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Chapter 25.docx

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McGill University
NUR1 233
Sonia Elizabeth Semenic

Chapter 25: Nursing Care of the Newborn Birth through the first 2 hours With possibility of transmission of viruses such as hep B and HIV via maternal blood and blood-stained amniotic fluid, the newborn must be considered a potential contamination source until proved otherwise use gloves always Assessment APGAR score: after 1 minute and 5 minutes o Heart rate, RR, muscle tone, reflex irritability, skin color (pallid, cyanotic, pink) score out of 2 o Scores 0-3: severe distress, scores 4-6: moderate difficulty, scores 7-10: good o Dont predict future neurological outcome but show newborns adjustment to extrauterine environment Initial physical assessment o CNS: moves all 4 extremities, flexion, muscle tone good symmetrical features, movement moro, suck, rooting, and grasp reflexes present, anterior fontanel soft and flat o Cardiovascular system: heart auscultation, regular rate and rhythm transient acrocyanosis, otherwise pink in color pulse strong, equal bilaterally capillary refill less than 3 seconds centrally and in peripheral tissues (not in nail beds) o Respiratory system: lungs auscultated, clear bilaterally with minimal fine crackles shortly after birth RR < 60 breaths/min respiratory effort nonlabored absence of nasal flaring, grunting, retractions o Genitouinary system: male urethral opening at tip of penis, testes descended bilaterally female labia minora and majora intact, hymenal tag may be visible o Gastrointestinal system: abdomen soft, no visible distention cord attached and clamped anus patent o Eyes, ears, nose, and throat: eyes clear palates intact nares patent ears in place, correct alignment o Skin: color (pink or acrocyanotic) skin lesions or abrasions documented birthmarks documented caput/molding Gestational age assessment completed within first hours of birth in stable newborn More comprehensive physical examination completed within 24 hours Immediately after birth dries infant thoroughly, assesses temp, places ID bracelets on infant, mother and father o May be wrapped in blanket and to mother or partner or immediate skin-to-skin o Observations and assessment can be made while baby on mother or when drying baby Implementation Airway maintenance o Most secretions moved by airway and brought by the cough reflex to the opopharynx to be drained or swallowed may be placed in side lying position until secretions cleared and then supine o Excess mucus: suction bulb syringe generally avoided o Choking on secretions: supported with his/her head on side mouth suctioned centre of mouth avoided so no gag reflex nasal passages suctioned one nostril at a time always keep bulb in crib o Listen to respirations and lung sounds to determine whether crackles, rhonchi, or stridor o Fine crackles: few hours after birth normal o Catheter insertion and suctioning: 5 seconds or less per catheter insertion help prevent vagal stimulation and hypoxia Pressure less than 80mmHg after catheter placed, suction created by placing ones thumb over the control as the catheter is carefully rotated and gently withdrawn o Maintaining O2 supply Clear airway Effective establishment of respirations Adequate circulation, adequate perfusion, and effective cardiac function Adequate thermoregulation (exposure to cold stress increases O2 and glucose needs) Body temperature maintenance o Clod stress increases need for oxygen and may deplete glucose stores can become cyanotic o Ways to stabilize temp: skin-to-skin on abdomen of mother and cover with blanket, dry and wrap in blanket after birth, keep head well covered, and keep ambient temp 22-26 degrees celsius o Vernix caseosa: allowing it to remain on skin has not been associated with decrease in axillary temp in first houro Use radiant warmer or warm incubator unit if no skin-to-skin for first few hours keep to 36-37 degrees Thermistor probe (automatic sensor): placed on upper quadrant of abdomen below right or left costal margin (never over a bone) ensure detection of minor temp changes from external environment before change in core temp Servocontroller: adjusts warmer temp to maintain infants skin temp within preset range Axillary temp: checked every hour until stabilizes o Rapid warming: after hypothermia can cause apnea and acidosis warming process progresses slowly over a period of 2-4 hours Immediate interventions o Eye prophylaxis: prophylactic agent necessary as precaution against ophthalmia neonatorum inflammation of eyes from gonorrheal or chlamydial infection contracted from birth canal Usual agents: or erythromycin, tetracycline, or sulfonamide Can be delayed for an hour to allow eye contact and parent-infant attachment and bonding o Vitamin K prophylaxis: single injection of 0.5-1mg intramuscularly to prevent hemorrhagic disease may be delayed until after first breastfeeding Intravenously: only in preterm infants who have no muscle mass give over 10-15 min Day 8: can produce own vitamin K o Promoting parent-infant bonding Oxytocin and prolactin levels rise in mother, and suckling activity activated in infant Process of developing active immunity begins as infant ingests flora from the mothers colostrum From 2 hours after birth until discharge Assessment Physical assessment o A complete physical examination is performed within 24 hours after the infants condition has stabilized o Observe skin color, tone and condition auscultate lungs, heart, and abdomen perform reflexes last measure head and length at same time to compare results Assessment of gestational age o Ballard scale: assess 6 external physical and 6 neuromuscular signs each sign has number score and cumulative score correlates with a maturity rating of from 20-44 weeks of gestation
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