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1
Exam 2 Class 2
Assessment of a New Born

First Period of Reactivity

Lasts up to 30 minutes after birth
o Newborns heart rate increases to
160-180 beats/min but gradually decreases after 30
minutes
Period of decreased responsiveness lasts from 60 to 100
minutes
o After first period of reactivity, newborn either sleeps or
has a marked decrease in motor activity

Respiratory
System
Adaptations

Second Period Of Reactivity

Occurs 2 to 8 hours after birth
Lasts from 10 minutes to several hours
Tachycardia, tachypnea occur
Increased muscle tone
Improved skin color
Mucous production
Meconium passed

Physiological Adaptions to Extra-uterine life

Initiation of breathing
o Chemical factors: The activation of chemoreceptors in the carotid arteries and aorta results from
the relative state of hypoxia associated with labor. With each labor contraction there is a
temporary decrease in uterine blood flow and transplacental gas exchange, resulting in transient
fetal hypoxia and hypercarbia. Although the fetus is able to recover between contractions, there
appears to be a cumulative effect that results in progressive decline in PO 2, increased PCO2, and
lowered blood pH. Decreased levels of oxygen and increased levels of carbon dioxide seem to have
a cumulative effect that is involved in initiating neonatal breathing by stimulating the respiratory
center in the medulla
o

Mechanical factors: Respirations in the newborn can be stimulated by changes in intrathoracic

pressure resulting from compression of the chest during vaginal birth. As the infant passes through
the birth canal, the chest is compressed. With birth this pressure on the chest is released, and the
negative intrathoracic pressure helps draw air into the lungs. Crying increases the distribution of
air in the lungs and promotes expansion of the alveoli. The positive pressure created by crying
helps keep the alveoli open.

Thermal factors: With birth the newborn enters the extrauterine environment, in which the
temperature is significantly lower. The profound change in environmental temperature stimulates
receptors in the skin, resulting in stimulation of the respiratory center in the medulla.

Sensory factors: Sensory stimulation occurs in a variety of ways with birth. Some of these include
handling the infant by the physician or nurse-midwife, suctioning the mouth and nose, and drying
by the nurses. Pain associated with birth also can be a factor. The lights, sounds, and smells of the
new environment also can be involved in stimulation of the respiratory center.
Signs of respiratory distress

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Respiratory
Distress

Cardiovascular
Adaptations

Signs of Respiratory Distress: nasal flaring, intercostal or subcostal retractions (in-drawing of

tissue between the ribs or below the rib cage), or grunting with respirations
o Suprasternal or subclavicular retractions with stridor or gasping most often represent an upper
airway obstruction
A respiratory rate of less than 30 or greater than 60 breaths/minute with the infant at rest must be
evaluated. The respiratory rate of the infant can be slowed, depressed, or absent as a result of the
effects of analgesics or anesthetics administered to the mother during labor and birth
Acrocyanosis: the bluish discoloration of hands and feet, is a normal finding in the first 24 hours
after birth. Transient periods of duskiness while crying are common immediately after birth; however,
central cyanosis is abnormal and signifies hypoxemia. With central cyanosis the lips and mucous
membranes are bluish.

Soon after birth cardiac output nearly doubles and blood flow increases to the lungs, heart, kidney,
and gastrointestinal (GI) tract
In utero fetal Po2 is 20 to 30 mm Hg. After birth, when the Po 2 level in the arterial blood approximates
50 mm Hg, the ductus arteriosus constricts in response to increased oxygenation.
o Heart rate and sounds:
The heart rate for a term newborn ranges from 110 to 160 beats/minute, with brief fluctuations
greater and less than these values usually noted during sleeping and waking states.
The range of the heart rate in the term infant is about 85 to 100 beats/minute during deep
sleep and can increase to 180 beats/min or higher when the infant cries.
A heart rate that is either high (more than 160 beats/minute) or low (fewer than 100
beats/minute) should be reevaluated within 30 minutes to 1 hour or when the activity of the
infant changes.
o Blood pressure:
Vary with gestational age, weight, state of alertness, and cuff size. The term newborn infants
average systolic BP is 60 to 80 mm Hg, and average diastolic BP is 40 to 50 mm Hg. The mean
arterial pressure (MAP) should be equivalent to the weeks of gestation.
Not usually measured unless complication
o Blood volume:
Blood volume in the term newborn averages 85 ml/kg of body weight.
Immediately after birth the total blood volume averages 300 ml, but this volume can increase
by as much as 100 ml, depending on the length of time to cord clamping and cutting.

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Signs of Cardiac
Distress

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Close monitoring of the infants vital signs is important in detecting impending problems early.
Persistent tachycardia (more than 160 beats/minute) can be associated with anemia, hypo-volemia,
hyperthermia, or sepsis.
Persistent bradycardia (less than 100 beats/minute) can be a sign of a congenital heart block or
hypoxemia.
The newborns skin color can reflect cardiovascular problems.
o Pallor in the immediate post birth period is often a sign of underlying problems such as anemia
or marked peripheral vasoconstriction as a result of intra-partum asphyxia or sepsis.
o Any prolonged cyanosis other than in the hands or feet can indicate respiratory and/or cardiac
problems.
o The presence of jaundice can indicate ABO or Rh factor incompatibility problems

Hematopoietic
system

Thermogenic
System
Adaptations
Next to
respirations and
adequate
circulation heat
regulation is most

Red blood cells: More needed because fetal circulation is less efficient
o Newborn RBC count 4.6-5.2
o Hgb 14-24
o Hct 51-56%
Leukocytes
o High right after birth and first day but decreases rapidly
o Infection may not produce increase in WBCs
Platelets
o Same as adults
Blood groups
Thermoregulation
Skin to skin: important for bonding and thermoregulation
Heat loss: the goal of care is to provide a neutral thermal environment for the neonate which heat
balance is maintained
o Convection: flow of heat from the body surface to cooler ambient air. Because of heat loss by
convection, the ambient temperature in the nursery is kept at approximately 24 C (75.2 F), and
newborns in open bassinets are wrapped to protect them from the cold. A cap may be worn to
decrease heat loss from the infants head.
o Radiation: loss of heat from the body surface to a cooler solid surface not in direct contact but in
relative proximity. To prevent this type of loss, cribs and examining tables are placed away from
outside windows, and care is taken to avoid direct air drafts.

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critical to newborn
survival

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o
o
o

Evaporation: heat loss by evaporation occurs as a result of moisture vaporization from the skin.
Heat loss is intensified by failing to dry the newborn directly after birth or by drying the infant too
slowly after a bath. The less mature the newborn, the more severe the evaporative heat loss.
Conduction: loss of heat from the body surface to cooler surfaces in direct contact. During the
initial assessment, the newborn is placed on a pre-warmed bed under a radiant warmer to
minimize heat loss.
Hyperthermia: must be corrected. A body temperature greater than 37.5 C (99.5 F) is considered
to be abnormally high and is typically caused by excess heat production related to sepsis or a
decrease in heat loss.

Cold Stress

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Renal System
Adaptations

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Gastrointestinal
Adaptations

Hepatic system
Adaptations

An infant should void within 24 hours of life

98% of infants void within 30 hours of life
If a newborn has not voided within 48 hours of life it may indicate a renal impairment
During the first few days term infants generally excrete 15 to 60 ml/kg/day; output gradually
increases over the first month
The frequency of voiding varies from 2 to 6 times per day during the first and second days of life and
increases during the subsequent 24 hours. After day 4, approximately 6 to 8 voids per day of pale
straw-colored urine indicate adequate fluid intake.
The ability to concentrate urine fully is attained by about 3 months of age.
Digestion
Stools
o Meconium:
The infants first stool is composed of amniotic fluid and its constituents, intestinal
secretions, shed mucosal cells, and possibly blood (ingested maternal blood or minor
bleeding of alimentary tract vessels).
Passage of meconium should occur within the first 24 to 48 hours, although it can be
delayed up to 7 days in very low birth weight. The passage of meconium can occur in
utero and can be a sign of fetal distress.
o Transitional Stools
Usually appear by third day after initiation of feeding
Greenish brown to yellowish brown; thin and less sticky than meconium; can contain
some milk curd.
o Milk Stool
Usually appears by the fourth day
Breastfed infants: Stools yellow to golden, pasty in consistency; resemble a mixture of
mustard and cottage cheese, with an odor similar to sour milk
Formula-fed infants: Stools pale yellow to light brown, firmer consistency, with a more
offensive odor
Feeding behaviors

The liver and gallbladder are formed by the fourth week of gestation. In the newborn the liver can be
palpated about 1 to 2 cm below the right costal margin because it is enlarged and occupies about
40% of the abdominal cavity.
The fetal liver, which serves as the site for production of hemoglobin after birth, begins storing iron in
utero.
o The infants iron store is proportional to total body hemoglobin content and length of gestation.

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Carbohydrate
Metabolism

Conjugation of
Bilirubin and
types new born
jaundice
Jaundice is
associated with
breastfeeding
Immune system
Adaptation

o At birth the term infant has an iron store sufficient to last 4 to 6 months.
Coagulation: The liver plays an important role in blood coagulation. Coagulation factors, which are
synthesized in the liver, are activated by vitamin K.
o The lack of intestinal bacteria needed to synthesize vitamin K results in transient blood
coagulation deficiency between the second and fifth days of life.
o The levels of coagulation factors slowly increase to reach adult levels by the age of 9 months.
The administration of intramuscular vitamin K shortly after birth helps prevent bleeding
problems.
In utero the glucose concentration in the umbilical vein is approximately 80% of the maternal level.
Glucose levels reach a low point between 30 and 90 minutes after birth and then rise gradually. In
most healthy term newborns blood glucose levels stabilize at 50 to 60 mg/dl during the first several
hours after birth. Within the first week they should be approximately 60 to 80 mg/dl
In general blood glucose levels less than 40 mg/dl are considered abnormal and warrant intervention.
The hypoglycemic infant can display the classic symptoms of jitteriness, lethargy, apnea, feeding
problems, or seizures; or the infant can be asymptomatic.

Conjugation of bilirubin
Physiologic jaundice
Results from breakdown of
Appears after 24 hours of
RBCs
life
Hyperbilirubinemia
Resolves without
Liver conjugates bilirubin
Unconjugated cannot be
excreted
Excreted through feces
At birth mostly IgG antibodies transported from placenta
Breast milk provides important immunity
Risk for infection
May be hypothermic with infection

Pathologic jaundice
Blood group incompatibility is
most common cause
May appear before 24 hours
Neurotoxicity can occur from
bilirubin in brain cells
Kernicterus