UNIT 3 Normal Newborn - Lecture notes 2 PDF

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UNIT 3 NORMAL NEWBORN

3.1 The learner will define key terms relating to normal newborn and family. Chapter 28 

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Barlow maneuver: to rule out the possibility of developmental dysplastic hip, also called congenital hip dysplasia (hip dislocatability). The examiner grasps and adducts the infant’s thigh and applies gentle downward pressure. Dislocation is felt as the femoral head slips out of the acetabulum. Brazelton’s Neonatal Behavioral Assessment Scale: The behavioral assessment tool attempts to identify the newborn’s repertoire of behavioral responses to the environment and also documents the newborn’s neurologic adequacy and capabilities. Dubowitz tool: a method of estimating the gestational age of an infant based on 21 strictly defined physical and neurological signs. The method was developed by Lilly and Victor Dubowitz, contemporary South African physicians Erb-Duchenne paralysis (Erb’s palsy): Involves damage to the upper arm (fifth and sixth cervical nerves) and is the most common type. Injury to the eighth cervical and first thoracic nerve roots and the lower portion of the plexus produces the relatively rare lower arm injury. The whole arm type results from damage to the entire plexus. Erythema toxicum: An eruption of lesions in the area surrounding a hair follicle that are firm, vary in size from 1 to 3 mm, and consist of a white or pale yellow papule or pustule with an erythematous base. It is often called “newborn rash” or “flea bite” dermatitis. Gestational age assessment tools: Have two components: external physical characteristics and neurologic or neuromuscular development evaluations. Harlequin sign: Color change is occasionally noted. A deep color develops over one side of the newborn’s body while the other side remains pale, so that the skin resembles a clown’s suit. Milia: Exposed sebaceous glands, appear as raised white spots on the face, especially across the nose Molding: Head may appear asymmetric in the newborn of a vertex presentation. Caused by the overriding of the cranial bones during labor and birth

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New Ballard Score (NBS): Added criteria for more accurate assessment of the gestational age of newborns between 20 and 28 weeks’ gestation and less than 1500 g. They suggest that the assessment be made within 12 hours of birth to optimize accuracy, especially in infants of 22 to 28 weeks’ gestational age. Ortolani’s maneuver: With the hips and knees flexed at a 90-degree angle, the examiner grasps the infant’s thigh with the middle finger over the greater trochanter and lifts the thigh to bring the femoral head from its posterior position toward the acetabulum. With gentle abduction of the thigh, the femoral head is returned to the acetabulum and the examiner feels a sense of reduction or a “clunk.” This reduction is palpable and may be heard. Confirming the diagnosis of an unstable or dislocatable hip Pseudo-menstruation: During the first week of life, the female newborn may have a vaginal discharge composed of thick whitish mucus. This discharge, which can become tinged with blood, is referred to as pseudomenstruation and is caused by the withdrawal of maternal hormones

3.2 The learner will distinguish the characteristics, normal variations, abnormal assessments, and implications for nursing care relating to the care of the normal neonate and family for the following: Timing of Newborn Assessments  

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Delivery room disposition – immediately after birth, determine need for resuscitation, stable newborn stays with family for early attachment, newborn w/ complications taken for eval Nursery or couplet care admission exam – 2nd exam done in nursey, routine admission procedure, physical assessment, estimate gestation age & evaluate newborns adaptation to extrauterine life (no later than 2 hrs. assess newborns status & any potential problem/risks) Before discharge exam – CNM/MD perform physical exam, behavioral exam & review additional info from baby’s stay

Physical Assessments 

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General Appearance o Head is disproportionately large for the body, neck looks short because chin rests on chest o Prominent Abd, sloping shoulders, narrow hips & round chest o Center of the body is the umbilicus o Body appears long & extremities short o Stay in flexed position o Hands tightly clenched  After breech feet dorsiflexed Weight and Measurements o Weight  avg 3405g (7lb, 8oz), range 2500-4000g (5lb, 8oz to 8lb, 13oz) o Factors influencing weight  age & size of parents  health of mother (smoking, malnutrition = decrease birth weight)  spacing b/w pregnancies (short intervals [q1yr] = lower birth weight) o after 1st week and 1st 6 months infants’ weight will increase by 198g (7oz) weekly o 70-75% of weight is water  During initial newborn period (1st 3-4 days) term newborns lose 5%-10% because of fluid shift  May reach 15% for preterm  Larger babies lose more weight

UNIT 3 NORMAL NEWBORN Factors Contributing to weight loss  Small fluid intake (delayed feeding, adjustment to formula, increase excretion or meconium & urine)  Weigh loss marked by increased temp (dehydration) consistent chilling (nonshivering thermogenesis) o Length  Avg 50cm (20in), range 48-52cm (18-22in)  Growth of 1in a month for the next 6 months o Head is 1/4 the size of an adult’s head o Head Circumference  Avg 33-35 cm (13-14in), range 32-37cm (12.-14.5in)  2cm greater than circumference of chest at birth o Chest Circumference  Avg 32cm (12.5in), range 30-35cm (12-14in) Skin Characteristics o All have pink tinge  d/t increased blood cell concentration & limited subq fat deposits o baby who is pink while crying & cyanotic at rest has choanal atresia  congenital blockage of passage between nose and pharynx o if crying increase cyanosis = heart or lung problem o Pale  anemia or hypovolemia (low blood volume or pressure) o Acrocyanosis  bluish discoloration of hands and feet (may be present in first 24hrs)  d/t poor peripheral circulation results in vasomotor instability and capillary stasis  should return in 2-3 sec, poor indicator of oxygenation  assess face and mucous membrane for pinkness and adequate oxygenation o mottling  lacy pattern of blood vessels under skin  circulation fluctuations  may go away periodically or last days-weeks  related to chilling, prolonged apnea, sepsis or hypothyroidism o harlequin sign (clown color)  deep color that develops over one side of the newborns body while the other remains pale  related to immaturity of the hypothalamic center  blood vessels on one side dilate and the other constrict  last few secs to 30mins o jaundice  yellowish discoloration of skin and mucous membrane  detected in the face & mucous membranes of the mouth  occurs from head to toe and regress in opposite direction  assess by blanching the skin over tip of the nose, forehead, sternum or gum line, area will appear yellow  also assess sclera o

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UNIT 3 NORMAL NEWBORN

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related to immature liver function, hematomas, poor feeding, blood incompatibility, oxytocin (Pitocin) augmentation or induction, severe hemolysis  check transcutaneous bilirubin level (TcB) o measurement obtained from the forehead or sternum and plotted on nomogram o total serum bilirubin (TSB) level checked as well  full term – receive phototherapy for bilirubin levels >12mg/dL  Tx ranges for premature erythema toxicum  lesions in the area surrounding a hair follicle that are firm  1-3mm, white or pale yellow papule or pustule with erythematous base  “newborn rash” “flea bite” dermatitis Milia  Exposed sebaceous gland, appear as raised white spots on the face (across nose)  Clear spontaneously Skin turgor  Determine hydration, need to initiate feeding & presence of infectious process  Assessed over the Abd, forearm, or thigh  Skin should be elastic and return rapidly to original shape Vernix caseosa  Whiteish cheese like substance, covers fetus in utero, lubricated skin  Posterm – less vernix, frequently dry, peeling common Forceps marks  Present of difficult forceps birth  May have reddened areas on cheeks or jaw  Reassure parent they disappear w/in1-2 days  Transient facial paralysis Birthmarks  Telangiectatic nevi (stork bites)  Pale, pink or red spots on eyelids, nose, lower occipital bone & nape of the neck  Common in light complexion babies, noticed during periods of crying  Fade by the second birthday  Congenital dermal melanocytosis (Mongolian blue spots)  Areas of dark bluish, black or gray-blue pigmentation  Found on dorsal area, buttocks or anywhere  Common in Asian, Hispanics, African American darker skinned races  Gradually fade during the first or second year or life, mistaken for bruises  Nevus flammeus (post wine stain)  capillary angioma below the epidermis, red or purple area of dense capillaries  African descent purple-black stain, common on face  Doesn’t fade or blanch  Nevus vasculosus (strawberry mark)  Capillary hemangioma, consists newly formed and enlarged capillaries in dermal & subdermal layers  Raise, clearly delineated (boundaries), rough surfaced  Common on the head, grow rapidly then shrink after reaching full size

UNIT 3 NORMAL NEWBORN

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Hair o o Face o o o

Pale purple, gray spot on surface of hemangioma signals the start of resolution Resolve spontaneously

General Appearance  Large w/ soft pliable skull bones  Occipital-front circumference – 32-37cm (12.6-14.6in)  asymmetrical due to molding, overriding of cranial bones during labor  second head measurement take after a few days  breech and c-section babies have well shaped head, lack of pressure during birth  microcephaly  abnormally small head  hydrocephaly  abnormal build up of fluid in the brain  craniosynostosis  premature closure of the cranial sutures, need surgery for correction  plagiocephaly  asymmetry d/t closure of one side by pressure in utero  two fontanelles (soft spots) palpated on newborns head, measured with fingers  measured with newborn in sitting position and not crying  anterior fontanelle (diamond shaped) 3-4cm long by 2-3 cm wide o closes w/in 18months o swells when newborn cries, passes stool, pulsate with heart beat  posterior fontanelle (triangular) 0.5cm by 1cm o closes w/in 8-12 weeks  bulging = increased intracranial pressure, sunken = dehydration Cephalohematoma  Collection of blood, from ruptured blood vessels between surface of cranial bones  Scalp feel loose and edematous, do not increase in size when newborn cries, does not cross suture lines  Common in vertex birth, disappear w/in 2wks-3months  Large ones lead to anemia or hypotension Caput succedaneum  Soft area of the scalp, result of long labor or vacuum extraction  Compression of local blood vessels & venous return is slowed causing edema, may cross suture lines  Fluid reabsorbed w/in 12hrs to a few days  Vacuum associated caput disappear more slowly, well defined, 2cm (0.8in thick) Smooth, texture variation with ethnic background Color, quantity, hairlines, direction of growth, whorls can identify genetic, metabolic and neurologic disorders Sucking fat pads on cheeks and labial tubercle (callus) found in the center of the lip Lips sensitive to touch, sucking reflex initiated early Symmetry is assessed to determine facial paralysis

UNIT 3 NORMAL NEWBORN

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Eyes o o o o

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May be due to forceps or maternal pelvis Disappears w/in few days to 3 weeks

Blue sclera associated with osteogenesis imperfecta Eye color establish at 3months may change after 1 year Check for size, reaction to light, blink reflex, edema & inflammation of eyelids Erythromycin & tetracycline used prophylactically  Instillation of silver nitrate drops may cause edema and chemical conjunctivitis  Disappear 1-2 days  Infectious conjunctivitis  Purulent (greenish yellow) discharge  Caused by gonococcus, chlamydia, staphylococci or gram-negative bacteria, requires ophthalmic bacteria Subconjunctival hemorrhages common on the sclera  Caused by changes in vascular tension or ocular pressure during birth Chemical conjunctivitis:  The instillation of silver nitrate drops in the newborn’s eyes may cause edema and chemical conjunctivitis, which may appear a few hours after instillation and disappear in 1 to 2 days Transient strabismus (pseudostrabismus) or squinting  Caused by neuromuscular control of the eye muscles  Regress after 3-4 months “Dolls eyes” eyes move to the opposite direction of the head Observe for red retinal reflex  abnormal with retinoblastoma, absent with cataracts  suspected with mom who had hx of rubella, cytomegalic inclusion disease or syphilis brush field spots (black or white spots on iris associated with trisomy 21 cries are tearless d/t immature lacrimal ducts, not fully functional until 2 nd month of life limited visual abilities (no accommodation or oculomotor coordination), does have peripheral vision and fixates on near objects perceive faces, shapes, color blink in response to light & tap on nose or eyelids Small narrow nose, nose breathers, sneeze to clear obstruction Nurse checks for choanal atresia (congenital blockage of passageway /w nose & pharynx when resp difficulty noted Able to smell after nasal passage is cleared of amniotic fluid  Turn head towards milk source (bottle or breast)  React to strong odor, turn head away or blink

Mouth o Lips pink touch produces sucking motion o Saliva scant, differentiate sweet & bitter o Examine by stimulating cry and depressing tongue  Assess for cleft palate o Precocious teeth should be removed if loose, avoid aspiration o Epstein pearls

UNIT 3 NORMAL NEWBORN

 Small glistening white specks (keratin cysts) feel hard to touch,  Disappear after few weeks, no significance o Thrush  White patches on mucous membrane, resemble milk curds  Bleeding occur when removed  Candida albicans, acquired from vaginal tract during birth, antibiotic use, poor hygiene  Treated with nystatin (mycostatin) o Tongue tied  Has a ridge of frenulum tissue attached to underside of tongue at varying lengths, cause heart shaped at tip of tongue  “Clipping tongue”, cutting tissue no recommended unless baby has trouble feeding 

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Ear o o o o o o o Neck o o o o

Soft and pliable, should recoil readily when folded Pinna should parallel to cantus of eyes Inspect for shape, size, position & firmness Low-set ear = syndrome and chromosomal abnormalities (trisomy’s 13 & 18), intellectual disability Preauricular tag, present in front of ears Visualization of tympanic membrane not done after birth, blocked by blood & vernix Following first cry newborn hearing becomes acute, hearing evaluated using moderate-loud noise Short with creases & folds Cannot fully support head, head lags from supine to sitting position, able to hold help slightly in prone Rom assessed by moving head and supporting, palpate for masses, webbing & lymph nodes Clavicle assessed for fracture after birth, lump will be felt along side of break with grating sensation (crepitus) Moro reflex also used to assess bilateral movement

o Chest o Cylindric and symmetrical, ribs flexible, protrusion of xiphoid cartilage (less apparent after several weeks) o Engorged breast common in male & female  Appears by the 3rd, last up to 2 weeks, d/t maternal hormones  Whiteish secretion may be toned  DO NOT massage or squeeze = abscess  Supernumerary (multiple) nipples noted, appear dimpled Cry o Strong, lusty, medium patch  High pitch = neurologic disorder or hypoglycemia Abdomen o Cylindrical, protrude slightly o Scaphoid (hollow-shaped) = absence of abdominal contents (diaphragmatic hernia o Should be no bulging, distention  More distended = tighter skin = gastrointestinal abnormalities o Auscultate for bowel sounds X4quad, then palpate  BS present 1hr after birth, palpation cause transient decrease  Move clockwise, check for softness, tenderness & presence of masses Umbilical Cord

UNIT 3 NORMAL NEWBORN White, gelatinous, two arteries one vein  One artery = congenital anomaly o Dries by 1-2 hrs. of birth, blackened by 2nd -3rd day o Cord bleeding abnormal  Tension or clamping was loosened o Foul drainage abnormal  Infection, require immediate Tx to prevent septicemia o Serous, serosanguinous drainage  Granuloma o Patent urachus (abnormal connection b/w bladder & umbilicus)  Moistness or urine drainage from cord o Umbilical cord hernia  Patent omphalomesenteric duct  Common in African descent, close spontaneously by 2yrs Genitals o Female  Examine labia majora, labia minora & clitoris  Note size as appropriate for gestational age  Pseudomestruation common - vaginal discharge, thick whitish mucous, may become tinged with blood  Smegma – white cheese like substance b/w labia (removing my traumatize tender tissue) o Male  Penis inspected to see if urinary orifice correctly position  Hypospadias – urinary meatus in ventral surface  Epispadias – meatus on dorsal surface of glans  Phimosis – opening (prepuce) too small, cant pull back  Scrotum inspected for size, & symmetry, palpate to verify presence of testes  Cryptorchidism – failure of testes to descend  Hydrocele – collection of fluid surrounding testes  Testicular torsion – noted with discoloration, dusky scrotum & solid testes Anus o Verify it is patent, has no fissure  Rule out imperforate anus & rectal atresia 9absence abnormal, narrowing) o Note passage of first meconium stool  not passed w/in 1st 24hr consider atresia of gastrointestinal tract or meconium ileus Extremities o Examine for deformities, webbing, clubfoot & ROM o Short, flexible & move symmetrically o Arms and Hands  term – nails extend beyond fingertips  count fingers & toes  polydactyly – extra digits hands or feet  syndactyly – webbing of fingers or toes o seen in trisomy 21  inspect for normal palmar creases o

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UNIT 3 NORMAL NEWBORN

 single crease seen in trisomy 21 brachial palsy – partial or complete paralysis or portion of the hand, from trauma during difficult birth  occur with shoulder dystocia or breech birth  Erb-Duchenne paralysis (Erb palsy)  Damage to the upper arm (fifth & sixth cranial nerve)  Damage to 8th cranial nerve & first thoracic nerve & lower portion of plexus = lower arm injury o Entire plexus = whole arm type o Arm lies limply, unable to elevate, recovery depends n degree of damage to nerve plexus Legs and Feet  Equal in length & symmetrical skin folds  Barlow & Ortolani maneuver check for hip dislocation or hip instability  Barlow o Rule our possible developmental dysplasic hip (congenital hip dysplasia/ hip dislocatability) o Adduct infant thigh apply gentle downward pressure, dislocation felt as femoral head slips out of acetabulum  Ortolani o Newborn relaxed & quiet on firm surface, hips and knees flexed at 90degree angle, grasp thigh over greater trochanter, bring femoral head to acetabulum, gently abduct return to acetabulum, feel reduction or clunk  Talipes deformity (clubfoot)  Feet appear turned inward  If easily manipulated no indication, ROM exercises taught to family  When foot will not turn to midline require further investigation 

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Prone, examine back, spine straight & flat (lumbar & sacral nerved don’t develop until infant sits) Assess for dermal sinus, nevus pilosus (hair nevus)  Associated with spina bifida Suspect pilonidal dimple reported

Gestational Age/Ballard/Dubowitz

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Essential w/in 1st 4hrs after b...