Physiologic Adaptation of The Newborn and Nursing Assessment

Chapter 9
Physiologic Adaptation of the Newborn

and Nursing Assessment
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 1

Adjustment to Extrauterine Life

Objectives
 Define key terms listed.
 Describe four important neonatal adaptations
to extrauterine life.
 Explain how fluid in the lungs is replaced with
air.
 Relate how the neonate’s pulmonary
circulation is established.
 Differentiate among the three fetal circulatory
shunts, including their reasons for closure.

 Quickly breathe and maintain respiration rate
 Replace fluid in the lungs with air
 Open up the pulmonary circulation and close
the fetal shunts
 Allow pulmonary blood flow to increase and
cardiac output to be redistributed

(cont.)
 Provide energy to maintain body temperature
and support metabolic processes
 Dispose of waste products produced by food
absorption and metabolic processes
 Detoxify substances entering from external
environment

Respiratory and Circulatory
Function

Preparatory Events to Breathing
 In utero, lungs are filled with fluid
 Secretions of alveolar cells of lungs with some
amniotic fluid
 Surfactant produced by mature lungs in full-
term fetus
 Reduces force between moist surfaces of alveoli
 Prevents collapse with expiration
 Promotes lung expansion

Onset of Breathing
 First breath of healthy term infant occurs
within seconds of birth
 Stimuli to respiratory center
 Neonate’s brain: sensory, chemical, thermal,
mechanical
 External environment: cold, touch, movement,
light, sound

Chemical Stimulus
 Once cord is clamped
 Decreased blood oxygen level
 Increased blood carbon dioxide level
 Decreased pH
 Acidosis results
• Activates respiratory center in medulla to initiate
respirations

Changing from Fluid-Filled
to Air-Filled Lungs

Comparison of Vaginal Delivery
and Cesarean Delivery
 Vaginal  Cesarean
 Chest is compressed as  Chest does not have
the fetus is delivered the compression, recoil,
• Promotes fluid drainage expansion
from lungs  Increases risk of
• Before chest is delivered, respiratory distress
almost half of fluid is forced
out  Some fluid is absorbed
 Chest recoils, and infant by lymphatic vessels
sucks in 20 to 40 mL of air  The rest is removed by
• Creates negative the pulmonary
intrapleural pressure capillaries

Functional Residual Capacity
 Established with first breath
 Means there is a small amount of air left in
alveoli; allows lungs to stay partially open
during expiration
 With the second and third breath, not as
much pressure is needed, and as newborn
continues to breathe, respirations should
become easier

Respiratory Rate
 Normal newborn rate is 30 to 60 breaths/min
 Pattern includes 5- to 15-second pauses,
called periodic breathing, and is normal
 Cessation of breathing for more than 20
seconds is called apnea and is abnormal
 Obligate nose breather
 Any nasal obstruction can cause respiratory
distress

Closing Down the Fetal
Structures (Shunts)
 Fetus: blood flow bypasses nonfunctional
lungs and liver
 Newborn: blood must circulate to lungs for
oxygenation and to liver for filtration
 Shunts close as a result of
 Shifts in heart pressure
 Increase in blood oxygenation
 Clamping of umbilical cord

Major Shunts of Fetal Circulation

Foramen Ovale
 Fetal  Newborn
 Opening between  Clamping cord
right and left atria causes blood from
 Blood flow and placenta to stop
pressure greater in  Pressure on left side
right atrium of heart becomes
 Functions like one- greater than on right
way valve  Closes about 1
 Shunts blood away minute after birth
from lungs to aorta  Takes about 2 weeks
 Cord clamped on for complete
delivery anatomic closure
Ductus Arteriosus
 Shunts blood from  Constricts and completely
pulmonary artery closes between 15 and 24
to aorta hours after birth
 Bypasses lungs  Anatomic closure takes about
 Pulmonary 3 to 4 weeks after delivery
arterioles dilate in  Can reopen (dilate) if
response to newborn has a decrease in
increased oxygen blood pressure or oxygen
needs of lungs at saturation
birth  Referred to as patent ductus
arteriosus (PDA)
Patent Ductus Arteriosus
 Can lead to right-sided heart failure and
pulmonary congestion
 If it does reopen, unoxygenated blood will
bypass lungs and go through the pulmonary
artery into aorta and general circulation
 Newborn becomes hypoxic and can die

Ductus Venosus
 Allows most  Blood redistributed on
oxygenated blood clamping of cord
to bypass liver and  Reduced blood flow through
enter inferior vena shunt
cava • Constricts, closes anatomically
 Clamping of cord at about 2 weeks after birth
birth cuts off venous • Eventually becomes a ligament
blood flow  Forces blood perfusion in the
liver
 Mechanism for is closure is
unknown
Audience Response System
Question 1
Once the umbilical cord is clamped, what type
of stimulus is needed to cause the newborn to
breathe on its own?
A. Thermal
B. Chemical
C. Mechanical
D. Sensory

Body Adaptation

Objectives
 Recall the location of brown fat and how it is
used in infant heat production.
 Explain three reasons why the newborn
should not be allowed to chill or experience
cold stress.
 Explain four ways to prevent heat loss in the
newborn.

Body System
Adaptations and Functions

Thermoregulation
 Ability to produce heat and maintain a normal
body temperature
 Newborn maintains body heat by flexing
extremities (if good muscle tone)
 Minimizes exposure of body surface area
 Decreases risk of cold stress

Nursing Responsibility
 Maintain neutral thermal environment
 Room temperature 25° C (77° F)
 Makes minimal demands on newborn’s
energy reserves
 Abdominal skin temperature of 36.5° C
(97.7° F)
 Allows for
 Minimal oxygen consumption
 Conservation of energy

Cold Stress
 Newborn responds by increasing basal
metabolic rate and oxygen consumption
 Depletes glycogen stores
 Results in acidosis

Factors Contributing to Heat Loss
 Skin is thin
 Blood vessels are close to surface
 Little subcutaneous fat for insulation
 A greater transfer of heat to the external
environment compared with adults

Heat Loss to Environment
 Evaporation – Wet surface exposed to air
 Conduction – Loss of heat to a cooler surface
by direct skin contact
 Convection – Loss of heat from warm body
surface to moving cooler air
 Radiation – Loss of heat from warm object to
cooler one when objects are not in contact
with one another

Nonshivering Thermogenesis
 Newborn cannot use muscle activity
(shivering) to produce heat
 Has difficulty conserving and dissipating heat to
maintain optimum temperature
 Relies on nonshivering thermogenesis
 Uses brown fat stores
 Vasoconstriction in cold environments
 Vasodilation in warm environments

Newborn Produces Heat
 By physiologic mechanisms or thermogenesis
 Includes
 Increased basal metabolic rate
 Muscular activity
 Chemical thermogenesis (nonshivering
thermogenesis)
• Primary method of heat production

Brown Adipose Tissue (BAT)
 Cells contains fat vacuoles
 Abundant blood and nerve supply
 As it is metabolized, heat produced warms
vital areas of body
 Can be depleted in newborns who are
exposed to prolonged periods of cold stress
 Thermogenesis can be impaired
 Typically disappears by 3 months of age

Brown Fat Locations

Nonshivering Thermogenesis
 Nonshivering thermogenesis causes
vasoconstriction in cold environments and
vasodilation in warm environments.

Newborn Assessment

Objectives
 Recognize the normal range of neonatal vital
signs.
 Differentiate among molding,
cephalohematoma and caput succedaneum.
 Describe the assessment of the anterior and
posterior fontanelles.

Nursing Assessment
of the Newborn
 Includes  Phase 1 begins in
 Observation the delivery room
 Inspection  Phase 2 begins
 Auscultation upon admission to
 Palpation nursery
 Percussion  1-4 hours of age
 Phase 3 is from 4
hours of age until
discharge

Assessment
 Not performed at one time
 Series of examinations
 Detailed evaluation of all body parts
 Includes
 Skin color
 Type of respirations
 Temperature
 Activity
 Feeding behavior

General Appearance
 Before disturbing infant, evaluate
 Resting posture
 Spontaneous movements
 Flexion and symmetry
• Term infant able to hold flexion while resting
• Preterm infant may not be able to maintain flexion

Central Nervous System (CNS)
 Extension of neck with arched back is
opisthotonos, associated with CNS problems
 Spontaneous movements potential clues to
CNS problems

Newborn’s Cry
 Means by which newborns communicate with
those around them
 Strong and lusty
 High-pitched: may indicate neurologic
disorder, hypoglycemia, or drug withdrawal

Vital Signs
 Best if taken while newborn is quiet or resting
 Measure at
 15- and 30-minute intervals for first hour after
birth, then
 Every 4 to 8 hours thereafter

Heart Rate
 Apical rate
 Listen for 1 full
minute
 Note
 Rate, rhythm,
intensity
 Location of pulse
 Presence of
abnormal sounds

Variations in Heart Rate
 In newborns
 Normal rate is between 110 and 160 beats/min
 Bradycardia is heart rate less than 110 beats/min
 Tachycardia is heart rate greater than 160
beats/min

Femoral Pulse
 Evaluate two pulses (in groin region)
 A weak or slow pulse suggests coarctation of
the aorta

Respirations
 Count for 1 full minute
 Observe abdominal movement
 Movement of the chest and abdomen should be
synchronized
 Rate is 30 to 60 breaths/min
 Intermittent cessation of respirations for less
than 15 seconds is normal
 Apnea—respirations that cease for more than 20
seconds—must be reported to the health care
provider

Symptoms of Respiratory
Distress
 Nasal flaring
 Costal or substernal retractions (sucking in of
chest wall with sternum moving inward with
inspiration)
 Grunting sound on expiration

Breath Sounds
 Should be clear over most of area; may hear
some moisture in lungs during first few hours
after birth
 Rales—rush of air through fluid
 Resembles rubbing hair together
 Rhonchi—coarse sounds
 Resembles snoring

Temperature
 Drops immediately after birth
 Internal organs poorly insulated
 Skin relatively thin
 Heat-regulating center not yet mature
 Rapidly reflects temperature of environment

Maintaining Temperature
 Newborns cannot shiver
 Use brown fat
 Skin temperature will drop before core will
 Allows for early interventions to prevent core
hypothermia

Methods for Temperature
Measurement
 Stable measurement is
36.5° C (97.7° F)
 Take every 30 minutes
until stable
 Each hour for 4 hours
 Every 8 hours in
normal term newborn

Elevated Temperature
 Dehydration
 Too much clothing
 Infection
 Environment too hot
 Can cause infant to break out in a pinpoint
red rash called prickly heat or miliaria

Blood Pressure
 At birth
 60 to 80 mm Hg systolic
 40 to 50 mm Hg diastolic
 If newborn is crying, can increase by 10 to 20

mm Hg
 If cardiac anomaly suspected, check blood
pressure in all four extremities

Assessment of Physical
Characteristics

Skin
 Provides visible record of health status
 Inspect for characteristics related to preterm,
term, postterm
 Greenish-brown discoloration (meconium
stain) of skin, nails, and cord can result if
meconium passed before birth
 Peeling or excessive cracking of skin
associated with postterm

Head
 If born head-first and vaginally
 Often elongated
 Called molding
 Usually resolves in a few days
 Cesarean or breech delivery

 Normally round
 No pressure exerted on head during delivery
process

Head Circumference
 Large surface area compared with body
 Average 33 to 35.5 cm (13 to 14 inches)
 Either equals or exceeds by about 2.5 cm (1 inch)
the circumference of the chest
 If head is more than 4 cm greater than chest
size, serial assessment for increased ICP or
hydrocephalus is indicated
 Small head, microcephaly, may be caused by
rubella or toxoplasmosis exposure in utero

Molding
 Overlapping of bones of head
 Result of head compression during birth
process
 Usually resolves within 2 or 3 days

Caput Succedaneum
 Localized swelling of soft
tissues of scalp caused by
pressure on head during
labor
 Palpated as soft, fluctuant
mass
 May cross over suture lines
 Absorbed within a few days
 No intervention needed

Cephalohematoma
 Collection of blood between periosteum and
bones of skull
 May be unilateral or bilateral
 Does not cross suture line
 Emerges first or second day after delivery
 May take as long as 3 weeks to be absorbed

Fontanelles
 “Soft spots”
 Covered with sturdy membranes
 Openings in skull allow fetal head to mold to
fit through birth canal
 Should be level with cranial bones in a quiet
infant, not elevated or depressed

Fontanelle Assessment
 Bulging may occur when infant cries, coughs,
or vomits
 If bulging at rest, may indicate hydrocephalus
 Depressed fontanelle may occur with
dehydration and is a late sign

Large or Delayed Closure
of Fontanelles
 May indicate
 Congenital hypothyroidism
 Down syndrome
 Congenital rubella or syphilis
 Increased intracranial pressure

Anterior Fontanelle
 At birth is between 3.6 and 6 cm (1.4 and 2.4
inches)
 Usually closed by 18 months of age
 Small fontanelle or early closure is called
craniosynostosis
 Associated with abnormal brain development
 Caused by chromosomal anomalies, fetal hypoxia, or
fetal alcohol syndrome

Posterior Fontanelle
 Triangle-shaped
 Located between occipital and parietal bones
 Smaller than anterior
 Closes between 2 and 3 months of age
 Late closure may indicate hydrocephalus

Face
 Somewhat recessed
 Nose often flat
 Cheeks full due to accumulation of fat
 Makes up the “sucking pads”
 Allows for strong sucking reflex in the newborn
 Movements should be symmetric

Eyes
 Assess placement, space between,
symmetry, blink reflex
 Iris of light-skinned newborns typically slate
blue or gray
 Permanent color established around 3 to 6 months
of age, or later
 Scleral colors blue-white due to relative thinness
 Dark-skinned newborns may have dark eyes

at birth

Vision
 Myopic
 See best at 7 to 10 inches
 Can follow or track objects
 Can focus on an object for about 10 seconds
 Can discriminate between simple and complex
patterns
 Prefer simple patterns
 High-contrast colors, such as black and white

Nose
 Usually flat due to passing through birth canal
 Obstruction can cause various degrees of
respiratory distress, since newborns are
obligate nose breathers
 Flaring nostrils is one sign of distress
 Sneezing common
 Helps clear nasal passages

Mouth
 Assess
 Palate for closure
 Presence of teeth
• If present, usually removed to prevent aspiration
 Excessive salivation
• May indicate tracheoesophageal fistula or atresia
 Tongue
• Large, protruding may indicate Down syndrome

Sucking
 Reflex present at birth
 Sucking stimulated when lips touched
 Depends on state of wakefulness and hunger
 Weak reflex may result from
• Respiratory depression
• CNS damage
• Drug exposure
• Prematurity

Rooting
 Elicited by stroking mouth or cheek
 Normal newborn should turn head toward
stimulated side (positive rooting reflex)

Extrusion
 Tongue pushes outward after it has been
touched
 Present until 4 months of age
 May be mistaken as a refusal to eat or
spitting out

Ears
 Placement
 Low-set may indicate
chromosomal or kidney problem
 Formation
 Amount of cartilage
 Term newborn—firm
 Hearing test
 Hearing established after first
sneeze

Nurse’s Role in Hearing Tests

Neck
 Short, creased with folds
 Cannot support full weight of head
 Lags when pulled from a supine to sitting position
 Palpate for masses or injury to large muscles

 Assess
 Clavicles for symmetry and smoothness
 Range of motion and neck muscle function with
head movement

Chest
 Normally round, symmetric, slightly smaller
than head
 Protrusion of lower part of sternum, called
xiphoid cartilage, common
 Measure at nipple line
 30.5 to 33 cm (12 to 13 inches)
 Approximately 2.5 cm (1 inch) less than head size
 Assess breath sounds

Nipples
 Distance between is about 8 cm (3 inches)
 Wide distance may indicate congenital defect
 Breast engorgement common in both sexes
due to maternal hormones
 Nipples may secrete milklike substance
called “witch’s milk” for a few weeks

Abdomen
 Slightly protuberant and symmetric
 Moves with chest during respiration
 No masses should be palpable

Umbilicus
 Umbilical stump assessed for two arteries,
one vein
 Single artery associated with congenital anomalies
 Stump falls off around 7 to 9 days after
delivery
 Assess for signs of bleeding, discharge, or
infection
 May appear as if it is a hernia
 Will slowly disappear or invaginate
 Primary site of infection is the umbilical stump
Bladder
 Document when first void occurs
 Urine should not have an odor
 Typically dark amber due to uric acid crystals
• May cause pink stain on diaper
 With fluid increases, urine lightens in color
 Monitor number of wet diapers per day

Female Genitalia
 Should be clearly differentiated
 Labia majora cover labia minora in term infant
 Hymenal tags—small tags of tissue
protruding from vaginal opening—disappear
in a few weeks
 May have milky white, mucoid discharge due
to withdrawal of maternal hormones
 Can be pink; called pseudomenstruation
 Smegma often seen on labia minora

Male Genitalia
 Urethral meatus should be on the tip of penis
 If on undersurface—hypospadias
 If on upper surface—epispadias
 Foreskin adhered to glans penis—phimosis

 Testes usually descended in term newborn
 Palpated bilaterally in scrotum
 If not palpated, observe for inguinal hernia
 Rugae present on scrotum of term newborn
 Preterm lacks rugae

Anus
 Assess if open and if anal sphincter has good
muscle tone
 Open anus allows for passage of meconium
stool
 If no stool is passed within first 24 hours after
birth, newborn must be assessed for bowel
obstruction

Stools
 GI tract begins to function at birth
 Stools change color over a few days
 Breastfed—may have more than three a day
 Should not be watery
 Bottle-fed—may have less than three a day

Normal Newborn Stool Cycle

Back
 Should be straight and flat
 Lumbar and sacral curves do not develop
until baby begins to sit up
 Assess for dimples, masses, hair tufts, spinal
curvatures

Spinal Reflex
 If one side of back is stroked or stimulated,
the spine should curve in the direction of the
stimulus

Ortolani Maneuver
 Hips are examined for dislocation
 Assess gluteal and popliteal folds
 Should be symmetric
 If asymmetric and limited abduction, requires
further evaluation

Ortolani Maneuver (cont.)

Extremities
 Assess for extra or missing digits, deformities,
palmar creases, and diminished femoral
pulses
 Extra digits: polydactyly
 Webbing of digits: syndactyly
 Hands should have three creases
 Assess location of feet
 If not in normal position, may be clubfoot

Erb-Duchenne Paralysis
 Also called Erb’s palsy
 Arm lies limply at side or newborn unable to
elevate arm
 Orthopedic care needs to implemented
immediately

Unilateral Moro’s Reflex
 May indicate fractured clavicle

Femoral Pulses
 Palpate at same time
 Diminished or unequal may indicate heart
defect

Question 2
A white- to pink-tinged mucoid discharge from the
vagina is noted during the nursing assessment of a
female newborn. The nurse knows this is not an
unusual finding as it is likely due to:
A. Withdrawal of maternal hormones.
B. Blood not completely removed during the bath.
C. Rust-colored uric acid crystals in the diaper.
D. Residual amniotic fluid.

Neurological and Behavioral
Assessment

Objectives
 Review key physical and behavioral
assessments of the newborn.
 Discuss normal newborn reflexes.
 State the purpose of newborn screening test.

Neurologic Assessment
 Noticeable jerky or jittery movements
 Excessive electrical discharge from neurons
or metabolic disorder such as
 Hypoglycemia, hypocalcemia, hypoxia
 Neurologic damage
 Drug withdrawal
 Repetitive blinking or pedaling movements of
lower extremities may represent seizure
activity

Estimation of Gestational Age
 Ballard scoring system
 12 scores are totaled and maturity rating is
expressed in weeks of gestation
 Performed within first few hours of birth and
repeated again at 24 hours
 Preterm born at less than 38 weeks
 Term is 38 to 42 weeks
 Postterm is born after 42 weeks

Fetal Size
 Small for gestational age (SGA): weight less
than 10th percentile
 Large for gestational age (LGA): weight
greater than 90th percentile
 Weight alone does not determine prematurity
or maturity level of newborn

Behavioral Assessment
 Phases of reactivity newborn passes through
during first 6 to 8 hours after birth

First Period of Reactivity
 At birth—quiet alertness
 Followed by phase of active alertness
 Demonstrates strong sucking reflex; may appear
hungry
 Facilitates bonding and attachment
 Eye-to-eye contact
 After 30 minutes to 1 hour becomes drowsy
and falls asleep; lasts about 2 to 4 hours

Second Period of Reactivity
 May last 4 to 6 hours
 Awake, alert, and may cry
 Shows activities such as rooting, sucking,
swallowing
 May respond to eye-to-eye contact
 Bonding promoted
 Feeding initiated if not done in first period

Understanding Newborn Cues
Newborn Desires Newborn Desires to End
Interaction Interaction
Focuses on face of parent Turns head away
Ceases random body movement Fussy
Reaches out Yawns
Squirms
Newborn Is Hungry Newborn Is Not Hungry

Places hand at mouth Arches back
Sucking, rooting are evident Falls asleep
Flexes arm and clenches fist over Relaxes arms at sides
body Turns head away from nipple

Behavioral States
 Sleep states
 Quiet sleep
 Active sleep
 Transitional state
 Drowsiness
 Awake state
 Quiet alert
 Active alert
 Crying

Screening
 Procedure used to detect abnormal condition
before symptoms appear
 Not diagnostic
 Enables early interventions
 Most are state-funded
 Screening for PKU mandatory in all states

Screening (cont.)
 Screening may include
 Endocrine conditions
 Organic acid metabolism
 Fatty acid metabolism
 Amino acid metabolism
 Hearing
 Cystic fibrosis

Question 3
What does it mean when a newborn turns its
eyes away, is fussy, yawns, and squirms?
A. The newborn wants some form of interaction with
others.
B. The newborn is hungry.
C. The newborn wants to be left alone.
D. The newborn no longer is hungry.

Review Key Points

Physiologic Adaptation of The Newborn and Nursing Assessment

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Chapter 9

Physiologic Adaptation of the Newborn

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 If newborn is crying, can increase by 10 to 20

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 Cesarean or breech delivery

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