NEWBORN SCREENING Head to toe physical examination of a newborn to look for any abnormalities or pathology.

Includes biochemical screening & certain special screening ( ROP, hearing assesment, Echocardiography) Assesment at birth Physical examination Biochemical screening Special screening Retinopathy Of Prematurity Hearing assesment Echocardiography

Newborn first exam : Apgar Score Physical examination COMPLETE physical examination within 24 hours of birth. It is best to examine when the infant is quiet. Ensure infant is naked : he/she can be in diapers, but you have to open it. Do not forget to wash your hands prior to examination. Measurements Head circumference : - a.k.a Occipitofrontal circumference - place measuring tape around front of head, below the brow and occipital area. - Normal range 32cm-37cm Length & Percentile (refer growth chart) Weight & Percentile (refer groth chart) Assesment of Gestational Age & Percentile -Small for Gestational Age - Appropriate for Gestational Age - Large for gestational age

Vital signs

a) Temperature : Rectal b) Respirations : Normal rate is 40-60 c) Blood pressure : Correlates with gestational age, post natal age, birth weight. d) Pulse rate : Awake 120-160bpm, Asleep 70-80bpm

SKIN Colour Plethora (deep rosy red) Jaundice Pallor Cyanosis(central, peripheral, acrocyanosis) Blue on pink: or Pink on blue Harlequin colouration Mottling

Rashes Milia Erythema toxicum Candida albicans rash Transient neonatal pustular melanosis Acne neonatorum SKIN Nevi/ Pigmented Lesions Macular hemangioma (stork bites) Port wine stain (nevus flammeus) Mongolian spot Cavernous hemangioma Strawberry hemangioma HEAD : General, Cuts, Bruises Large anterior fontanelle Small anterior fontanelle Bulging fontanelle Molding Caput succedaneum Cephalohematoma Increased intracranial pressure Craniosynostosis o Anterior and posterior fontanelles -

Craniotabes Neck & Facial Features

Face : Look for obvious abnormalities.Note the general shape of the nose, mouth and chin. Presence of syndromic features is often diagnosed clinically throughout experience. Neck : Note shape, range of motion, and any webbing; palpate for masses Brachial palsy Erbs palsy Fractured clavicle Ears : Unusual shape, low set ears, periauricular skin tags (papillomas), hairy ears.

Chest Observation : respiratory rate, chest symmetrical, sternal/intercostal /subcostal recession, nasal flaring, grunting, stridor Breath sounds : Equality bilaterally, presence of any additional sound. Pectus excavatum : sternum that is altered in shape. Breast in newborn : May be abnormally enlarged (3-4cm) due to effects of maternal estrogens. Heart : Observation : heart rate, rhythm, quality of heart sounds, active precordium Position of heart : may be determined by auscultation Presence of murmur Palpate the pulses (femoral) & define whether its normal, weak or absent. Check for perfusion Neck & Facial Features Eyes : Observe shape, size and position of eyes. Note integrity and color of iris and sclera. Ophthalmoscopic examination to assess pupillary size and red retinal reflex Nose : Size and Shape; Note placement of the septum Formation of the nasal bridge; Verify patency (Flat nasal bridge , Deviated septum , Choanal atresia , Nasal pit ) Mouth : Hard & soft palate for evidence of cleft palate : Neonatal tooth (predeciduos,true deciduos) : Macroglossia : Oral thrush : Smooth philtrum

Signs of congestive heart failure : gallop, tachycardia & abnormal pulses Abdomen Observation : scaphoid abdomen, omphalocele, gastroschisis Palpation : Check for distension, tenderness or masses. Palpate liver, spleen, kidneys and groin and note any masses Auscultation : Listen for bowel sound Inspect anus for position and verify patency Umbilicus Should have 2 arteries 1 vein. Inspect for discharge, redness or edema around base of the cord Appearance : should be translucent. A greenish yellowish colour suggest meconium staining Genitalia : Any infant with ambiguos genitalia should not undergo gender assignment until a formal endocrinology evaluation Male Length : > 2cm Determine site of meatus Palpate bilateral testicles Examine for inguinal hernia Look for hypospadias, epispadias, chordae. Observe colour of scrotum Phimosos-foreskin cannot be retracted Cryptotorchidism-testes not descended Female Inspect for size and location of the labia, clitoris, meatus, and vaginal opening Pseudomenses Vaginal tag a small appendage or flap on the mucous membranes; common neonatal variation that usually disappears in a few weeks Extremities : Examine the arms & legs paying close attention to the digits Syndactyly Polydactyly Oligodactyly Congenital Talipes Equinovarus (CTEV) Metarsus Varus Trunk & Spine

Observe curvature and integrity Check for any gross defects of the spine. An abnormal pigmentation/ hairy patches over the lower back should increase the suspicion that an underlying vetebral abnormality exists. A sacral or pilonidal dimple may indicate a small meningocele or other anomaly. Spina bifida defect in closure of the neural tube that is associated with malformations of the vertebrae & spinal cord Hips Congenital hip dislocation ( Ortolani & Barlow Maneuvers) Assymetry of the skin folds on the dorsal surface Shortening of the affected leg

Nervous System : Observe for any abnormal movement/ excessive irritability Muscle tone Hypotonia : Floppiness Hypertonia : Extended arms&legs, hyperextension of back & tightly clenched fists.

Reflexes Rooting reflex Glabellar reflex Grasp reflex Neck righting reflex Moros reflex

Biochemical screening Simple laboratory investigation to diagnose congenital metabolic disorder that may lead to mental retardation and even death if left untreated. The goal of this screening is to give all newborns a chance to live a normal life. It provides the opportunity for early treatment of diseases that are diagnosed before symptoms appear Malaysia : G6PD deficiency & Congenital Hypothyroidism G6PD deficiency G6PD deficiency is one of the most common genetic diseases affecting an estimated 400 000 000 people worldwide. All newborn screened for G6PD and in case of deficiency should be explained to both parents. Test : Beutler fluorescent spot test : rapid & cheap test that identifies NADPH produced by G6PD under UV light. Congenital Hypothyroidism Significant decrease in, or absence of thyroid function present at birth. Approximately 1 in 4000 newborn infants has a severe deficiency of thyroid function, while even more

have mild or partial degrees. If untreated for several months after birth, severe congenital hypothyroidism can lead to growth failure and permanent mental retardation. Screening for ROP : is a disorder of the developing retina of low birth weight preterm infants that potentially leads to blindness. Infants with a birth weight of less than 1500 g Gestational age of 32 weeks or less Infants who required oxygen supply Hearing Assesment Early identification of hearing loss and appropriate intervention within the first 6 months of life has been demonstrated to prevent many of these adverse consequences and facilitate language acquisition. The Newborn By: Zosi Farah W. Fernandez, RN APGAR SCORING Developed by Dr. Virginia Apgar to provide a valuable index for assessing newborns condition at birth Used to evaluate the newborn in five specific categories at 1 and 5 minutes after birth The one minute score reflects transitional values The five minutes provides the best direction for the planning of newborn care Ballard Scoring is a commonly used technique of gestational age assessment. It assigns a score to various criteria, the sum of all of which is then extrapolated to the gestational age of the baby. These criteria are divided into Physical and Neurological criteria. This scoring allows for the estimation of age in the range of 26 weeks-44 weeks. The New Ballard Score is an extension of the above to include extremely pre-term babies i.e. up to 20 weeks. Respiratory Evaluation Can be used to estimate the degree of respiratory distress in newborns. Each item is given a value of 0,1, or 2; the values are then added A total score of 0 indicates no respiratory distress, score of 4 to 6 indicate moderate distress, score of 7 to 10 indicate severe distress Hygenic Care and Safety DELIVERY ROOM Suction the mouth first then the nose with the bulb suction B. Prevent heat loss

A. Initiate, establish and maintain respirations and heartbeat

1. Dry infant immediately after birth

2. Wrap newborn warmly, cover head or place in especially warm area 3. Place newborn in warm surface 4. Skin to skin contact with the mother C. Identify mother and infant with matching bands D. Perform rapid all physical and neurologic examination 1. Apply ID band or bracelet to infant 1. Identify obvious congenital anomalies 2. Identify injuries from birth trauma 3. Perform APGAR scoring at 1 and 5 minutes after birth 4. Place infant in Trendelenburgs position 5. Suction gently 6. Administer oxygen PRN 7. Promote bonding 8. Transfer to nursery at appropriate time E. Administer medication as ordered 1. 0.5% erythromycin or 1% Tetracycline into conjuctival sacs 2. Vitamin K 3. Hepatitis B vaccine F. Measure and weigh newborn E. Stabilize Temperature F. Assess for physiologic jaundice G. Perform Screening test before discharge Newborn Screening Republic Act No. 9288, otherwise known as the Newborn Screening Act of 2004 institutionalizes a comprehensive, integrative and sustainable national newborn screening system to ensure that every newborn baby in the Philippines have the chance to undergo newborn screening, which will ultimately spare them from either mental retardation, serious health complication or death from heritable diseases that are left untreated and undetected. What disorders does the Newborn Screening test for? Congenital Hypothyroidism - A lack or absence of thyroid hormone, which is necessary for growth of the brain and the body. Treatment is required within the first four weeks to prevent stunted physical growth and mental retardation. Congenital Adrenal Hyperplasia - An endocrine disorder that causes severe salt loss, dehydration, and abnormally high levels of male sex hormones. Left undetected and untreated, a baby may die within

seven to 14 days. Galactosemia - A condition in which babies are unable to process galactose. or the sugar present in milk. Increased galactose levels in the body lead to liver and brain damage, and to the development of cataracts. Phenylketonuria - The inability to properly utilize the enzyme phenylalanine, which may lead to brain damage. Glucose-6-Phosphate Dehydrogenase (G6PD) Deficiency - A condition where the body lacks the enzyme called G6PD, which may cause hemolytic anemia resulting from exposure to oxidative substances present in certain drugs, foods and chemicals. Parents of G6PD-positive babies are given a list of these substances. How is Newborn Screening administered? Your baby will be pricked at the heel and three drops of blood are taken. This process is ideally done during the 48th to 72nd hour of life. A negative screen means that results are normal. A positive screen will require the newborn to be brought back to her pediatrician for further testing. Normal Newborn A. Weight

1. Average between 2750g and 3800g at term 2. Under 2750g: small for gestational age 3. Over 3800g large for gestational age 4. Initial loss of 5%-10% weight normal during first few days, should be regained in 1-2 weeks B. Length Average 46-55.9 cm Under 45.7 in SGA Over 55cm in LGA C. Head Circumference

1. Average 33-33.5 cm equal to or 2-3 cm slightly larger than chest 2. Under 31.7 cm is microcephaly 3. Over 36.8cm hydrocephaly a. Caput succedaneum Swelling of the soft tissue of the scalp because of pressure from the cervix against presenting part. It disappears in 3-4 days without intervention b. Cephalhematoma

Subperiosteal hemorrhage with collection of blood between periosteum and bone; swelling does not cross suture lines c. Molding - Overlapping of skull bones caused by compression during labor and delivery D. Fontanels Diamond shaped; palpable Generally closes in 12-18 months 2. Posterior fontanel triagular, may obliterated because of molding Closes in 2-3 months Physiologic Adaptation of the Newborn Transition to Extrauterine Life infant undergo phases of instability during the first 6 to 8 hours after birth First phase of transition period last up to 30 minutes after birth and is called the first period of reactivity. The newborn heart rate increases rapidly 160 to 180/min. But gradually falls by 30 min. To a baseline rate between 100 to 120 beats/min Respiratory rate are irregular with a rate between 60 and 80 cycles/min. Crackles may be present on auscultation, audilble grunting, nasal flaring and retractions of the chest may also be noted. Brief periods of apnea may occur Body temperature may decrease The infant is alert and may have spontaneous startles, tremors, crying and movement of the head from side to side After the first period the newborn sleeps or has a marked decrease in motor activity, last from 60 to 100 minutes and is followed by a second period of activity The second period of reactivity occurs roughly between 4 to 8 hours after birth and lasts from 10 minutes to several hours Meconium is commonly passed at this time Cardiovascular System Changes in fetal circulation at birth Circulatory events at birth Drying or clamping of the umbilical cord and stimulation of cord receptors

1. Anterior fontanel

Increased PCO2, decreased PO2, and increasing acidosis First breath Decreased Pulmonary artery pressure Increased PO2 Closure of ductus arteries and vein due to Decreased flow Thermoregulation and Metabolic Changes Newborns temperature may drop several degrees after delivery because the external environment is cooler than the intrauterine environment Rapid heat loss in a cool environment occurs by conduction, convection, radiation and evaporation Cold stress in the newborn Pulse The heart rate may often remains slightly irregular because of immaturity of the cardiac regulatory center in the medulla Transient murmurs may result from the incomplete closure of the fetal circulation During crying the heart rate rise again to 180 bpm Heart rate decrease during sleep ranging from 90 to 110 bpm Respiration In the few minutes of life may be high as 90 breaths per minute As respiratory activity is established and maintained, the rate settles to an average of 30 to 60 per minute Respiratory depth, rate and rhythm are likely to be irregular, and short period of apnea, sometimes called periodic respirations Newborn are obligate nose-breathers and show signs of acute distress if their nostrils become obstructed Coughing and sneezing reflexes are present at birth to clear the airway. Gastrointestinal System Accumulation of bacteria in the gastrointestinal tract is necessary for digestion and the synthesis of Vitamin K. Stomach hold 60 to 90 ml. Regurgitates easily because of an immature cardiac sphinter between the stomach and esophagus. Immature liver function may lead to lowered glucosed and protein serum level. First stool of a newborn is usually passed within 24 hours after birth, called as meconium. If a newborn does not pass a meconium stool by 24 to 48 hours after birth, the possibility of meconium ileus, imperforated anus, or bowel obstruction should be suspected About the second or third day of life, a newborn stool changes in color and consistency, becoming green Closure of foramen ovale Closure of ductus venousus and arteriosus umbilical

and loose, this is termed transitional stool Breast feed babies pass three or four light yellow stool per day Formula usually passes two or three bright yellow stools a day Urinary System Average newborn voids within 24 hours after birth. A newborn who does not take in much fluid for the first 24 hours may void later than this, but the 24 hours point is a good general rule Newborn who do not void within this time should be examined for the possibility of urethral stenosis or absent kidneys or ureters. Single void in a newborn is only about 15 mL, the daily urine output for the first 1 or 2 days is about 30 to 60 mL total. A small amount of protein may be normally present in voiding for the first few days life, until the kidney glomeruli are more fully mature. Immune System Newborn routinely administered hepatitis B vaccine during the first 12 hours after birth to protect against this disease. They have difficulty forming antibodies against incading antigen until about 2 months of age, newborns are prone to infection. This inability to form antibodies is the reason that most immunizations against childhood disease are not given to infants younger than 2 months of age Neuromascular System Mature newborns demonstrate neuromuscular function by moving their extremities, attempting to control head movement, exhibiting a strong cy and demonstrating newborn reflexes. A newborn occasionally makes twitching or flailing movements of the extremities in the absence of stimulus because of the immature of the nervous system. Newborn Reflex Blink Reflex - In a newborn serves the same purpose as it does in an adult-to protect the eye from any object coming near it by shining a strong light such as a flashlight or otoscope light on an eye. A sudden movement to ward the eye sometimes can elicit the blink reflex. Rooting reflex If the check is brushed or stroke near the corner of the mouth, a newborn infant will turn the head in that direction. This reflex serves to help a newborn find food: when a mother holds the child and allows her breast to brush the newborns cheek, the reflex makes the baby turn toward the breast. This reflex disappear at about the sixth week of life. It about time, newborn eyes focus steadily. Sucking reflex

When a newborn lips are touched, the baby makes a sucking motion. This reflex helps a newborn find food: when the newborn lips touch the mothers breast or bottle, the baby sucks and takes food. The sucking reflex begins to diminish at about 6 months of age. Swallowing reflex - In a newborn is the same as in adult. Food that reaches the posterior portion of the tongue id automatically swallowed. Gag, cough, and sneeze reflexes are present to maintain airway in the event that normal swallowing does not keep the pharynx free from obstructing mucous.

Extrusion Reflex A newborn extrudes any substance that is placed on the anterior portion of the tongue. This protective reflex prevents the swallowing reflex of inedible substance. It disappears at about 4 months of age Palmar Grasp Reflex Newborn grasp an object placed in their palm by closing fingers on it. Mature newborn grasp so strongly that they can be raised from a supine position and suspended momentarily from an examiners fingers. Reflex disappears at about 6 weeks to 3 months of age. Step-in-place reflex Newborn who are held in a vertical position with their feet touching a hard surface will take a few quick, alternating steps. This reflex disappears by 3 months of age. Plantar Grasp Reflex When an object touches the sole of a newborns foot at the base of the toes, the toes grasp in the same manner as the finger do. Reflex disappears at about 8 to 9 months. Tonic neck reflex When newborn lie on their backs, their head usually turn to one side or the other. The arm and the legs on the side toward which the head turns extend, and the opposite arm and leg contract. This is also called the boxer or fencing reflex The reflex disappears between the second and third months of life. Moro Reflex - Can be initiated by startling a newborn with a loud noise or by jarring the bassinet. The most accurate method to eliciting the reflex is to hold a newborns in a supine position and allow their heads to drop backward about 1 inch. In response to this sudden head movement, they abduct and extend their arms and legs.

Babinski Reflex When the side of the sole of the foot is stroked in an inverted J curve from the heel upward, a newborn fans the toes It remains positive until at least 3 months of age. Magnet Reflex If pressure is applied to the soles of the feet of a newborn lying in a supine position, he or she pushes back against the pressure. Crossed Extension Reflex - If one leg of a newborn lying supine is extended and the sole of that foot is irritated by being rubbed with a sharp object, the infant raises the other leg and extends it, as if trying to push away the hand irritating the first leg

Trunk Incurvation Reflex - When newborns lie in a prone position and are touched along the paravertebral area by a probing finger, their trunk and swing their pelvis toward the touch. Landau Reflex - A newborn who is held in a prone with a hand underneath, supporting the trunk, should demonstrate some muscle tone. Babies may not be able to lift their head or arch their back in this position Deep Tendon Reflex A patellar reflex can be elicited in a newborn by tapping the patellar tendon with the top of the finger. The lower leg moves perceptibly if the infant has an intact reflex. Is a test for spinal nerve L2 through L4 The Senses Hearing As soon as amniotic fluid drains or is absorb from the middle ear by way of the eustachian tube- within hours after birth hearing becoming acute. Newborns appears to have difficulty locating sounds. Vision Newborns seen as soon as they are born and possibly have been seeing light and dark into utero for the last few months of pregnancy. Newborns focus on black and white objects at a distance of 9 to 12 inch. Touch The sense of touch is also well developed at birth. Demonstrate this by quieting at a soothing touch and by positive sucking and rooting reflexes. Taste

A newborn has the ability to discriminate taste, because taste buds are developed and functioning even before birth. Smell - The sense of smell is present in newborns as soon as the nose is clear of mucus and amniotic fluid. Birthmarks Hemangiomas Are vascular tumors of the skin. Three types of hemangiomas occur: Is a macular purple or dark-red lesion that is present at birth Sometimes called a port-wine stain These lesion typically appear on the face, although they often found on the face; it is less likely to fade. Can be covered by a cosmetic preparation later in life or removed by laser therapy, although lesions may reappear after treatment. 2. Strawberry Hemangioma Are elevated areas formed by immature capillaries and endothelial cells. Most are present at birth in term neonates, although may appear up to 2 weeks after birth. Application of hydrocortisone ointment may speed the disappearance of the lesions by interfering with the binding of estrogen to its receptor site. 3. Cavernous Hemangioma Are dilated vascular spaces, they are usually raised and resemble a strawberry hemangioma in appearance. However they do not disappear with time as the strawberry hemangioma. Suncutaneous infusions of interferon-alfa-2a can be used to reduce these lesions in size, or they can be removed surgically. Usually their hematocrit levels assed at health maintenance to evaluate for possible internal blood loss Mongolian Spot Are collections of pigment cells that appears as slate-gray patches across the sacrum or buttocks and possibly on the arms and legs. They disappear by school age without treatment. Vernix Caseosa Is a white, cream cheese-like substance that serves as a skin lubricant. It is noticeable in on a term newborns skin, at least in the skin folds, at birth. Lanugo Is the fine hair, downy hair that covers a newborns shoulder, back and upper arm. It maybe found also

1. Nevus Flammeus -

on the forehead and ears. A baby born after 37 to 39 weeks of gestation has more lanugo than a newborn of 40 weeks. Is rubbed away by the friction of bedding and clothes against the newborns skin. By 2 weeks of age it disappear Desquamation Within 24 hours after birth, the skin of most newborns has become extremely dry. The dryness is particularly evident on the palms of the hands and soles of the feet. This results in areas of peeling similar to those caused by sunburn. Milia all newborn sebaceous glanda are immature. At least one pinpoint white papule can be found on the cheek or across the bridge of the nose of every newborn. Disappear by 2 to 4 weeks of age, as sebaceous glands mature and drain. Erythema Toxicum In most normal mature infants, a newborn rash This usually appears in the first to fourth day of life, but may appear up to 2 weeks of age. It begins with papule, increases in severity to become erythema by the second day, and then disappears by the third day Sometimes called flea-bite rash Caused by a newborns eosinophils reacting to the environment as the immune system matures. Epsteins Pearls One or two small round, glistening, well circumscribed cysts are present on the palate, as a result of the extra load of calcium that was deposited in utero. Nursing Diagnosis Risk for ineffective thermoregulation related to newborns transition to extrauterine environment Risk for ineffective airway clearance related to presence of mucus in mouth and nose at birth Risk for infection related to newly clamped umbilical cord and exposure of eyes to vaginal secretions Hearing Assesment Family History of Hearing Loss Perinatal Infection Craniofacial Anomalies Very Low Birth Weight Hyperbilirubinemia (>340mmol/L) Bacterial Meningitis

Ototoxic Medications Syndrome Associated with Hearing Loss Prolonged Ventilation Severe Asphyxia at Birth Admission to NICU ECHOCARDIOGRAPHY GDM ON S/C INSULIN GDM ON DIET CONTROL ANY CLINICALLY HEARD MURMUR LARGE FOR GESTATION AGE NEWBORN WITH MACROSMIC FEATURES SYNDROMIC NEWBORN (DOWNS SYNDROME, Surfactant What is the function of surfactant? When is it produced? When it is sufficient to support extrauterine life? Respiratory Changes Chemical Events 1. With cutting of the cord, remove oxygen supply 2. Asphyxia occurs 3. CO2 and O2 and pH = ACIDOSIS 4. Acidotic state-- stimulates the respiratory center in the medulla and the chemoreceptors in carotid artery to initiate breathing Mechanical Events As the chest passes through the birth canal the lungs are compressed Subsequent recoil of the chest wall produces passive inspiration of air into the lungs Mechanical Events About 60-110 ml. of fluid is squeezed out of the lungs as the chest is compressed The remaining fluid evaporates or is reabsorbed by the blood vessels and lymphatics surrounding the lungs.

**When a baby is delivered in a presentation other than vertex, it takes longer for the lungs to rid themselves of the fluid Sensory / Thermal Events Thermal--the decrease in environmental temperature after delivery is a major stimulus of breathing Tactile--nerve endings in the skin are stimulated Visual--change from a dark world to one of light Auditory--sound in the extrauterine environment stimulates the infant Answer this ! When a baby is born by cesarean delivery, which of the mechanisms to initiate breathing does it lack? Fetal Circulation What is the flow of blood through the fetal heart?

1. ____________ 2. ____________ 3. ____________ 4. ____________ Fetal Circulation Fetal Circulation What is the stimulus for the change in circulation? What are the changes in circulation from Intrauterine to Extrauterine? Intrauterine to Extrauterine Cardiovascular Changes True / False An infants first breath results in reduced pulmonary vascular resistance, decreased left atrium pressure, and increased right atrium pressure Increase CO2 , decreased O2, and increased pH help trigger initial breathing Temperature Regulation

Why is the newborn at a DISADVANTAGE in maintaining a normal temperature ? Four Avenues of Heat Loss Conduction --Loss of heat to a cooler surface by direct skin contact Convection--Loss of heat to cooler air currents Radiation--loss of heat to cooler surfaces and objects not directly in contact with the skin Evaporation-- loss of heat when water is converted to a vapor. What are nursing interventions to decrease each of these? Heat Production 1. Increase in Muscular activity--shown by crying and restlessness = increases BMR 2. Non-Shivering Thermogenesis - unique to newborns. Uses the infants stores of brown fat. Brown fat is found in the midscapular area, around the neck, in the axillas, and around the trachea, kidneys, and adrenal glands 1. Skin receptors perceive a drop in environmental temperataure 2. Transmit impulses to the central nervous system 3. Which stimulates the sympathetic nervous system 4. Norepinephrine is released at local nerve endings in the brown 5. Metabolism of brown fat 6. Release of fatty acids 7. Release of HEAT! Blood Changes At birth, an infant has more RBCs and higher hemoglobin and hematocrit levels than an adult Once proper oxygenation is established, the need for the high RBCs diminishes Lab values for Newborn hemoglobin 14-20 g/dl hematoctrit 43-63% WBC 10,000-30,000/mm3 glucose 45-96 mg/dl Gastrointestinal Changes By 36-38 weeks of fetal life, the GI system is fully mature and ready to digest simple carbohydrates, fats, and protein. What is the capacity of the newborns stomach? What is meconium? Why is it important for the newborn to pass this? Hepatic and Liver Functions

 iron storage and RBC production carbohydrate metabolism conjugation of bilirubin Coagulation--coagulation factors are under the influence of vit. K. The absence of normal flora needed to synthesize vit. K results in low levels of vitamin K and creates a transient blood coagulation alteration between the second and fifth day after birth. Vitamin K is given prophylactically to combat potential clinical bleeding problems Physiological Jaundice What is Physiological Jaundice? What is the main cause? Conjugation of Bilirubin Where do we get bilirubin? What is the difference in Unconjugated bilirubin and conjugated bilirubin? Why does it need to be conjugated? Physiological Jaundice About 50% of all infants exhibit signs in 2 - 3 days after birth Bilirubin levels at birth are about 3 mg./dl and should not exceed 12 mg. Peak bilirubin levels are reached between days 3 & 5 in the term infant. Toxic levels are approximately 20mg/dl. Nursing Care: Keep well hydrated Promote elimination early feedings tend to keep bilirubin levels down by stimulating intestinal activity thus removing the contents and not allowing reabsorption Renal / Kidney Changes Intrauterine Urine if formed in utero and some excreted into the amniotic fluid Excretion of wastes is the function of the placenta Extrauterine GFR is low --decrease ability to excrete drugs Limited ability to reabsorb Sodium Decreased ability to concentrate urine Bladder capacity is 6 - 44 ml

Void within the first 24 hrs. and should void 6 - 10 times per day Immunologic Adaptation Active acquired immunity Pregnant woman forms antibodies herself Passive acquired immunity Mom passes antibodies to the fetus Lasts from 4-8 months Newborn begins to produce own immunity about 4 weeks of age Behavorial / Sleep - Awake States Sleep States: Deep or quiet sleep Active rapid eye movement/ light sleep Drowsy Wide awake/quiet alert Active awake/ active alert Crying

Alert States:

Which state is optimal for parent-infant interaction? Quiet Alert Sensory Visual Can follow and fixate on visual stimuli for short period of time Hearing Alert to and searches for auditory stimulus Olfactory Able to select people by smell Taste Able to respond to different tastes Tactile Sensitive to touch, cuddling, and being held Immediate Care of the Newborn Ensure a Patent Airway Position on side Suction mouth then nares

 supply warmed oxygen is necessary Apgar Score Score of 7 - 10 = Good Condition Score of 4 - 6 Score of 0 - 3 Score This ! Baby girl Doe has a heart rate of 102, with slow, irregular respirations. She grimaces when stimulated. She has some flexion in her extremities and her skin color is pale. What is her Apgar Score? Identification of the Newborn Mother and infant should have matching identibands. Bands should be placed on infant prior to leaving the delivery room Footprint of infant and fingerprint of the mother Eye Care Legal requirement that all newborns have treatment to prevent Ophthalmia neonatorium which can lead to newborn blindness. Treated with antibiotic eye medication either ointment or drops (Tetracycline or Erythromycin ) = Fair Condition = Poor Condition Apgar Score **Always have bulb suction in view ! Maintain Body Temperature Dry off Place in warmer Clamping of the Cord Cord should be clamped off about 1 from base of cord. Inspect the cord for 2 arteries and 1 vein. Skin to skin contact Apgar Score Scoring system to appraise the newborn Done at 1, 5, and 10 minutes after birth

Hemorrhage Prophylaxis Administration of Vitamin K (AquaMEPHYTON) This promotes liver formation of clotting factors The newborn does not have bacteria in the GI tract to synthesize vit. K. By 5 - 8 days after birth, it is formed. Transfer to the Nursery Identification checks Full report must be given to the nursery nurse by the L & D nurse Condition of the neonate Labor and Birth record Antepartal history Parent-newborn interaction

Physical Assessment Temperature - 97.6 - 98.6 Heart Rate - 120 - 160 BPM. Regular rate. PMI on the left side of the chest Respirations- 30 - 60 breaths / min. Diaphragmatic with a shallow, irregular rate and rhythm. Chest and abdominal movements should synchronize. Periodic Breathing is normal. They are nose breathers. Tachypnea is abnormal

Blood Pressure - 80-60 / 45-35. Measurements and Weights

Length = 18 - 22 inches Head and Chest Circumference = Head is 13; Chest is 12. Head is larger than the chest by one inch or 2 cm. Weight - 6 - 9 lbs average. Newborns lose 5% - 10% of birth weight the first few days after birth. Reflexes Moro Tonic Neck Palmar and Plantar grasp Babinski Feeding--Rooting, Sucking, Swallowing, Gag Protective -- Sneezing, Blinking, Gag

Daily Nursing Care Need for warmth and dry

Need for protection from infection Need for food Need for attachment and loving Need for bathing and cord care The newborns diet must supply nutrients to meet the rapid rate of physical growth and development Daily caloric intake should be 110 - 120 calories / kg. / day

Nutritional Needs

Circumcision It is not medically necessary. It is a personal decision of the parents. What is the priority nursing assessment following a circumcision? Explain? What is important to teach parents about care?