Neonatal Assessment and Care
Just the factsIn this chapter, you’ll learn:
changes that occur in the neonate after birth
the proper way to perform a neonatal assessment
nursing interventions critical to neonatal care.
Adapting to extrauterine life
After birth, a neonate must quickly adapt to extrauterine life, even though many of the neonate’s body systems are still developing. During this time of adaptation, the nurse must be aware of normal neonatal physiologic characteristics and assessment findings in order to detect possible problems and initiate appropriate interventions. (See Physiology of the neonate.)
Respiratory system
The major adaptation for the neonate is that he must breathe on his own rather than depend on fetal circulation. At birth, air is substituted for the fluid that filled the neonate’s respiratory tract in the alveoli during gestation. In a normal vaginal delivery, some of this fluid is squeezed out during birth. After delivery, the fluid is absorbed across the alveolar membrane into the capillaries.
At first breath
The onset of the neonate’s breathing is stimulated by several factors:
low blood oxygen levels
increased blood carbon dioxide (CO2) levels
low blood pH
temperature change from the warm uterine environment to the cooler extrauterine environment.
Physiology of the neonate
This chart provides a summary of the physiologic characteristics of a neonate after birth, including adaptations the neonate must make to cope with extrauterine life.
|
Noise, light, and other sensations related to the birth process may also influence the neonate’s initial breathing.
Delicate and developing
Although the neonate can breathe on his own, his respiratory system isn’t as developed as an adult’s is. The neonate is an obligatory nose breather. In addition, the neonate has a relatively large tongue whereas the trachea and glottis are small.
Other significant differences between a neonate’s respiratory system and an adult’s system include:
|
airway lumens that are narrower and collapse more easily
respiratory tract secretions that are more abundant
mucous membranes that are more delicate and susceptible to trauma
alveoli that are more sensitive to pressure changes
a capillary network that’s less developed
rib cage and respiratory musculature that are less developed.
Cardiovascular system
The neonate’s first breath triggers the start of several cardiopulmonary changes that help him transition from fetal circulation to postnatal circulation. During this transition, the foramen ovale, ductus arteriosus, and ductus venosus close. These closures allow blood to start flowing to the lungs.
Ovale to no avail
When the neonate takes his first breath, the lungs inflate. When the lungs are inflated, pulmonary vascular resistance to blood flow is reduced and pulmonary artery pressure drops. Pressure in the right atrium decreases, and the increased blood flow to the left side of the heart increases the pressure in the left atrium. This change in pressure causes the foramen ovale (the fetal shunt between the left and right atria) to close. Increased blood oxygen levels then influence other fetal shunts to close.
From ducts to ligaments
The ductus arteriosus, located between the aorta and pulmonary artery, eventually closes and becomes a ligament. The ductus venosus, between the left umbilical vein and the inferior vena cava, closes because of vasoconstriction and lack of blood flow; then, it also becomes a ligament. The umbilical arteries and vein and the hepatic arteries also constrict and become ligaments.
Renal system
After birth, the renal system is called into action because the neonate can no longer depend on the placenta to excrete waste products. However, renal system function doesn’t fully mature until after the first year, which means that the neonate is at risk for chemical imbalances. The neonate’s limited ability to excrete drugs because of renal immaturity, coupled with excessive neonatal fluid loss, can rapidly lead to acidosis and fluid imbalances.
|
Gastrointestinal system
At birth, the neonate’s gastrointestinal (GI) system isn’t fully developed because normal bacteria aren’t present in the digestive tract. The lower intestine contains meconium, which usually starts to pass within 24 hours. It appears greenish black and viscous.
Ongoing developments
As the GI system starts to develop, these characteristics appear:
audible bowel sounds 1 hour after birth
uncoordinated peristaltic activity in the esophagus for the first few days of life
limited ability to digest fats because amylase and lipase are absent at birth
frequent regurgitation because of an immature cardiac sphincter.
Thermogenic system
Among the many adaptations that occur after birth, the neonate must regulate his body temperature by producing and conserving heat. This can be difficult for the neonate because he has a thin layer of subcutaneous fat and his blood vessels are closer to the surface of the skin. In addition, the neonate’s vasomotor control is less developed, his body surface area to weight ratio is high, and his sweat glands have minimal thermogenic function until he’s age 4 weeks or older.
Where’s the heat?
The neonate’s body also has to work against four routes of heat loss:
convection—the flow of heat from the body to cooler air
radiation—the loss of body heat to cooler, solid surfaces near (but not in direct contact with) the neonate
evaporation—heat loss that occurs when liquid is converted to a vapor
conduction—the loss of body heat to cooler substances in direct contact with the neonate.Warming things up
To maintain body temperature, the neonate must produce heat through a process called nonshivering thermogenesis. This involves an increase in the neonate’s metabolism and oxygen consumption. Thermogenesis mainly occurs in the heart, liver, and brain. Brown fat (brown adipose tissue) is another source of thermogenesis that’s unique to the neonate. Brown fat is located in the axillary region at the root of the neck, posterior to the sternum, around the adrenal glands and the perianal area.
|
Immune system
The neonatal immune system depends largely on three immunoglobulins: immunoglobulin (Ig) G, IgA, and IgM.
Fighting infection with shear numbers
IgG (which can be detected in the fetus at 3 months’ gestation) consists of bacterial and viral antibodies. It’s the most abundant immunoglobulin and is found in all body fluids. In utero, IgG crosses from the placenta to the fetus. After birth, the neonate produces his own IgG during the first 3 months while the leftover maternal antibodies in the neonate break down.
The enforcer of bacterial growth
IgA, an immunoglobulin that limits bacterial growth in the GI tract, is produced gradually. Maximum levels of IgA are reached during childhood. The neonate obtains IgA from maternal colostrum and breast milk.
First responder
IgM, found in blood and lymph fluid, is the first immunoglobulin to respond to infection. It’s produced at birth, and by age 9 months, the IgM level in the neonate reaches the level found in adults.
Still in training
Even though these immunoglobulins are present in the neonate, the inflammatory response of the tissues to localized infection is still immature. All neonates, especially preterm neonates, are at high risk for infection during the first several months of life.
Hematopoietic system
In the neonatal hematopoietic system, blood volume accounts for 80 to 85 ml/kg of body weight. Immediately after birth, the neonatal blood volume averages 300 ml; however, it can drop to as low as 100 ml, depending on how long the neonate remains attached to the placenta via the umbilical cord. In addition, neonatal blood has a prolonged coagulation time because of decreased levels of vitamin K.
Neurologic system
The neurologic system at birth isn’t completely integrated, but it’s developed enough to sustain extrauterine life. Most functions of this system are primitive reflexes. The full-term neonate’s neurologic system should produce equal strength and symmetry in responses and reflexes. Diminished or absent reflexes may indicate a serious neurologic problem, and asymmetrical responses may indicate that trauma, such as nerve damage, paralysis, or fracture, occurred during birth.
|
Hepatic system
Jaundice (yellowing of the skin) is a major concern in the neonatal hepatic system. It’s caused by hyperbilirubinemia, a condition that occurs when serum levels of unconjugated bilirubin increase because of increased red blood cell lysis, altered bilirubin conjugation, or increased bilirubin reabsorption from the GI tract.
A mellow yellow
Jaundice resulting from physiologic hyperbilirubinemia occurs in 50% of full-term neonates and 80% of preterm neonates. It’s a mild form of jaundice that appears after the first 24 hours of extrauterine life and usually disappears in 7 days (9 or 10 days in preterm neonates). However, if bilirubin levels rise, pathologic conditions such as bilirubin encephalopathy may develop.
Shades of an underlying condition
Jaundice resulting from pathologic hyperbilirubinemia is evident at birth or within the first 24 hours of extrauterine life. It may be caused by hemolytic disease, liver disease, or severe infection. Prognosis varies depending on the cause.
Education edgeProtecting neonates from the sun
Neonates are more susceptible to the harmful effects of the sun because the amount of melanin (pigment) in the skin is low at birth. Teach parents the importance of avoiding sun exposure by giving them these tips.
Keep a hat with a visor on the neonate when outside.
Make sure that the hood of the stroller covers the neonate.
Use a blanket to shade the neonate from the sun when necessary.
Be especially careful in the car. Sun roofs and windows may expose the neonate to too much sun. Use commercially available window shades and visors.
Integumentary system
At birth, all of the structures of the integumentary system are present, but many of their functions are immature. The epidermis and dermis are bound loosely to each other and are very thin. In addition, the sebaceous glands are very active in early infancy because of maternal hormones. (See Protecting neonates from the sun.)
Musculoskeletal system
At birth, the skeletal system contains more cartilage than ossified bone. The process of ossification occurs very rapidly during the first year of life. The muscular system is almost completely formed at birth.
|
Reproductive system
The ovaries of the female neonate contain thousands of primitive germ cells. These germ cells represent the full potential for ova. The number of ova decreases from birth to maturity by about 90%. After birth, the uterus undergoes involution and decreases in size and weight because, in utero, the fetal uterus enlarges from the effects of maternal hormones.
For 97% of male neonates, the testes descend into the scrotum before birth. However, spermatogenesis doesn’t occur until puberty.
Neonatal assessment
Neonatal assessment includes initial and ongoing assessments, a head-to-toe physical examination, and neurologic and behavioral assessments.
|
Initial assessment
The initial neonatal assessment involves draining secre tions, assessing abnormalities, and keeping accurate records. To complete an initial assessment, follow these steps:
For infection control purposes, all caregivers should wash their hands and wear gloves when assessing or caring for a neonate until after his initial bath.
Ensure a proper airway by suctioning, and administer oxygen as needed.
Dry the neonate under the warmer while keeping his head lower than his trunk (to promote the drainage of secretions)
Apply a cord clamp and monitor the neonate for abnormal bleeding from the cord; check the number of cord vessels. Inspect the size and thickness of the cord. Assess for defects such as omphalocele or umbilical hernia.
Observe the neonate for voiding and meconium; document the first void and stools.
Assess the neonate for gross abnormalities and clinical manifestations of suspected abnormalities.
Continue to assess the neonate by using the Apgar score criteria even after the 5-minute score is received.
Obtain clear footprints and fingerprints. (In some facilities, the neonate’s footprints are kept on a record that also includes the mother’s fingerprints.)
Apply identification bands with matching numbers to the mother (one band) and the neonate (two bands) before they leave the delivery room. Some facilities also give the father or significant other an identification band.
Promote bonding between the mother and the neonate by putting the neonate to the mother’s breast or having the mother and neonate engage in skin-to-skin contact.
Apgar scoring
During the initial examination of a neonate, expect to calculate an Apgar score and make general observations about the neonate’s appearance and behavior. Developed by anesthesiologist
Dr. Virginia Apgar in 1952, Apgar scoring evaluates neonatal heart rate, respiratory effort, muscle tone, reflex irritability, and color. Evaluation of each category is performed 1 minute after birth and again at 5 minutes after birth. Each item has a maximum score of 2 and a minimum score of 0. The final Apgar score is the sum total of the five items; a maximum score is 10.
Dr. Virginia Apgar in 1952, Apgar scoring evaluates neonatal heart rate, respiratory effort, muscle tone, reflex irritability, and color. Evaluation of each category is performed 1 minute after birth and again at 5 minutes after birth. Each item has a maximum score of 2 and a minimum score of 0. The final Apgar score is the sum total of the five items; a maximum score is 10.
Recording the Apgar score
Use this chart to determine the neonatal Apgar score at 1-minute and 5-minute intervals after birth. For each category listed, assign a score of 0 to 2, as shown. A total score of 7 to 10 indicates that the neonate is in good condition; 4 to 6, fair condition (the neonate may have moderate central nervous system depression, muscle flaccidity, cyanosis, and poor respirations); 0 to 3, danger (the neonate needs immediate resuscitation, as ordered). Each component should be assessed at 1, 5, 10, 15, and 20 minutes after delivery, as necessary. Resuscitation efforts such as oxygen, endotracheal intubation, chest compressions, positive pressure ventilation or nasal continuous positive airway pressure, and epinephrine administration should also be documented.
| ||||||||||||||||||||||||||||
|
Evaluation at 1 minute quickly indicates the neonate’s initial adaptation to extrauterine life and whether resuscita tion is necessary. The 5-minute score gives a more accurate picture of his overall status. (See Recording the Apgar score.)
First and foremost
Assess heart rate first. If the umbilical cord still pulsates, you can palpate the neonate’s heart rate by placing your fingertips at the junction of the umbilical cord and the skin. The neonate’s cord stump continues to pulsate for several hours and is a good, easy place (next to the abdomen) to check heart rate. You can also place two fingers or a stethoscope over the neonate’s chest at the fifth intercostal space to obtain an apical pulse. For accuracy, the heart rate should be counted for 1 full minute.
Second to one
Next, check the neonate’s respiratory effort, the second most important Apgar sign. Assess the neonate’s cry, noting its volume and vigor. Then auscultate his lungs using a stethoscope. Assess his respirations for depth and regularity. If the neonate exhibits abnormal respiratory responses, begin neonatal resuscitation according to the guidelines of the American Heart Association and the American Academy of Pediatrics. Then use the Apgar score to judge the progress and success of resuscitation efforts. (See Monitoring for effects of medication.)
|
Move along to the muscles
Determine muscle tone by evaluating the degree of flexion in the neonate’s arms and legs and their resistance to straightening. This can be done by extending the limbs and observing their rapid return to flexion—the neonate’s normal state.
Assess reflex irritability by evaluating the neonate’s cry for presence, vigor, and pitch. Initially, he may not cry, but you should be able to elicit a cry by flicking his soles. The usual response is a loud, angry cry. A highpitched or shrill cry is abnormal.
Now add a little color
Finally, observe skin color for cyanosis. A neonate usually has a pink body with blue extremities. This condition, called acrocyanosis , appears in about 85% of normal neonates 1 minute after birth. Acrocyanosis results from decreased peripheral oxygenation caused by the transition from fetal to independent circulation. When assessing a non-Caucasian neonate, observe for color changes in the mucous membranes of the mouth, lips, palms, and soles.
Gestational age and birth weight
Perinatal mortality and morbidity are related to gestational age and birth weight. Classifying a neonate by both weight and gestational age provides a more accurate method for assessing mortality risk and offers guidelines for treatment. The neonate’s age and weight classifications should also be considered during future assessments.
Advice from the expertsMonitoring for effects of medication
Closely observe a neonate whose mother has received heavy sedation just before delivery or magnesium sulfate during labor. Even if he has a high Apgar score at birth, he may exhibit secondary effects of sedation later. Be alert for respiratory depression or unresponsiveness. Monitor the neonate whose mother received magnesium sulfate during labor for hypotonia. Monitor the neonate whose mother has received analgesia during labor or who has used narcotic drugs during their pregnancy.
How old are you now?
The clinical assessment of gestational age classifies a neonate as preterm (fewer than 37 weeks’ gestation), term (37 to 42 weeks’ gestation), or postterm (42 weeks’ gestation or longer). The Ballard scoring system uses physical
and neurologic findings to estimate a neonate’s gestational age within 1 week, even in extremely preterm neonates. This evaluation can be done at any time between birth and 42 hours after birth, but the greatest reliability is between 30 and 42 hours after birth. (See Ballard gestational age assessment tool.)
and neurologic findings to estimate a neonate’s gestational age within 1 week, even in extremely preterm neonates. This evaluation can be done at any time between birth and 42 hours after birth, but the greatest reliability is between 30 and 42 hours after birth. (See Ballard gestational age assessment tool.)
Too small, too big, just right
Normal birth weight is 2,500 g (5 lb, 8 oz) or greater. Large for gestational age falls above the 90% or greater than 4.0 kg. A neonate is considered to have a low birth weight if he weighs between 1,500 g (3 lb, 5 oz) and 2,499 g. A neonate of very low birth weight ranges between 1,000 g (2 lb, 3 oz) and 1,499 g. A neonate weighing less than 1,000 g has an extremely low birth weight.
Ballard gestational age assessment tool
To use this tool, evaluate and score the neuromuscular and physical maturity criteria, total the score, and then plot the sum in the maturity rating box to determine the neonate’s corresponding gestational age.
Posture
With the neonate supine and quiet, score as follows:
Arms and legs extended = 0
Slight or moderate flexion of hips and knees = 1
Moderate to strong flexion of hips and knees = 2
Legs flexed and abducted, arms slightly flexed = 3
Full flexion of arms and legs = 4
Square window
Flex the hand at the wrist. Measure the angle between the base of the thumb and the forearm. Score as follows:
>90 degrees = -1
90 degrees = 0
60 degrees = 1
45 degrees = 2
30 degrees = 3
0 degrees = 4
Arm recoil
With the neonate supine, fully flex the forearm for 5 seconds, then fully extend by pulling the hands and releasing. Observe and score the reaction according to this criteria:
Remains extended 180 degrees or displays random movements = 0
Minimal flexion (140 to 180 degrees) = 1
Small amount of flexion (110 to 140 degrees) = 2
Moderate flexion (90 to 110 degrees) = 3
Brisk return to full flexion (<90 degrees) = 4
Popliteal angle
With the neonate supine and the pelvis flat on the examining surface, use one hand to flex the leg and then the thigh. Then use the other hand to extend the leg. Score the angle attained:
180 degrees = -1
160 degrees = 0
140 degrees = 1
120 degrees = 2
100 degrees = 3
90 degrees = 4
<90 degrees = 5
Scarf sign
With the neonate supine, take his hand and draw it across the neck and as far across the opposite shoulder as possible. You may assist the elbow by lifting it across the body. Score according to the location of the elbow:
Elbow reaches or nears level of opposite shoulder = -1
Elbow crosses opposite anterior axillary line = 0
Elbow reaches opposite anterior axillary line = 1
Elbow at midline = 2
Elbow doesn’t reach midline = 3
Elbow doesn’t cross proximate axillary line = 4
Heel to ear
With the neonate supine, hold his foot with one hand and move it as near to the head as possible without forcing it. Keep the pelvis flat on the examining surface. Score as shown in the chart.
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
