Infant and Postpartum Care - NCLEX-PN

An infant begins to show signs of anxiety toward strangers between 8 and 12 months of age and may recur until two years of age. This anxiety can show as silence, staring, writhing or crying in the presence of people they don't know.

Object permanence is the understanding that an object still exists even when it can not be seen, heard, or touched. It is often tested by placing an object on a surface, then covering that object and allowing the infant to attempt to uncover it, thus demonstrating a knowledge that the object remains present though it is hidden.

The grasping reflex is the earliest reflex developed by the infant. It is often present at birth: the infant will grasp at objects such as a finger placed into their open palm.

The inferior pincer grasp is the ability to pick up small objects such as by resting the forearm on a surface and pinching using the sides of the thumb and the index finger. It is an important milestone in the development of fine motor skills.

Feelings of sadness, hopelessness, or guilt, insomnia, difficulty coping with normal life activities, social avoidance, and anxiety after giving birth are all signs of postpartum depression, a condition that affects as many as four out of five people after giving birth. Postpartum psychosis is a much more serious condition, involving delusions, extreme mood swings, and risk of self harm.

While vitamin deficiencies, lack of sleep, and social stresses can all contribute to depressed mood after giving birth, the primary cause of postpartum depression is an extreme drop in hormones (primarily estrogen and progesterone) that occurs after delivery of the placenta.

Postpartum bleeding, referred to as lochia, is a normal process wherein the individual sheds blood, mucus, and uterine tissue after delivery. This bleeding can continue for up to six weeks, and coloration can change from bright red blood (lochia rubra) to pinkish-brown discharge (lochia serosa).

Mastitis is an inflammation of the breast tissue, often due to milk stasis in a breastfeeding individual and occurring most commonly in the first few weeks after delivery. Causes can include poor latching, tight bras or clothing, or infection. Incidence is higher in individuals who are immunocompromised, and in people with cracked nipples or a past history of mastitis with a previous birth. Mastitis is not an emergency, nor is it any type of cancer, cyst, or serious breast disease.

The most common treatment for mastitis is frequent breastfeeding, along with rest and loosening of any tight-fitting clothing. Most cases of mastitis are non-infectious and do not require antibiotics. However, high fever can be a sign of infectious mastitis, and may require pharmaceutical intervention.

The stump of the umbilical cord will generally remain for 2-3 weeks after delivery. During that time the stump's coloration will change from blue to black as it dries. Eventually it will fall off much like a healing scab, leaving behind the umbilicus (navel).

An umbilical cord stump will normally turn black and may bleed slightly when it falls off. These are not signs of infection. If, however, there is pus or swelling around the umbilicus, this may be signs of infection and should be further evaluated by a pediatrician. Newborns cry for many different reasons - this is not necessarily a sign of physical illness or infection.

Normal hematocrit in a newborn is 45-65%. This is measured via heel-stick just after delivery. This test is useful in assessing for anemia (suggested by a low hematocrit) and polycythemia (suggested by a hematocrit over 65%).

The APGAR score is a test of newborn health and physical function, designed to assess a newborn for need of emergency assistance. The factors used to calculate the score are the following:

• Appearance
• Pulse
• Grimace response
• Activity
• Respiration

The "grimace" category of the APGAR score actually refers to a wide variety of reflexive behavior. These include sneezing and coughing, crying on stimulation, pulling away, and facial expression.

The APGAR score is calculated one minute after birth, and then again at five minutes after birth. It is common for infants to be born with depressed respiration, cyanosis, and other physical signs of struggle that are quickly resolved within five minutes after birth. If signs of respiratory or cardiovascular distress do not improve by this time, however, emergency intervention may be required.

The APGAR scale goes from 0-10. A score of 0-3 would indicate severe depression of function, 4-6 would indicate moderate depression, and 7-10 would be a normal, healthy score. In the case of moderate depression, the newborn should be monitored closely. Immediate emergency intervention may not be required, as healthy neonates can have moderately low APGAR score indicators that improve in the first few hours of life.

It is normal for infants to lose 5-10% of their birth weight in the first seven days of their lives. In a healthy baby, this weight will be regained by the end of their second week. Infants who are born ill or premature may take longer to regain this weight. If an infant has passed the second week of life and it has not returned to or surpassed it's birthweight, the family may need to seek lactation counseling or bring the infant in for further evaluation.

An examiner can look for hip dysplasia in an infant using the Ortolani test. This is performed by placing the child supine, then flexing the hip and knee to 90 degrees. They would then gently abduct the leg while placing downward pressure on the greater trochanter. In a healthy joint, the hip will move freely. In hip dysplasia, there will be a feeling of a "clunk" as the femoral head is relocated into the acetabulum. The Ober test, Thomas test, and Faber test all check for hip stability and injury in adult populations, rather than pediatric.

Fine, downy hair, called lanugo, generally appears on the fetus around five months of gestation. It is often shed before birth, but some infants are born with this hair still intact. The hair is normally shed within the first 1-3 weeks of life. In most cases it is entirely normal and not a sign of hormone or metabolic disorder.