Summary HESI OB EXAM STUDY GUIDE - NEWBORN

HESI OB EXAM STUDY GUIDE NEWBORN HESI OB EXAM STUDY GUIDE NEWBORN Respiratory transition in the newborn Respiratory function • Established when cord is cut. • Air inflates lungs with first breath. • 4 factors influence the initiation of the 1st breath  Chemical factors: hypercarbia, acidosis, and hypoxia which stimulate the resp center in the brain to initiate breathing. Sensory factors stimulate the first breath. Thermal factors are involved when the neonate exits the warm environment they have been used to. Mechanical factors such as removal of fluid from the lungs and replacements of air is the primary mechanical factor. • The fetal chest compression that occurs during a vaginal birth increases the intrathoracic pressure and helps push fluid out of the lungs. Circulatory transition in the newborn • Successful adaptation in the neonate involves five major changes and increased aortic pressure • Decreased venous pressure and increased systemic pressure • Decreased pulmonary pressure • Closure of the foramen ovale, the ductus arteriosus and the ductus venosus. • Foramen ovale closes functionally 1-2 hrs anatomically 1-2 weeks Hyperbilirubinemia in the newborn • Unconjugated: fat soluble and toxic to body • Normal bili = 4-6 mg/dl • CONJUGATED: water soluble and nontoxic & conjugation happens in the liver • Bili increases after birth r/t increased RBC • Elevated bili = jaundice in the newborn - will rise over first 3-5 days and then decrease • Total above 5 from unconjugated = yellowing of the skin, one of the most common reasons for newborn readmission • Patho within 24 hours of life r/t polycythemia, blood incompatibilites, acidosis • Physio after 24 hours of life r/t limitations and abnormalities of bili metabolism, r/t increased bili load because of polycythemia, shortened RBC lifespan, immature hepatic uptake and conjugation process - delayed passage of meconium puts at risk Temperature regulation in the newborn Thermoregulation: • Newborns have poor thermal stability due to excessive heat loss. • It is closely related to rate of metabolism, oxygen consumption, amount of brown fat, and amount of subcutaneous tissue. • Increased metabolic demands and/or increased oxygen demands can quickly lead to hypoglycemia (neonatal hypoglycemia is less than 40 mg/dl blood glucose level). • Infants produce heat by increasing their metabolic rate, increasing muscular activity, or through nonshivering thermogenesis (break down brown fat into heat). • Four ways an infant loses heat: ▪ Convection: Air current blows heat away ▪ Radiation: Cold area, body radiates/loses heat ▪ Evaporation: When water evaporates it takes heat with it ▪ Conduction: If baby is put on cold surface it loses body heat to warm the surface • Things you can do to help keep baby warm: ▪ Skin to skin contact, radiant warmer, wrap in warm blankets, use hats, monitor temperature, dry them after a bath, heat oxygen and humidify (if on oxygen therapy), teach family to keep them warm. You want their temp to stay around 98.6 but the normal range is 97.7-99.4. Blood glucose changes in the newborn • Normal BG • 1-Day: 40-60 mg/dL • 1-Day: 50-90 mg/dL • Baby experiences an energy crunch @ the time of birth with the cutting of the umbilical cord and resultant removal of the maternal glucose supply (baby’s BG 15 mg/dL lower than maternal BG) • This is significant because baby needs adequate amount of glucose in order to withstand the birth process and extrauterine life. • Fuel sources are consumed at a faster rate because: ▪ The work of breathing ▪ Loss of heat when exposed to cold ▪ Activity ▪ Activation of muscle tone. Patho: As stores of liver and muscle glycogen and blood glucose decrease, the newborn compensates by changing form a predominantly carbohydrate metabolism to fat metabolism. ▪ Energy is derived from fat and protein as well as from carbohydrates. • Assessment: • 1st and 2nd hour after birth: blood glucose declines • 3rd hour after birth: blood glucose reaches a steady level Umbilical cord clamping and cutting • Must use two clamps: one to cut off blood flow to placenta and one to keep baby form bleeding out • Placement should be closer to baby than placenta and an inch or two between both clamps • When cutting between two clamps: make sure clamps are tight enough and no blood is being exploited from umbilical cord • After cutting: make sure two arteries and one vein are visible because baby may have cardiac problems if all vessels are not present • Then cover with triple dye to increase time of closure and prevent infection • It should be cleaned with alcohol swab each diaper change to prevent infection Coagulation capabilities of the newborn • Born without coagulation factors • Given Vit K to initiate coagulation • If not, bleeding is a risk • The clinical presentation is often: ▪ Bruising ▪ Gastrointestinal blood loss or bleeding from the umbilicus and puncture sites. ▪ Intracranial hemorrhage is a severe presentation. Modes of infection of the newborn • Infants can acquire infection from uterus doting delivery • Risk for infection increases the more premature the newborn is due to undeveloped immune system • Hep B is given with in the first 24 hours of birth Behavioral states of the newborn • Alert states: • Drowsy: Fluttering eyelids, slow regular movements of extremities. Mild startles from time to time. • Quiet alert: Baby is alert and follows and fixates on attractive objects, faces or sounds. • Active alert: Eyes are open, motor activity is intense. • Crying: Intense crying is accompanied by jerky motor movements. May be signaling hunger or pain. • Most active in the first 30 mins • Sleep about 16-18 hours a day Newborn teaching Feeding/feeding cures, burping, spitting, Positioning Bulb syringe, Bathing, nail care, dress, cord care, rash Diaper changing, Circumcision care, Newborn screenings Hearing screen, Alert state--talk to, cooing, Sleeping back to sleep Quiet crying infant---swaddling, Temperature, handling, safety, Proper use of • Call Dr; Signs of Illness: Temperature---How to take T--Axillary T above 38 degrees (100.4F) or below 36.6 C (97.8F) Continual rise in temperature More than one episode of forceful or frequent vomiting over 6 hours Refusal of 2 feedings in a row Lethargy (listlessness), Development of eye drainage • Inconsolable infant Discharge/bleeding from umbilical cord, circumcision, or any opening Two consecutive green, watery stools No wet diapers for 18 to 24 hours---Fewer than 6 to 8 wet diapers a day Development of eye drainage Know when to call the physician Safety • Soft bedding and sleep position contribute to infant suffocation death No pillows, comforters, sheepskins, should be under infants while sleeping Always place healthy infants on their backs to sleep High risk newborn & breast feeding Initial stabilization of the neonate • ABC and thermoregulation (warmth, clear airway, dry and stimulate) • Complication • Administer Positive Pressure Ventilation • Continuous Positive Airway Pressure • Intubation • Different ways to deliver oxygen • SPO2 Monitoring • Take ventilation corrective steps • Chest compression • IV access • Umbilical Arterial (UAC) or Venous Catheter (UVC) • Peripheral IV • HR below 60 bpm administer IV epinephrine Common complications for SGA: Small gestational age • Perinatal asphyxia due to placental insufficiency • Bradycardia due to decreased cardiac glycogen stores; decreased glycogen stores also lead to hypoglycemia and hypothermia • SGA fetuses have often been exposed to intrauterine infections such as rubella, CMV, or toxoplasmosis • Frequent polycythemia; probably a response to chronic fetal hypoxia • 35% of SGA babies have congenital anomalies frequently associated with intrauterine insult • Common complication: Fetal hypoxia, Aspiration syndrome, hypothermia, hypoglycemia, polycythemia • Maintain airway and temp, observe for resp distress, admin O2, monitor glucose, VS, initiate feeding schedule, support the psychological well-being of the behavior Complications for LGA Macrosomia BB to big baby • Birth trauma from vaginal birth: clavicle fracture, brachial plexus palsies, depressed skull fractures, cephalhematoma • At risk for hypoglycemia due to early depleted glycogen stores • Fetal distress caused by prolonged and difficult second stage • Things that may occur: Shoulder dystocia; passage of meconium in utero with risk of aspiration • Complication: poor motor skills, difficulty regulating behavioral states, difficult to arouse, problems maintaining a quiet alert state, birth trauma, hypoglycemia, polycythemia, hyper viscosity • Early identification and treatment of common disorders: ▪ Monitor VS, blood sugar, polycythemia, birth-related trauma, and encourage parental interaction and attachment. Complications for IUGR- intrauterine growth rate • Increased risk for cesarean delivery • Increased risk for hypoxia • Increased risk for meconium aspiration, could cause: over distended alveoli, pneumothorax, and/or bacterial pneumonia • Hypoglycemia • Polycythemia • Decreased blood flow due to increased # of RBCs • Increased risk for motor and neurological disabilities Complication with preterm • All organ systems are immature and cannot handle functioning to maintain homeostasis • Respiratory distress syndrome due to immature lungs; apnea due to immature respiratory center • High incidence of patent ductus arteriosus; risk for intraventricular hemorrhage due to impaired blood pressure regulation • If the preterm infant cannot get colostrum, they cannot get IgA which is one of the three essential immunoglobulins needed for immunological ability • Hypoglycemia and hypocalcemia are common • Lung/Surfactant ration 2:1 and PG absent • Betamethasone • Interevent for respiratory distress syndrome, patent ductus arteriosus, apnea, pulmonary interstitial emphysema, intraventricular hemorrhage, sepsis. • Complications for pre-term: Resp and thermo • Respiratory: inadequate surfactant, underdeveloped pulmonary blood vessels, patent ductus arteriosus. Thermoregulation: High ratio of body surface/ weight, decreased fat, thinner skin, extended posture, decreased ability to vasoconstrict • Renal complications for pre-term ▪ GFR is low, possible anuria or oliguria, inability to concentrate urine, reduced buffering ability, drugs become toxic more quickly. ▪ Play audio for this term • GI complications for pre-term infants ▪ poor sucking, gag, and swallowing reflex, small stomach capacity, limited ability to convert amino acids, kidney immaturity, difficulty with fat and lactose digestions, deficient calcium and phosphorus, increased BMR, feeding intolerance • Complications for pre-term ▪ Hepatic: Low glycogen and iron, increased bilirubin. Immune: sepsis, risk for infection, fragile skin. ▪ Neuro: decreased myelination. ▪ Behavior: delayed reactivity. Preterm complications • Hyperbilirubinemia caused by immature liver • Difficulty maintaining body temperature because of excess heat loss primarily due to inadequate subcutaneous fat supplies • Decreased ability to concentrate urine and lack of selectiveness in filtration: caused by immature renal system • Necrotizing enterocolitis caused by ischemic injury to intestinal mucosa or the presence of bacteria • Nutritional intake impacted by: immature GI functioning, immature suck and swallow reflexes, compromised respiratory status Respiratory Distress Syndrome R/F: gestational age, size 5.8 lbs, medical complication (DM), asphyxia, Rh factor will delay surfactant production S/S: Cyanosis, apnea, grunting, nasal flaring, rapid breathing, retracting, shallow breathing, unusual breathing movements, fine rales. DX test: Blood gas, x-ray, lab test, low Apgar (may not reflect), L/S ratio 2:1 and PG absent • N/I • Ventilation and oxygenation • Continue monitoring to the infant status • Suctioning • APGAR = Appearance, pulse, grimace, activity & respiration Complications: Hypoglycemia/Hyperbilirubinemia/Cold stress/Sepsis Hypoglycemia • Blood Glucose 40mg/dl in a term newborn • At risk infants are diabetic mothers • Small for gestational age • Premature • S/S: tremors and jitteriness • Lethargy, decreased muscle tone, apnea, anorexia Hyperbilirubinemia • Bilirubin is formed by the breakdown of hemoglobin of RBC’s • Kernicterus: causes permanent impaired neurological function. • Jaundice • Rh or AB O incompatibility, Coombs, serum bilirubin, hemoglobin, reticulocyte percentage, white blood cell count, assessing for risk factors • Interventions for hyperbilirubinemia ▪ alleviating anemia, removing antibodies, increasing serum albumin levels, phototherapy, exchange transfusion, drug therapy • Assessment for Hypoglycemia 40mg/dL ▪ Possibly asymptomatic, or lethargy, apathy, limpness, poor feeding, hypothermia, pallor, cyanosis, apnea, irreg resp, resp distress, cyanosis, tachypnea, tremors, seizure activity, irritability, eye rolling, high-pitched cry. • Interventions for Hypoglycemia ▪ Early breastfeeding or formula feeding, IV infusions of D5W to D10W, possible corticosteroids. Cold Stress • Neonates produce body heat by nonshivering thermogenesis using brown fat. • Thermogenesis requires increased oxygen and glucose consumption. • Hypothermia, Cyanotic truck, decreased respiration • Infant is at risk for jaundice and metabolic acidosis because of the fatty acids released into the blood stream Sepsis • Generalized infection that has spread rapidly through the blood stream. • S/S: hypothermia, feeding intolerance, abdominal distention, vomiting, poor sucking, hyperbilirubinemia, lethargy, seizure activity, pallor, respiratory distress, tachycardia, followed by periods of apnea and bradycardia. • Assessment for cold stress ▪ excessive heat loss resulting in the use of compensatory mechanisms. Preterm and SGA at risk, also hypoxemia, intracranial hemorrhage, hypoglycemia. • Interventions for cold stress ▪ Maintain neutral thermal enviro, warm slowly, increase air temps 1 Celsius/ hr, monitor skin temp, remove any plastic wraps, warm IV fluids, Block heat loss. Birth defects: congenital Heart defects, gastrochisis CHD • Aortic Stenosis ▪ Aortic valve is stiffened and has a narrowed opening. ▪ Does not open properly, which increases strain on the heart because the left ventricle has to pump harder to send blood out to the body. • Atrial Septal Defect (ASD) ▪ Hole in the wall (called the septum) that separates the left atrium and the right atrium. ▪ When this hole is present, it allows extra blood flow to travel from the left atrium into the right heart and out to the lungs. • Coarctation of the Aorta (COA) ▪ Coarctation of the Aorta is a narrowing of a portion of the aorta, and often seriously decreases the blood flow from the heart out to the lower portion of the body. ▪ This presents as bounding upper extremity pulses and weak lower extremity pulses Congenital Heart Disease • Tetralogy of Fallot (TOF) (four heart defects) Tetralogy of Fallot is actually a combination of four heart defects: ▪ Pulmonary stenosis; Ventricular hypertrophy; Ventricular septal defect; and an aorta that can receive blood from both the left and right ventricles, instead of draining just the left. ▪ Because deoxygenated (blue) blood can flow out to the body, children with this defect often appear bluish. • Transposition of the Great Arteries ▪ In this condition, the pulmonary artery and the aorta are switched so that the aorta arises from the right side of the heart and receives blue blood, which is sent right back out to the body without becoming oxygen-rich. ▪ The pulmonary artery arises from the left side of the heart, receives red blood and sends it back to the lungs again. ▪ As a result, babies with this condition often appear very blue and have low oxygen levels in the bloodstream. Breastfeeding: A Public Health Issue • Society views breasts as sexual objects, which leads to many women feeling uncomfortable about breastfeeding, especially in public. • 43 states have made laws allowing women to breastfeed in public • Many organizations help promote breast feeding including WHO, La Leche League International, World Alliance for Breastfeeding Action, and many more. • On January 20, 2011, Surgeon General Regina M. Benjamin released The Surgeon General’s Call to Action to Support Breastfeeding in the Jack Morton Auditorium at The George Washington University. • Since then, more hospitals have encouraged breastfeeding, although numbers still aren’t as high as they should be. Role of Healthcare providers & facilities in Breastfeeding • Everyone involved in the nursing care of mother and baby should: • Value breastfeeding as an important health promotion and disease prevention strategy • Support mother’s decision to breast feed their babies** • Include breastfeeding support as a standard of care** • Hospitals should: • Not send moms home with free formula samples • Cut back on advertising formula companies in the hospitals (badge holders, pens, office supplies, etc.) • Provide education and training in breastfeeding for all health professionals who care for women and children. ** • Develop skilled lactation care teams** Role of nurse in breastfeeding • Nurses should: • Provide information about breastfeeding support after hospital discharge** • Seek assistance from and refer to appropriate lactation specialists • Seek out opportunities to improve mothers’ knowledge and skills** • Help mothers initiate breastfeeding when baby starts displaying hunger cues (hand-to-mouth movements, rooting, sucking, smacking, fussing) • Show mothers proper latching on techniques, different breastfeeding positions and how to breast feed • Answer any questions mothers may have regarding breastfeeding. Nutrition choices: pros & cons Pro • Ideal balance of nutrients • Higher levels of nutrients essential for nerve and brain growth • Long-term decrease in incidence of diabetes, cancer, obesity, asthma • Unsaturated fats • Infants determine volume consumed • Anti-infective properties • Contains immunoglobulins, enzymes, and leukocytes needed to protect against pathogens • Hypoallergenic • Faster return to pre-pregnancy weight • Lower risk of breast, ovarian cancer • Skin-to-skin contact for bonding • Low cost • Healthy diet for mother Cons • Infant’s fluid intake depends on mother’s milk supply and breastfeeding efficiency • Frequency of feeding may be more as milk digestion is faster • Value system of modern-day society creates barriers • Mothers feel ashamed/embarrassed • Returning to work • Breast pump may be needed • Discomfort Contraindications for Breastfeeding • People with • HIV/AIDS • Active TB/Varicella • Active Herpes on breast • Illicit drug use • Certain medications (radioactive meds, chemotherapy) • Infant galactosemia Barriers to Breastfeeding • Pain • Sore nipples • Leaking milk • Embarrassment • Stress • Father may feel left out • Diet restrictions • Birth Control limitations • Low milk supply • Medications • Breast surgery (mostly reductions or depending on where the incision is) • Mom going back to work Postpartum Normal physiological changes postpartum (breasts, uterus, lochia, cardiovascular, etc) Breast ▪ General appearance: Smooth, even pigmentation, changes of pregnancy still apparent; one may appear larger ▪ Palpation: Depending on postpartal day, may be soft, filling, full, or engorged ▪ Nipples: Supple, pigmented, intact; become erect when stimulated. Not cracked or bleeding