Mr.SAM

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Published on January 10, 2009

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CARE OF THE NEWBORN : CARE OF THE NEWBORN PYRAMID POINTS : PYRAMID POINTS Initial care of the newborn Apgar scoring system General guidelines for the initial physical examination Normal findings on physical assessment of a newborn Normal vital signs for a newborn PYRAMID POINTS : PYRAMID POINTS Assessment of the fontanels Assessment of the umbilical cord Assessment of reflexes Assessment findings and interventions in respiratory distress syndrome (RDS) Assessment findings in hyperbilirubinemia Interventions for the newborn receiving phototherapy PYRAMID POINTS : PYRAMID POINTS Assessment findings and interventions for the addicted newborn and the newborn with fetal alcohol syndrome (FAS) Care to the newborn born to a human immunodeficiency virus (HIV) positive mother Assessment findings and interventions for the newborn of a diabetic mother Parent education regarding care to the newborn INITIAL CARE OF THE NEWBORN : INITIAL CARE OF THE NEWBORN From James, S., Ashwill, R., & Droske, S. (2002). Nursing care of children: Principles and practices, ed 2, Philadephia: W.B. Saunders. INITIAL CARE OF THE NEWBORN : INITIAL CARE OF THE NEWBORN ASSESSMENT Observe or assist with initiation of respirations Assess Apgar score Note characteristics of cry Monitor for nasal flaring, grunting, retractions, abnormal respirations Obtain vital signs Observe newborn for signs of hypothermia or hyperthermia or gross anomalies Suction mouth, then nares, with bulb syringe SUCTIONING THE NEWBORN : SUCTIONING THE NEWBORN From Nichols, F. & Zwelling, E. (1997). Maternal newborn nursing: Theory and Practice, ed 2, Philadelphia: W.B. Saunders. INITIAL CARE OF THE NEWBORN : INITIAL CARE OF THE NEWBORN IMPLEMENTATION Dry newborn and stimulate crying by rubbing Maintain temperature stability; wrap newborn in warm blankets and place a stockinette cap on newborn’s head Keep newborn with mother to facilitate bonding Place newborn at mother’s breast if breastfeeding is planned or place on mother’s abdomen INITIAL CARE OF THE NEWBORN : INITIAL CARE OF THE NEWBORN IMPLEMENTATION Place newborn in warmer Position newborn to facilitate drainage of mucus Ensure newborn’s proper identification Footprint newborn and fingerprint mother on identification sheet per agency policies and procedures Place matching identification bracelets on mother and newborn APGAR SCORING SYSTEM : APGAR SCORING SYSTEM FIVE VITAL INDICATORS Heart rate Respiratory rate Muscle tone Reflex irritability Skin color APGAR SCORING SYSTEM : APGAR SCORING SYSTEM Perform and record the Apgar score at 1 minute and at 5 minutes If the score is less than 7 at 5 minutes, the Apgar score should be performed at 10 minutes Assess each of five items to be scored and assign value of 0 (very poor) to 2 (excellent) for each item Add the points to determine the newborn’s total score A score of 7 to 10 indicates a healthy newborn A score of 3 to 6 is considered moderately depressed A score of 0 to 2 is severely depressed APGAR SCORING SYSTEM : APGAR SCORING SYSTEM HEART RATE Absent = 0 points Less than 100 beats per minute (BPM) = 1 point More than 100 BPM = 2 points RESPIRATORY RATE Absent = 0 points Slow, irregular weak cry = 1 point Good, vigorous cry = 2 points APGAR SCORING SYSTEM : APGAR SCORING SYSTEM MUSCLE TONE Flaccid, limp = 0 points Minimal flexion of extremities, sluggish = 1 point Good flexion, active motion = 2 points REFLEX IRRITABILITY No response = 0 points Weak cry and grimace = 1 point Vigorous cry, active movement = 2 points APGAR SCORING SYSTEM : APGAR SCORING SYSTEM SKIN COLOR Blue = 0 points Body skin normal, extremities blue = 1 point Body and extremity skin color normal = 2 points APGAR SCORE: IMPLEMENTATION : APGAR SCORE: IMPLEMENTATION SCORE 7 to 10 IMPLEMENTATION Rarely need resuscitation APGAR SCORE: IMPLEMENTATION : APGAR SCORE: IMPLEMENTATION SCORE 3 to 6 IMPLEMENTATION Requires resuscitation Suction, dry quickly, and maintain warmth Ventilate 30 to 50 times a minute until heart rate is above 100, color is pink, and spontaneous respirations begin Provide oxygen Careful observation needed during the first few days of life APGAR SCORE: IMPLEMENTATION : APGAR SCORE: IMPLEMENTATION SCORE 0 to 2 IMPLEMENTATION Requires intensive resuscitation Clear airway and insert endotracheal tube; use Ambu bag if necessary Ventilate with 100% oxygen at 40 to 60 breaths per minute Initiate full CPR as needed Maintain body temperature Support parents INITIAL PHYSICAL EXAMINATION : INITIAL PHYSICAL EXAMINATION GENERAL GUIDELINES Keep newborn warm during the examination Begin with general observations, then perform assessments that are least disturbing to the newborn first Initiate nursing interventions for abnormal findings Document all abnormal findings NORMAL NEWBORN VITAL SIGNS : NORMAL NEWBORN VITAL SIGNS HEART RATE 100 to 170 beats per minute (apical); assess for a full minute due to irregularities after birth RESPIRATIONS 30 to 80 breaths per minute; assess for a full minute AXILLARY TEMPERATURE 96.8° to 99° F BLOOD PRESSURE 73/55 mmHg TAKING THE AXILLARY TEMPERATURE : TAKING THE AXILLARY TEMPERATURE From Nichols, F. & Zwelling, E. (1997). Maternal newborn nursing: Theory and Practice, ed 2, Philadelphia: W.B. Saunders. PALPATING PULSES : PALPATING PULSES From Nichols, F. & Zwelling, E. (1997). Maternal newborn nursing: Theory and Practice, ed 2, Philadelphia: W.B. Saunders. TAKING THE BLOOD PRESSURE : TAKING THE BLOOD PRESSURE From Nichols, F. & Zwelling, E. (1997). Maternal newborn nursing: Theory and Practice, ed 2, Philadelphia: W.B. Saunders. BODY MEASUREMENTS : BODY MEASUREMENTS Length: 45 to 55 cm (18 to 22 inches) Weight: 2500 to 4300 g (5.5 to 9.5 lb) Head circumference: 33 to 35.5 cm (13 to 14 inches) Chest circumference: 30 to 33 cm (12 to 13 inches) and should be equal, to or 2 to 3 cm less than the head circumference MEASURING BODY LENGTH : MEASURING BODY LENGTH From Nichols, F. & Zwelling, E. (1997). Maternal newborn nursing: Theory and Practice, ed 2, Philadelphia: W.B. Saunders. WEIGHING THE NEWBORN : WEIGHING THE NEWBORN From Nichols, F. & Zwelling, E. (1997). Maternal newborn nursing: Theory and Practice, ed 2, Philadelphia: W.B. Saunders. MEASURING HEAD CIRCUMFERENCE : MEASURING HEAD CIRCUMFERENCE From Nichols, F. & Zwelling, E. (1997). Maternal newborn nursing: Theory and Practice, ed 2, Philadelphia: W.B. Saunders. MEASURING CHEST CIRCUMFERENCE : MEASURING CHEST CIRCUMFERENCE From Nichols, F. & Zwelling, E. (1997). Maternal newborn nursing: Theory and Practice, ed 2, Philadelphia: W.B. Saunders. HEAD : HEAD 25% of the body length (cephalocaudal development) Bones of the skull are not fused Palpable sutures (connective tissue between the skull bones) Fontanels: Unossified membranous tissue at the junction of the sutures ANTERIOR FONTANEL : ANTERIOR FONTANEL CHARACTERISTICS Soft, flat, diamond-shaped, 3 to 4 cm wide by 2 to 3 cm long CLOSURE Closes between 12 and 18 months of age POSTERIOR FONTANEL : POSTERIOR FONTANEL CHARACTERISTICS Triangular 0.5 to 1 cm wide Located between occipital and parietal bones CLOSURE Closes between birth and 2 to 3 months of age PALPATION OF THE ANTERIOR FONTANEL : PALPATION OF THE ANTERIOR FONTANEL From Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing, ed 3, Philadelphia: W.B. Saunders. HEAD : HEAD MOLDING Asymmetry of the head due to pressure in birth canal; disappears in about 72 hours MASSES FROM BIRTH TRAUMA Caput succedaneum: Edema of the soft tissue over bone (crosses over suture line); subsides within a few days Cephalhematoma: Swelling caused by bleeding into an area between the bone and its periosteum (does not cross over suture line); usually absorbed within 6 weeks with no treatment CAPUT SUCCEDANEUM AND CEPHALHEMATOMA : CAPUT SUCCEDANEUM AND CEPHALHEMATOMA From Nichols, F. & Zwelling, E. (1997). Maternal newborn nursing: Theory and Practice, ed 2, Philadelphia: W.B. Saunders. HEAD : HEAD HEAD LAG Common when pulling newborn to a sitting position When prone, newborn should be able to lift head slightly and turn the head from side to side EYES : EYES Slate gray (light skin) or brown-gray (dark skin) in color Symmetrical and clear Pupils equal, round, react to light by accommodation Blink reflex present Eyes cross due to weak extraocular muscles Able to track and fixate momentarily Red reflex present Eyelids often edematous due to pressure during the birth process and the effects of eye medication EARS : EARS Symmetrical Firm cartilage with recoil Pinna should be on or above line drawn from canthus of eye Low-set ears associated with Down syndrome EARS : EARS From Nichols, F. & Zwelling, E. (1997). Maternal newborn nursing: Theory and Practice, ed 2, Philadelphia: W.B. Saunders. NOSE : NOSE Flat, broad, in center of face Obligatory nose breathing Occasional sneezing to remove obstructions Milia (white cysts) may be noted on the face over the forehead, nose, and chin and disappear within 2 months without treatment MILIA : MILIA From Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing, ed 3, Philadelphia: W.B. Saunders. MOUTH : MOUTH Pink, moist gums Soft and hard palates intact Epstein's pearls (small, white cysts) may be present on hard palate Uvula in midline Tongue moves freely, is symmetrical, has short frenulum Sucking and crying movements symmetrical Able to swallow Gag reflex present NECK : NECK Short and thick Head held in midline Trachea on midline Good range-of-motion (ROM) and is able to flex and extend CHEST : CHEST Appears circular since anteroposterior and lateral diameters are about equal Respirations appear diaphragmatic Bronchial sounds heard on auscultation Nipples prominent and often edematous Milky secretion (witch's milk) common Breast tissue present Clavicles need to be palpated to assess for fractures CHEST : CHEST From James, S., Ashwill, R., & Droske, S. (2002). Nursing care of children: Principles and practices, ed 2, Philadephia: W.B. Saunders. SKIN : SKIN Pinkish-red (light-skinned newborn) to pinkish-brown or pinkish-yellow (dark-skinned newborn) Vernix caseosa Lanugo Milia Dry, peeling skin Dark red color common in premature newborns LANUGO : LANUGO From Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing, ed 3, Philadelphia: W.B. Saunders. SKIN : SKIN Cyanosis common with hypothermia, infection, and hypoglycemia, and with cardiac, respiratory, or neurological abnormalities Acrocyanosis is a normal phenomenon and may be due to compromised peripheral circulation Assess for ecchymoses and petechiae due to the trauma of birth Assess skin turgor over the abdomen to determine hydration status Observe for forceps marks SKIN: HARLEQUIN SIGN : SKIN: HARLEQUIN SIGN CHARACTERISTICS Deep red color develops over one side of the newborn’s body while the other side remains pale Due to vasomotor disturbance Skin resembles a clown’s suit TELANGIECTATIC NEVI : TELANGIECTATIC NEVI CHARACTERISTICS Also called stork bites Pale pink or red, flat, dilated capillaries On eyelids, nose, lower occipital bone, and nape of neck Blanch easily More noticeable during crying periods Disappear by age 2 years TELANGIECTATIC NEVI : TELANGIECTATIC NEVI From Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing, ed 3, Philadelphia: W.B. Saunders. NEVUS FLAMMEUS : NEVUS FLAMMEUS CHARACTERISTICS Capillary angioma directly below epidermis Known as port wine stain Nonelevated, sharply demarcated, red to purple, dense area of capillaries Commonly appears on face Does not fade with time May require surgery in the future NEVUS FLAMMEUS : NEVUS FLAMMEUS From Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing, ed 3, Philadelphia: W.B. Saunders. Courtesy of Jane Deacon, The Children’s Hospital, Denver, CO. NEVUS VASCULOSUS : NEVUS VASCULOSUS CHARACTERISTICS Capillary hemangioma Known as a strawberry mark Raised, clearly delineated, dark red, with a rough surface Common in head region Disappears by age 7 to 9 years MONGOLIAN SPOTS : MONGOLIAN SPOTS CHARACTERISTICS Bluish-black pigmentation On lumbar dorsal area and buttocks Gradually fade during first and second years of life Common in Asian and dark-skinned races MONGOLIAN SPOTS : MONGOLIAN SPOTS From Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing, ed 3, Philadelphia: W.B. Saunders. ABDOMEN : ABDOMEN UMBILICAL CORD Three vessels, two arteries, and one vein in cord If less than three vessels are noted, notify the physician Small, thin cord may be associated with poor fetal growth Assess for intact cord and assure that clamp is secured ABDOMEN : ABDOMEN UMBILICAL CORD Cord should be clamped for at least the first 24 hours after birth; clamp can be removed when the cord is dried and occluded Note any bleeding or drainage from the cord Triple dye may be applied for initial cord care because it minimizes microorganisms and promotes drying; use a cotton-tipped applicator to paint the dye, one time, on the cord and on 1 inch of surrounding skin ABDOMEN : ABDOMEN UMBILICAL CORD Apply 70% isopropyl alcohol to the cord with each diaper change and at least 2 to 3 times a day to minimize microorganisms and promote drying If symptoms of infection such as moistness, oozing, discharge, and a reddened base occur, antibiotic treatment is prescribed ABDOMEN : ABDOMEN Monitor cord for meconium staining Assess for umbilical hernia Note abdominal depression associated with diaphragmatic hernia Assess for abdominal distension associated with obstruction, mass, or sepsis Monitor bowel sounds, which should occur within 1 to 2 hours after birth ANUS : ANUS Anal opening patent First stool meconium should pass within first 24 hours MECONIUM STOOL : MECONIUM STOOL From Nichols, F. & Zwelling, E. (1997). Maternal newborn nursing: Theory and Practice, ed 2, Philadelphia: W.B. Saunders. GENITALS : GENITALS FEMALE Labia edematous, clitoris enlarged Smegma present (thick, white mucus discharge) Pseudomenstruation possible (blood-tinged mucus) Hymen tag may be visible First voiding should occur within 24 hours FEMALE GENITALIA : FEMALE GENITALIA From Nichols, F. & Zwelling, E. (1997). Maternal newborn nursing: Theory and Practice, ed 2, Philadelphia: W.B. Saunders. GENITALS : GENITALS MALE Prepuce (foreskin) covers glans penis Scrotum edematous Meatus at tip of penis Testes descended but may retract on cold Assess for hernia or hydrocele First voiding should occur within 24 hours MALE GENITALIA : MALE GENITALIA From Nichols, F. & Zwelling, E. (1997). Maternal newborn nursing: Theory and Practice, ed 2, Philadelphia: W.B. Saunders. SPINE : SPINE Straight Posture flexed Supports head momentarily when prone Arms and legs flexed Chin flexed on upper chest Sporadic movements that are well-coordinated A degree of hypotonicity or hypertonicity is indicative of central nervous system (CNS) damage EXTREMITIES : EXTREMITIES Flexed Full ROM; movements symmetrical Fists clenched Fingers and toes should be 10 each in number and separate Legs bowed Major gluteal folds and creases even Creases on soles of feet EXTREMITIES : EXTREMITIES Assess for fractures (especially clavicle) or dislocations (hip) Assess for hip dysplasia; when thighs are rotated outward, no clicks should be heard Pulses palpable (radial, brachial, femoral) Slight tremors are common but could be a sign of hypoglycemia or drug withdrawal GLUTEAL AND THIGH CREASES : GLUTEAL AND THIGH CREASES From Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing, ed 3, Philadelphia: W.B. Saunders. CARDIOVASCULAR SYSTEM : CARDIOVASCULAR SYSTEM Keep the newborn warm Take apical heart rate for 1 full minute Listen for murmurs Palpate pulses Assess for cyanosis; blanch skin on trunk and extremities to assess circulation Observe for cardiac distress when feeding RESPIRATORY SYSTEM : RESPIRATORY SYSTEM Position newborn on side Suction as necessary: use a bulb syringe for upper airway suctioning (compress bulb before insertion) and a French catheter for deeper suctioning RESPIRATORY SYSTEM : RESPIRATORY SYSTEM Observe for respiratory distress and hypoxemia Nasal flaring Increasingly severe retractions Grunting Cyanosis Bradycardia and periods of apnea lasting longer than 15 seconds Administer oxygen via hood if necessary as prescribed HEPATIC SYSTEM : HEPATIC SYSTEM Normal or physiological jaundice appears after the first 24 hours in full-term neonates and after the first 48 hours in premature neonates; jaundice occurring prior to this time (pathological jaundice) may indicate early hemolysis of red blood cells (RBCs) and must be reported to the physician Physiological jaundice peaks about the fifth day of life (indirect bilirubin levels: 6 to 7 mg/dl) Monitor serum bilirubin levels HEPATIC SYSTEM : HEPATIC SYSTEM Feed early to stimulate intestinal activity and to keep the bilirubin level low If being breastfed, temporarily discontinue breastfeeding for 48 hours if bilirubin levels exceed 15 to 20 mg/dl if prescribed by the physician Prevent chilling, as hypothermia can cause acidosis that interferes with bilirubin conjugation and excretion HEPATIC SYSTEM : HEPATIC SYSTEM Liver stores iron passed from the mother for 5 to 6 months Glycogen storage occurs in the liver Neonate is at risk for hemorrhagic disorders; coagulation factors synthesized in the liver are dependent on vitamin K, which is not synthesized until intestinal bacteria is present Handle neonate carefully and monitor for any bruising or bleeding episodes Watch for meconium stool and subsequent stools HEPATIC SYSTEM : HEPATIC SYSTEM Administer one dose of vitamin K (AquaMEPHYTON) 0.5 to 1.0 mg IM to the neonate in the lateral aspect of the middle third of the vastus lateralis muscle as prescribed, to prevent hemorrhagic disorders Assess newborn’s hemoglobin and blood glucose levels VASTUS LATERALIS MUSCLE : VASTUS LATERALIS MUSCLE From Nichols, F. & Zwelling, E. (1997). Maternal newborn nursing: Theory and Practice, ed 2, Philadelphia: W.B. Saunders. RENAL SYSTEM : RENAL SYSTEM The immature kidneys are unable to concentrate urine A weight loss of 5 to 15% during the first week of life occurs due to voiding and limited intake Weigh newborn daily Monitor intake and output (I&O); weigh diapers if necessary Measure specific gravity of urine if necessary Assess for signs of dehydration (dry mucous membranes, sunken eyeballs, poor skin turgor, sunken fontanels) IMMUNE SYSTEM : IMMUNE SYSTEM Passive immunity via the placenta (IgG) Passive immunity from colostrum (IgA) Elevations in IgM indicate infection in utero Use aseptic technique when caring for the newborn; ensure meticulous hand washing Observe universal (standard) precautions when handling the newborn Wear gowns when caring for the newborn Monitor newborn’s temperature Observe for any cracks or openings in the skin AXILLARY AND RECTAL TEMPERATURE : AXILLARY AND RECTAL TEMPERATURE From Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing, ed 3, Philadelphia: W.B. Saunders. IMMUNE SYSTEM : IMMUNE SYSTEM EYE CARE Administer eye medication within 1 hour after birth to prevent ophthalmia neonatorum Eye prophylaxis may be delayed until an hour or so after birth so that eye contact and parent-infant attachment and bonding are facilitated IMMUNE SYSTEM : IMMUNE SYSTEM EYE CARE Erythromycin (0.5%) and tetracycline (1%) ophthalmic ointment or drops are both bacteriostatic and bactericidal and provide prophylaxis against Neisseria gonorrhoeae and Chlamydia trachomatis Silver nitrate (1%) solution may be prescribed but its use is minimal because it does not protect against chlamydial infection and can cause chemical conjunctivitis INSTILLING EYE MEDICATIONS : INSTILLING EYE MEDICATIONS From Nichols, F. & Zwelling, E. (1997). Maternal newborn nursing: Theory and Practice, ed 2, Philadelphia: W.B. Saunders. IMMUNE SYSTEM : IMMUNE SYSTEM UMBILICAL CORD CARE Umbilical clamp can be removed after 24 hours Teach mother how to perform cord care Keep the cord clean and dry by wiping with alcohol after each diaper change and at least two to three times a day Keep diaper from covering cord; fold diaper below cord Assess cord for odor, swelling, or discharge Sponge bathe the newborn until the cord falls off (within 2 weeks) UMBILICAL CORD CARE : UMBILICAL CORD CARE From Nichols, F. & Zwelling, E. (1997). Maternal newborn nursing: Theory and Practice, ed 2, Philadelphia: W.B. Saunders. IMMUNE SYSTEM : IMMUNE SYSTEM CIRCUMCISION CARE Apply petroleum jelly gauze to the penis except when a Plastibell is used Remove petroleum jelly gauze, if applied, after first voiding following circumcision Observe for swelling, infection, or bleeding from the circumcision site IMMUNE SYSTEM : IMMUNE SYSTEM CIRCUMCISION CARE Cleanse the penis after each voiding by squeezing warm water over the penis; a milky covering over the glans penis is normal and should not be disrupted Monitor for urinary retention Teach the mother care of the circumcision site CIRCUMCISION CARE : CIRCUMCISION CARE From Nichols, F. & Zwelling, E. (1997). Maternal newborn nursing: Theory and Practice, ed 2, Philadelphia: W.B. Saunders. METABOLIC AND GASTROINTESTINAL SYSTEMS : METABOLIC AND GASTROINTESTINAL SYSTEMS Newborns are able to digest simple carbohydrates but are unable to digest fats due to the lack of lipase Proteins may be only partially broken down, so may serve as antigens and provoke an allergic reaction The newborn has a small stomach capacity (about 90 ml) with rapid intestinal peristalsis (bowel emptying time is 2.5 to 3 hours) METABOLIC AND GASTROINTESTINAL SYSTEMS : METABOLIC AND GASTROINTESTINAL SYSTEMS Breastfeeding can usually begin immediately after birth; bottle-fed newborns may be offered a few milliliters of sterile water or 5 percent dextrose 1 to 4 hours after birth prior to a feeding with formula Observe feeding reflexes, such as rooting, sucking, and swallowing Assist mother with breastfeeding or formula-feeding BREASTFEEDING : BREASTFEEDING From Nichols, F. & Zwelling, E. (1997). Maternal newborn nursing: Theory and Practice, ed 2, Philadelphia: W.B. Saunders. METABOLIC AND GASTROINTESTINAL SYSTEMS : METABOLIC AND GASTROINTESTINAL SYSTEMS Burp newborn during and after feeding Assess for regurgitation or vomiting Position newborn on right side after feeding Observe for normal stool and the passage of meconium METABOLIC AND GASTROINTESTINAL SYSTEMS : METABOLIC AND GASTROINTESTINAL SYSTEMS Meconium stool–which is greenish-black in color with a thick, sticky, tar-like consistency–is usually passed within the first 24 hours of life Transitional stool–the second type of stool excreted by the newborn–is greenish-brown and of looser consistency than meconium Soft, yellow stools are noted in breastfed newborns; seedy, yellow stools in formula-fed newborns METABOLIC AND GASTROINTESTINAL SYSTEMS : METABOLIC AND GASTROINTESTINAL SYSTEMS Perform newborn phenylketonuria (PKU) screening test before discharge and as an outpatient after sufficient protein intake occurs The newborn should be on formula or breast milk for 24 hours before PKU screening, and screening must be repeated in 7 to 14 days NEUROLOGICAL SYSTEM : NEUROLOGICAL SYSTEM Newborn head size is proportionally larger than that of adults due to cephalocaudal development Myelinization of nerve fibers is incomplete, so primitive reflexes are present Fontanels are open to allow for brain growth Assess for an abnormal head size and a bulging or depressed anterior fontanel Measure and graph head circumference in relation to chest circumference and length NEUROLOGICAL SYSTEM : NEUROLOGICAL SYSTEM Assess newborn’s movements, noting symmetry, posture, and abnormal movements Observe for jitteriness, marked tremors, and seizures Test newborn’s reflexes Assess for lethargy Assess pitch of cry INFANT STATES : INFANT STATES From Nichols, F. & Zwelling, E. (1997). Maternal newborn nursing: Theory and Practice, ed 2, Philadelphia: W.B. Saunders. THERMAL REGULATORY SYSTEM : THERMAL REGULATORY SYSTEM Newborns do not shiver to produce heat Newborns have brown fat deposits, which produce heat Heat is dissipated through vasodilation Keep temperature in room warm Take newborn’s axillary temperature every hour for the first 4 hours of life, every 4 hours for the remainder of the first 24 hours, and then every shift THERMAL REGULATORY SYSTEM : THERMAL REGULATORY SYSTEM Prevent heat loss due to evaporation by keeping newborn dry and well-wrapped with a blanket Prevent heat loss due to radiation by keeping newborn away from cold objects and outside walls Prevent heat loss due to convection by shielding the newborn from drafts Prevent heat loss due to conduction by performing all treatments on a warm, padded surface METHODS OF HEAT LOSS : METHODS OF HEAT LOSS From Nichols, F. & Zwelling, E. (1997). Maternal newborn nursing: Theory and Practice, ed 2, Philadelphia: W.B. Saunders. SUCKING AND ROOTING REFLEXES : SUCKING AND ROOTING REFLEXES Touch the newborn’s lip, cheek, or corner of the mouth with a nipple Newborn turns head toward the nipple, opens the mouth, and takes hold of the nipple, and sucks Usually disappears after 3 to 4 months but may persist for up to 1 year SWALLOWING REFLEX : SWALLOWING REFLEX Occurs spontaneously after sucking and obtaining fluids Newborn swallows in coordination with sucking without gagging, coughing, or vomiting TONIC NECK OR FENCING REFLEX : TONIC NECK OR FENCING REFLEX While the newborn is falling asleep or sleeping, gently and quickly turn the head to one side As the newborn faces the left side, the left arm and leg extend outward while the right arm and leg flex When turned to the right side, the right arm and leg extend outward while the left arm and leg flex Usually disappears within 3 to 4 months PALMAR-PLANTAR GRASP REFLEX : PALMAR-PLANTAR GRASP REFLEX Place a finger in the palm of the newborn’s hand, then place a finger at the base of the toes The newborn’s fingers curl around the examiner’s fingers and the newborn’s toes curl downward Palmar response lessens within 3 to 4 months Plantar response lessens within 8 months MORO REFLEX : MORO REFLEX Hold the newborn in a semi-sitting position, then allow the head and trunk to fall backward to at least a 30 degree angle The newborn symmetrically abducts and extends the arms The newborn fans the fingers out and forms a C with the thumb and the forefinger The newborn adducts the arms to an embracing position and returns to a relaxed flexion state Present at birth; a complete response may occur for up to 8 weeks MORO REFLEX : MORO REFLEX A body jerk motion occurs from 8 to 18 weeks No response may be noted by 6 months as long as neurological maturation has not been delayed A persistent response lasting more than 6 months may indicate the occurrence of brain damage that occurred during pregnancy MORO REFLEX : MORO REFLEX From Lowdermilk, D., Perry, S., & Bobak, I. (2000). Maternity and women’s health care, ed 7, St Louis: Mosby. STARTLE REFLEX : STARTLE REFLEX The response is best elicited if the newborn is a least 24 hours old The examiner makes a loud noise or claps hands to elicit the response The newborn’s arms adduct while the elbows flex The hands stay clenched The reflex should disappear within 4 months PULL-TO-SIT RESPONSE : PULL-TO-SIT RESPONSE Pull the newborn up from the wrist while the newborn is in the prone position The head will lag until the newborn is in an upright position, then the head will be level with the chest and shoulders momentarily before falling forward The head will then lift for a few minutes The response depends on the newborn’s general muscle tone and condition as well as maturity levels STEPPING OR WALKING REFLEX : STEPPING OR WALKING REFLEX Hold the newborn in a vertical position, allowing one foot to touch a table surface The newborn simulates walking, alternately flexing and extending the feet The reflex is usually present for 3 to 4 months STEPPING REFLEX : STEPPING REFLEX From Lowdermilk, D., Perry, S., & Bobak, I. (2000). Maternity and women’s health care, ed 7, St Louis: Mosby. CRAWLING REFLEX : CRAWLING REFLEX Place the newborn on the abdomen The newborn begins making crawling movements with the arms and legs The reflex usually disappears after about 6 weeks BABINSKI’S REFLEX : BABINSKI’S REFLEX Beginning at the heel of the foot, gently stroke upward along the lateral aspect of the sole, then the examiner moves the finger along the ball of the foot The newborn’s toes hyperextend while the big toe dorsiflexes (recorded as a positive sign) Reflex disappears after the newborn is 1 year old Absence of this reflex indicates the need for a neurological examination BABINSKI’S REFLEX : BABINSKI’S REFLEX From Lowdermilk, D., Perry, S., & Bobak, I. (2000). Maternity and women’s health care, ed 7, St Louis: Mosby. PARENT TEACHING : PARENT TEACHING FORMULA FEEDING Teach sterilization techniques if the water supply is located in areas where the purification process of the water is questionable Remind the mother not to heat the bottle of formula in the microwave oven Inform the mother that formula is a sufficient diet for the first 4 to 6 months Assess the mother’s ability to burp the newborn PARENT TEACHING : PARENT TEACHING BREASTFEEDING Assess the newborn’s ability to attach to the mother’s breast and suck Teach the mother about engorgement Teach the mother how to pump her breasts and how to store breast milk properly Inform the mother that breast milk is a sufficient and superior diet for the first 4 to 6 months Give the mother the phone number of the local organizations that offer support to breastfeeding mothers BREASTFEEDING : BREASTFEEDING From Nichols, F. & Zwelling, E. (1997). Maternal newborn nursing: Theory and Practice, ed 2, Philadelphia: W.B. Saunders. PARENT TEACHING : PARENT TEACHING BATHING Bathe newborn in a warm room before feeding Have all equipment for bathing available Use a mild soap (not on the face) Proceed from the cleanest area to the dirtiest Clean eyes from the inner canthus outward Special care should be taken to clean under the folds of the neck, underarms, groin, and genitals Make bath time enjoyable for both the newborn and mother PARENT TEACHING : PARENT TEACHING CLOTHING Assess diaper and clothing needs for the newborn with the mother Instruct the mother that the newborn’s head should be covered in cold weather to prevent heat loss Instruct the mother to layer the newborn’s clothing in cooler weather PARENT TEACHING : PARENT TEACHING UNCIRCUMCISED NEWBORN Inform the mother that the foreskin and glans are two similar layers of cells that separate from each other and that the separation process is normally complete between 3 and 5 years of age Instruct the mother not to pull back the foreskin but to allow for the natural separation to occur As the process of separation occurs, sterile sloughed cells build up between the layers of the foreskin and the glans, and when retraction occurs, daily gentle washing of the glans with soap and water is sufficient to maintain adequate cleanliness PRETERM NEWBORN : PRETERM NEWBORN DESCRIPTION A neonate born before 37 weeks gestation The primary concern relates to immaturity of all body systems PRETERM NEWBORN : PRETERM NEWBORN ASSESSMENT Respirations irregular with periods of apnea Body temperature is below normal Newborn has poor suck and swallow reflexes Bowel sounds are diminished Increased or decreased urinary output Extremities are thin, with minimal creasing on soles and palms PRETERM NEWBORN : PRETERM NEWBORN ASSESSMENT Newborn extends extremities and does not maintain flexion Lanugo on the skin and in the hair on the newborn’s head is present in woolly patches Skin is thin with visible blood vessels and minimal subcutaneous fat pads Skin may appear jaundiced Testes are undescended in boys Labia are narrow in girls LANUGO IN A PRETERM INFANT : LANUGO IN A PRETERM INFANT From Nichols, F. & Zwelling, E. (1997). Maternal newborn nursing: Theory and Practice, ed 2, Philadelphia: W.B. Saunders. PRETERM NEWBORN : PRETERM NEWBORN IMPLEMENTATION Monitor vital signs every 2 to 4 hours Maintain cardiopulmonary functions Administer oxygen and humidification as prescribed Monitor I&O and electrolyte balance Monitor daily weight PRETERM NEWBORN : PRETERM NEWBORN IMPLEMENTATION Maintain newborn in a warming device Position every 1 to 2 hours and handle newborn carefully Avoid exposure to infections Provide newborn with appropriate stimulation such as touch POST-TERM NEWBORN : POST-TERM NEWBORN DESCRIPTION A neonate born after 42 weeks of gestation POST-TERM NEWBORN : POST-TERM NEWBORN ASSESSMENT Hypoglycemia Parchment-like skin (dry and cracked) without lanugo Fingernails long and extended over ends of fingers Profuse scalp hair Body is long and thin Extremities show wasting of fat and muscle Meconium staining may be present on nails and umbilical cord POST-TERM NEWBORN : POST-TERM NEWBORN IMPLEMENTATION Provide normal newborn care Monitor for hypoglycemia Maintain newborn’s temperature Monitor for meconium aspiration Slide 129: From Nichols, F. & Zwelling, E. (1997). Maternal newborn nursing: Theory and Practice, ed 2, Philadelphia: W.B. Saunders. SMALL FOR GESTATIONAL AGE : SMALL FOR GESTATIONAL AGE DESCRIPTION A neonate who is plotted at or below the 10th percentile on the intrauterine growth curve SMALL FOR GESTATIONAL AGE : SMALL FOR GESTATIONAL AGE ASSESSMENT Fetal distress Assess gestational age and physical maturity Lowered or elevated body temperature Physical abnormalities Hypoglycemia Signs of polycythemia (ruddy appearance, cyanosis, jaundice) Signs of infection Signs of aspiration of meconium SMALL FOR GESTATIONAL AGE : SMALL FOR GESTATIONAL AGE IMPLEMENTATION Maintain airway Maintain body temperature Observe for signs of respiratory distress Monitor for infection and initiate measures to prevent sepsis Monitor blood glucose levels and for signs of hypoglycemia Initiate early feedings and monitor for signs of aspiration Provide stimulation such as touch and cuddling LARGE FOR GESTATIONAL AGE : LARGE FOR GESTATIONAL AGE DESCRIPTION A neonate who is plotted at or above the 90th percentile on the intrauterine growth curve ASSESSMENT Gestational age Birth trauma or injury Respiratory distress Hypoglycemia LARGE FOR GESTATIONAL AGE : LARGE FOR GESTATIONAL AGE IMPLEMENTATION Monitor vital signs Monitor blood glucose levels and for signs of hypoglycemia Initiate early feedings Monitor for infection and initiate measures to prevent sepsis Provide stimulation such as touch and cuddling RESPIRATORY DISTRESS SYNDROME (RDS) : RESPIRATORY DISTRESS SYNDROME (RDS) DESCRIPTION A serious lung disorder caused by immaturity and inability to produce surfactant, resulting in hypoxia and acidosis RESPIRATORY DISTRESS SYNDROME (RDS) : RESPIRATORY DISTRESS SYNDROME (RDS) ASSESSMENT Tachypnea Flaring nares Expiratory grunting Retractions Decreased breath sounds Apnea Pallor and cyanosis Hypothermia Poor muscle tone RESPIRATORY DISTRESS SYNDROME (RDS) : RESPIRATORY DISTRESS SYNDROME (RDS) IMPLEMENTATION Monitor color, respiratory rate, and degree of effort in breathing Support respirations as prescribed Monitor arterial blood gases (ABGs) and oxygen saturation levels (ABGs from umbilical artery) Monitor ABGs so oxygen administered to the newborn is at the lowest possible concentration necessary to maintain adequate arterial oxygenation RESPIRATORY DISTRESS SYNDROME (RDS) : RESPIRATORY DISTRESS SYNDROME (RDS) IMPLEMENTATION Schedule any premature newborn who required oxygen support for an eye examination before discharge to assess for retinal damage Suction every 2 hours or more often as necessary Position newborn on side or back with neck slightly extended Prepare to administer surfactant replacement therapy (instilled into the endotracheal tube) RESPIRATORY DISTRESS SYNDROME (RDS) : RESPIRATORY DISTRESS SYNDROME (RDS) IMPLEMENTATION Administer respiratory therapy (percussion and vibration) as prescribed Use padded small plastic cup or small oxygen mask for percussion Use padded electric toothbrush for vibration RESPIRATORY DISTRESS SYNDROME (RDS) : RESPIRATORY DISTRESS SYNDROME (RDS) IMPLEMENTATION Provide nutrition Support bonding Prepare parents for short- to long-term period of oxygen dependency if necessary Encourage mother to pump breasts for future breastfeeding if she so desires Encourage as much parental participation in newborn’s care as condition allows HYPERBILIRUBINEMIA : HYPERBILIRUBINEMIA DESCRIPTION At any serum bilirubin level, the appearance of jaundice during the first day of life indicates a pathological process Evaluation is indicated when serum levels are over 12 mg/dl in the term newborn Therapy is aimed at preventing kernicterus, which results in permanent neurological damage from the deposition of bilirubin in the brain cells HYPERBILIRUBINEMIA : HYPERBILIRUBINEMIA ASSESSMENT Jaundice Elevated serum bilirubin levels Enlarged liver Poor muscle tone Lethargy Poor sucking reflex HYPERBILIRUBINEMIA : HYPERBILIRUBINEMIA IMPLEMENTATION Monitor for the presence of jaundice Examine the newborn’s skin color in natural light Press finger over a bony prominence or tip of the newborn’s nose to press out capillary blood from the tissues Note that jaundice starts at the head first, spreads to the chest, then the abdomen; then the arms and legs, followed by the hands and feet, which are the last to be jaundiced HYPERBILIRUBINEMIA : HYPERBILIRUBINEMIA IMPLEMENTATION Keep newborn well hydrated to maintain blood volume Facilitate early, frequent feeding to hasten passage of meconium and encourage excretion of bilirubin Report any signs of jaundice in the first 24 hours and any abnormal signs and symptoms to the physician Prepare for phototherapy and monitor the newborn closely during the treatment PHOTOTHERAPY : PHOTOTHERAPY DESCRIPTION Use of intense florescent lights to reduce serum bilirubin levels in the newborn Injury from treatment such as eye damage, dehydration, or sensory deprivation can occur PHOTOTHERAPY : PHOTOTHERAPY From Nichols, F. & Zwelling, E. (1997). Maternal newborn nursing: Theory and Practice, ed 2, Philadelphia: W.B. Saunders. Courtesy of Wesley Medical Center, Wichita, KS. PHOTOTHERAPY : PHOTOTHERAPY IMPLEMENTATION Expose as much of the newborn’s skin as possible Cover the genital area and monitor genital area for skin irritation or breakdown Cover the newborn’s eyes with eye shields or patches; make sure eyelids are closed when shields or patches are applied Remove the shields or patches at least once per shift to inspect the eyes for infection or irritation and to allow eye contact PHOTOTHERAPY : PHOTOTHERAPY IMPLEMENTATION Measure the quantity of light every 8 hours Monitor skin temperature closely Increase fluids to compensate for water loss Expect loose, green stools and green urine Monitor the newborn’s skin color with the florescent light turned off every 4 to 8 hours Monitor the skin for bronze baby syndrome, a grayish-brown discoloration of the skin PHOTOTHERAPY : PHOTOTHERAPY IMPLEMENTATION Reposition newborn every 2 hours Provide stimulation After treatment, continue monitoring for signs of hyperbilirubinemia, as rebound elevations are normal after therapy is discontinued ERYTHROBLASTOSIS FETALIS : ERYTHROBLASTOSIS FETALIS DESCRIPTION Destruction of RBCs that results from an antigen-antibody reaction Characterized by hemolytic anemia or hyperbilirubinemia Exchange of fetal and maternal blood takes place primarily when the placenta separates at birth ERYTHROBLASTOSIS FETALIS : ERYTHROBLASTOSIS FETALIS DESCRIPTION Rh antigens from the baby’s blood enter the maternal bloodstream The mother produces anti-Rh antibodies against the fetal blood cells Antibodies are harmless to the mother but attach to the erythrocytes in the fetus and cause hemolysis Sensitization is rare with the first pregnancy ABO incompatibility is usually less severe ERYTHROBLASTOSIS FETALIS : ERYTHROBLASTOSIS FETALIS ASSESSMENT Anemia Jaundice that develops rapidly after birth and before 24 hours Edema ERYTHROBLASTOSIS FETALIS : ERYTHROBLASTOSIS FETALIS IMPLEMENTATION Administer Rho (D) Immune Globulin (RDIG) to the mother during the first 72 hours after delivery if the Rh-negative mother delivers a Rh-positive fetus but remains unsensitized Assist with exchange transfusion after birth or intrauterine transfusion as prescribed ERYTHROBLASTOSIS FETALIS : ERYTHROBLASTOSIS FETALIS IMPLEMENTATION The baby’s blood is replaced with Rh-negative blood to stop the destruction of the baby’s red blood cells; the Rh-negative blood is replaced with the baby’s own blood gradually Reassure the mother that the newborn will suffer no untoward effects from the condition SEPSIS : SEPSIS DESCRIPTION Generalized infection resulting from the presence of bacteria in the blood ASSESSMENT Pallor Tachypnea, tachycardia Poor feeding Abdominal distention Temperature instability SEPSIS : SEPSIS IMPLEMENTATION Assess for periods of apnea or irregular respirations Stimulate if apnea is present by gently rubbing chest or foot Administer oxygen as prescribed Monitor vital signs Maintain warmth in an Isolette Provide isolation as necessary SEPSIS : SEPSIS IMPLEMENTATION Assess for fever Monitor I&O and obtain daily weight Monitor for diarrhea Assess feeding and sucking reflex, which may be poor Assess for jaundice Assess for irritability and lethargy Administer antibiotics as prescribed and observe carefully for toxicity, because a newborn’s liver and kidneys are immature TORCH SYNDROME : TORCH SYNDROME DESCRIPTION Refers to infections of the fetus or newborn Caused by one of the following T — Toxoplasmosis O — Other infections R — Rubella C — Cytomegalovirus H — Herpes TOXOPLASMOSIS : TOXOPLASMOSIS CHARACTERISTICS Protozoan infection Produces no serious effects in the mother Can be transmitted to the fetus Can result in severe physical and developmental abnormalities Common carriers include cat feces and raw beef RUBELLA : RUBELLA CHARACTERISTICS Systemic viral infection Causes congenital rubella syndrome, which includes congenital heart disease, cataracts, growth retardation, and pneumonia if the mother becomes infected within the first trimester Deafness and some learning disabilities can occur if the mother becomes infected during the first trimester CYTOMEGALOVIRUS : CYTOMEGALOVIRUS CHARACTERISTICS A viral infection that persists in the body indefinitely, with periods of reactivation without symptoms Can infect the fetus or infant during delivery or after birth through breast milk, blood transfusions, or contact with infected secretions May cause microcephaly, blindness, deafness, and mental and motor retardation HERPES SIMPLEX : HERPES SIMPLEX CHARACTERISTICS Sexually transmitted disease caused by a virus Periods of reactivation Neonate is commonly infected during delivery by direct contact with lesions in the genital tract Can cause neurological impairment or death SYPHILIS : SYPHILIS DESCRIPTION Sexually transmitted disease Congenital syphilis can result in premature delivery, skin lesions, abnormal skeletal development The organism Treponema pallidum, a spirochete, is able to cross the placenta throughout pregnancy and infect the fetus, usually after 18 weeks gestation Risks include preterm birth, stillbirth, and low birth weight Congenital effects are irreversible and may include CNS damage and hearing loss SYPHILIS : SYPHILIS ASSESSMENT Hepatosplenomegaly Joint swelling Palmar rash Anemia Jaundice Snuffles Ascites Pneumonitis Cerebrospinal fluid changes SYPHILIS : SYPHILIS IMPLEMENTATION Monitor newborn for signs of syphilis Monitor for palmar rash and snuffles Prepare newborn for serological testing if prescribed Administer antibiotic therapy as prescribed SYPHILIS : SYPHILIS IMPLEMENTATION Use universal (standard) precautions and drainage/secretion precautions with suspected congenital syphilis Wear gloves when handling neonate until 24 hours of antibiotic therapy has been administered Provide psychological support to the mother and provide instructions regarding follow-up care to the newborn THE ADDICTED NEWBORN : THE ADDICTED NEWBORN DESCRIPTION Newborn who has become passively addicted to drugs that have passed through the placenta ADDICTING DRUGS : ADDICTING DRUGS HEROIN Newborn may appear normal at birth with a low birth weight Withdrawal occurs within 12 to 24 hours and may last 5 to 7 days COCAINE Causes decreased interactive behavior Feeding problems are present Irregular sleep patterns and diarrhea occur ADDICTING DRUGS : ADDICTING DRUGS METHADONE Withdrawal occurs within 1 to 2 days to 1 week or more, is most evident 48 to 72 hours, and may last 6 days to 8 weeks Newborn appears very ill May develop jaundice due to prematurity THE ADDICTED NEWBORN : THE ADDICTED NEWBORN ASSESSMENT Irritability Tremors Hyperactivity and hypertonicity Respiratory distress Vomiting High-pitched cry Sneezing THE ADDICTED NEWBORN : THE ADDICTED NEWBORN ASSESSMENT Fever Diarrhea Excessive sweating Poor feeding Extreme sucking of fists Seizures THE ADDICTED NEWBORN : THE ADDICTED NEWBORN IMPLEMENTATION Monitor respiratory and cardiac status frequently Monitor temperature and vital signs Hold newborn firmly and close to the body during feeding and when giving care Initiate seizure precautions (pad sides of crib) Provide small, frequent feedings and allow a longer period for feeding Administer IV hydration if prescribed THE ADDICTED NEWBORN : THE ADDICTED NEWBORN IMPLEMENTATION Protect neonate’s skin from injury that can be caused by the constant rubbing from hyperactive jitters Swaddle newborn Place newborn in a quiet room and reduce stimulation Allow mother to ventilate feelings of anxiety and guilt Refer mother for treatment of substance abuse problem FETAL ALCOHOL SYNDROME : FETAL ALCOHOL SYNDROME DESCRIPTION Caused by maternal alcohol use during pregnancy Most serious cause of teratogenesis Causes mental and physical retardation FETAL ALCOHOL SYNDROME : FETAL ALCOHOL SYNDROME ASSESSMENT Facial changes Short palpebral fissures Hypoplastic philtrum Short, upturned nose Flat midface Thin upper lip Low nasal bridge FETAL ALCOHOL SYNDROME : FETAL ALCOHOL SYNDROME ASSESSMENT Abnormal palmar creases Respiratory distress (apnea, cyanosis) Congenital heart disorders Irritability, hypersensitivity to stimuli Tremors Poor feeding Seizures FETAL ALCOHOL SYNDROME : FETAL ALCOHOL SYNDROME IMPLEMENTATION Monitor for respiratory distress Position newborn on side to facilitate drainage of secretions Keep resuscitation equipment at the bedside Monitor for hypoglycemia FETAL ALCOHOL SYNDROME : FETAL ALCOHOL SYNDROME IMPLEMENTATION Assess suck and swallow reflex Administer small feedings and burp well Suction as necessary Monitor I&O Monitor weight and head circumference Decrease environmental stimuli ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) : ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) DESCRIPTION The fetus of a human immunodeficiency virus (HIV) antibody-positive woman should be monitored closely throughout the pregnancy Serial ultrasound screenings should be done during pregnancy to identify intrauterine growth restriction Weekly nonstress testing after 32 weeks of gestation and biophysical profiles may be necessary during pregnancy ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) : ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) DESCRIPTION Neonates born to HIV-positive clients may test positive because the mother’s positive antibodies may persist for as long as 18 months after birth The use of antiviral medication, the reduction of neonate exposure to maternal blood and body fluids, and the early identification of HIV in pregnancy reduce the risk of transmission to the newborn ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) : ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) DESCRIPTION All neonates born to HIV-positive mothers acquire maternal antibody to HIV infection, but not all acquire the infection The neonate may be asymptomatic for the first several years of life ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) : ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) TRANSMISSION Across placental barrier During labor and delivery Breast milk ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) : ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) ASSESSMENT May have no outward signs for the first several months of life Signs of immune deficiency Hepatomegaly Splenomegaly Lymphadenopathy Impairment in growth and development ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) : ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) IMPLEMENTATION Cleanse newborn’s skin carefully before any invasive procedure, such as administration of vitamin K, heel sticks, or venipunctures Circumcisions are not done on newborns with HIV-positive mothers until the newborn’s status is determined Newborn can room with mother ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) : ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) IMPLEMENTATION All HIV-exposed newborns should be treated with medication to prevent infection by Pneumocystis carinii Zidovudine (AZT) may be administered as prescribed for the first 6 weeks of life Monitor for early signs of immune deficiency, such as enlarged spleen or liver, lymphadenopathy, and impairment in growth and development ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) : ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) IMPLEMENTATION Newborns at risk for HIV infection should be seen by the physician at birth, 1 week, 2 weeks, 1 month, and 2 months of life Inform the mother that an HIV culture is recommended at age 1 month and after 4 months of age ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) : ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) IMMUNIZATIONS Newborns at risk for HIV infection need to receive all recommended immunizations at the regular schedule Immunizations with live vaccines, such as oral polio and measles-mumps-rubella (MMR), should not be done until the newborn’s, infant’s, or child’s status is confirmed If a child is infected, live vaccines will not be given NEWBORN OF A DIABETIC MOTHER : NEWBORN OF A DIABETIC MOTHER DESCRIPTION Neonate born to an insulin-dependent mother or gestational diabetic mother High incidence of congenital anomalies High incidence of hypoglycemia, respiratory distress, hypocalcemia, and hyperbilirubinemia NEWBORN OF DIABETIC MOTHER : NEWBORN OF DIABETIC MOTHER ASSESSMENT Excessive size and weight due to excess fat and glycogen in tissues Edema or puffiness in the face and cheeks Signs of hypoglycemia such as twitching, difficulty in feeding, lethargy, apnea, seizures, and cyanosis Hyperbilirubinemia Signs of respiratory distress such as tachypnea, cyanosis, retractions, grunting, nasal flaring NEWBORN OF DIABETIC MOTHER : NEWBORN OF DIABETIC MOTHER IMPLEMENTATION Monitor for signs of respiratory distress Monitor bilirubin and blood glucose levels Monitor weight Feed early, with 10% glucose in water, breast milk, or formula as prescribed Administer IV glucose to treat hypoglycemia if necessary as prescribed Monitor for edema Monitor for tremors, seizures, apnea, and acidosis HYPOGLYCEMIA : HYPOGLYCEMIA DESCRIPTION Abnormally low level of glucose in the blood (less than 30 mg/dl in the first 72 hours or below 45 mg/dl after the first 3 days of life) Normal blood glucose level is 40 to 60 mg/dl in a 1-day-old neonate and 50 to 90 mg/dl in a neonate older than 1 day HYPOGLYCEMIA : HYPOGLYCEMIA ASSESSMENT Increased respiratory rate Twitching, nervousness, or tremors Unstable temperature Cyanosis HYPOGLYCEMIA : HYPOGLYCEMIA IMPLEMENTATION Prevent low blood glucose through early feedings Administer glucose orally or by IV as prescribed Monitor blood glucose levels as prescribed Monitor for feeding problems Monitor for apneic periods Assess for shrill or intermittent cries Evaluate lethargy and poor muscle tone

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