3. Fetal Lung DevelopmentFetal Lung Development (681)(681)
Between 24-28 weeks Surfactant synthesis and
storage begins to occur.
Surfactant (composed of a group of surface
active phospholipids, lecithin and sphingomyelin,
which are critical for aveolar stability.
The newborn born before the
lecithin/sphingomyelin (L/S) ratio is 2:1 will have
varying degrees of respiratory distress.
May need synthetic surfactant if born with
respiratory distress.
4. Breathing MovementsBreathing Movements (pg. 681-684)(pg. 681-684)
Breathing is a continuation of a process that began
inutero.
Lungs convert from fluid filled to gas filled organs.
Pulmonary ventilation must be established through
lung expansion following birth.
A marked increase in pulmonary circulation must
occur.
Mechanical events, chemical stimuli, thermal stimuli,
and sensory stimuli.
Factors opposing the first breath: 1) aveolar surface
tension, 2) viscosity of lung fluid within the
respiratory tract and 3) degree of lung compliance.
6. Transitional PhysiologyTransitional Physiology (pg. 686-(pg. 686-
687)687)
1) Increased aortic pressure and
decreased venous pressure:.
2) Increased systemic pressure and
decreased pulmonary artery pressure.
3) Closure of the foramen ovale:
venosus.
occurs due to increased pressure in
the left atrium.
4) Closure of the ductus arteriosus.
5) Closure of the ductus
8. Heart rateHeart rate
The average resting heart rate for full
term newborns is 120 to 160 (when the
newborn cries the heart rate may exceed
180).
Apical pulses should be obtained by
auscultation for a full minute, preferably
while the newborn is asleep.
The heart rate should be evaluated fore
abnormal rhythms or beats.
9. Blood PressureBlood Pressure
The newborn blood pressure tends to be
higher immediately after birth.
Blood pressure is sensitive to the changes
in blood volume that occur in the
transition to newborn circulation.
Capillary refill should be less than 2 to 3
seconds when the skin is blanched.
10. Blood PressureBlood Pressure
Crying may cause an elevation in blood
pressure.
Blood pressure should be taken while the
newborn is in a quiet state.
Measurement of blood pressure is best
accomplished by using the Doppler
technique or a 1 to 2 inch cuff and a
stethoscope over the brachial artery.
11. Heart MurmursHeart Murmurs
Murmurs are usually produced by
turbulent blood flow.
90% of all murmurs are transient and not
associated with anomalies.
Usually involve incomplete closure of the
ductus arteriosis or foramen ovale.
12. Cardiac WorkloadCardiac Workload
Systemic blood volume and pulmonary
blood volume are not equal in the
neonate.
The right ventricle does most of the
work prior to birth.
The left ventricle increases its workload
after birth and gains in size and
thickness.
Right sided heart defects appear better
tolerated than left sided defects.
14. Temperature RegulationTemperature Regulation
Thermal neutral zone (TNZ)
Heat loss: Convection, Radiation,
Evaporation and Conduction
Heat production (Thermogenesis)
Brown adipose tissue (BAT, brown fat)
Response to heat
15. Hepatic AdaptationsHepatic Adaptations
Iron Storage and Red Blood Cell Production:
1) Iron is stored in the liver until needed for red
blood cell (RBC) production.
2) Newborn iron stores are determined by total
body hemoglobin content and length of
gestation.
3) If the mother’s iron intake has been
adequate, newborn iron stores will be stored to
last until 5 month of age.
4) After about 6 months of age, foods containing
iron or iron supplements may be given to
prevent anemia.
16. Hepatic AdaptationsHepatic Adaptations
Carbohydrate Metabolism:
1) Neonatal carbohydrate reserves are relatively
low.
2) Energy crunch occurs at birth with the removal
of maternal glucose supply and increased energy
expenditure adjusting to extrauterine life.
3) Glucose is the main source of energy in the first
4 to 6 hours following birth.
4) Blood glucose level stabilizes at values of 50 to
60 mg/dL.
5) Glucose level is assessed by using a chemstrip
method on admission to the nursery and at 4
hours of age.
17. Hepatic AdaptationsHepatic Adaptations
Conjugation of Bilirubin:
1) Conjugation of bilirubin is the conversion of yellow lipid
soluble pigment into water soluble pigment.
2) Unconjugated (indirect) bilirubin is a breakdown product
derived from hemoglobin that is released primarily from
destroyed red blood cells.
3) Unconjugated bilirubin is not in an excretable form and
is a potential toxin.
4) Total serum bilirubin is the sum of conjugated (direct)
and unconjugated (indirect) bilirubin.
5) Total bilirubin at birth is less than 3mg/dL.
6) Direct bilirubin is excreted into the tiny bile ducts, then
into the common duct and duodenum. The direct
(conjugated) bilirubin then progresses down the intestines
where bacteria transform it into urobilinogen. This product
is not reabsorbed but is excreted as a yellow-brown
pigment in the stools.
18. Hepatic AdaptationsHepatic Adaptations
Physiologic Jaundice:
Physiologic jaundice is caused by accelerated destruction of fetal
RBCs, impaired conjugation of bilirubin, and increased bilirubin re-
absorption from the intestinal tract.
A normal biologic response of the newborn.
Six factors give rise to physiologic jaundice: 1) Increased amounts of
bilirubin are delivered to the liver, 2) Defective uptake of bilirubin
from the plasma, 3) Defective conjugation of the bilirubin, 4) Defect
in bilirubin excretion, 5) Inadequate hepatic circulation, and 6)
Increased re-absorption of bilirubin from the intestines.
About 50% of full term and 80% of pre-term newborns exhibit
physiologic jaundice on the second or third postpartum day.
There appears a characteristic yellow color that results from
increased levels of unconjugated bilirubin and a temporary inability to
eliminate bilirubin.
The signs of physiologic jaundice occur after 24 hours after
birth.
Breast milk jaundice is controversial and difficult to distinguish from
prolonged jaundice.
19. Hepatic AdaptationsHepatic Adaptations
Coagulation:
Coagulation factors II, VII, IX, and X are
activated under the influence of vitamin K
and are considered vitamin K dependant.
The absence of normal intestinal flora
needed to synthesize vitamin K in the
newborn gut results in low levels of
vitamin K.
Although newborn bleeding problems are
rare, an injection of vitamin K
(AquaMEPHYTON) is given prophylactically
on admission to the nursery to combat
potential clinical bleeding problems.
20. Gastrointestinal AdaptationsGastrointestinal Adaptations
(pg.697-698)(pg.697-698)
By 36 to 38 weeks gestation, the gastrointestinal tract is
adequately mature: 1) enzymatic activity present, 2) able
to transport nutrients.
Lactose is the primary carbohydrate in the breastfeeding
newborn and is usually easily digested and well absorbed.
By birth the newborn has experienced swallowing, gastric
emptying, and intestinal propulsion.
The newborn’s stomach has a capacity of 50 to 60 mls.
The cardiac sphincter is immature, as is neural control of
the stomach, so some regurgitation may be noted.
Term newborns normally pass meconium (dark green to
black) within 8 to 24 hours of life and almost always by 48
hrs.
Transitional (thinner brown to green) stools are passed for
the next day or two then they become completely fecal.
The stools of the breastfed infant are yellow, more liquid ,
and more frequent than formulas fed infants.
21. Urinary AdaptationsUrinary Adaptations (pg. 698-699)(pg. 698-699)
Full term newborns are less able than adults to concentrate
urine (reabsorb water back into the blood) due to shorter
and narrower tubules.
Concentrating and dilutional limitations of renal function
are important considerations in monitoring fluid therapy to
avoid dehydration and overhydration.
Many newborns void immediately after birth. A newborn
who has not voided by 48 hours should be assessed
for inadequate fluid intake, bladder distention,
restlessness, and symptoms of pain.
The first two days of birth the newborn voids two to six
times a day, thereafter 5 to 25 times a day.
First voiding frequently appears cloudy, occasionally pink
“brick dust” may be observed.
Pseudomenstruation (related to the withdrawal of
maternal hormones) may be seen as blood on the newborn
female’s diaper.
22. Immunologic AdaptationsImmunologic Adaptations
Limitations in the newborn’s inflammatory response results in
failure to recognize, localize, and destroy invasive bacteria.
The signs and symptoms of infection are often subtle and
nonspecific in the newborn.
The newborn has a poor hypothalamic response to pyrenogens,
therefore fever is not a reliable indicator of infection.
Hypothermia is a more reliable indicator of infection in the
newborn.
Passive acquired immunity : transfer of antibodies (IgG) from
the mother to the fetus in utero.
Newborns have maternally induced immunity to tetanus,
diphtheria, smallpox, measles, mumps, poliomyelitis, and a
variety of other bacterial and viral disease.
Immunity against common viral infections such as measles may
last 4 to 8 months; whereas immunity to certain bacteria may
disappear within 4 to 8 weeks.
Colostrum, the forerunner of breast milk is very high in
immunoglobulin IgA which may provide some passive immunity
to the breastfeeding newborn.
23. Neurological andNeurological and
Sensory/PerceptualSensory/Perceptual
FunctioningFunctioning
Intrauterine factors influencing newborn behavior:
maternal nutrition and extrauterine environment (noise).
Characteristics of newborn neurological function: partially
flexed extremities, eye movements are observable, may
fixate on faces, or geometric objects, cry is lusty and
vigorous, knee jerk is brisk, plantar flexion is present.
Periods of reactivity: First Period of reactivity, Period of
Inactivity to sleep phase, Second period of reactivity.
Behavioral states of the newborn: Sleep states and Alert
states.
Behavioral and sensory capacities of the newborn:
Habituation, Orientation, Self-quieting ability, auditory
capacity, olfactory capacity, taste and sucking, and tactile
capacity.
24. Nursing Assessment of theNursing Assessment of the
NewbornNewborn
Assessment of the newborn is a continuous
process used to evaluate development and
adjustments to extrauterine life.
Assess immediately after birth: r/o
resuscitation and allow bonding.
Assessment within 1 to 4 hours after birth:
progress of newborns adaptation, gestational
age, ongoing assessment of high-risk
problems.
Assessment procedures in the first 24 hours
or prior to discharge.
26. Estimation of Gestational AgeEstimation of Gestational Age
Must be established in the first four hours
of birth.
Ballard and Dubowitz.
Include external physical characteristics
and neurological or neuromuscular
development evaluations.
Some maternal conditions may affect
certain gestational age assessment
components. (PIH, Diabetes, analgesia).
27. Estimation of Gestational AgeEstimation of Gestational Age
(pg 707- 714)(pg 707- 714)
PHYSICAL CHARACTERISTICS:
Resting posture: assessed undisturbed on a flat
surface
Skin: thin, opaque, peeling
Lanugo: decreases as gestational age increases
Sole (plantar) creases: increase with gestational age
Areola and breast bud tissue: increases with age.
Ear form and cartilage distribution: Cartilage gives
shape. Pinna is firm at term.
Male genitals: Size of scrotal sac, the presence of
rugae, and descent of the testicles.
Female genitals: size of labia majora and minora.
Vernix: None in the post term infant. More seen with
prematurity.
Hair: Preterm patchy, term silky.
Skull firmness: increases as the fetus matures.
Nails: long may be a sign of postmaturity.
28. Estimation of Gestational AgeEstimation of Gestational Age
(pg 707- 714)(pg 707- 714)NEUROMUSCULAR CHARACTERISTICS
The square window sign: elicited by flexing the baby’s
hand toward the ventral forearm until resistance is felt (the
angle formed at the wrist is measured).
Recoil: test of flexion development. Lower extremities are
tested first.
Popliteal angle: degree of knee flexion, angle is increased
in the preterm infant.
Scarf sign: elicited by placing the newborn in supine
position and drawing an arm across the chest toward the
newborn’s opposite shoulder. The location of the elbow is
noted in relation to the midline of the chest.
Heel to ear extension: with advancing age greater
resistance an smaller angle is noted.
Ankle dorsiflexion: flexing the ankle on the shin.
Head lag: Full term may support head momentarily.
Ventral suspension: position of the head, back, and degree
of flexion in the arms and legs are noted.
Major reflexesevaluated.
29. Physical AssessmentPhysical Assessment
General appearance: Head
larger than body
Weight and measurements:
average birth weight is 7lbs,
8oz, average length is 18 -22
inches.
Temperature: assessed by
axillary method after initial
rectal temp. 97.7 to 98.6.
Skin characteristics: (719)
Head: 12.5 to 14.5 inches,
approximately 2 cms larger
than the chest circumference.
Cephalohemotoma, caput
succedenum
Face: blue or dark. Chemical
conjunctivits, subconjunctival
hemorrhages. Epsteins pearls
or thrush.
Neck looks short, creased
with skin folds. Fractured
clavicle.
Chest:engorged breasts
Cry: strong and of medium
pitch
Respiration: 30 to 60
respiratory rate
Heart: 120 -160 HR
Abdomen: appears prominent
Umbilical cord: white and
gelatinous, bleeding is
uncommon, umbilical cord
hernia abnormal.
Genitals: may have vaginal
discharge in the first week of
life (white, thick)
Anus: check for imperforate
anus or atresia (done
visually)
Extremities: check for
abnormalities, polydactyly,
Erb’s palsy.
32. Newborn BehavioralNewborn Behavioral
AssessmentAssessment
Habituation
Orientation to inanimate and animate
visual and auditory assessment stimuli.
Motor activity
Variations in quiet alert states, state
changes and color changes.
Self quieting activity assessment on how
often and how quickly newborns quiet
themselves.
Cuddliness or social behaviors.
33. Nursing Diagnosis
Risk for ineffective breathing pattern
Altered nutrition: less than body
requirements
Altered urinary elimination
Risk for infection
Knowledge deficit
Altered family processes
34. Nursing Plan andNursing Plan and
ImplementationImplementation (pg. 762-772)(pg. 762-772)
Maintenance of cardiopulmonary function
Maintenance of a neutral thermal
environment
Promotion of adequate hydration and
nutrition
Promotion of skin integrity
Prevention of complications and
preventing safety
Enhancing parent-newborn attachment
35. Maintenance of CardiopulmonaryMaintenance of Cardiopulmonary
FunctionFunction
Assess vital signs every 6 to 8 hrs or more
depending on the newborn’s status.
“Back to Sleep” , side lying to prevent
aspiration and facilitate drainage of mucus.
Keep bulb syringe readily available.
Vigorous fingertip stroking of the spine
frequently stimulates respiratory activity.
Cardiac/respiratory monitor may be required.
At-risk indicators: pallor, cyanosis, ruddy
color, and apnea.
36. Maintain the newborn’s temperature within the
normal range.
Make certain the infant is dressed and bundled
appropriately. Small caps may be used for the
LBW or premature infant.
Newborns use calories for warmth rather than
growth.
Chilling increases the affinity of serum albumin
for bilirubin.
Chilling increases oxygen use and may cause
respiratory distress.
Overheating will increase respiratory rate and
activity in an attempt to cool the body, also
increasing insensible fluid loss.
37. Weigh at the same time each day.
Weight loss of up to 10% is considered normal during
the first week of life.
Birth weight should be regained by the 2nd
week of
life.
The nurse records voiding and stooling patterns.
The first void should occur within the first 24 hours
and passage of stool in the first 48 hours.
Assess for abdominal distention, bowel sounds,
hydration, fluid intake, voiding pattern, and
temperature stability.
Excessive handling may cause an increase in the
newborn’s metabolic rate, calorie use and fatigue.
38. Promotion of Skin IntegrityPromotion of Skin Integrity (pg(pg
764-765)764-765)
Bathing is important for health, appearance,
and infect5ion control in the nursery.
Ongoing skin care includes cleansing of the
buttocks and perineal area with water and a
mild soap with diaper changes.
Assess the umbilical cord for signs of
bleeding or infection: 1) apply triple dye on
admission to nursery and 2) alcohol after
each diaper change.
Cord care with each diaper change.
Eye and skin care related to phototherapy.
Skin care following circumcision.
39. Prevention of Complications and PromotingPrevention of Complications and Promoting
SafetySafety (pg 765-767)(pg 765-767)
Pallor may be an early sign of hemorrhage.
Circumcision is assessed for signs of hemorrhage and
infection.
Initial scrub for 2-3 minutes when direct contact with
the newborn is anticipated.
Handwashing between each client contact and contact
with floor, face, or any soiled surface.
Encourage parents to wash hands prior to holding the
infant and wear a gown over street clothes.
Teach parents to limit visitors who may have a
communicable disease.
Check namebands with each encounter with the
parents.
Instruct clients in security measures in place to
prevent infant abduction.
40. Enhancing Parent-Newborn AttachmentEnhancing Parent-Newborn Attachment
(pg. 767)(pg. 767)
Involve the entire family in newborn care
Infant massage may be encouraged
Increase skin to skin contact
Read to or play music for the newborn
Encourage cuddling and talking to the
infant
41. Discharge Planning andDischarge Planning and
PreparationPreparation (pg. 767-773)(pg. 767-773)
Parent teaching
General instructions for newborn care
Nasal and oral suctioning
Wrapping the newborn
Sleep and activity
Safety considerations
Newborn screening and immunization
Program
42. Community-Based NursingCommunity-Based Nursing
Care for the NewbornCare for the Newborn (pg. 773-776)(pg. 773-776)
The family should have access to the
birthing unit and physician phone
numbers.
The client should be made aware of
follow-up programs such as PRS, early
intervention and high-risk referral.
Referral to the public health department.
Hospital phone follow-up.
