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198 Cards in this Set

  • Front
  • Back
What is the neonatal period?
The time from birth through day 28 of life
What physiologic adjustment tasks do neonates have to make during extrauterine life?
1. Establishing and maintaining respirations
2. Adjusting to circulatory changes
3. Regulating temperature
4. Ingesting, retaining, and digesting nutrients
5. Eliminating waste
6. Regulating weight
What behavioral tasks do neonates have to make during extrauterine life?
1. Establishing a regulated behavioral tempo independent of the mother, which involves self-regulation of arousal, self-monitoring of changes in state, and patterning of sleep

2. Processing, storing, and organizing multiple stimuli

3. Establishing a relationship with caregivers and the environment
What is the transition period?
1. A time of vulnerability for the neonate and warrants careful observation by nurses

2. The first 6-8 hours of life
What sympathetic responses occur in the neonate?
Changes in heart rate, color, respiration, motor activity, gastrointestinal function, and temperature
What is the first phase of the transition period called?
First period of reactivity
How long does the first period of reactivity last?
Up to 30 minutes
What happens during the first period of reactivity?
1. The newborns' HR increases rapidly to 160 to 180 BPM, but gradually decreases after 30 minutes or so to a baseline rate of between 100 and 120 BPM

2. The respirations are irregular for the first 15 minutes after birth, with a possible rate between 60 and 80 breaths/min. There may be pauses for up to 10 seconds between breaths

3. Crackles may be present on auscultation; audible grunting, nasal flaring, and retractions of the chest also may be noted

4. Infant is alert
What is the second phase of the transition period?
Period of decreased responsiveness
When does the period of decreased responsiveness occur?
Between 30 minutes abd 2 hours after birth
What happens during the period of decreased responsiveness?
1. Marked decrease in motor activity and/or sleep

2. Respirations are rapid and shallow with a rate of up to 60 breaths per minute

3. The HR averages 100-120 BPM

4. Infant's color is pink

5. Bowel sounds are audible, and peristaltic wavse may be noted over the abdomen
How long does the period of decreased responsiveness last?
About 60-100 minutes, followed by a second period of reactivity
When does the second period of reactivity occur?
Between 2 to 8 hours after birth
How long does the second period of reactivity last?
10 minutes to several hours
What happens during the second period of reactivity?
1. Periods of tachycardia and tachypnea

2. Increased muscle tone, skin color, and mucus production

3. Meconium is commonly passed

4. Stabilization of vitals
What is the most critical adaptation necessary for survival of the neonate?
Establishment of effective respirations
Who experiences the transition period?
All well newborns experience this transition, regardless of the gestational age or type of birth
What difficulty do preterm infants commonly encounter?
Respiratory difficulties related to immaturity of lungs
How does oxygenation of the fetus occur during intrauterine life?
Transplacental gas exchange
What is the purpose of clamping the umbilical cord at/after birth?
It causes a rise in blood pressure, which increases circulation and lung perfusion to establish the lungs as a site of gas exchange
What initiates respirations in the neonate?
A combination of chemical, mechanical, thermal, and sensory factors that stimulate the respiratory center in the medulla
When is an ideal time for moms to breastfeed their neonate?
At the first period of reactivity or at the second period of reactivity when the child is alert and responsive
What activates the chemoreceptors in the carotid arteries and the aorta?
1. The relative state of hypoxia associated with labor

2. Clamping of the umbilical cord that results in a drop in levels of a prostaglandin that may inhibit respirations
What happens during each labor contraction?
A temporary decrease in uterine blood flow and transplacental gas exchange resulting in transient fetal hypoxia and hypercarbia
What happens while the fetus is recovering between each labor contraction?
1. There seems to be a cumulative effect that results in progressive decline in P-O2, increased P-CO2, and lowered blood pH

2. Decreased levels of oxygen and increased levels of carbon dioxide seem to have a cumulative effect on the initiation of neonatal breathing
What mechanical factors stimulate breathing in neonates?
1. Changes in the intrathoracic pressure resulting from compression of the chest during vaginal birth

2. The negative intrathoracic pressure helps draw air into the lungs
What thermal factors stimulate breathing in neonates?
The profound change in environmental temperature (which is significantly lower than the intrauterine environment) stimulates receptors in the skin resulting in stimulation of the respiratory center in the medulla
What sensory factors stimulate neonatal breathing?
1. Handling of infant by physician or midwife

2. Suctioning of mouth and nose

3. Drying of the body by the nurses

4. Pain associated with birth

5. Environmental triggers - lights, sounds, and smells
What is considered abnormal neonatal apnea?
Pauses in breathing lasting longer than 20 seconds
How much fluid does the lung hold at term?
20 mL of fluid per kilogram
What happens in the days preceding labor?
There is a reduction in production of fetal lung fluid and a concomitant decrease in alveolar fluid volume
What provides a powerful stimulus for fluid clearance in a neonate?
The process of labor
How does movement of lung fluid from the air spaces occur?
Through active transport into the interstitium, with drainage occurring through pulmonary circulation and lymphatic system
What might infants born by cesarean experience?
Retention of lung fluid, although it typically clears without deleterious effects on the infant
What is surfactant?
A protein manufactured by type II cells of the lungs
What is the function of surfactant?
1. Assist with lung expansion (in conjunction with chest wall contraction)

2. Reduce surface tension, therefore reducing the pressure required to keep the alveoli open with inspirations

3. Prevent total alveolar collapse on exhalation, thereby maintaining alveolar stability
What is significant about reduced surface tension?
It increases lung compliance, helping to establish the functional residual capacity of the lungs
What are characteristics of normal neonate breathing pattern?
Breaths are shallow and irregular, ranging from 30-60 breaths/min, with short pauses of less than 15 seconds
What are signs of neonatal respiratory distress?
1. Nasal flaring

2. Retractions (in-drawing of tissue between the ribs, below the rib cage, or above the sternum and clavicles)

3. Grunting with expirations

4. Any increased use of intercostal muscles
What causes retractions?
Use of accessory muscles to breath
What is seesaw respiration?
Abnormal respiratory pattern, in which the chest wall retracts and the abdomen rises with inspiration
What is most often associated with respiratory difficulty?
Pallor or central cyanosis (seen as circumoral cyanosis)
What events are apneic episodes related to?
1. Rapid increase in body temperature
2. Hypothermia
3. Low blood glucose (<40 mg/dL)
4. Sepsis
What may cause tachypnea?
Inadequate clearance of lung fluid or may be indicative of newborn respiratory distress syndrome (RDS)
What is normal assessment of lung sounds?
Breath sounds should be clear and equal bilaterally
At 24 hours of age, what is a normal value of bilirubin?
5 mg/dL
What cardiovascular changes indicate normal development?
1. Closure of foramen ovale
2. Closure of ductus arteriosus
3. Closure of ductus venosus
What causes a functional/normal closure of the foramen ovale?
Increased pulmonary blood flow from the left side of the heart which increases pressure in the left atrium
What causes functional closure of the ductus arteriosus?
Increased pulmonary circulation and arterial oxygen tension
What causes the functional closure of the ductus venosus?
Clamping of the umbilical cord
What causes the foramen ovale to stay open/patent?
Asphyxia
What causes the ductus arteriosus to stay open/patent?
Low oxygen levels, associated with hypoxia, asphyxia, or prematurity
How is a patent ductus arteriosus detected?
As a heart murmur during auscultation of the chest
What does the ductus venosus convert to?
Ligament (within 2 to 3 months afrter birth)
What is the resting heart rate of a term newborn?
100 to 160 BPM
What is the orientation of the infant heart?
It lies midway between the crown of the head and the buttocks, and the axis is more transverse than that in the adult
Where is the infant's pulse assessed?
At the apex
What causes congenital cataracts in newborns?
Measles

(if mom had measles during pregnancy)
How long should the pulse be assessed for?
1 full minute
What are normal heart sounds of a newborn?
Higher pitch, shorter duration, and greater intensity than those during adult life
When are murmurs considered normal?
During the first few days of life
What causes (normal) murmurs in a newborn?
Patent ductus arteriosus, tricuspid regurgitation, or the acute angle of the pulmonary artery bifurcation
What is PDA?
Patent ductus arteriosus
What needs to be assessed when a murmur is heard?
Other signs of cardiovascular dysfunction such as tachycardia, tachypnea, pallor, cyanosis, absence of peripheral pulses, or poor perfusion (capillary refill)
When would blood pressure be assessed?
A common practice is to obtain four-extremity BPs in the presence of any cardiovascular symptoms such as tachycardia, persistent murmur, abnormal pulses, poor perfusion, or abnormal precordial activity
What is the average range of blood pressure for newborns?
1. SBP: 60 to 80 mmHg

2. DBP: 40 to 50 mmHg
What is the normal blood volume of a term infant?
Approximately 85 ml/kg
What changes the circulatory dynamics of a newborn?
Early or late clamping of the umbilical cord
What happens with early clamping of the umbilical cord?
Reduction of the mean blood volume
What happens with late clamping of the umbilical cord?
Expansion of the blood volume from the so-called placental transfusion, which causes an INCREASE in heart size, higher SBP, and increased respiratory rate
What is persistent tachycardia (more than 160 BPM) associated with?
1. Anemia
2. Hypovolemia
3. Hyperthermia
4. Sepsis
What is persistent bradycardia (less than 100 BPM) a sign of?
Congenital heart block or hypoxemia
What is an early sign of coarctation of the aorta?
A significant difference between upper and lower extremity BPs
What are the normal hematologic values in term newborns?
1. Hgb 14-24 g/dl
2. Hct 44%-64%
3. RBC 4.8-7.1 x 10^6/mcl
4. Platelet 150,000-300,000/mm^3
5. WBC 10,000-30,000/mm^3
What is the hematocrit level of newborns by age 8 weeks?
39%-59%
Why are newborns injected with vitamin K?
1. The newborn cannot synthesize vitamin K, and levels of platelet factors ii, VII, IX, and X (found in the liver) are decreased during the first few days of life

2. Helps prevent bleeding problems (because it activates the coagulation factors in the liver)
What is the umbilical cord blood samples used for?
To identify the infant's blood type and Rh status
What three things must newborns be able to do in order to be discharged?
1. Breath on own
2. Show adequate signs of circulation
3. Capable of thermoregulation
What is thermoregulation?
The maintenance of balance between heat loss and heat production
What characteristics of neonates place them at risk for heat loss?
1. Having less adipose tissue and subcutaneous fat

2. Blood vessels are closer to the surface of the skin

3. A larger body surface-to-body weight (mass) ratio
How do term newborns make an effort to conserve heat?
1. By assuming a position of flexion that helps guard against heat loss because it diminishes the amount of body surface exposed to the environment

2. By constricting peripheral blood vessels
What factors influence a newborn's heat loss to the environment?
1. Temperature and humidity of the air
2. Flow and velocity of the air
3. Temperature surfaces in contact with and around the infant
By what modes do infants lose heat?
1. Convection
2. Radiation
3. Evaporation
4. Conduction
What is convection?
Flow of heat from the body surface to cooler ambient air
What is radiation?
Loss of heat from the body surface to a cooler solid surface not in contact but in relative proximity
What is evaporation?
Loss of heat when a liquid is converted to a vapor

(i.e. wetness to dryness)
What is conduction?
Loss of heat from the body surface to a cooler surface in direct contact
How is an infant protected from heat loss by convection?
The ambient temperatures in the nursery are kept at approximately 24 degrees C and newborns are wrapped to protect from heat loss
What is done to prevent heat loss by radiation?
Nursing cribs and examining tables are kept away from outside windows
What can intensify the heat loss by evaporation?
Failure to dry the newborn directly after birth or by too-slow drying of infant after a bath
How is heat loss by conduction minimized?
Placing a newborn in a warmed crib
What is thermogenesis?
Generation of heat by increasing muscle activity
Is the shivering mechanism present in the newborn?
Insignificantly only, not enough to produce enough heat
What is the primary mechanism of heat production in infants?
Nonshivering thermogenesis by metabolism of brown fat
What is brown fat?
1. A type of adipose tissue that is unique to the newborn

2. Has a richer vascular and nerve supply than ordinary fat
Where is brown fat found?
1. As superficial deposits in the interscapular region and axillae

2. In deep deposits at the thoracic inlet

3. Along the verterbral column

4. Around the kidneys
What is the heat production effectiveness of brown fat?
100%
How long does brown fat present?
For several weeks after birth, and is rapidly depleted with cold stress
What is cold stress?
The diversion of oxygen consumption and energy from maintaining normal brain and cardiac function and growth to thermogenesis for survival
What are the effects of cold stress?
1. Oxygen consumption and respiratory rate increases

2. This causes pulmonary and peripheral vasoconstriction, which decrease O2 uptake by the lungs and O2 delivery to the tissues

3. Decreased O2 induces anaerobic glycolysis

4. Leads to a decrease in P-O2 and pH, leading to metabolic acidosis
What is hyperthermia?
A body temperature greater than 37.5 degrees C
What is the clinical appearance of hyperthermic infants due to environmental factors (i.e. blankets)?
Skin vessels dilate, flushed skin, hands & feet warm to touch, infant assumes position of extension
What is the clinical appearance of hyperthermic infants due to sepsis?
Appearance of stress, vessels are constricted, color is pale, hands & feet are cool
What is the origin of palpable abdominal masses in the newborn?
Renal in origin
What is indicative of renal impairment in a newborn?
No urinary output within 48 hours (infant has NOT voided)
How often do 4-day-old newborns void?
A least 6 to 8 voidings of straw colored urine
What % of a term neonate consists of water?
75%
What is the daily fluid requirement of full-term neonates?
40 to 60 mL/kg during the first two days of life; and increases thereafter to 100 to 150 mL/kg/day
What accounts for a 5% to 10% loss of birth weight?
1. Urine
2. Feces
3. Lungs
4. Increased metabolic rate
5. Limited fluid intake
When should weight loss be evaluated by a physician?
Anything greater than 7%
When does a mother's milk "come in"?
3 or 4 days after birth
When should a neonate regain the birth weight?
Within 14 days after birth
What is neonatal sucking behavior influenced by?
1. Neuromuscular maturity

2. Maternal medications and anesthetics received during labor and birth

3. Type of initial feeding
What influences tooth development in neonates?
1. Neonatal or infant illnesses
2. Medications
3. Illnesses of or medications taken by the mother during pregnancy
4. Fluoride levels in water
What is the stomach capacity of an infant?
30 to 90 mL
What do neonates experience some regurgitation?
The cardiac sphincter is immature
How can regurgitation be decreased?
1. Avoid overfeeding
2. Burping the infant after feeding
3. Positioning the infant with the head slightly elevated during feeding
What enzymes are not present in infants until after 3- 6 months of age?
1. Amylase (enzyme that breaks down starch)
2. Lipase (enzyme that breaks down fat)

(therefore, infants can only digest simple carbohydrates and proteins)
What is meconium?
The FIRST stool formed during fetal life from the amniotic fluid and its constituents, intestinal secretions (including bilirubin), and cells (shed from mucosa)

(passed within the first 12 hours)
What is the appearance of meconium?
Greenish black and viscous, and contains occult blood
What should an infant's first stool be noted for?
Time, color, and character
What does a lack of passage of stool indicate?
Bowel obstruction related to conditions such as an inborn error of metabolism (i.e. cystic fibrosis) or a congenital disorder (i.e. Hirschsprung disease or an imperforate anus)
What usually is a good sign of sphincter tone?
An active rectal "wink" reflex
What is an active rectal "wink" reflex?
Contraction of the anal sphincter muscle in response to touch
What is th function of the liver in newborns?
1. Iron storage
2. Carbohydrate metabolism
3. Conjugation of bilirubin
4. Coagulation
Where can the liver be palpated?
About 1 to 3.5 cm below the right costal margin in the midclavicular line
What is the normal feel of the liver upon palpation?
Liver edge is normally sharp and soft, and the hepatic surface is smooth
What does a full and firm liver edge indicate?
1. Increased total blood volume
2. Increased extramedullary hematopoiesis
3. Chronic infection
What is the ideal blood glucose level for newborns?
50 mg/dl
What blood glucose level is considered abnormal and warrants intervention?
Below 35 mg/dl
What is bilirubin?
A yellow pigment derived from the hemoglobin released with the breakdown of RBCs and the myoglobin in muscle cells
What is physiologic jaundice?
Yellowing discoloration of the skin due to normal newborn physiology, such as increased bilirubin production resulting from increased RBC mass, shortened life span of the fetal RBCs, and liver immaturity

(also known as neonate jaundice or hyperbilirubinemia)
What is the ideal level of bilirubin?
5 mg/dl
What is considered pathologic jaundice?
1. If it appears BEFORE 24 hours of age

2. INCREASES more than 0.5 mg/dl/hr

3. Any value above 5 mg/dl
Why is jaundice such a big deal?
Because it is associated with blood glucose levels, and hypoglycemic or hyperglycemic conditions have ill effects on newborns
What is kernicterus?
1. Acute bilirubin encephalopathy

2. Bilirubin levels > 25 mg/dl

3. Bilirubin levels > 20 mg/dl in the presence of sepsis, menigitis, hypothermia, hypoglycemia, prematurity, and bilirubin displacing drugs
When does kernicterus occur?
When bilirubin is deposited in the basal ganglia and brainstem, disrupting neuronal function and metabolism
What are the consequences of kernicterus?
If the infant survives, there may be residual cerebral palsy, epilepsy, and mental retardation
Which anitbodies are present at highest levels in the newborn?
IgG
When do newborns produce adult concentrations of IgG independently?
By 4 to 6 years of age
When is the fetus capable of producing IgM?
8th week of gestation (and low levels are present at birth)
When do newborns produce adult concentrations of IgM independently?
By age 2 years
Which antibodies are produced more gradually?
IgA, IgD, and IgE
What substances maintain the sterility of the small intestine?
Pepsin and trypsin
How do the WBCs of newborns respond?
The influx of phagocytic cells to areas of inflammation is somewhat slowed, but the ability of these cells to attack and destroy bacteria is equivalent to that of adults
What is the leading cause of morbidity and mortality among newborns during the first several months of life?
Infection
Why are newborns prone to infections?
Because of generalized hypofunctioning of the inflammatory and immune mechanisms
What are the clinical signs suggestive of infection in newborns?
1. Lethargy
2. Irritabilty
3. Poor feeding
4. Vomiting or diarrhea
5. Decreased reflexes
6. Pale or mottled skin
What are the clinical signs of pneumonia in newborns?
1. Apnea
2. Tachypnea
3. Grunting
4. Retractions
What is the greatest risk for neonatal infection?
Prematurity because the immune system is immature
What is vernix caseosa?
A cheeslike, whitish substance (protective covering) normally found on newborns at birth
What is acrocyanosis?
Slight bluish coloring of hands and feet due to vasomotor instability, capillary stasis, and a high hemoglobin level
What is caput succedaneum?
A generalized, easily identifiable edematous area of the scalp, mostly found on the occiput

(normal boggy, edematous swelling)
What is cephalhematoma?
Collection of blood between a skull bone and its periosteum
What is the difference between caput succedaneum and cephalhematoma?
Cephalhematoma usually does not cross the suture line
What is subgaleal hemorrhage?
Bleeding into the subgaleal compartment
What are the early signs of subgaleal hemorrhage?
1. Boggy scalp
2. Pallor
3. Tachycardia
4. Increasing head circumference
What is the normal head-to-chest circumference ratio?
1:1

(the same)
What should be monitored in infants suspected of subgaleal hemorrhage?
VS (including BP and hemoglobin, hematocrit, and bilirubin levels) and coagulation studies
What is desquamation?
Peeling of the skin that is indicative of postmaturity
What are Mongolian spots?
Nonpathogenic, bluish-black areas of pigmentation that fade gradually over months are years

(may be mistaken for bruises)
What are "stork bites"?
Telangiectatic nevi that are pink and easily blanched; have no clinical significance and fade by second year of life
What are "flea bites"?
A transient rash that has no clinical significance and requires no treatment (looks like a bug bite surrounded by redness)

(also known as erythema toxicum)
What happens to the number of ova from birth to sexual maturity?
Decreases by 90%
What is the normal presentation of the genitalia of newborns?
1. Females - swelling and redness of labia majora covering internal genitalia completely

2. Males - foreskin covers the glans, urethral covered by prepuce and not retractable, swollen and reddened scrotum
What is hypospadias?
Abnormal location of the urethral opening (usually on dorsum of penis)
What is a contraindication of hypospadias?
Circumcision, since the foreskin is used to repair the anomaly
What indicates a rectovaginal fistula in female infants?
Fecal discharge from the vagina
What is the proportion of the infant's head at term?
Head = 1/4 total body length
What is molding?
The shaping of the fetal head by overlapping of cranial bones to facilitate movement through birth canal

(cranial bones are normally not fused at birth)
What are the primary curvatures of the newborn's vertebral column?
1. Thoracic region

2. Sacral region
What are the secondary curvatures of the infant's vertebral column?
1. Cervical region (when able to lift head)

2. Lumbar region (when able to walk)
What is the normal presentation of the spine?
Straight and flat, and easily flexed
What needs further inspection concerning the spine?
Pilonidal dimple
What is the clinical significance of a pilonidal dimple?
Need to check if sinus is present, because a pilonidal dimple (especially with a sinus and nevus pilosis) is associated with spina bifida
What is nevus pilosis?
Hairy nevus
What must assessment of newborn reflexes be done as early as possible?
Because abnormal signs present early in the neonatal period may disappear and remain undiagnosed
What does an absence of newborn reflex indicate?
Major neurological problems
What is the cry of a term newborn like?
Strong and "lusty"
What is a weak cry associated with?
Prematurity, neuromuscular disease, or sepsis
What type of cry may suggest CNS abnormality?
High-pitched or shrill cry
What is a low-pitched, husky cry related to?
Hypothyroidism
What does stridor cry indicate?
Airway obstruction
What is the characteristic response of the tonic neck or "fencing" reflex?
With infant facing left side, arm and leg on that side extend, while opposite arm and leg flex (turn head to right, and extremities assume opposite postures)

*Infant assumes a fencing position
What is the Babinski's sign?
When the infant's sole is stroked upward along the lateral aspect, all toes hyperextend with dorsiflexion of the big toe
What is the magnet reflex?
1. With infant in supine position, apply pressure on the soles of the feet

2. Both lower limbs should extend against examiner's pressure
What are sleep-wake states?
Variations in the state of consciousness of infants
What are the six sleep-wake states?
1. Deep sleep
2. Light sleep
3. Drowsy
4. Quiet alert
5. Active alert
6. Crying
What is the optimal state of arousal?
Quiet alert state
What occurs during the quiet alert state?
Infant smiles, vocalizes, moves in synchrony with speech, watches parents' faces, and responds when people talk
What purposeful behaviors do infants use to maintain the optimal arousal state (the quiet alert state)?
1. Actively withdrawing by increasing physical distance

2. Rejecting by pushing away with hands and feet

3. Decreasing sensitivity by falling asleep or breaking eye contact by turning head

4. Using signaling behaviors such as fussing and crying
How much does a newborn sleep?
Approximately 17 hours a day, with periods of wakefulness gradually increasing
How does an infant respond to a pinprick of the foot?
1. A term infant withdraws only the foot

2. An infant with an immature CNS responds with the entire body
When does visual acuity reach adult levels?
By age 4 or 5
Where is the clearest visual acuity for infants?
Within 19 cm
What is the incidence of newborn sensorineural hearing loss?
1 in 1000 infants
What is habituation?
A protective mechanism that allows the infant to become accustomed to environmental stimuli

(desensitized, "getting use to something")
What does crying signify?
1. Hunger
2. Pain
3. Desire for attention
4. Fussiness (wet diaper, startledness, etc.)