PEDIATRIC NURSING III: COMMON DISORDER

Hemolytic Disorders
 Pathologic jaundice (w/in
1st 24 hours) is the result
of hemolytic disease of
the newborn.
Treatment: phototherapy
(bilirubin lights) to let bilirubin break down and exit
the body through stool, exchange transfusion
*** If Pathologic jaundice continues to rise, it
causes brain damage
Kernicterus, = increased bilirubin in brain tissue
Jaundice mgmt. - Routine assessment
- Bilimeter: routinely done once they are 8
hours of age
- Serum bilirubin levels: drawn on babies who
are at risk or appear to have jaundice
- Phototherapy
- Exchange blood transfusion
 Phototherapy uses
lightwaves to treat
certain skin
conditions. The skin
is exposed to an
ultraviolet (UV) light
for a set amount of
time.Phototherapy
uses a man-made
source of UV light.
UV light also comes from the sun. When
combined with a medication called psoralen,
the procedure is known as psoralen UVA
(PUVA).
BLOOD INCOMPATIBILITY
 Rh incompatibility: mom rh- and baby rh+
 If baby is rh+, and blood mixes antibodies will
build up in mom’s blood and attack the baby
 Everyone gets RhoGAM at 28 weeks and w/in
the first 72 hours after birth to protect the next
pregnancy.
 ***RhoGAM is a medicine that stops your
blood from making antibodies that attack Rh-
positive blood cells.
 We don’t know babies blood type until birth so
any mom who is rh- will get RhoGAM
throughout pregnancy
 Indirect Coombs test: drawn on mom for
screening test
 (+) a chance baby will have pathologic
jaundice
 (-) baby will not have pathologic jaundice
 When a major blood group antigen of the
fetus is different from the moms
AOB INCOMPATIBILITY
f mixing of blood where in antibodies form
attacks the opposite blood type
 Prevention: giving RhoGAM within 72 hours
of event causing blood to mix, intrauterine
transfusion, exchange transfusion
 Intrauterine transfusion: infuses blood
through the umbilical vein into the fetus
 Exchange transfusion: removing small
amts of blood and replacing it with
compatible blood if indirect Coombs is +
- pregnancy
 Diagnosis: recognizing jaundice, drawing a
direct Coombs test (done on baby using
umbilical cord blood) o + direct Coombs = @
risk of having hemolytic disorders
P
assive immunity from mom, immunoglobulin
IMMUNE SYSTEM
G IgG
 Baby hasn’t developed IgG yet, offer DTap
and flu shot
 -Breast milk provides immunity= lessens the
risk of allergies & food intolerance
 - Capable of immune response to vaccines
 - Inflammatory and immune mechanisms
hypo-functioning
 Sepsis: presence of toxins/infection
 Occurs easierNEONATAL INFECTION
in newborns due to immature
immune defenses
 Can occur in utero, during, or shortly after
birth - Increased risk
 Maternal infection/fever, prolonged ROM > 18
hours, PROM, preterm birth, asphyxia during
birth, invasive procedures, stress and
congenital anomalies
 Group B strep - Not an STI and usually
asymptomatic in women, test mom at 36 wks
 - Extremely virulent for newborns: harms
newborns very quickly
 - Not all babies exposed get infected, if mom
is + baby stays in the hospital for 48hrs
 - Acquired at birth or in utero if the
membranes are ruptured
 - Intrapartum decrease early onset but not
late onset
Risk factors: preterm birth, untreated GBS in
mom, mom with previous newborn with GBS
infection, chorioamnionitis, precipitous delivery
Tx: ampicillin and gentamicin IV to newborn
with possible GBS; PCN G to newborn with positive
GBS
- If baby is symptomatic, we take a culture
then immediately start antibiotics (abx)
 TORCH complex – a group of virus’s mom
can be infected with during pregnancy
 Toxoplasmosis: avoid cat feces or uncooked
meat, if fetus has it there is nothing you can
do about it
 Hepa B Vaccine: offer vaccine to all
newborns, if mom is + baby will get an
additional injection (HBV immunoglobulin)
 Parovirus: 2nd exposure is more serious, if
mom is + it can cause aplastic crises in baby
(reduced count of reticulocytes – immature
RBCs)
  Varicella: can cause many birth defects
I  Syphilis: can be transferred to baby without
knowing that mom has it
 Listeriosis: can cause birth defects but
depends on when mom is exposed during
pregnancy
 Rubella: for pregnant, cannot give vaccine,
do not give for 28 days after MMR
could cause severe birth defects
 Cytomegalovirus: can be contracted through
 Herpes Simplex Virus: can be transmitted at
birth and deadly to baby, must deliver via c/s
Prevention: give antiviral meds at 36 wks.
Prophylactically
Integumentary System
 NORMAL
 Vernix caseosa: cheese like substance to
protect the baby’s skin
 Acrocyanosis is normal up until 24 hours,
after that, it may only appear intermittently
 Lanugo: fine/thin downy hair that covers the
body
 Chart any bruising, edema, petechiae, signs
of birth injury
 Creases on palms and soles should be
assessed
Term infants will have more creases
Premature infants have fewer creases on the soles
of their feet
Integumentary Variations
1. Single palmar crease: one single crease
across the hand, common finding in baby’s
with downs syndrome, normal in a baby with
Asian descent
2. Milia: tiny white sebaceous glands, little dots
on nose or forehead, “baby acne”
3. Desquamation: skin peeling off, usually seen
in post term babies
4. Mongolian spots: dark pigmentation on the
back and buttocks, usually seen in darker
skin, fades over the years
 Nevi: “stork bite or angle kisses”, flat pink
capillary angiomas, blanches white
 Port wine stain: does not blanch white,
capillary malformations in the skin, they tend
to get darker as children grow and do not
resolve on their own
 Erythema toxicum: newborn rash that
appears in the first 24-72 hours, inflammatory
response due to baby coming in contact with
all new substances, usually on the face, no
treatment needed
 Pallor/plethora, petechiae, central cyanosis,
or jaundice must be investigated
 Pallor: deep purple color
 Petechiae: little purple dot
 appear with bruising or after vacuum
S extraction
wollen breasts (especially on females) and
labia changes is normal
 Due to mom’s high estrogen levels
- Witch’s milk: a thin discharge from the
breasts, can be seen in both sexes
- Swollen, darker labia with hymenal tag,
slight bloody spotting
- In preterm, clitoris is prominent
 Labia folds have not filled out to cover the
clitoris yet
 In term baby, labia cover the clitoris
 Palpable descended testes
- Teach parents not to try to wash off all the
vernix from the labial folds
Signs of Reproductive Problems
 Cryptorchidism: undescended testicle
 Epispadias: urethral opening above, no
circumcisions Hypospadias: urethral opening
underneath, ventral side, no circumcisions
 Hydrocele: accumulation of fluid around the
testes, gets worse with crying
 Ambiguous genitalia: unable to tell if baby is
female or male based on external parts,
requires UTZ to tell us what is internal
 Inguinal hernia: intestines bulge through the
abdominal wall, more present when an infant
cries
 Rectovaginal fistula: stool is coming from
the vagina
Reproductive System
Skeletal System
NORMAL
 Molding occurs to allow movement through
birth canal
 Suture lines can be palpated, sometimes
overlapping
 Fontanels should be palpable
- Anterior fontanel is a diamond, closes at 18
months
- Posterior fontanel is triangle shaped, closes
at 6-8 wks./1-2mo after birth
 Best to examine them when baby is lying flat
and not crying
-Bulging fontanels = too much fluid, crying
- Sunken in fontanels = dehydration
 Spine should be straight with no pilonidal
dimple (dimple at the base of the spine)
Skeletal variations and problems
 Caput succedaneum: generalized edema of
the scalp that crosses suture lines, commonly
found on the back of the skull (occiput), may
-Can occur from sustained pressure of the
presenting part (it can happen from the baby sitting
in the birth canal)
 Cephalohematoma: collection of blood, does
not cross over suture lines, can occur with
caput, may occur with spontaneous vaginal
deliver
 Subgaleal hemorrhage: bleeding in the skull,
not the brain
 Oligodactyly: not having enough fingers/toes
 Polydactyly: having too many fingers/toes
 -If the extra finger/toe doesn’t have a
bone in it they put a mitten on baby and tie a
suture around it to let it fall off, if it has a bone,
it is surgically removed
 Syndactyly: having webbed fingers/toes
 Developmental dysplasia of the hip: birth
defect where the hips are not even, one is
lower than the other
 Asymmetric moro reflex: one side doesn’t
respond to the moro reflex, could be due to a  Facial nerve injuries: s/s affected side
broken clavicle Nursing care: help with sucking/feeding
 *** check the clavicles to make sure they are techniques, may require gavage feedings, protect
even affected eye (often tape shut and administer eye
drops daily)
 Phrenic nerve paralysis causes
diaphragmatic paralysis
Treatment – position on affected side so that
expansion of the unaffected side can be
maximized, same nursing care of any infant with
respiratory distress

Normal Newborn Behavioral Characteristics

Birth injuries - Occur during labor and birth, most

are avoidable except long difficult labors and
abnormal fetal presentations
- Few are fatal, but some cause lasting injury
Skeletal injuries
- Molding of soft skull to prevent fractures, but
fractures still can occur.
 Usually linear fractures and require no
treatment
 Clavicle bone is most common fracture during
birth due to shoulder dystocia
 Humerus or femur are less common
 Treatment: immobilization with slings, splints,
swaddling

neuromuscular system - Transient tremors of

mouth and chin when crying
 Flexion of arms at elbows and legs at knees
 Babies respond to pain Signs of
neuromuscular problems
 Persistent tremors, seizures,
hypotonia: poor tone, hypertonia:
increased tone (seen in babies with moms
addicted to drugs), lack of response to
painful stimuli

 Peripheral nervous system injuries -

Brachial plexus injuries occur when any part
of the nerves from the spine through the neck
into the arms is injured.
 Moro reflex absent on affected side
in all plexus injuries

 Erb’s palsy: an upper plexus injury, causes

paralysis of affected extremity and muscles.
Arm hangs limp rotated internally, hand or
wrist not affected
Treatment – prevent contractures, positioning,
passive ROM Complete recovery from stretched
nerves takes 3-6 months. If nerves are completely
damaged or pulled out, permanent damage occurs