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Newborn

44

2. Heatisgeneratedimmediatelybyshivering;infant

shivering ischaracterizedbyincreasedmuscular

activity,restlessness,andcrying.

3. Metabolismofbrownfat(brownadiposetissue)

functionstoproduceheatunderthestressof

cooling.

4. Effectofchillingontheneonate.

a. Increasedheatproductionleadstoincreased

oxygenconsumption,whichleadestoincreased

metabolismofglucoseandbrownfat.

b. W henheatproductionishigh,caloricneedis

high.

c. Tendencytodevelopmetabolicacidosisoccurs.

d. Productionofsurfactantisinhibitedbycooling,

andrespiratorydistresssynd romemayoccur.

e. Increasedriskwithsmallerneonates.

D. Length.

1. Averagelengthoftermneonate:45to55cm(18to

22inches).

2. Infantismeasuredbybeingplacedatontheback

onpaperanddeterminingthedistancefromheadto

heel;apencilisusedtomarkthelocationsofhead

andheels,andthedistancebetweenlocationsis

measuredwhentheinfantisremoved.

E. Weight. 1. Averagebirthweightforatermneonate:3400gm

(7lb8oz).

2. Weightloss:between5%and10%ofbirthweight

withintherstfewdaysoflife;infantusuallyre-

gainsweightwithin10to14days.

F. Head.

1. Molding.

a. Headmayappearelongatedatbirth;molding

usuallydisappearswithin24to48hours.

b. Occursasaresultofabnormalfetalposturein

uteroandpressuredu ringpassageth roughthe

birthcanal.

2. Caputsuccedaneum(Figure21-1). a. Edemaofthescalpcausedbythepressureoc-

curringatthetimeofdelivery.

b. Disappearswithin3to4days.

c. Edemagoesacrossthecranialsuturelines.

3. Cephalhematoma.

a. Acollectionofbloodbetweentheperiosteum

andtheskull.

b. Usuallyresultsfromtraumadu ringlaborand

delivery.

NORMAL NEWBORN

Biological Adaptations in theNeonatal Period

Data Collection

A. Respiratorysystem.

1. Respirationsareusuallyestablishedwithin1minute

afterbirth,oftenwithintherstfewseconds.

2. Lustycryusuallyaccompaniesgoodrespiratory

effort.

3. Newbornrespirationshouldbequiet;nodyspneaor cyanosis.

4. Cyanosismaybeapparentinthehandsandfeet

(acrocyanosis);circumoralcyanosis(aroundthe

mouth)maypersistforanhourortwoafterbirthbut

shouldsubside.

5. Averagerespiratoryrate:30to60breaths/min.

6. Respirator ymovements:Diaphragmaticand

abdominalmusclesareused;verylit tlethoracic

movement.

7. Neonatebreathesthroughthenose(obligatenose-

breather);consequently,nasalobstructionwith

mucuswillleadtorespiratorydistress.

B. Circulatorysystem.

1. Closureoftheductusarteriosus,theforamenovale,

andtheductusvenosus.

2. Circulatorychangesarenotalwaysimmediateand

complete:usuallycompleteinafewdays;oftenthis

periodiscalledtransitional circulation.

3. Pulserate:100-160beats/min.

4. NormalBPissystolic60-80mmHganddiastolic

40-50mmHgmeasuredusingDopplerultrasonog-

raphy–needcorrectlysizedcuff.

C. Bodytemperatureandheatproduction.

1. Bodytemperaturemaydropto94°F(34.4°C)or

evenaslowas92°F(33.3°C)afterbirthunlessthe infantisadequatelyprotected.

NURSING PRIORITY: Excessive heat loss occurs

from radiation and convection because of the newborn’s

larger surface area as compared with body weight. It

is important to remember that conduction loss occurs

as a result of the marked difference between core body

temperature and skin temperature.

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444 CHAPTER 21 Newborn

c. Absorbedinafewweeks;doesnotcrosscranial

suturelines.

4. Headmeasurement.

a. Averageheadcircumferenceofthetermneo-

nate:34.2cm;usualvariationrangesfrom33to

35cm(13to14inches).

b. Headcircumferenceisapproximately2to3cm

greaterthanthechestcircumference;extremes

insizemayindicatemicrocephaly,hydrocephaly,

orincreasedintracranialpressure.

TEST ALERT: Compare physical development

of newborn with identied norms

5. Fontanels(anteriorandposterior).

a. Palpateforsizeandtension.

b. Increaseintensionmayindicatetumor,hemor-

rhage,infection,orcongenitalanomaly.

c. Decreaseintension(sunkenfontanel)may

indicatedehydration.

d. Anteriorwillcloseinabout12to18months;

poster iorwillclosein2to3months.

G. Umbilicalcord.

1. Determinenumberofbloodvessels;thereshouldbe

twoarteriesandoneveinsurroundedbyWharton’s jelly.

2. Cordatrophiesandsloughsoffbyday10to14.

H. Nervoussystem.

1. Nervoussystemisrelativelyimmatureandcharac-

terizedbythefollowing:

a. Poornervouscontrol;easilystartled.

b. Quiveringchin.

c. Tremorsofthelowerextremitiesofshort

duration.

d. Sleepandawakestates.

(1) Newbornsleepsanaverageof16to20

hoursadaydur ingtherst2weeksoflife,

withanaverageof4hoursatatime.

(2) Mayvaryfromadrowsyorsemi-dozing

statetoanalertstatetoacryingstate.

2. PresenceofpositiveBabinskisign.

a. Normalndinguntiltheageof1year.

b. Dorsiexionofbigtoeandfanningoftheother toes.

3. Neonatalreexes(Table21-1).

NURSING PRIORITY: Intactness of the neonate’s

nervous system is indicated by the state of alertness,

resting posture, cry, and quality of muscle tone and motor

activity.

I. Hematologicalsystem.

1. Physiological jaundice;increasedincidencein

breast-fedinfants;occursonthesecondorthirdday

oflifeasaresultofanincreaseintheserumbiliru- binlevel.

2. Pathological jaundiceoccurswithin24hoursof

birth(seehemolyticdiseaseofthenewborn).

3. Transitorycoagulationdefects.

a. Resultfromthelackofintestinalsynthesisof

vitaminKbecauseofinsufcientbacterialora

intheGItract.

b. VitaminK(0.5to1.0mg)isadministered

intramuscularlyinthevastuslateralistoprevent

complications.

J. GItract.

1. Stools.

NURSING PRIORITY: Monitor the passage of the

rst meconium stool.

a. Meconium:sticky,black,odorless,sterilestool

thatispassedwithintherst24to48hoursafter

birth;ifnostoolispassed,furtherassessmentis

needed.

b. Stoolschangeaccordingtotypeandamountof

feedings.

(1) Transitionalstools:occursduringperiod

betweensecondandfourthday;consistof

meconiumandmilk;greenishbrownor greenishyellow;looseandoftencontain

mucus.

(2) Milkstools:usuallyoccurbythefou rthday

stoolsofformula-fedinfantaredrier,more

for med,paler,andoccuronceort wicedaily

or1stoolevery2-3days

(3) Stoolsofbreast-fedinfantsaregoldenyel-

low,haveapastyconsistency,andoccur

morefrequentlythanstoolsofformula-fed

infants,3-4stoolsin24hours.

✔

✔

FIGURE 26-1 Caput succedaneum. (From Zerwekh J, Claborn J:Memory notebook of nursing , vol 2, ed 3, Ingram, Tex, 2007, NursingEducation Consultants.)



CHAPTER 21 Newborn 445

TABLE 21-1 MAJOR NEONATAL REFLEXES

Reex Disappears How to Elicit Response

Rooting

Babinski

Sucking

Moro(startle)

GraspPalmar

Asymmetrictonicneck

(fencer’sposition)

3to4mo;maypersist

duringsleepuntil7to8mo

1yr

10to12mo

3to4mo

3to4mo

3to4mo

Strokecheek.

Lightlystrokelateralsideoffoot

fromheeltotoeacrossthefoot.

Touchorstrokelips.

Makealoudnoiseorsuddenly

disturbinfant’sequilibrium.

Pressangeragainstinfant’spalm.

Turnsupineinfant’sheadovertheshouldertooneside.

Headturnstowardsidethatis

touched.

Infant’stoesfan,with

dorsiexionofgreattoe.

Infantsucks.

Infantstiffens,brisklyabducts,

andextendsarmswithhands

openandngersextendedto

Cshape.Infant’slegsexand

abduct,andarmsreturntoan

embracingposture.Cryingis

usual.

Infant’sngersmomentarily

closearoundobject.

Infant’sarmandlegpartially

orcompletelyextendonsideto

whichheadisturned;opposite

armandlegex.

K. Genitourinarysystem.

1. Thirtyto60millilitersisvoidedperdayduringthe

rst2daysoflife;followedby200mlperdayby

theendoftherstweek.

2. Frequencyofvoiding:averageoftwotosixtimes

perday,increasingupto10to15timesperday.

NURSING PRIORITY: Most newborns void within

the rst 24 to 48 hours after birth. Weigh dry diaper before

applying, then weigh wet diaper after infant voiding. Each

gram of added weight equals 1ml of urine.

L. Integumentarysystem.

1. Vernixcaseosa:awhitecheesy-likematerialcovers

theskinatbirth,particularlynotedinthefoldsand

creases.

2. Petechiae:pinpointbluishdiscolorationsprimarily

ontheskinandfaceasaresultofpressurefromde- livery;bruisingoftissuesmaybeseen.

3. Lanugo:downy,necoveringofhairthatmaybe

presentontheshoulders,back,earlobes,and

forehead;disappearsduringtherstweek.

4. Milia:pinpointwhitebumpsseenoverthebridgeof

thenoseandonthecheeksduringtherst2weeks

oflife.

5. Erythematoxicum:splotchypinkpapularrashap-

pearinganywhereonthebody;disappearswithin

therstfewdaysoflife;notreatmentisnecessary.

✔

6. Mongolianspots:bluishdarkenedpigmentedareas

seenonthebackorbuttocksofdark-skinnedinfants

(AfricanAmericanandAsianAmericaninfantsand

thoseofMediterraneandescent);usuallydisappears

byschoolage.

M. Sensorysystem. 1. Eyesappearlarge,andpupilsappearsmall.

2. Tearsdonotdevelopuntil2to4weeksofage.

3. Suddenloudnoisesmayelicitstartleresponse.

4. Differentiatesbetweenpleasantandunpleasant

tastes.

5. Mostsensitiveareaisaroundthemouth.

6. Searchesforfoodwhencheekistouchedorbegins

suckingmovementwhenlipsaretouched.

O. Musculoskeletalsystem.

1. Assumesthepositionofcomfort,whichisusually

thepositionassumedinutero.

2. Normalpalmarcreaseispresent(simiancreaseisin

dicativeofDownsyndrome). 3. Spineisstraightandatwheninproneposition.

Nursing Intervention

TEST ALERT: Provide physical care for a

newborn.

v Goal: Toestablishand maintaina patentairway and

promoteoxygenation.




A. Positioninfantwithheadslightlylowerthanchest;

mayuseposturaldrainageorside-lyingposition.

B. Suctionnostrilsandoropharynxwithbulbsyringe.

C. Observe for apnea, cyanosis, and mucus collection and

if noted report to RN.

NURSING PRIORITY: During rst 4 hours

after birth, the priority nursing goals are to maintain a

clear airway, maintain a neutral thermal environment,

and prevent hemorrhage and infection. Bathing will be

initiated when infant’s temperature is stabilized; feeding

may begin immediately if infant is interested.

v Goal:Toprotectagainstheatloss.

A. Immediatelyafterbirth,wrapinfantinwarmblanket

anddryoffamnioticuid.

B. Replacewetblanketwithwarmdryblanket.

C. Coverwethairandheadwithablanketorcap.

D. Giveinfanttomothertocuddle;placeinfantonawarm

paddedsurface,preferablyunderaradiantheateror inanincubator;orprovideforskin-to-skincontactwith

themother.

v Goal:Tocollectdataandassessphysicalconditionand

behavior.

A. DetermineApgarscoreat1minuteandagainat5min-

utes(seeTable20-7forApgarscoring).

NURSING PRIORITY: The APGAR score at 1

minute evaluates the neonate’s intrauterine oxygenation;

at 5 minutes it evaluates the status of the neonate’s

cardiorespiratory adaptation after birth.

B. Monitorvitalsignsevery15minutesto1houruntil

infant’stemperaturestabilizes(usuallyinabout4

hours)andrecordincubatortemperature.

C. Weighandmeasureinfant.

1. Infantismeasuredbybeingplacedatontheback

anddeterminingthedistancefromheadtoheelby

usingapenciltomarkthedistanceandthen

measuringthedistancewhentheinfantisremoved.

v Goal: Toassessperiodsofreactivity.

A. Firstperiodofreactivity-newbornisalert,awake,and

usuallyhungry.

B. Sleepphase-stsleepusuallyoccursanaverageof3to 4hoursafterbirthandmaylastfromafewminutes

toseveralhours.

1. Newbornisdifculttoawakenduringthisphase.

C. Secondperiodofreactivity.

1. Infantisalertandawake.

2. Lastsapproximately4to6hours.

NURSING PRIORITY: It is important to monitor

the infant closely because apnea, decreased heart rate,

gagging, choking, and regurgitation may occur and

require nursing intervention.

✔

✔

✔

v Goal: Toprotectagainstinfection.

A. Followguidelinesforproperhandwashingbeforehan-

dlinginfant.

B. Preventophthalmianeonatorum.

1. Administerprophylactictreatmenttoeyessoon

afterbirth.

2. Placeophthalmicointmentinthelowerconjunctiva

sac.C. Avoidexposuretopeoplewithpossibleupperrespira-

torytract,skin,orGIinfections.

D. HepatitisBvaccinationrecommendedatbirthand

routineHIVscreening.

v Goal:Topreventbleedingproblems(hypobrinogen-

emia).

A. Administer0.5to1.0mgofvitaminK,intramuscularly

intotheupperthirdofthelateralaspectofthethigh

(vastuslateralis).

v Goal:Toproperlyidentifyinfant.

A. Secureidenticationbandstowristorankleofinfant

andwristofmotherinthedeliveryroom.

B. Printsofinfant’sfoot,palms,orngersmaybe obtainedaccordingtohospitalpolicy;mother’spalm

printsorngerprintsmayalsobeobtained.

C. Adviseparentsnottoreleasetheinfanttoanyonewho

doesnothaveproperunitidentication.

TEST ALERT: Promote newborn and family

bonding.

v Goal:Toinitiatefeedingandtoevaluateparents’

abilitytofeedinfantandprovidenutrition.

A. Encouragebreastfeeding,ifdesired,immediatelyafter

deliveryorinrecoveryarea;breastmilkisbacteriologi

callysafe.

B. Firstformulafeedingortestfeeding:administer10to

15mlofsterilewatertoassistGItractpatencyfollowed

byformula.

C. Considerationsininfantfeeding.

1. Aninfantshouldalwaysbeplacedontherightside

afterfeedingtoavoidaspirationandpreventregur-

gitationanddistention.

2. Infantwillrequiremorefrequentfeedingsinitially;

willgenerallyestablisharoutineoffeedingevery3

to4hours.

v Goal:Toprovidedailygeneralcare.A. Careoftheumbilicalcordstump.

1. Hospitalprotocoldirectsroutinecordcare,which

mayincludeusingadryingsolutionofalcoholand

tripledyethatisappliedtothecord.

2. Cleantheumbilicalcordstumpseveraltimesaday

withsoapandwater,especiallyafterinfantvoids

(foramaleinfant).

3. Toencouragedryingofthecord,exposeumbilical

areatoairfrequentlyandposit iondiaperbelow

umbilicus.

4. Observeforbleeding,oozing,orfoulodor.




B. Circumcisioncare.

1. Keepareaclean;changediaperfrequently.

2. Observeforbleeding–checksitehourlyfor12

hourspostprocedure.

3. Asmallsterilepetrolatumgauzedressingmaybe

appliedtotheareaduringtherst2to3days

(GomcoandMogenclamp).

4. IfaPlastiBellwasused,keepareaclean;application ofpetrolatumjellyisnotnecessary;plasticringwill

dislodgewhenareahashealed(5-7days).

NURSING PRIORITY: Teach the parents that a

whitish-yellow exudate around the glans is granulation

tissue and is normal and not indicative of infection. It may

be observed for 2 to 3 days and should not be removed.

C. Neonate’sbath.

1. Bathisdelayeduntilvitalsignsandtemperature

stabilize.

2. Warmwaterisusedfortherst4days;donotim-

merseinfantinwateruntilumbilicalcordstumphas

beenreleased.

3. Whenbathingneonate,applyprinciplesofclean-

to-dirtyareas;washareasinthefollowingorder:

eyes,face,ears,head,body,genitals,buttocks.

4. Headisanareaofsignicantheatloss;keepit

covered.

D. Determineweightlossoverrst24hoursafterbirth

–monitorwetdiapers.

E. Assessstools.

1. Meconiumstools.

2. Transitionalstools.

v Goal:Todetectcomplicationsandprovideearlytreat-ment.

A. Newbornscreeningtestafterrst24hoursforaformu-

la-fedinfantorneonate;ifmotherisbreast-feeding,

explainimportanceofreturningwheninfantis1week

oldtoobtainbloodsample;newbornsarescreenedfor

thefollowingdisorders:galactosemia,hypothyroidism,

andsicklecellanemia.

B. AdministrationofrsthepatitisBvaccinebeforedis-

charge;also,hepatitisBimmuneglobulinisgiven

intramuscularly,ifmotherisahepatitisBcarrier.

1. Encouragefollow-upvisitsforsecondandthird

dosesofhepatitisBvaccineandotherimmuniza-

tions.

NURSING PRIORITY: Explain to parents the

importance of returning for a well-baby check when the

infant is 2 to 4 weeks old.

v Goal:Topromoteinfantfeeding.

B. Breast-feeding.

1. Firstfeedingshouldoccurimmediatelyorwithina

fewhoursafterbirth.

✔

✔

2. Frequentfeedingsareimportantinitiallytoestab-

lishmilkproduction,oftenevery1½to2hours.

C. Bottle-feeding.

1. Itisnotnecessarytosterilizethewaterusedtore-

constituteinfant’sfor mula.

2. Theinfantshouldbeplacedinasemi-uprightposi-

tionforfeeding.

3. Neverpropthebottle,andalwaysholdtheinfant. 4. Donotwarmbottlesoranyfoodforinfantsinthe

microwave.

NURSING PRIORITY: Proportions of formula must

not be altered, teach mother to not dilute or expand the

amount of formula or concentrate it to provide more

calories.

HOME CARE

v Goal:Toteachabouthomephototherapyformildto

moderatejaundice.

1. Placenudeinfantunderbili-lights,exposingall

areastothelightexceptforeyesandgenitalia;cove

infant’seyeswithanopaquemaskoreyepatchand

covergenitaliawithadiaperoradisposableface

mask(stringbikinitoexposemoreskin).

a. Reposit ioninfantevery2hourstoexposeas

muchbodysurfaceaspossible.

b.Chartpertinentinformationrelatingtotime

phototherapywasstar tedandstopped,mainte-

nanceofshieldingoftheeyesfrombili-light,

typeandintensityoflampused,distanceoflight

frominfant,whetherusedincombinationwith anisoletteoranopenbassinet,andanyside

effects.

NURSING PRIORITY: If a face mask is used to

cover genitalia, remove the metal nose strip to prevent

burning the infant. If a beroptic blanket is used, infant’s

eyes do not need to be covered;

2. Ifaberopticblanketisused,shouldhaveacover-

ingpadbetweentheinfant’sskinandtheberoptic

blanket;withthismethod,theinfantmayremainin

theroomwiththemother.

HIGH-RISK NEWBORN

Gestational Age Variation

Data Collection

A. Respiratoryparameters.

1. Observerespiratoryrate,rhythm,anddepth.

a. Initially,rateincreaseswithoutachangein

rhythm.

✔

✔




b. Flaringofnaresandexpirator ygr untingare

earlysignsofrespiratorydistress.

2. Increaseinapicalpulserate.

3. Subcostalandxiphoidretractionsprogresstointer-

costal,substernal,andclavicularretractions.

4. Color.

a. Progressesfrompinktocircumoralpallortocir-

cumoralcyanosistogeneralizedcyanosis. b. Increasedintensityofacrocyanosis.

5. Progressiverespiratorydistress.

a. Chintug(chinpulleddownandinwithmouth

openingwider—auxiliarymusclesofrespiration

areused).

b. Abdominalseesawbreathingpatterns.

c. Distinguishbetweenapneicepisodes(15seconds

orlonger)andirregularbreathing(cessationof

breathingfor5to10seconds).

6. Fallingbodytemperature.

7. Progressinganoxialeadingtocardiacdecompensa-

tionandfailure.

8. Increasedmuscleaccidity:frog-likeposition.D. Nutrition.

1. Assessreadinessandabilitytofeed:swallowing,

gagreexes.

2. Screenforhypoglycemia.

3. Observeforcongenitaldysfunctionandanomalies

relatedtotracheoesophagealstula,analatresia,

andmetabolicdisorders.

4. Checkamountandfrequencyofelimination.

5. Assessforvomitingorregurgitation;apretermin-

fant’sstomachcapacityissmall,andoverfeeding

canoccur.

6. Checkmucousmembranes,urineoutput,andskin

turgortoidentifyuidandelectrolyteimbalances.

a. Skinturgoroverabdomenandinnerthighs.

b. Sunkenfontanel.

c. Urinaryoutputoflessthan30ml/day.

E. Temperatureregulation.

1. Assessinfant’stemperature:frequentlydonewith

askinprobeforcontinuousmonitoringoftempera-

tureininfantsathighriskforcomplications.

2. Checkcoolnessorwarmthofbodyandextremities.

3. Detectearlysignsofcoldstress.

a. Increasedphysicalactivityandcrying.

b. Increasedrespiratoryrate.

c. Increasedacrocyanosisorgeneralizedcyanosis alongwithmottlingoftheskin(cutis

marmorata).

d. Malewithdescendedtestes:presenceofcremas-

tericreex(testesarepulledbackupintothe

inguinalcanalonexposuretocold).

4. Monitorinfant’stemperature.

a. Axillarytemperature:36.5°C(97.7°F).

b. Placeatemperatureskinprobeoninfantwhile

heorsheisintheradiantwarmerorisolette.

Nursing Interventionfor the High-Risk Newborn

Disorders Acquired During and After Birth(Table 21-2)

v Goal:Tomaintainrespiratoryfunctioning.

A. Providegentlephysicalstimulationtoremindinfantto

breathe.

1. Gentlyrubtheinfant’sback.

2. Lightlytaptheinfant’sfeet.

B. Ensurepatencyofrespiratorytract.

1. Maintainopenairwaybymeansofnasal,oral,or

pharyngealsuctioning.

2. Positiontopromoteoxygenation.

a. Elevatehead10degreeswithneckslightlyex-

tendedbyplacementofasmallfoldedtowel

undertheshoulders.

b. Flexandabductinfant’sarmsandplaceatsides.

c. Avoiddiapersoradherethemloosely.

d. Turnsidetosideevery1to2hours. e. Donotplaceinproneposit ion.

C. Assistinfant’srespiratoryefforts.

1. Monitoroxygenpressure.

a. Avoidhighconcentrationsofoxygenforpro-

longedperiods:leadstocomplicationsof

bronchopulmonarydysplasia.

2. Continuouspositiveairwaypressure(CPAP)coun-

teractsthetendencyofthealveolitocollapseby

providingcontinuousdistendingairwaypressure

andisadministeredeitherbyendotrachealtube

ornasalprongs.

v Goal:Toprovideadequatenutrition.

A. Detecthypoglycemiaandtreatimmediately:Adminis- ter5%dextroseinwaterintravenouslyifinfantis

unabletotolerateoralfeeding.

B. Oralfeeding:initialfeeding.

1. Usesterilewater:1to2mlforasmallinfant.

2. Usepreemienippletoconserveinfant’senergy.

3. Becauseofsmallsizeofinfant’sstomach,feedings

aresmallinamountandincreasedinfrequency.

C. Orogastrictubefeedings.

1. Usuallyadministeredbycontinuousowofformula

withaninfusionpump(kangaroopump)whenthe

infantis:

a. Havingsevererespiratorydistress.

b. Tooimmat ureandweaktosuck. c. Tiredandfatigueseasilywhenapreemienipple

isused.

2. Placementandinsertionoforogastricfeedingtube.

a. Positioninfantonthebackortowardtheright

sidewiththeheadandchestslightlyelevated.

b. Measurecorrectlengthofinsertionbymarking

onthecatheterthedistancefromthet ipofthe

nosetotheearlobetothet ipofthesternum.

c. Lubricatet ubewithsterilewaterandslowly




1. Weakorabsentsuckingandswallowingreexes.

2. Necessityofhighcaloriccontentwithaverysmall

stomachcapacity.

3. Poorgagreex,leadingtoaspiration.

4. Increasedincidenceofvomitinganddevelopmento

abdominaldistention.

5. Inabilitytoabsorbessentialnutrients.

6. Excessivelossofwaterthroughevaporationfrom theskinandrespirator yt ract.

v Goal:Tomaintainwarmthandtemperaturecontrol

(seemaintainingtemperatureofnormalnewborn).

A. Oxygenandairshouldbewarmedandhumidied.

B. Maintainabdominalskintemperatureat36.1°to36.7°

C(97°to98°F);axillarytemperature36.5°C(97.8°F)

C. Monitorinfant’stemperaturecontinuously;makesure

thattemperatureprobeissetoncontrolpanel,probeis

incontactwithinfant’sskin,andallsafetyprecautions

aremaintained.

D. Preventrapidwarmingorcooling;warmingprocessis

increasedgraduallyoveraperiodof2to4hours.

E. Infantmayneedextraclothingorneedtobewrappedin anextrablanketforadditionalwarmth.

insertcatheterintomouthanddownthe

esophagusintothestomach.

d. Testforplacementofthet ubebyaspirating

stomachcontentsorinjecting0.5to1.0ccof

airfortheprematureinfant(upto5ccforlarger

infants)andauscultatingtheabdomenforthe

sound.

e. Beforeinfusingafeedingbygravityinto stomach,checkforresidual;thisisdonebyaspi-

ratingandmeasuringamountleftinstomach

frompreviousfeeding;often,theresidual

amountissubtractedfromthecurrentfeedingso

thatoverfeedingdoesnotoccur.

f. Iffeedingisnotcontinuous,removetubingby

pinchingorclampingitandwithdrawingit

rapidly.

g. Burpinfantafterfeedingbyturningheadorpo-

sitioninghimorherontherightside.

D. Hyperalimentation(totalparenteralnutrition)maybe

orderedtoprovidecompletenutritionthroughan

indwellingcatheterthreadedintothevenacava.E. Detectcomplicationsthatarisewithfeedingthepre-

terminfantasaresultof:

TABLE 21-2 DISORDERS ACQUIRED DURING AND AFTER BIRTH

Trauma Peripheral Nerve Injuries Neonatal Sepsis

Assessment

Nursing

Interventions

Softtissueinjury.

Caputsuccedaneum.

Cephalhematoma.Injurytobone:Fracturedclavicleis

themostcommon;oftenoccurs

withalarge-sizedinfant.

1. Placeaffectedarmagainstchest

wallwithhandlyingacross

chest.2. Positionisheldbyagure-8

stockinettearoundthearmand

chest.

3. Pickinfantupcarefully;shoulder

shouldnotbepressedtoward

middleofbody.

4. Affectedsideshouldnotbe

placedingownorundershirt.

Temporaryparalysisofthefacialnerve

isthemostcommon.

Affectedsideofthefaceissmooth.Eyemaystayopen.

Mouthdroopsatthecorner.

Foreheadcannotbewrinkled.

Possibledifcultysucking.

Brachialpalsy:apartialorcomplete

paralysisofthenervebersofthe

brachialplexus.

Cannotelevateorabductthearm.

Abnormalarmpositionordiminished

armmovements.

Facialnervepalsy:

1. Applyeyepatch;mayusearticial

tearstopreventcornealirritation.2. Providesupportduringfeeding;

infantmaynotlatchontonipple

well.

Brachialnervepalsy

1. Keeparmabductedandexternally

rotatedwithelbowexed.

2. Armisraisedtoshoulderheight,

andelbowisexed90degrees.

Apathy,lethargy,low-grade

temperature.

Poorfeeding,abdominaldisten-tion,diarrhea.

Cyanosis,irregularrespirations,

apnea.

Hyperbilirubinemia.

Infantoftendescribedas“not

actingright”

CBC,chestx-raylm,andviral

studiesTORCHblood

screening.

1.Prenatalprevention,maternal

screeningforSTDs,and

assessmentofrubellatiters.2.Maintenanceofsterile

technique.

3.Prophylacticantibiotic

treatment.

4.Possiblecesareandeliveryfor

motherwithgenitalherpes.

CBC ,Completebloodcount;TORCH ,toxoplasmosis,other(congenitalsyphilisandviruses)rubella,cytomegalovirus,andherpesvirus.




Respiratory Distress

Hyaline membrane disease (HMD), also referred to as

respiratory distress syndrome (RDS), occurs as a result of

the deciency of surfactant that lines the alveoli.

Meconium aspiration syndrome occurs when the fetus

passes meconium in utero and aspirates the meconium into

the lungs, which leads to obstruction in the small airway

passages.

Data Collection

A. Tachypnea:morethan60breaths/min.

B. Apneicspells(inexcessof15seconds).

C. Abnormalbreathsounds:ralesandrhonchi.

D. Chestretraction.

E. Chintug:noticedoninspiration;mouthopen,lips

apart.

F. Flaringofthenares.

G. Expiratorygrunting.

NURSING PRIORITY: Grunting is an ominous sign

and indicates impending need for respiratory assistance;

most often, mucus needs to be cleared from airway.

Complications

A. Hypoxia,acidosiscausedbyalveolarhypoventilation.

B. Bronchopulmonarydysplasia:chronicstiff,noncompli-

antlungs.

Treatment

A. Respiratorydistresssyndrome. 1. CPAPistheprimarytreatment.

2. Administrationofsurfactantthroughtheairway

intotheinfant’slungs.

B. Meconiumaspiration.

1. Administrationofoxygenwithhumidication.

2. Posturaldrainageandpercussion;antibiotictherapy.

3. Acid-baseimbalancecorrection,ifneeded.


v Goal:Topromoteoxygenationandrespiratoryfunc-

tioning.

A. Administerasteroid(betamethasone)tomotheratleast 48hoursbeforedeliveryandadministersurfactant

toneonateafterdeliver ytostimulatesurfactant

production.

B. Refertonursinginterventionforthehigh-risknewborn.

✽

✽

✔

Cleft Lip and Cleft Palate

Cleft lip is a ssure or split in the upper lip, which

may vary from a slight notch to a complete separation

extending into the nostril; may be unilateral or bilateral.

Cleft palate is a ssure or a split in the roof of the

mouth (palate).

Data Collection

A. Visibleatbirthonanincompletelyformedlip.

B. Suckingdifcultiesandbreathingproblemswithcleft

palate.

C. Increasedincidenceofupperrespiratorytractinfection

andotitismedia.

D. Laterproblemsrelatedtospeechandhearingdifcul-

tieswithcleftpalate.

Treatment

A. Surgical:closureoflipdefectusuallyprecedestreat-

mentforacleftpalate(whichisdoneinstages).B. Long-termcaremanagement:speechtherapy,orthodon

tics;frequentoccurrencesofotitismedia.


v Goal:Toprovidepreoperativecare.

A. Maintainnutrition.

1. Usealarge-holednippleoramodiednippletoin

creaseinfant’sabilitytoobtainmilkwithout

sucking.

2. Feedslowly.

3. Bubbleandburpfrequently(afterevery15to30ml)

4. Rinsecleftwithwateraftereachfeedingtohelp preventinfection.

5. Donotplaceinfantonpillow,elevateheadofbed,

orputthepillowunderthemattress.

B. Prepareparentsfornewborn’ssurgery.

1. Encourageparentstopositioninfantatonbackor

onsidetoaccustominfanttothepostoperative

positioning.

2. Encourageparentstoplaceinfantinarmrestraints

periodicallybeforehospitaladmission,sothey

becomefamiliarwithrestrict ionofarmmotion

aftersurgery.

3. Encourageparentstofeedinfantwiththesame

methodthatwillbeusedaftersurgery.v Goal:Toprovidepostoperativecare.

A. Preventtraumatosutureline.

1. Positioninfantonbackorsideandelevatehead(in-

fantseat).

2. Restrainarmswithsoftelbowrestraints.

3. Cleansesuturelinegentlyaftereachfeeding;use

cotton-tippedapplicatorwithprescribedsolution

androllalongthesutureline;mayapplyantibiotic

ointment.

✽

✽




4. Preventanycrustorscabformationonlipandsu-

tureline.

5. Mayuseprotectivelipdevice.

B. Maintainapatentairwayandfacilitatebreathing.

1. Assessforrespiratorydistress.

2. Observeforswellingofthenose,tongue,andlips.

C. Provideadequatenutrition.

1. Feedinanupright,sittingposition. 2. Feedslowlyandburp/bubbleatfrequentintervals.

D. Providedischargeteachingtoparents.

1. Encourageparentstocuddleandplaywithinfantto

decreasecryingandpreventtraumatosutureline.

2. Teachfeeding,cleansing,andrestrainingproce-

dures.

Esophageal Atresia withTracheoesophageal Fistula

Proximal end of esophagus ends in a blind pouch and

the lower segment connects to the trachea.

Data Collection

A. Characterizedbytheclassic3Cs:choking, coughing ,

andcyanosis.

B. Excessivefrothysalivaandconstantdrooling.

C. Aspirationisacomplication,especiallyduringfeeding.


NURSING PRIORITY: When there is any

suspicion of possible esophageal problems, infant should

receive nothing by mouth (have NPO status) until further

evaluation can be done.

v Goal: Toprovidepreoperativecare.

A. Maintainpatentairway.

1. Supinepositionwithheadelevatedonaninclined

planeofatleast30degrees.

2. Suctionnasophar ynx.

3. Observeforsymptomsofrespiratorydistress.

4. MaintainNPOstat us.

B. Prepareparentsforinfant’ssurgery.

v Goal: Toprovidepostoperativecare.

A. Maintainrespirationsandpreventrespiratorycomplica-

tions.

1. Administeroxygen. 2. Oralsuctionofsecretionsandpositionforoptimum

ventilation.

3. Maintaincareofchesttubes.

4. Administerantibiotics.

5. Placeinwarm,high-humidityisolette.

6. Maintainnasogastricsuctioning.

B. Provideadequatenutrition.

1. Gastrostomyfeedingsmaybestartedonthesecond

orthirdpostoperativeday.

✽

✔

2. Oralfeedingsmaybedelayeduntil2weeksafter

surgery.

3. Meetoralsuckingneedsbyofferinginfanta

pacier.

Imperforate Anus

An imperforate anus is an absence of the ana

opening.

Data Collection

A. Absenceofmeconium.

B. Noanalopening.

C. Gradualincreaseinabdominaldistention.


v Goal: Toidentifyanalmalformation.

A. Detectincreasingabdominaldistention.

B. Inspectanalareaforopening.

NURSING PRIORITY: Record the rst passage of

meconium stool. If infant does not pass stool within 24

hours, further assessment is required.


A. Preventinfectionbymaintaininggoodperinealcare

andkeepingoperativesitecleananddry,especially

afterpassageofstoolandurine.

B. Donottaketemperaturesrectally.

C. Placeinfantinside-lyingproneposition.

D. Mayhaveacolostomy.

Neural Tube Defects

A neural tube defect (spina bida) results in midline

defects and closure of the spinal cord (may be noncystic or

cystic); most common site is lumbosacral area.

Data Collection

A. Types.

1. Spinabidaocculta–bonydefect(boneofspine

doesnotcoverspinalcord).

2. Spinabidacystica.

a. Meningocele:asac-likecystofmeningeslled

withspinaluidthatprotrudesthroughadefect

inthebonypartofthespine.

b. Myelomeningocele:asac-likecystcontaining

meninges,spinaluid,andaportionofthe

spinalcordwithitsnervesthatprotrudesthrough

adefectinthevertebralcolum n;otherdefect

mostf requentlyassociatedwiththisishydro-

cephalus.

✽

✔

✽




Treatment

A. Surgical:closureofdefectwith24to48hourstode-

creaseriskofinfection,relievepressure,repairsac,and

possiblyinsertashunt.


NURSING PRIORITY: Correct positioning of the

infant is critical in preventing damage to the sac, as well

as in providing nursing care after surgery.

v Goal: Toprovidepreoperativecare.

A. Preventandprotectsacfromdrying,rupturing,and

infection.

1. Positioninfantproneonabdomen.

2. Avoidtouchingsac.

3. Providemeticulousskincareaftervoidingand

bowelmovements.

4. Often,sterile,normalsalinesoaksonanonadherent

dressingmaybeusedtopreventdrying.B. Detectearlydevelopmentofhydrocephalus.

1. Measureheadandcheckcircumferencefrequently.

2. Checkfontanelsforbulgingandseparationofsu-

tureline.

C. Monitoreliminationfunction.

1. Notewhetherurineisdrippingorisretained.

2. Indwellingcathetermaybeinserted,intermittent

catheterizationmaybedone,orcredémethodmay

beusedatregularinter vals.

3. Assessforbowelfunction:Glycerinsuppository

maybeorderedtostimulatemeconiumpassage.


A. Preventtraumaandinfectionatthesurgicalsite.

1. Placeinfantinsameposition(proneonabdomen)as

beforesurgery.

2. Continuetoprovidescrupulousskincareasde-

scribedunderpreoperativegoals.

B. Assessneurologicalstatusfrequentlyforindications

ofincreasingintracranialpressure,developmentof

hydrocephalus,orearlysignsofinfection.

1. Continuetomeasureheadcircumferencedaily.

2. Performfrequentneurologicalchecks.

C. Provideparentswitheducationinregardtopositioning,

feeding,skincare,eliminationprocedures,andrangeof

motionexercises. 1. Encourageandfacilitateparentalbonding.

2. Refertocommunityandsocialagenciesfornan-

cialandsocialsupport.

3. Encouragelong-rangeplanningandsupportofpar-

entsforlong-termrehabilitationofinfant.

Neonatal Sepsis

An infection in the neonate can be caused by maternal

antepartal or intrapartal infection.

✔

✽

Data Collection

A. Apathy,lethargy,poortemperaturecontrol.

B. Poorfeeding,abdominaldistention,diarrhea.

C. Cyanosis,irregularrespirations,apnea.

D. Infantoftendescribedas“notactingright”;maybe

irritable


v Goal: Topreventneonatalsepsisbyprenatalprevention;

maternalscreeningforsexuallytransmitteddiseasesandas

sessmentofrubellatiters.

A. TORCH(toxoplasmosis,other[congenitalsyphilisand

viruses],rubella,cytomegalovirus,andherpessimplex

virus)syndromeisdiscussedasitrelatestotheinfant

andadultinChapter17.

Isoimmune Hemolytic Diseaseof the Newborn

An antigen-antibody response causing destruction

of fetal RBCs as a result of maternal sensitization of feta

RBC antigens and subsequent transfer of the resulting

antibodies to the fetus.

Data Collection

A. Clinicalmanifestations:ABOincompatibility.

1. Jaundiceoccursinacephalocaudaldirection:It

beginsattheface,advancesdownwardonthe

bodytotrunkandextremities,andnallytothe

palmsandthesolesofthefeet.

NURSING PRIORITY: Press skin against abony prominence (e.g., chin, nose) to detect early color

change.

2. Anemia.

B. Diagnostics.

1. Prenatalscreeningandprevention:Rhincompati-

bility.

a. AdministrationofRho(D)immuneglobulinto

preventRhsensitizationinrstpregnancyof

Rh-negativemother(seeprenatalcare).

b. IndirectCoombs’test:performedonthe

mother’sserum.

c. Postdeliverydetection(R hincompatibility): directCoombs’testoncordblood

d. Rho(D)immuneglobulinisadministeredwithin

72hoursofanRh-negativemother’sdeliveryof

anRh-positiveinfant.


v Goal: Torecognizejaundiceanddistinguishthephysi-

ologicaltype(whichoccurswithin48to72hours)fromthe

pathologicaltype(whichoccurswithin24hours).

✽

✔




A. Prenatalmonitoringofmaternal-fetalstatus.

B. Identifyhigh-riskmother.

C. Monitorbilirubinlevelsinthenewborn.

Infant of a Diabetic Mother

Data CollectionA.Clinicalmanifestations

1. Puffy,cushingoidappearance,withroundcheeks

andstockyneck.

2. Enlargedheart,liver,andspleen.

3. Rapid,irregularrespirations.

4. IncreasedMororeexandirritabilityonslight

st imulationorlethargyattimes.

B. Commoncomplications.

1. Hypoglycemia:bloodglucoselevelofbelow36mg/

dlwithin1½to4hoursafterbirth.

a. Lethargy,irritabil ity,hy pocalcemia.

b. High-pitchedcry.

c. Twitching,jit teriness,seizures.

d. Apneicspellsandabdominaldistention.

2. Respiratorydistresssyndrome.

3. Polycythemia.

4. Birthtraumacausedbyexcessivesize.

5. Congenitaldefects,specicallycardiac(patentduc-

tusarteriosusismostcommon)andcentralnervous

systemdefects(anencephaly,myelomeningocele,

andhydrocephalus).

NURSING PRIORITY: Prolonged hypoglycemia

can cause irreversible brain damage.


v Goal: Tomonitorglucoselevels.

A. Frequentlycheckbloodglucoselevels.

B. Minimizetraumatoheelsitebyperformingheelstick

correctly.

1. Warmheelfor5to10minutesbeforesticking.

2. Cleansesitewithalcoholanddrybeforesticking.

3. Thelateralheelisthesiteofchoice.

✔

1. Whatequipmentshouldthenursehaveavailableimme-

diatelyafterbirthtoassisttheinfantwiththeinitial

respirator yeffor t?

1 Stethoscopeandsuctioncatheter.

2 Heatedcribandastockingcap.

3 Bulbsyringeandoxygen.

4 Oxygenandstethoscope.

2. Thenurseisassessinganewbornforthepresenceofa

caputsuccedaneum.Whatndingswouldconrmthe

presenceofthiscondition?

1 Swellingconnedtotheparietalareasoftheskull.

2 Diffuseedemaunderthescalp.

3 Acollectionofbloodunderthescalp.

4 Petechialhemorrhagesintheconjunctivae.

3. Whatsignswouldanurseobserveinanewbornwith

respiratorydistress?

1 Flaringofthenares,grunting,andchestwallretrac-

tions.

2 Lustycrying,heavingchestwall,andailingarms.

3 Respiratoryrateof50breathsperminute,pulserate of166beatsperminute,andsneezing.

4 Uncontrolledcrying,acrocyanosis,andrespiratory

rateof60breathsperminute.

4. Thenurseisassessingthenewborn.Whatnursingas-

sessmentdatawouldcausethemostconcern?

1 Hasloudcryingwithperiodsoflightsleep.

2 Hasabloodglucoselevelof75mg/dl.

3 Turnsduskyandcyanoticwhencrying.

4 Acrocyanosisispresent4hoursafterbirth.

5. ThenewbornisgivenvitaminKsoonafterbirth.What

isthepurposeofthismedication?

1 Isusedasaprophylacticmeasurebecausethenew

borndoesnothaveanimmediatesupply.

2 Assistswithbuildingironstoresinthebloodofthe

newborn.

3 Helpstostabilizetheelectrolytesinthenewborn’s

system.

4 Preventsjaundicebybreakingdownthenewborn’s

bilirubin.

6. Tomeetthegoalofpromotinginfantfeedingina

breastfedbaby,thenurseshouldteachthemotherto:

Selectallthatapply:

_____ 1 Feedthebabyona3-to4-hourschedule.

_____ 2 Alternatebreastandformulaforeachfeeding.

_____ 3 Stopbreast-feedingifhernipplesgetsore.

4 Maintaindemandbreast-feedingfortherst4

weeks.

_____ 5 Drinklotsofuidsandgetadequaterest.

6 Offerapacierbetweenfeedingstomeetsucking

needs.

7. Whatisacharacteristicndingwhenperforminga nursingassessmentonanewbornwithhypoglycemia?

1 Acrocyanosis.

2 Respirationsof50breathsperminute.

3 Increasedir ritability.

4 Decreasedpulserate.

8. Whatnursingmeasuresareimportanttodecreasethe

lossofbodyheatinanewborn?

1 Keeptheinfantbundledwithastockingcaponthe

head.

2 Regulatetheroomtemperaturebetween68̊ Fand

70˚F.

Study Questions: Newborn




4 Thenewbornwillsleepmorecomfortably.

16. Thenewborn’smotherisconcernedabouttheshapeof

thebaby’sheadafterdelivery.Shestatesthatitlooks

likea“conehead.”Themostappropriateresponseby

thenurseisthefollowing:

1 “Youdon’tneedtoworryaboutit.Itisperfectly

normalafterbirth.”

2 “Itismoldingcausedbythepressureduringbirth andwilldisappearinafewdays.”

3 “IwillreportittothePCPandhewillordera

diagnosticscan.”

4 “Itisacollectionofbloodrelatedtothetraumaof

deliveryandwillabsorbinafewweeks.”

17. Thenurseisresponsiblefordocumentingtherst

meconiumstoolthenewbornpasses.Ifthenewborn

doesnothaveastoolintherst24hoursoflife,the

nurseshouldrst:

1 Insertarectalthermometertofacilitatetheprocess.

2 Inspecttheanalareaforanopening.

3 Monitorthevitalsignsforanincreaseintempera-

ture. 4 Increaseoralfeedingtostimulatepassageofstool.

18. Thebestwayforthenursetomaintainthesafetyofthe

newborninthehospitalisto:

1 Havethemothercometothenurserytopickupthe

babyforfeedings.

2 Takethebabytothemother’sroomforrooming-in.

3 Askthemotherhernameandsocialsecurit y

number.

4 Comparethenamebandinformationofthemother

andbaby.

19. AnewbornhasaPlastibellcircumcision.Inreinforcing

theteachingwiththeparents,whichinstructionswould

yougivetheparentsforcareofthecircumcisedpenis?

Selectallthatapply:

______ 1 Removeanyexudatesthatformduringtherst

24hours.

______ 2 Washpenisgentlyduringdiaperchangetore-

moveurineandfeces.

______3 Applysterilepetroleumgauzetothepenisfor

rst24hours.

______4 Cleantheglanswithalcoholtopromotehealing.

______5 Avoidpositioningtheinfantontheabdomen

duringthehealingprocess.

______ 6 Reportanyedema;purulent,malodorousdis-

charge;increasedtemperature.20. Thenurseunderstandsthatmeconiumis:

1 Wellformedanddarkincolor.

2 Oftenpassedintherst4hoursoflife.

3 Lightincolorandloose.

4 Passedwithintherst2daysoflife.

Answers and rationales to these questions are in the section a

the end of the book titled Chapter Study Questions: Answers

and Rationales.

3 Keeptheinfantinawarmerfortherst8hours

afterbirth.

4 Assessthecoretemperatureandrespirationsevery

3hours.

9. Whatisanursingmeasuretoreducethepossibilityof

infectioninthenewborn?

1 Keepthecribsatleast3feetapartinthenursery.

2 Washhandsbeforeandaftercaredeliveredtoeach newborn.

3 Washhandsbeforediaperchanges.

4 Decreasevisit ingtimestoonly1hourandfor

groupsofthreepeople.

10. Thenurseisobservinganewmotherbreastfeedherin-

fant.Todecreasetheamountofairtheinfantswallows,

whatwouldthenursesuggesttothemother?

1 Placethenewbornonthebackwiththeheadturned

totheleft.

2 Offertheinfantthepacieraftereachfeeding.

3 Burporbubbletheinfantaftertherstfewminutes

offeeding.

4 Limittheinfanttoonly10minutesofnursingatone feeding.

11. InwhichsituationwouldthenurseanticipateRho(D)

immuneglobulinhuman(RhoGAM)tobegiven?

1 WhenthemotherisRhpositive.

2 Within48hoursafterdelivery.

3 Afterapostpartalhemorrhage.

4 WhenthemotherisRhnegative.

12. Whatlaboratorytestisimportanttoobtainonthenew

borninordertodetectcomplications?

1 Alpha-fetoprotein.

2 Urinalysis.

3 Phenylketonur ia(PKU).

4 Serumiron.

13. Whichbehaviorexhibitedbythemotherwithhernew

bornwouldthenurseidentifyasmaladaptiveregarding

parent-infantattachment?

1 Cuddlesnewbornclosetoherbreast.

2 Looksatthefaceofthenewborn,whiletalking.

3 Explainstothenursehowthenewbornisfeeding.

4 Seldomlooksatnewbornwhenfamilyisvisiting.

14. Theclinicnurseobservesthata3-day-oldbabygirlis

jaundiced.Abilirubinlevelisdrawn,anditis11.4mg/dl.

Whatcausesthisbilirubinlevel?

1 Physiologicjaundice.

2 Hemolyticdisease. 3 Er ythroblastosisfetalis.

4 Sepsis.

15. Thenurseassignedtothenurseryunderstandstheim-

portanceofkeepingthenewbornswaddledinawarm

blanketinordertopreventheatlossbecause:

1 Chillingleadstoincreasedheatproductionand

greateroxygenneeds.

2 Thenewborn’smetabolicrateisdecreased.

3 Evaporationwillaffectthenewborn’sabilityto

feed.

Nclex-pn Chapter 21 Bwfinal

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