NGN – NEWBORN: SHERPATH

Normal Newborn – Patient 1

A 2-day-old baby girl was delivered vaginally using a vacuum and has a cephalohematoma. She weighed 3987 g at birth. Today she weighs 3589 g (10% weight loss since birth). She is breastfeeding. Her assessment and vital signs are otherwise normal. She is alert and active at the time of assessment with good muscle tone and is demonstrating good feeding cues.

The parents state that they are worried about removing the baby from phototherapy for feeds and care because the doctor told them she should remain under the lights as much as possible. They confide to you that she is not feeding well and does not seem to be as eager at the breast as she was before light therapy.

Parent Feeding Log with Intake and Output

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Rationale:

Potential conditions

The baby girl is at risk for dehydration as evidenced by her infrequent voids; this is secondary to infrequent feeding, increased weight loss (10% of birth weight or greater), and phototherapy treatment. There is not assessment data to support a concern for cardiovascular collapse. This neonate has lost 10% of weight which indicates the need for more nutrition but is still above thresholds which raise concern for failure-to-thrive. The nurse must assess the neonate’s feeding and attempt alternatives to feeding before a diagnosis of failure-to-thrive would be considered. Assessment and vital signs are within normal limits so the nurse would not be concerned about hypothermia for this neonate.

Actions to take

She is feeding, but not enough, according to the parent feeding log. The nurse will encourage feeding at least every 2-3 hours to increase nutritional and fluid intake. She may need supplementation but should first work with the lactation consultant and the registered nurse (RN) to assess whether or not supply or latch is an issue in addition to frequency. This neonate is also stooling and voiding, but infrequently. By increasing the frequency of feeding, the neonate should begin to void and stool more. This will also assist with elimination of excess bilirubin. There is no evidence that her blood glucose is suspected to be either high or low so obtaining a capillary glucose level would not be necessary at this time. The neonate should remain with the mother whenever possible to assist with frequent feeding and bonding. Phototherapy may be done at the bedside unless contraindicated. It is not necessary that the neonate be placed on a cardiac monitor, because her vital signs within expected parameters and she is not lethargic.

Parameters to monitor

Intake and output as well as weight should be closely monitored. If these parameters fail to improve with appropriate action, supplementation should be considered by the healthcare team. There is no evidence to support a concern for cardiovascular issues so monitoring of echocardiogram rhythms would not be necessary. This neonate’s temperatures are normal, so axillary temperatures should be implemented to prevent damage to the rectal mucosa. Serum bilirubin levels should be monitored; however, this monitoring is not in relation to dehydration but, rather, related to hyperbilirubinemia. With more frequent feeding, adequate colostrum, and milk supply, it is expected that neonatal weight loss should slow, and the neonate should begin to gain weight.

Normal Newborn – Patient 2

A client has just given birth to a baby boy at 39 3/7 weeks’ gestation, and the nurse is assuming care for the neonate. The client’s labor began at 0400, and the time of birth was 1938. She is a G2/P2 and began prenatal care at 17 weeks’ gestation. The baby is vigorous and crying with good tone, and the presenting part was the face at the time of delivery. The hands and feet appear blue in color, and the trunk and face are pink. The healthcare provider is waiting for the umbilical cord to stop pulsating, and the baby has been placed on the mother’s abdomen with the umbilical cord still intact and attached.

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Rationale:

The neonatal resuscitation algorithm is the standard of care for immediate post-birth care of the neonate in the delivery room. If the infant is term, vigorous, has good tone, and is breathing or crying, the neonate may remain with the mother immediately after birth, and further assessment should occur on the mother’s chest, including APGAR scoring and vital signs. The mother’s gravida and parity do not assist in determining the neonate’s stability at birth. Late entry to prenatal care alone does not indicate that a neonate requires separation from the mother at birth. The decision to resuscitate a neonate using the neonatal resuscitation algorithm should be initiated before the 1-minute APGAR score. The neonate may remain on the mother’s abdomen during and after delayed cord clamping, provided that the infant is assessed to be healthy.

Normal Newborn – Patient 2

A client has just given birth to a baby boy and 39 3/7 weeks’ gestation, and the nurse is assuming care for the neonate. The client’s labor began at 0400, and the time of birth was 1938. She is a G2/P2 and began prenatal care at 17 weeks’ gestation. The baby is vigorous and crying with good tone, and the presenting part was the face at the time of delivery. The hands and feet appear blue in color, and the trunk and face are pink. The healthcare provider is waiting for the umbilical cord to stop pulsating, and the baby has been placed on the mother’s abdomen with the umbilical cord still intact and attached.

1938:

Delivery attended of viable male neonate. Infant warmed and dried and placed skin-to-skin with mother, after clamping and cutting of umbilical cord.

1939:

The infant has blue hands and feet, the heart rate by palpation is 165, the baby has good tone and is crying, and there is visible movement in the chest wall with breaths.

1942:

Identification bands placed on mother, father, and neonate.

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Rationale:

APGAR scoring is a standardized assessment based on the newborn’s heart rate, color, tone, reflex irritability, and breathing pattern. The newborn is demonstrating acrocyanosis, so receives a score of 1 for blue hands and feet. A vigorous cry, heart rate greater than 100, strong tone and flexion, and visible movement of the chest wall with appropriate respiratory effort each receive a score of 2. This neonate’s APGAR at 1 minute of life is 9.

1938:

Delivery attended of viable male neonate. Infant warmed and dried and placed skin-to-skin with mother, after cutting and clamping of umbilical cord.

1939:

The infant has blue hands and feet, the heart rate by palpation is 165, the baby has good tone and is crying, and there is visible movement in the chest wall with breaths.

1942:

Identification bands placed on mother, father, and neonate.

1943:

The infant has blue hands and feet, the heart rate by palpation is 165, the baby has good tone and is crying, and there is visible movement in the chest wall with breaths.

1950:

There is facial ecchymosis noted in the neonate due to face presentation at birth.

Mother’s Prenatal Record:

Current Condition List:

• Term pregnancy
• Depression
• Anxiety
• Gestational diabetes mellitus type A1

Prenatal Laboratory Values:

• Blood type: O+
• Rubella: Nonimmune (reference range: immune)
• Human immunodeficiency virus (HIV): Negative (reference range: negative)
• Hepatitis B: Negative (reference range: negative)
• RPR syphilis: Nonreactive (reference range: nonreactive)
• Hepatitis C: Negative (reference range: negative)
• Group beta streptococcus: Negative (reference range: negative)

Obstetric (OB) History:

• G 2 T 1 P 0 A 0 L 1
• 2020 – Spontaneous vaginal delivery – girl – 3785 g – first-degree vaginal laceration – neonate requiring phototherapy for hyperbilirubinemia

Current Pregnancy Education Needs:

• Feeding choice: Breast
• Fetus gender: Male
• Circumcision desired: Yes
• Pediatrician chosen: Yes
• Name: Not yet chosen

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Rationale:

The nurse must recognize important information from the prenatal record to hypothesize important risk factors that may present in the neonate. This neonate is at risk for hypoglycemia because it was born to a mother with gestational diabetes. It is also at risk for hyperbilirubinemia because the mother had previously delivered an infant who required phototherapy at birth, and there is facial ecchymosis, noted by the nurse, due to face presentation. The information provided does not indicate that this neonate is at risk for respiratory distress. It is a term infant with an uncomplicated birth. The mother is rubella nonimmune. This places her at increased risk for contracting rubella, and she will need a booster immunization but the infant is not necessarily at increased risk. There is also nothing to indicate that this neonate would be at increased risk for infection, such as chorioamnionitis infection, group beta streptococcus-positive maternal status, or other causes.

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Rationale:

The interventions that are essential in the first 2 hours of life include monitoring this neonate for hyperglycemia because of the mother’s gestational diabetes. It is recommended that the infant feed as soon as possible within the first hour of life and that a blood glucose test is performed 30 minutes after the feeding. Thermoregulation is essential for all neonates as is bonding. Uninterrupted skin-to-skin contact helps facilitate both. It is recommended that neonatal vital signs be monitored every 30 minutes in the first 2 hours of life by the nurse. This may be performed while the neonate remains skin-to-skin. A bath should be delayed for this neonate until euglycemia is achieved and breastfeeding is well-established. Bilirubin screening will be a priority for this neonate but is not indicated in the first 2 hours of life. Additionally, the nurse must witness informed consent for the circumcision, but it is not prioritized in the first 2 hours of the neonate’s life.

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Rationale:

Erythromycin is administered within the first 1-2 hours of life for best protection against ophthalmia neonatorum as a result of exposure to Neisseria gonorrhoeae. Side effects include temporarily blurred vision and chemical conjunctivitis. It should be administered as directed in the lower conjunctiva. It is not known to cause hyperglycemia. Vitamin K should be administered intramuscular and should be administered soon after birth but may be delayed until after the first breastfeed to promote feeding and bonding. It prevents hemorrhage in the neonate in the first week of life before the body begins to make its own stores of vitamin K. Side effects include pain, edema, and erythema at the injection site, as well as hemolysis, jaundice, and hyperbilirubinemia in preterm infants. Hepatitis B vaccine is given in 3 doses to protect against the hepatitis B virus. Rash, fever, edema, pain, and erythema at the injection sites are common side effects. Parental consent is required to administer this vaccine before discharge, and it is administered via an intramuscular injection in the vastus lateralis.

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Rationale:

The nurse is responsible for monitoring neonatal glucose levels and ensuring interventions are appropriate to prevent hypoglycemia in neonates at risk for hypoglycemia. It is suggested that the neonatal glucose level remains above 40-45 mg/dL. This is achieved through frequent, adequate feeds and maintaining appropriate thermoregulation. Normal neonatal temperature range is from 36.5-37.5° C. Inadequate thermoregulation through skin-to-skin contact or swaddling increases the risk for hypoglycemia as a result of increased metabolic demand. It is essential that the parents understand the importance of thermoregulation and practice safe care. Evidence shows that preventing separation of mother and infant helps prevent hypoglycemia, especially when the neonate is placed skin-to-skin. This assists with thermoregulation as well as euglycemia. The neonate should remain at the bedside with the mother whenever possible, and trips to the nursery should be discouraged unless necessary for stability or procedures. Meconium is very thick and sticky and can be difficult to remove from the skin. The nurse would instruct the parents on proper techniques for diaper changing; however, this would not help promote normoglycemia in the neonate. Breastfed infants should have at least three stools every 24 hours, but this would not help promote normoglycemia in the neonate.