied.
Nursing Alert Leave the Kelly clamp on the cord stump until after the plastic umbilical cord clamp has been applied. Otherwise, the infant will lose blood through the cord stump.
