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150 Cards in this Set
- Front
- Back
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transition period
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the first 6-8 hours after birth the newborn experiences phases of instability in adapting to extrauterine life.
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First period of reactivity
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lasts up to 30 minutes
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First period of reactivity
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HR increases to 160-180 bpm, then gradually decreases to baseline of 100-120 bpm
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First period of reactivity
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Respirations irregular, rate of 60-80; may have crackles, audible grunting, nasal flaring, chest retractions
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First period of reactivity
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"Infant is alert. Spontaneous startle reactions, tremors, crying, moving head side to side as body temp decreases, and motor activity/muscle tone increases
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Decreased activity
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lasts for 60 – 100 minutes
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Decreased activity
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infant sleeps or has marked decrease in motor activity
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Second period of reactivity
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occurs between 4 to 8 hours after birth, and lasts from 10 minutes to several hours
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Second period of reactivity
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"Episodes of tachycardia and tachypnea. Increased muscle tone, skin color, mucus production. Meconium is commonly passed
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All infants go through this transition, regardless of gestational age or type of birth
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first period and second period
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Infant must establish respirations
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Air must substitute for the fluid in the lungs
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Initial breathing probably a reflex triggered
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by pressure changes, chilling, noise, light
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Exaggerated respiratory reaction follows stimulation of
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the chemoreceptors in the aorta and carotid body, and the infant takes a gasping breath and cries (usually within 1 minute)
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Infant breaths may be
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shallow, irregular, with periods of apnea
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Newborns are what type of breathers
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preferential nose breathers (need to keep nasal passages clear)
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Signs of respiratory distress
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Nasal flaring, Retractions, Grunting with expiration, Seesaw respirations (chest wall retracts while abdominal wall rises with inspiration)
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Seesaw respirations
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"chest wall retracts while abdominal wall rises with inspiration
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Factors affecting oxygen supply
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"Rib cage horizontal, limiting expansion with inspiration. Relies primarily on diaphragmatic contraction. Surfactant (a phospholipid) reduces surface tension in alveoli. Lecithin/sphingomyelin (L/S) ratio 2:1 in mature fetal lungs
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With first respiration
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lungs inflate –> pulmonary artery pressure decreases –> pressure in right atrium declines –> increase in pulmonary blood flow to left atrium increases pressure –> causes functional closure of the foramen ovale
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In first few days, crying may temporarily reverse
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blood flow through the foramen ovale and lead to mild cyanosis (“blue baby”)
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Ductus arteriosus begins to constrict as
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pulmonary circulation increases – functional closure in term infants within 24 hours – permanent closure in several weeks
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Umbilical arteries, umbilical vein and ductus venosus are functionally closed by
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the clamping and cutting of the umbilical cord – they convert into ligaments in 2-3 months
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Resting heart rate between
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100 -160 bpm (increased rate with crying)
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HR in sleep
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85 -100 bpm
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HR while awake
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120 -160 bpm
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Apical pulse of infant
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PMI is fourth ICS, left of MCL. Pulse is visible. HR is always taken as the ______.
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Heart Sounds of infant
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"Higher pitch, shorter duration, greater intensity than adults. S1 louder and duller than S2, which is sharp. Most heart murmurs in first few days are not pathologic-just part of adjustment
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Infant’s pulse rate is always taken at
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at the apical pulse – auscultate for a full minute, preferably when infant is asleep
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Sinus arrythmia may be
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physiologic phenomenon in infancy, and an indication of good heart function
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"
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60 – 80 mm Hg
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"
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40 -50 mm Hg
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Infant BP
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"Newborn systolic average 60 – 80 mm Hg – diastolic average 40 -50 mm Hg. Commonly see a 15 mm Hg systolic decrease in first hour. Choose appropriate cuff size, and Doppler device.
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Hgb
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14-24 g/dl
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Hematocrit
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44-64%
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RBC’s and Hgb
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at birth are higher than adults, since fetus circulation was less efficient at oxygen exchange
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Leukocytes
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"WBC count of approx 18,000 (range 9,000 – 30,000), Decreases rapidly to resting level of 12,000, Serious infection is unlikely to increase the count markedly.
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Platelets
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"Ranges 150,000 – 300,000, essentially the same as adults. Newborn cannot synthesize vitamin K (no bacteria until they eat), so several clotting factors in the liver are decreased in first few days after birth (why we give Vit K injection). Unless serious Vit. K deficiency, clotting is usually sufficient to prevent hemorrhage.
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Blood groups
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ABO and Rh determined from cord blood
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Persistent tachycardia
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of > 160 bpm may indicate RDS (respiratory distress syndrome)
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Persistent bradycardia of
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< 120 bpm may be a sign of congenital heart block
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Prolonged cyanosis other than hands and feet may indicate
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respiratory and/or cardiac problems
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Differences of upper and lower extremities BP may be sign of
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coarctation of the aorta
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Jaundice may indicate
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ABO or Rh problems
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Caput succedaneum
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"generalized edematous area of scalp, usually over the occiput – disappears in 3-4 days. If vacuum used, may have a caput and bruising
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Cephalhematoma
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a collection of blood between the skull bone and its periosteum – does not cross cranial suture lines – usually resolves in 3-6 weeks
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Desquamation
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peeling of the skin, does not appear until a few days after birth – in postdate infants, however, it is present at birth
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Milia
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distended small white sebaceous glands on the face
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Mongolian spots
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bluish-black areas of pigmentation may appear anywhere, but more commonly on back and buttocks – more common in darker skinned infants regardless of race
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Telangiectatic nevi
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aka “stork bites” and “angel kisses” – pink and easily blanched – may appear on upper eyelids, nose, upper lip, lower occiput and nape of neck – fade by age 2
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Strawberry mark (nevus vasculosus)
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capillary hemangioma, caused by dilated newly formed capillaries – raised, sharply demarcated, bright pink or dark red, rough-surfaced swelling – usually a single lesion, but may be multiple – usually occur on the head – can remain through school age
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Port-wine stain (nevus flammeus)
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red to purple, vary in size and location – do not blanch on pressure or disappear
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Eythema toxicum
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"a transient rash (aka erythema neonatorum, “newborn rash” or “flea bite” dermatitis). Lesions in different stages: macules, papules, vesicles. Probably an inflammatory response May appear suddenly anywhere. Appears in first 3 weeks, no clinical significance.
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Assess for skin changes
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"Skin color. Birth injuries. Bruises or petechiae. Periauricular papillomas (skin tags) – usually a family trait, with no clinical significance
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Ovaries of full term infant contain
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full complement of potential ova (number decreases by 90% by age of sexual maturity)
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pseudomenstruation
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Mucoid vaginal discharge or slightly bloody spotting from withdrawal of maternal estrogen
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pseudomenstruation is caused by
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withdrawal of maternal estrogen
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Female External genitalia look like
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edematous with increased pigmentation (especially edematous in breech delivery)
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Female labia cover…
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the vestibule in term infants; in preterm infants the clitoris is prominent and labia majora small and widely separated
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Testes will descend into scrotum when?
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Happens by birth in 90% of male newborns (or by one year of age in preterm infants)
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Thermoregulation
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the maintenance of balance between heat loss and heat production
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Thermogenesis
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"the ability to produce heat. Infant’s ability is similar to adults, but tendency to rapid heat loss in cold environments presents a hazard.
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Brown fat
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Infants have stores of this for several weeks after birth, with intense lipid metabolic activity to warm the infant – stores are depleted more rapidly with cold stress (and infants less than term have smaller deposits of this)
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Convection
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flow of heat from body to cooler ambient air
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Radiation
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loss of heat from body surface to cooler solid surface in close proximity (why we don’t place babies close to windows)
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Evaporation
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loss of heat from vaporization of moisture from the skin
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Conduction
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loss of heat from body surface to cooler solid surfaces in direct contact
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Cold stress
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causes physiological and metabolic demands in all infants, regardless of gestational age and condition
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Cold stress does what to oxygen and energy?
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are diverted from normal brain and cardiac function and growth to maintain temperature
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Cold stress does what to the infant's vascualture?
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Vasoconstriction jeopardizes pulmonary perfusion, PaO2 and blood pH decline, aggravating RDS
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cold stress and pulmonary perfusion does what?
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Decrease pulmonary perfusion and oxygen tension may reopen the right-to-left shunt of the patent ductus arteriosus
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Cold stress and ph level?
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Metabolic acidosis develops, displacing bilirubin into circulation, increasing risk of kernicterus
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Hyperthermia
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sweat glands not as efficient – can lead to dehydration, or heat stroke and death
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An infant who has not voided by 24 hours should be assessed for
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adequate fluid intake, bladder distention or signs of pain
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How many times should a newborn void?
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Should void at least once in first 24 hours, twice in second 24 hours and three times in third 24 hours (1day=1, 2day=2, 3day=3).
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Urine output increases when?
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in breastfed infants once mother’s milk comes in
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After first 4 days, all newborns should have at least voided how many times?
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"6-8 straw-colored voidings every 24 hours (wet diapers they are getting enough fluid)
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Pinkish or blood stains on diapers indicate?
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“Brick dust” from uric acid crystals normal in first few days, later may be signs of dehydration
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Female infants may have slight vaginal bleeding from?
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withdrawal of maternal hormones
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Male infants may have slight bleeding from
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circumcision site
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Neonates will have 5-10% loss in birth weight when?
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in first 3-5 days (fluid loss) – should regain birth weight by 14 days
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Infants should be assessed for gross anomalies such as?
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hypospadias and enlarged or cystic kidneys
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Sucking behavior is not coordinated in infants of…
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less than 32 weeks gestation, or weighing less than 1500 g.
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Special mechanism in normal newborns coordinates what three basic survival skills?
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breathing, sucking and swallowing
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Sucking
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Small bursts of 3 – 8 sucks at a time
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Swallowing
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Nipple needs to be placed well inside baby’s mouth (cannot move food from lips to pharynx) (ability to swallow)
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Normal colonic bacteria are established when?
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established in the first week after birth,
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normal intestinal flora help synthesize what?
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Vit. K, folate and biotin – bowel sounds present shortly after birth.
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Stomach capacity varies from?
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30 to 90 mL (which is why feedings are only about 30ml)
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Most digestive enzymes, except what, are present from birth?
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Except amylase and lipase. Infant can digest simple carbohydrates and proteins, but limited ability to digest fats.
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Lower intestine is filled with what at birth?
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meconium
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Meconium is made from?
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Formed from amniotic fluid constituents, intestinal secretions, bilirubin and cells shed from mucosa.
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Meconium stool looks like?
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Greenish-black, viscous and contains occult blood
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First meconium BM is?
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is sterile, but later contains bacteria
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Majority of term infants pass meconium when?
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in first 12 hours, and almost all will do so by 24 hours.
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Normal breastfed infant should have at least how many stools per 24 hours?
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Normal breastfed infant should have at least 3 stools per 24 hours after mother’s milk comes in.
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Amount of food the infant takes at any given feeding depends upon..?
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size, hunger, level and alertness. Observe for hunger cues (sucking on fingers)
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No passage of stool within 24 hours could indicate:
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"Metabolic problem (cystic fibrosis), Congenital disorder (Hirschsprung disease or imperforate anus=An active rectal “wink” reflex is usually a sign of good sphincter tone),
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Signs of risk for GI problems
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Digestive difficulties (may be allergic to or unable to digest a formula) – may have fluid ring on the diaper around the stool (high water content), no stool in 24 hours, abdominal distention, scaphoid abdomen
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Abdominal distention at birth is
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is serious! Could be a tumor.
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Later abd. distention may be
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overfeeding or other GI disorder
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Scaphoid (sunken) abdomen with bowel sound heard in the chest, and signs of respiratory distress indicate
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a diaphragmatic hernia (intestinal contents are pushing through a hole in the diaphram)
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Iron stores in the liver should be adequate for
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4-6 months in term infant, and for 2-3 months in preterm or small for SGA infants
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Why observe all newborns for hypoglycemia (jittery, or has tremors)
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Initial decrease in serum glucose when cut off from maternal glucose supply
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In most healthy term infants, blood sugar stabilizes at
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40-60 mg/dl during first several hours – should be 60-70 by third day – initiation of feeding helps stabilize glucose
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Bilirubin
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a yellow pigment derived from the hemoglobin released with the breakdown of RBC’s and the myoglobin in muscle cells
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Describe how hemoglobin is converted to direct bilirubin.
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When the hemoglobin is converted to bilirubin, the bilirubin circulates as unconjugated bilirubin (aka indirect bilirubin), until it is bound to circulating albumin (a plasma protein) and enters the liver, where it becomes conjugated (or direct) bilirubin
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Unconjugated (or indirect) bilirubin is
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water soluable and unbound – can leave the circulatory system and permeate other tissues (skin, sclera, oral mucous membranes) – the resulting yellow coloring is called jaundice
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Unbound bilirubin is
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conjugated in the liver cells, and becomes a part of bile – converted into urobilinogen in the duodenum, it is then excreted in urine and feces
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hyperbilirubinemia
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"Physiologic (neonatal) jaundice. Occurs in most infants, but more severely in preterm infants. Higher incidence in Asian and Native Americans
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Most neonatal jaundice is
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benign, but if bilirubin accumulates to hazardous levels, physiological damage can occur
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Benign jaundice is caused by
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"Caused by greater mass of RBC’s, shortened lifespan of fetal RBC’s and liver immaturity; can be a temporary effect of breastfeedin.(?) Infant appears well, and develops signs of jaundice after 24 hours.
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Jaundice appearing in less than 24 hours requires
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immediate attention!
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Some causes of jaundice appearing in less than 24 hours
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"ABO incompatibility, RBC enzyme defects (G6PD, pyruvate kinase), RBC membrane disorders (spherocytosis, ovalocytosis), Hemoglobinopathy (thalassemia)
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The appearance of jaundice during first 24 hours, or lasting more than 7 days, no matter what serum bilirubin levels may be, is…
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a pathologic process
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Movement of jaundice
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"Jaundice appears in a cephalocaudal manner, First noticed in sclera and mucous membranes, Gradual progression to thorax, abdomen, extremities, Dissipates in reverse order, Early and frequent feedings help keep serum bilirubin low by stimulating intestinal function and passage of meconium.
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Kernicterus
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aka Bilirubin Encephalopathy is the most serious complication – bilirubin is deposited in basal ganglia and brainstem, disrupting neuron function/metabolism (brainstem regulates RR..?, why it is lifethreatening)
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Kernicterus usually occurs with bilirubin levels of
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"greater than 25 mg/dl, but can occur at less than 20 mg/dl in the following conditions:Sepsis, Meningitis, Hypothermia, Hypoglycemia, Prematurity, Bilirubin-displacing drugs (e.g., sulfa, ASA)
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In acute stage of kernicterus
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infant is lethargic, hypotonic and has a poor suck
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"Infant becomes hypertonic (with backward arching of the neck and trunk), High-pitched cry, May develop fever, If infant survives, may have residual cerebral palsy, epilepsy and mental retardation
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Recent resurgence in kernicterus, possibly related to
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shorter hospital stays after birth, an increase in neonatal jaundice and lack of concern and attention to infants exhibiting signs of jaundice
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Lack of intestinal flora causes
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resultant deficiency in synthesis of Vitamin K, and causes transient blood coagulation deficiency between 2 to 5 days after birth
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Injection of Vitamin K soon after birth helps
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prevent clotting problems
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Clotting factors will increase to adult levels by
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9 months
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Tests for clotting deficiencies should be given to
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any infant with bleeding problems
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Infant has passive immunity from the mother for how long?
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first 3 months
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Stomach acids not fully developed
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until 3-4 weeks
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IgA in newborns is
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missing from respiratory and urinary tracts, and from GI tract in formula-fed infants
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IgG
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begins synthesis, and reaches 40% adult level by age 1
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IgM
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is produced at birth – adult level by 9 month
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IgA, IgD, IgE do not reach maximal levels until
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early childhood
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All newborns are at high risk for what?
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For infection in first several months – infection is leading cause of morbidity and mortality in this period. Assess any rashes and unusual discharges from eyes, nose, mouth or other orifaces
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Intial symptom of sepsis in infants is?
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respiratory distress
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Vernix caseosa
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cheese-like, whitish substance fused with epidermis, as a protective covering
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Acrocyanosis
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hands and feet appear slightly cyanotic – appears intermittently over first 7-10 days, especially with exposure to cold
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Healthy newborn skin is usually
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plump, with redness of the skin fading over a few hours
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Lanugo
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fine hair, may cover face, shoulders, back
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With face presentation or forcep delivery, the skin will have?
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Edema, ecchymoses or petechiae
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Simian line
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a single palmar crease, often seen in Asian infants or Down syndrome
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More creases are signs of?
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Greater maturity. Preterm infants have few plantar creases.
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prepuce
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Foreskin which is common and urethral opening may be completely covered by it (and not retractable until age 3-4 years)
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Smegma
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a white cheesy substance commonly found under foreskin and small white firm lesions (epithelial pearls) commonly seen at tip of prepuce.
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By 40 weeks gestation the testes are?
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Palpable in the scrotum, and rugae cover the scrotal sac – more deeply pigmented than rest of the skin
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"Hyperestrogenism in pregnancy. Occasional thin discharge from nipples (witch’s milk). Nipples should be symmetric on the chest.
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Infant reproductive system assessment includes:
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Ambiguous genitalia, Absence of hymenal tags in female (possible vaginal agenesis), Presence of testes in the scrotum, Inguinal hernias, Hypospadias or epispadias
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Head is how big?
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one-fourth of body length
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Arms are?
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slightly longer than legs
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Legs are?
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one-third of body length, but only 15% of body weight
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Face appears
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small in relation to the skull (which can by distorted by molding)
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How many primary curves in the vertebral column?
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Two primary curves in the vertebral column, at thoracic and sacral levels, both forward
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Extremities should be
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symmetric and equal length
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