THE NORMAL

AND THE HIGH

RISK NEONATE:
BIRTH -28 DAYS
Professor Emily Cummiskey, MSN, RN,
CNE
Professor Keith Scally, MSN RNC-OB,
CCE
WHO WANTS TO HAVE FUN TODAY?!

A baby was born that was so advanced that he could

talk. He looked around the delivery room and saw the
doctor.
"Are you my doctor?" he asked.
"Yes, I am."
The baby said "Thank you for taking such good care
of me during birth."
He looked at his mother and asked, "Are you my
mother?"
"Yes, I am," she said.
"Thank you for taking such good care of me before I
was born" he said. He then looked at his father and
asked "Are you my father?"
"Yes, I am," his father answered.
The baby motioned him close, then poked him on the
forehead with his index finger 5 times, saying "I want
you to know that
THAT HURTS!"
STUDENT LEARNING OBJECTIVES

Differentiate Construct Prioritize Explain

Differentiate between Construct a teaching Prioritize normal Explain the clinical

normal and abnormal plan for infant newborn care. manifestations and
findings on the feeding. care of the newborn
systematic with selected high
assessment of the risk conditions:
newborn. • Prematurity
• Birth Trauma
• Respiratory Distress
Syndrome/Transient
Tachypnea of the
Newborn
• Jaundice
• Sepsis
• Neonatal Abstinence
Syndrome
 Nutrition

• The process of taking in and utilizing food substances to generate energy and supply materials used in
body processes.

Oxygenation

• Provision of oxygen, through gas exchange, to all cells and tissues of the body.

Protection

• That which prevents the body from suffering harm or injury; mechanisms of protection include skin
integrity, the immune system and the inflammatory response.

Perfusion

• A normal physiological process that requires the heart to generate sufficient cardiac output to transport
blood through patent blood vessels for distribution in the tissues throughout the body. Tissue perfusion
refers to the flow of blood through the arteries and capillaries, delivering nutrients and oxygen to cells, and
removing cellular waste products.

CONCEPTS
ENCOURAGE FAMILY CARE AND BONDING

 Create warm environment

 Keep family together, “rooming in”
 Teach infant care
 Provide positive feedback
 Remain open minded
 Support caregiver(s)
 Provide culturally sensitive care
NURSING CARE OF THE
NEWBORN AND FAMILY: BIRTH
TO TWO HOURS OF LIFE

 Promoting skin to skin

 Maintaining airway,
circulation and temperature
 Encouraging breast feeding
 Eye prophylaxis
 Vitamin K prophylaxis
APGAR SCORING CHART
TRANSITION TO EXTRAUTERINE LIFE:
NEUROBEHAVIORAL

First period of reactivity • First hour of life

Period of decreased
responsiveness
• 1-2 hours

Second period of
reactivity
• 10 minutes to several hours
 A After the 2nd Apgar Score, at
5 minutes post delivery
WHEN
WOULD BE B Immediately after delivery,
A GOOD before the cord is cut
TIME TO
INITIATE C After the mother has
BREAST recovered, at 3 hours post
FEEDING? delivery
D After the neonate has
received Vitamin K, at 2 hours
post delivery
 ADJUSTMENT TO EXTRAUTERINE LIFE

 Biological Tasks  Behavioral Tasks

 Establish and Maintain  Establish awake sleep
Respirations cycles
 Adjust to Circulatory  Processing, Storing, and
Changes Organizing Multiple
 Thermoregulation Stimuli
 Feeding/Elimination  Establishing
relationships
 Regulate Weight
 Initial breath triggered by changes in
 Pressure
 Removal of amniotic fluid from fetal lungs
 Chemical
 Activation of chemoreceptors during labor
 Environment
 light, noise, temperature
 Physical
 Stimulation, cutting of the cord

RESPIRATORY SYSTEM
 CIRCULATORY SYSTEM

Breathing leads to
closure of foramen Murmurs common Clamping of the
Acrocyanosis
ovale cord

subsequent
increases in arterial
pressure cord clamping
• closure of the ductus
arteriosus and ductus
venosus

blood volume
THERMOGENIC REGULATION

• Balance of heat production/ loss

• Risk factors
• Prematurity, SGA, Sepsis leading cause of death =(signs are
OUTSIDE of NORMAL peramator either HIGH or LOW HR
and LOW TEMP)- , Prolonged resuscitation, large surface
area
• Clinical Manifestations
• Lethargy, pallor, Hypoglycemia, Hypotonia,
hypoglycemia=Jitteriness= test blood sugar MUST BE OVER
40. Babies DON’T SHIVER if looks like shiver it could be
jitters**
• Nursing care
• Brown adipose tissue
• Main source of heat
• Intense lipid metabolic activity
• Surrounds vital organs and vertebral column
 HEAT LOSS IN THE NEONATE

 Convection
 Air

 Radiation
 Surface within close proximity

 Evaporation
 Liquid to vapor

 Conduction
 Surface to surface
WHY DO NEWBORNS LOOSE HEAT QUICKLY?

Large body surface

related to body mass

Neonates can not

shiver

Neonates have an
immature central
nervous system

Neonates have a thin

epidermis
HEAD TO TOE ASSESSMENT

 Nursing Care
 Special Considerations Related to Gestational
Age
 Preterm
 Late preterm
 Term
 Postterm
WEIGHT

 LGA – wt. >90th %= LARGE

 SGA – wt. <10th%= SMALL
 LBW – wt.  2500 gms
 VLBW - < 1500 gms
 ELBW - < 1000 gms
 IUGR-Symmetric vs. Asymmetric
SMALL FOR GESTATIONAL LARGE FOR
AGE/ INTRAUTERINE GESTATIONAL AGE
GROWTH RESTRICTION

 May be neonates of diabetic

 Many have experienced chronic moms
perinatal asphyxia
 At risk for
 At risk for
 Hypoglycemia
 Injury
 Polycythemia  Asphyxia
 Hypothermia
GESTATIONAL AGE

 New Ballard Score

GENERAL APPEARANCE

 Pink to ruddy color

 Soft smooth skin

 Vernix caseosa

 Posture
VITAL SIGNS
 Heart Rate
 120-160
 http://newborns.stanford.edu/PhotoGallery/HeartNL1.html

 Temperature
 36.5-37.2C
 Respiratory Rate
 30-60
 http://newborns.stanford.edu/PhotoGallery/RespNL1.html

 Blood pressure
 50-75/30-45
 Pain scale
 I&O
MILIA

 Blocked sebaceous
glands

 Most common on chin

and nose

 No clinical significance
ERYTHEMA TOXICUM

 Rash of no known
cause appearing within
48 hours of birth

 Resolves spontaneously
MONGOLIAN SPOT

 Bluish gray or dark non-

elevated pigmented area
usually found over the lower
back and buttocks

 Primarily in nonwhite

 The spot usually fades by age

5
TELANGIECTATIC NEVI

 Stork bite

 Natural deposit of
pigmentation

 Easily blanchable

 Usually fade by age 2

NEVUS FLAMMEUS

Port wine stain

Reddish, flat,
discoloration of the
face or neck
 PETECHIAE

 Can indicate infection

or bleeding disorder
 May be due to delivery
 Report to MD
 Obtain CBC
HEAD

Molding
Anterior and
posterior fontanels
Circumference
CEPHALOHEMATOMA

 Palpable, flat, soft

 Collection of blood
between skull and
periosteum
 Doesn’t cross suture
lines
 CAPUT SUCCEDANEUM

 Edema of the
scalp
 Crosses suture
lines
FACE
 Round with symmetrical
movement
 Ear pinna in line with
eyes
 Mouth and tongue
midline, appropriate
size
 Palate
 Epstein pearls
 Teeth
CHEST

 Barrel shaped
 Symmetric
 Smaller than head
 Clavicles
 Nipples
ABDOMEN

 Protrudes
 Bowel sounds
 Three vessel cord
 2 arteries, 1 vein
GENITALS
 Male
 Penis straight with urethral
opening at end
 Testes palpable in scrotum
 Female
 May have vaginal
discharge
 Labia, urethra, clitoris
 Pseudomenses
 Brick Urine
OUTPUT
Meconium passage
within 24-48 hours
Transitional Stool
Milk stool
Void
Pseudomenses
Brick Urine
EXTREMITIES

 Symmetry
 Creases on palm (3)
 Simian Crease
 Spine is straight, midline
 Sacral dimple or tuft of
hair
 Ortalani maneuver
 Digits
NEUROLOGICAL ASSESSMENT

 Rooting
 Sucking
 Tonic neck
 Watch
 Stepping
 Babinski
 Grasp
 Moro
COMMON PROCEDURES/ INTERVENTIONS
 Immunizations
 Hepatitis B
 Consent
 Procedure
 Circumcision
 Consent
 Procedure
 Post procedural assessment
 Parental education
 Laboratory and Diagnostic Testing
 Universal newborn screening
 Newborn hearing screening
 Glucose screening
 Normal range Hypoglycemia Risk factors Symptoms Nursing Care

Diabetic mother, birth

trauma, infection, LGA, Jitteriness, lethargy, Glucose gel, dextrose sticks,
70-100 <40 SGA, pre or post term, temperature instability, early feed, observe for
hypothermia, respiratory apnea, hypotonia clinical manifestations
distress

BLOOD GLUCOSE
PRIORITIZING NURSING CARE
NUTRITION FOR THE
NEONATE

• Nurses job is to educate parents about both so that

they may make an informed decision that meets
their needs

• Breast Feeding

• Formula Feeding
 SUCCESSFUL BREAST FEEDING

 Breast and nipple evaluation upon

admission
 Early feeding, before other
interventions
 Avoid supplements, artificial
nipples
 Teach about feeding cues, latch,
and how to evaluate baby’s intake
 Reassure and support patient and
partners
 Provide positioning support,
comfort measures, enhance let
down reflex
 Encourage on demand feeding
 Offer lactation consultant
SUCCESSFUL FORMULA FEEDING

 Prevent infection
 Clean bottles and nipples, store and discard of
excess formula as directed
 Feeding every 3-4 hours
 Average infant takes 15-30ml per feeding first
day or two and increases to 2-3 oz over 2 weeks
 No Bottle Propping
 Mixing Formulas according to manufacturer
 BPA Free Bottles
Acquired disorders
Congenital disorders
 Typically occur at, or
soon after, birth  Present at birth; usually due to some
type of malformation occurring
during the antepartal period
 May result from problems
or conditions experienced
by the woman during her  Typically involve some problem
pregnancy or at birth with inheritance

 There may be no
 Majority have a complex etiology
identifiable cause for the
disorder
CONGENITAL CONDITIONS OF THE
NEWBORN
 Congenital heart disease

 Inborn errors of metabolism

 Central nervous system structural anomalies

 Respiratory system structural anomalies

 Gastrointestinal system structural anomalies

 Genitourinary system structural anomalies

 Musculoskeletal system structural anomalies

• Transient tachypnea of the newborn
• Respiratory distress syndrome
• Birth trauma
• Necrotizing enterocolitis (NEC)
• Infants of diabetic mothers
• Neonatal Abstinence Syndrome
• Hyperbilirubinemia
• Sepsis

ACQUIRED
CONDITIONS OF THE
NEWBORN
TRANSIENT TACHYPNEA
• Respiratory distress within 24 hours of
delivery that resolves within 48 hours
• Manifestations
• Grunting on exhalation
• Listen

• Nasal Flaring
• Intercostal Retractions
• Hypotonia
• RR apnea or >60
• Listen

• Cyanosis
 RESPIRATORY DISTRESS SYNDROME
Breathing disorder
Leads to increased
caused by lack of Manifestations Risk factors
work of breathing
alveolar surfactant
• LS ratio isn’t 2:1 until • Use of accessory • Grunting • Prematurity
35-36 weeks gestation muscles • Flaring
• Retractions
• Apnea or Increased
respiratory rate
• Cyanosis
FACTORS PLACING THE NEWBORN AT
RISK FOR BIRTH INJURY

• Cephalopelvic disproportion (CPD)

• Maternal pelvic anomalies
• Oligohydramnios
• Prolonged or rapid labor
• Abnormal presentation (breech, face,
brow)
• Instrument-assisted extraction (vacuum or
forceps)
• Fetal prematurity, fetal macrosomia and
fetal abnormalities
 Description

 Pathophysiology

 Clinical Manifestations

 Diagnostic Evaluations

 Nursing Care Management

 Parent and Family Teaching

NECROTIZING ENTEROCOLITIS
(NEC)
  Description

 Pathophysiology

 Clinical Manifestations

 Diagnostic Evaluations

 Nursing Care Management

 Parent and Family Teaching

INFANTS OF DIABETIC MOTHERS

NEONATAL ABSTINENCE
SYNDROME

• These babies may or may not be confined to the nursery.

• PRE with hold or PRE without hold
• The nurse is responsible for treating family with respect
• May need to utilize interdisciplinary care such as OT &
PT
• Finnegan scores
WITHDRAWAL ACRONYM

W = Wakefulness
I = Irritability
T = Temperature variation, tachycardia, tremors
H = Hyperactivity, high-pitched cry, hyperreflexia, hypertonus
D = Diarrhea, diaphoresis, disorganized suck
R = Respiratory distress, rub marks, rhinorrhea
A = Apneic attacks, autonomic dysfunction
W = Weight loss or failure to gain weight
A = Alkalosis (respiratory)
L = Lacrimation
http://newborns.stanford.edu/PhotoGallery/Jittery3.html
HYPERBILIRUBINEMIA
• Abnormally high level of unconjugated
bilirubin in the blood
• Jaundice develops from the deposit of
bilirubin in tissue
• Moves from top to bottom, inner to
outer
• Total serum bilirubin level rises
approximately 5mg/dl per day
• Coombs Test
• Measurement of antibodies on
RBC’s
Fetal circulation less efficient at oxygen exchange

Need more RBC for oxygenation

High proportion of RBC/kg at birth

Fetal RBC have a short life span

After birth, decreased need so RBC breakdown and byproduct is BILIRUBIN

HYPERBILIRUBINEMIA
PHYSIOLOGICAL PATHOLOGICAL
JAUNDICE JAUNDICE

 Occurs after 24 hours of life  Occurs within 24 hours of

 Maximum concentration life
day 4-5  Excessive destruction of red
 Resolves within 7-10 days blood cells
 Maternal-fetal blood
incompatibilities
 ABO Incompatibility
 Rh Incompatibility
RH INCOMPATIBILITY
 Rh negative mother has an Rh positive fetus (fetus inherited from
father)
 1st pregnancy
 Mother is Rh neg and fetus is pos, mother builds up antibodies
against fetal blood cells (maternal sensitization)
 Sensitization can occur during pregnancy, birth, miscarriage, abortion,
amniocentesis, trauma
 Subsequent pregnancies
 Causes hemolytic disease
 Lysis of RBCs
 Marked anemia
 Hydrops fetalis
 Most severe, multiorgan failure, fetal or neonatal death can occur without intrauterine
transfusions
 Rhogam prevents
 Immune globulin
 ABO INCOMPATIBILITY

Naturally occurring anti A

Occurs if fetal blood type and anti B antibodies are
is A, B, or AB and the present in maternal blood
maternal blood type is O stream and cross the
placenta
 KERNICTERUS

Results from deposits of

bilirubin in brain cells Occurs at bilirubin
leading to their levels above 25mg/dl
destruction

Neurological damage Neonatal death

 NURSING INTERVENTIONS

 Encourage frequent
feedings
 Monitor stools
 Obtain bilirubin levels
per protocol
 Possible phototherapy
 Blood transfusions may
be necessary for
pathological jaundice
 SEPSIS
 Risk Factors
 GBS Positive
 Prolonged rupture of membranes

 One of most significant causes of neonatal morbidity

and mortality

 Signs and Symptoms

 Tachypnea
 Hypotension
 Bradycardia/Tachycardia
 Temperature instability will drop
 Lethargy
 Feeding intolerance
 Glucose instability
 Treatment
 Triple Antibiotics
 Infant care
• Bathing
• Circumcision care
• Umbilical cord site care
• Feeding
• Diapering
• Skin care
• Nail care

DISCHARGE • Genital care

PLANNING AND Infant safety

•

TEACHING
NEVER STOP ASKING QUESTIONS