New Born Assessment — Free MOHAP Study Notes

THE NEW BORN

A. CARE OF THE NEWBORN IN THE DELIVERY ROOM

1. Maintain patent airway a. Drain secretions
   • Put the baby in a trendelenburg position for drainage except when signs of increase ICP are observed: bulging fontanel's, high-pitched cry (earliest sign), vomiting (surest sign), increase BP, decrease PR, decrease RR. b. Suction newborn
   • Suction the mouth first before the nose to prevent aspiration
   • Suctioning should be gentle to prevent laryngospasm
   • It should not be more than 1 minute otherwise, it will stimulate vagus nerve causing bradycardia.
   • Occlude one nostril at a time to test for patency since newborns are nasal breathers c. Observe characteristics of respirations

2. Administer oxygen as needed
   • Oxygen concentration should be <40% to prevent retinal scarring which may lead to blindness (retrolental fibroplasia).
   • Oxygen is best administered thru a tent
3. Keep the newborn warm
   • The body temperature of the newborn at birth is 37.2 C (99 F). Shortly after birth, it falls below normal because of the immature temperature-regulating mechanism and heat loss. In addition, the cold temperature of the delivery room contributes to this.
   • A newborn losses heat thru the following mechanisms:
     • Conduction: heat is transferred to a cooler solid object in contact with the body
     • Convection: heat flows from the body surface to a cool surrounding air
     • Evaporation: heat loss thru conversion of liquid to vapor (wet skin).
     • Radiation: heat is transferred to a cooler solid object but not in contact with the body

• Subcutaneous fats to act as insulators. Shivering is also not present at birth because of this, they are prone to cold stress which may cause metabolic acidosis as fatty acids accumulate due to the breakdown of brown fat
• Dry newborn immediately
• Wrap in a blanket
• Place under a radiant warmer or isolette with a temp of 33-34 C.
• Place under a droplight which should be 12-18" far from the newborn

4. Take the Apgar score

• Done at 1 minute after birth to know the conditions of the newborn. Then at 5 minutes after to determine how well the newborn is adjusting to extra uterine life.

Administer Vitamin K Vitamin K is normally synthesized in the presence of bacterial flora in the intestines. Since newborn's intestines are still sterile, Vitamin K is administered to facilitate production of clotting factor thus, preventing hemorrhage. Vitamin K (1 mg) is injected into the vastus lateralis (IM). This site is preferred because gluteal muscles of children below 12 months who have not yet learned how to walk are still not fully developed.

Place proper identification of newborn

This should be done before they are removed from the delivery room Take newborn's footprints

Initial feeding

If to be formula fed: give 1 oz sterile water at 4-6 hours. This is a test feeding to be certain that the infant can swallow without aspiration. Formula milk is given on the 4th feeding (rationale: if formula milk is aspirated, this may cause bacterial pneumonia). If to be breast fed: usually 30 minutes after normal delivery, 4 hours after CS (rationale: ability to suck and swallow in breast fed infants is not significant because if colostrums is aspirated, it has no effect on the lungs).

Circumcision

Surgical removal of penis foreskin usually done on the 1st or 2nd day of life after the baby has synthesized enough Vitamin K to prevent hemorrhage. Contraindications: hypospadias, epispadias

Procedure:

• Place infant in supine position
• Restrain the infant
• Prepare & drape the area around the penis
• Clamp is fitted over the end of penis, stretching the foreskin taut
• Prepuce is separated from the glans & a circle of prepuce is existed
• Complications: hemorrhage, infection, urethral fistula formation
• Nursing responsibilities:
  • Observe closely & check for bleeding
  • Wrap penis with a strip of petroleum gauze to prevent the diaper from adhering from the circumcised area
  • Don't want away a film of yellowish mucous which often covers the glands.

THE NEWBORN IN THE NURSERY

1. Check ID band (wrist or ankle)
2. Take vital statistics (anthropometric measurement) a. Weight
   • Average birth weight is 6.5 – 7.5 lbs. or 3.0 – 3.4 kg or 3000 – 3400 gm
   • Arbitrary lower limit is 2.5 kg or 55 lb or 2500 gm. Below this weight, the newborn is considered low birth weight infant
   • Newborns lose 5-10% of birth weight (6-10 oz) during the first few days of life (physiologic wt loss) due to:
     • Newborn is no longer in the influence of maternal hormones
     • Newborn voids & passes stools
     • If breast fed, they have limited intake because colostrum has low caloric content
     • If bottle fed, sucking is not yet effective

Birth weight is doubled by 6 mos, tripled by 1 year, quadrupled by 2 ½ years. Length

• Average length is 19-21.5 inches or 47-53 cm

Head circumference

• Normal: 33-35 cm
• <32—microcephaly
• >37—macrocephaly
• measured with a tape measure drawn across the center of the forehead and the most prominent portion of the posterior head

Chest circumference

• Normal: 31-33 cm
• Measured at the level of the nipples
• Head circumference >chest circumference till 2 years of age

Abdominal circumference

• Normal: 31-33 cm

Take vital signs

Temperature

• At birth, it is 37.2 C & must be maintained at 35.5–36.5 C
• Immediately after birth take rectal temp to check patency of anus.

Pulse rate

• Immediately after birth, PR is 100-180 beats per minute as the neonate struggles for respiration
• Normal PR is 120-140 beats/min
• Palpate femoral pulses because absence may suggest possible coarctation of aorta
• Radial pulses are not ordinarily palpable

b. Respiratory rate

• Immediately after birth, it may be as high as 80/min
• Normal RR is 30-60/min
• Observe movement of abdomen c. Blood pressure
• No routinely taken unless cardiac anomaly is suspected
• At birth, BP is 80/46 mm Hg
• After 10 days, Bp is 100/50
• The cuff to be used must not be more than 2/3 of the length of the upper arm or thigh
• FLUSH METHOD may be used
  • Apply cuff to an extremity
  • Elevate extremity & apply elastic bandage on the distal part of the extremity
  • Inflate cuff to 200 mmHg (extremity is pale)
  • Slowly deflate cuff as you observe extremity
  • As soon as the extremity turns pink, read the manometer
  • Only 1 reading is obtained which is the average between the diastolic & systolic pressures
  • Normal: 60 at birth, 75 after 10 days

Physical examination:

a. Skin

• Color- most newborns have a ruddy complexion due to increased concentration of rbc in blood vessels and decrease subcutaneous fats. This fades slightly over the first month
• Acrocyanosis- extremities are blue and the body is pink. This is normal during the first 2 days of life
• Pallor- may be due to anemia due to blood loss when cord was cut; few iron stores due to poor maternal nutrition; blood incompatibility; fetal-maternal transfusion.
• Gray- may indicate infection
• Jaundice- yellowing of the skin & sclerae due to the inability of the newborn to conjugate bilirubin due to immature liver function.

• Physiologic jaundice (Icterus Neonatorum)
• Onset- 2nd or 3rd day
• Duration- 5-7 days

Direct bilirubin

• Babies being breast fed have longer duration of physiologic jaundice because breast milk contain pregnandiol which depresses action of glucoronyl transferase
• Management of physiologic jaundice:
• Morning sunlight will stimulate liver to produce glucoronyl transferase & convert indirect bilirubin to direct bilirubin.
• Harlequin sign- due to immature circulation
• Neonate lying on his side will appear red on the dependent side of the body & pale on the upper side.
• Change position of infant.
• Birthmarks
• Hemangiomas- vascular tumor of the skin Nevus flammeus (port-wine stain)
  • Macular purple or dark red lesion, usually on the face
  • Strawberry hemangioma Elevated, thick, hard
  • Associated with high estrogen level Cavernous hemangiomas
  • Dilated vascular spaces, elevated

Ο Mongolian spots- slate gray patches found across the sacrum or buttocks, usually disappears by school age.

Vernix caseosa- white cream cheese-like substance noticeable on newborn's skin at birth Lanugo- fine downy hair covering newborn's shoulders, back & upper arms

• Ο Immature newborns has more lanugo than mature infant
• Disappear by 2 weeks

Desquamation- drying of newborn's skin within 24 hours of birth which results in areas of peeling

• Milia- pinpoint white papule (plugged or unopened sebaceous gland) on cheek or across the bridge of the nose
• Ο Disappear by 2-4 weeks
• Skin turgor- should be resilient & elastic

.Head- 1/4 of the total length; disproportionately large Large and prominent forehead Receding chin which quivers if the infant is startled or is crying Well-nourished newborns have full-bodied hair while those poorly nourished or immature newborns have stringy, lifeless hair Fontanelles should not be sunken (may indicate dehydration) nor bulding (may indicate increase ICP) Anterior fontanelle (diamond shape) normally closes at 12-18 MONTHS (1 TO 1 ½ YEAR) Posterior fontanelle (triangular in shape) normally closes by the end of the 2^nd month Overriding of suture linens is normal due to extreme pressure exerted by passage thru the birth canal. Sutures should never be separated (increased ICP)

Eyes

• Infant's head may appear prominent & asymmetric due to molding so that it can fit the cervix contours. This is normal and the head will be restored to its normal shape within a few days
• Craniotabes which are localized softening of the cranial bones are due to pressure of fetal skull against the mother's pelvic bone in utero. It is more common in first born infants
• Caput Succedaneum is edema of the scalp at the presenting part of the head. It may involve both hemispheres(CROSSES SUTURE LINE). Edema will slowly be absorbed about the 3rd day of life. It needs no treatment
• Cephalhematoma is a collection of blood between periosteum of skull bone and the bone itself. Unlike caput Succedaneum, caphalhematoma is confined to an individual bone and does not cross suture lines. It usually takes weeks for cephalhematoma to be absorbed.

Newborns cry tearlessly due to immature lacrimal ducts Iris of newborns are gray or blue till the 3^rd month of life Edema is usually present around the orbit or on the eyelids which will remain for 2-3 days Cornea should be round and adult-sized Larger cornea may indicate congenital glaucoma Pupils are round, dark and regular in shape Key holed pupils- coloboma White pupil- congenital cataract

There is physiologic strabismus due to underdeveloped eye muscles till 4 mos.

Ears

Pinna, tends to bend easily Level of top part of the ear should be in line with the upper canthus of the eye Ears set lower may indicate chromosomal abnormalities Nose- may appear large for the face

Mouth

Should open evenly when newborn cries, otherwise it may indicate cranial nerve injury Tongue appears large and prominent Palate should be intact Epstein's pearls maybe mistaken for oral thrust which are white or gray patches on th sqe tongue and sides of cheeks due to candida infection It is unusual for a newborn to have teeth but if 1 or 2 are found (natal teeth), it should be evaluated for stability. Loose teeth should be extracted to prevent aspiration.

Neck

Short and chubby, creased with skin folds Rigid neck- cogenital torticollis Strong enough to support the weight of the head Trachea may be prominent in front of the neck Thyroid gland is not palpable

Chest

• Breast may be engorged due to influence of maternal hormones
• Occasionally, breasts of newborns secrete thin, watery fluid (witch's milk) due to maternal hormones
• Should be symmetric in appearance
• Retractions should not be present

Abdomen

• Contour is slightly protuberant, globular
• Scaphiod or sunken abdomen – missing abdominal contents
• bowel sounds should be heard within an hour after birth
• edge of the liver is palpable at 1-2 cm below the right costal margin
• if >3cm - developing CHF the coastal edge of the spleen is palpable 1-2 cm below the coastal margin
• for the 1st hr of birth, umbilical cord is white, gelatinous marked with red and blue streaks of umbilical vein and arteries. After 1 hour, cord begins to shrink, dry and be discolored.
• 2nd or 3rd day – black
• 6th – 10th day – breaks free, leaving a granulating area a few cm across that heals during the following week
• right kidney can usually be palpated

Anogenital Area

1. Check for the patency of the anus
2. Note the time that the infant passed out meconium.
3. If the newborn does not pass meconium in the 1st 24 hrs, suspect imporforate anus or meconium ileus

Male genitalia

• scrotum is edematous due to maternal hormones
• testes should be present in the scrotum
• Cryptorchidism- undescended testes, may be due to short vas deferens, closed scrotal sac, ectopic testes, agenesis, deficient testosterone
• Penis appears small. Inspect if urethral opening is at the tip of the glans. If found on the dorsal surface- epispadias If found on the ventral surface- hypospadias Prepuce (foreskin) of the penis should be examined to test for phimosis (tight foreskin)

Female genetalia

Vulva maybe swollen due to influence of maternal hormones May have mucous vaginal secretion which is sometimes blood-tinged, also due to maternal hormones

Back

Supine appears flat in the lumbar & sacral areas Curve starts to form when the child is able to sit & walk

Extremities

• Arms & legs appear short
• Hands are plump & clenched into fists
• Fingernails are soft and smooth & are long to extend over the fingertips
• Arms and legs should move symmetrically
• Check the digits for webbing (syndactyly), extra toes or fingers (polydactyly), lacking toes or fingers (oligodactyly)
• Observe for thalidomide effects:
  • complete absence of extremities (Amelia), absence of distal extremities (pocomelia), absence of either upper or lower extremity (hemmelia).
• Check pulses
• Radial pulses are normally nonpalpable in the 1st 3 months due to decrease peripheral resistance from upper extremities. If palpable, suspect coarctation of aorta.
• Femoral pulses are normally palpable due to high peripheral resistance from lower extremities. If non palpable, conclusive of coarctation of aorta.
• Abnormal rotation & extension of foot suggests talipes/club foot

Types:

• Talipes equinovarus inward rotation of foot most common.
• Talipes equinovalgus- outward rotation of foot Talipes calcaneous- upward rotation of foot Talipes equinas- downward rotation of foot
• Abduct hip to 90

Limited abduction to 60- congenital hip dislocation

GENERAL PRINCIPLES OF GROWTH AND DEVELOPMENT

• Growth- increase in physical size quantitative change
• 2 aspects
  • weight- most sensitive measure of growth
  • birthweight- 2x at 6 mos 3x at 1 year 4x at 2 ½ years
  • height
  • Increase in ht. is 1"/mo from 1 mo- 6 mos. 1/2"/mo from 7 mos. - 12 mos.
  • rate of growth is rapid during infancy and adolescence, slow during toddler, pre-school, and school age period
  • rapid growth of limb occurs at school age period
• Development- increase in skill or ability to function

Qualitative change

• Principles of growth and development
• Growth and development are continuous process from conception till death
• Growth and development proceed in an orderly sequence
• Different children pass thru the predictable stages at different rates
• All body systems do not develop at the same rate
• Development is cephalo-caudal
• Development proceeds from gross to refined skills
• Development proceeds from proximal to distal body parts
• There is an optimum time for initiation of experience or learning
• Neonatal reflexes must be lost before development can proceed
• A great deal of skill & behavior is learned by practice

Gross motor

Check parent is happy for you to put the child on a play-mat on the floor Lie child on back – see if they can roll Put child in a sitting position – look for head control (3 months) See if they can sit aided/unaided (6-9 months) Look at curvature of spine and sitting reflexes Pull to a standing position – see how much support is needed (9-12 months) Get them to walk if able (15-18 months) or run (2 years) Lastly, place prone see if child lifts head/chest or crawls (10 months)

Fine motor and vision

Get child to take a toy and observe Transfers (6 months) Type of grip (palmar grasp at 6 months; pincer grip at 9-10 months) The pincer grasp is the ability to hold something between the thumb and first finger.

Offer bricks

• 3-cube tower (18 months)
• Builds bridge (3 years)

Give paper and pen if old enough

• Scribbles (18 months)
• Circular scribbles and lines (2 years)
• Copies circle (3 years)
• Copies cross (4 years)

Vision – wave toy

• Fixes and follows (3 months)

Hearing and language

• Click fingers or use rattles (see if they turn to sounds)
  • Startles to noise (neonate)
  • Turns to sounds (6 months)
  • Turns to name (12 months)
• Talk to child and ask parents what words/noises the child can say/make
  • Babble (6 months)
  • 'Mamma' and 'Dadda' (12 months)
  • 2-word phrases (2 years)
  • Knows own name and colours (3 years)
• Commands
  • One-step command, e.g. 'take the brick' (18 months)
  • Two-step command, e.g. 'take the brick and place it in the cup' (2 years)

Social •Observe interaction with people/environment

• Smiles (6 weeks)
• Laughs (3 months)
• Stranger anxiety (9 months)
• Plays 'peek-a-boo' (9 months)
• Waves goodbye (12 months) •Ask parents about the child's diet
• Solids (6 months)
• Fork and spoon (2 years)