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abruptio placentae

(uh-brup-tee-oh, uh-brup-shee-oh pluh-sen-tee)
premature partial or complete separation of the placenta from the uterus
bluish color of the hands and feet, not pathological in newborns
treatment method that involves therapeutic massage of points along the
body’s energy pathways
treatment method that involves therapeutic stimulation of points along the
body’s energy pathways with thin needles
Apgar scoring
(app-gar score-ing)
an assignment of numbers to assessment parameters of a newborn at 1 and
5 minutes after birth, named after its developer, Virginia Apgar
(air-ee-oh-luh, uh-ree-uh-luh)
the pigmented tissue around the nipple
inadequate oxygenation that causes unconsciousness and, without
intervention, death
lack of muscle tone
(bil-uh-rue-bin, bil-ee-rue-bin)
yellow or orange product of the breakdown of hemoglobin
Braxton-Hicks contraction
(braks-tin hiks kin-trak-shin)
painless, ineffective uterine contractions that occur during late pregnancy
the low narrow end of the uterus that contains its opening
surgical removal of the foreskin of the penis
white to yellowish fluid that precedes breast milk

application of pressure to the sacrum during contractions
cradle cap
(cray-dul cap)
infant scalp dermatitis manifesting as thick yellowish scales
a bluish discoloration, especially of the skin and mucous membranes, due to
excessive concentration of deoxyhemoglobin (hemoglobin not combined with
oxygen) in the blood
stretching of the opening of the cervix to accommodate childbirth
hemorrhagic spot, or bruise, caused by bleeding under the skin and
irregularly formed in blue, purple, or brown patches
accumulation of excess fluid, causing swelling in the cells, in intercellular
spaces within tissues, or in potential spaces inside the body
thinning and shortening of the cervix in preparation for childbirth
light massage or stroking, usually on the patient’s abdomen, in rhythm with
breathing during contractions
entrance of the fetal presenting part into the upper pelvic channel or birth
unborn child still inside the uterus
a stethoscope for listening to fetal heart tones
easily broken
rounded upper portion of the uterus

black.localized collection of blood underneath the tissues. sticky initial stools of a newborn milk-ejection reflex (milk ee-jek-shin ree-fleks) release of breast milk in response to oxytocin. nutritional deficits. also called the milk-ejection reflex lightening (lite-in-ning) descent of the uterus into the pelvic cavity about 2 weeks before term labor lochia (low-key-uh) vaginal discharge following childbirth meconium (mih-coe-nee-um) odorless. appearing as a swelling or mass often characterized by a bluish discoloration hydramnios (high-dram-nee-ose) excessive amniotic fluid hyperemesis gravidarum (high-per-em-ih-sis grav-ih-dar-um) complication of pregnancy that involves excessive vomiting. electrolyte imbalances. and ketonuria hyperglycemia (high-per-gly-see-mee-uh) an elevated blood glucose level hyperventilation (high-per-ven-til-ae-shun) excessively rapid or deep breathing hypoglycemia (high-poe-gly-see-mee-uh) a low blood glucose level hypothermia (high-poe-ther-mee-uh) body temperature below the expected reference range lanugo (luh-new-go) fine. green-tinged. downy hair on the fetus after 20 weeks of gestation Leopold maneuvers (lee-uh-pold mih-new-vers) a series of four types of abdominal palpitation for determining fetal position let-down reflex (let-down ree-fleks) release of breast milk in response to oxytocin. weight loss. also called the let-down reflex Moro reflex (more-oh ree-fleks) .

ok-see-toks-ik) a drug that stimulates uterine contractions perinatal (peh-ree-nate-ul) referring to the time or process of birth perineum (peh-rih-nee-um) a skin.and muscle-covered area over pelvic structures. and hemoconcentration quickening (kwik-in-ing) perception of fetal movement preterm (pre-turm) referring to the period of a pregnancy prior to 37 weeks of gestation rooting reflex (roo-ting ree-fleks) expected newborn response that involves moving toward whatever touches the mouth and initiating sucking motions sitz bath (sits bath) immersion of the perineum in warm water in a tub or basin supine hypotension (sue-pine high-poe-ten-shin) a drop in blood pressure due to altered venous return from a gravid uterus exerting pressure on the ascending vena cava symphysis pubis (sim-fih-sis pew-bis) . proteinuria.expected newborn response to a loud noise or other readily perceived stimulus. usually meaning the area between the vagina and the anus in females placenta previa (pluh-sen-tuh pree-vee-uh) implantation of the placenta low in the uterus and completely or partially covering the cervix popliteal (pop-lih-tee-ul) referring to the posterior part of the leg behind the knee joint pre-eclampsia (pre-eh-clamp-see-uh. demonstrated as arm flexion and an embracing posture oxygen saturation (ok-sih-jun sah-chuh-ray-shun) a clinical measurement of the percentage of hemoglobin that is bound with oxygen in the blood oxytocic (ok-see-toe-sik. pre-eh-clamp-shuh) a complication of middle to late pregnancy that involves hypertension.

case-ee-oh-suh) a grayish white protective substance that coats fetal skin and has a creamcheese-like consistency viability (vie-uh-bil-ih-tee) capability of living outside the uterus. generally at 20 weeks of gestation and beyond .the semi-rigid articulation or union of the two pubic bones in the midline of the lower anterior part of the abdomen therapeutic touch (ther-ih-pew-tik touch) an energy therapy that is useful for promoting relaxation and healing and involves a practitioner moving hands over the patient’s body to detect energy imbalances and then directing balanced energy toward the patient translucent (trans-loo-sent) allowing the passage of light trimester (try-mes-ter) one of three periods of time. muscular female reproductive organ where a fetus develops vernix caseosa (ver-niks cass-ee-oh-suh. about 3 months each. that comprise a pregnancy umbilical cord (um-bil-ik-cul cord) the long structure that connects a fetus with the placenta and encases two arteries and one vein surrounded by a clear gel called Wharton’s jelly uterus (you-ter-is) the hollow.

use Nӓgele’s rule. It can be an exciting time. and then add 7 days and adjust the year as needed to make it a future date. Burning with urination could mean a urinary tract infection. many women undergo an ultrasound examination and find out their baby’s gender. However. and adding 7 days and one year makes her “due date” August 27 of the following year. Your patient’s first question is likely to be about when her baby will arrive. Your patient may also look to you for help with some of the common discomforts of pregnancy that develop from her ever-expanding uterus. She may have any of a wide range of emotional responses and might not be prepared to take in a lot of information about pregnancy and childbirth at this time. Many women develop “morning sickness” during early pregnancy. In the first trimester. Make sure she knows to report severe vomiting. Be sure she is aware of the dangers to her fetus from her ingestion of alcohol or other dangerous substances. Besides answering any questions she might have. fluid and electrolyte imbalances. if the first day of her last menstruation was November 20 of the current year. Also instruct your patient to avoid taking any prescription or over-the-counter medications or supplements without first checking with her provider. subtract 3 months. your patient might tell you that she does feel nauseated from time to time. Diarrhea could mean a gastrointestinal infection. And fever and chills could indicate a systemic infection. it is essential have to basic understanding of what she might experience during each of these phases. or quickening. she has probably just found out that she is pregnant. Tell your patient to report abdominal cramping and any vaginal bleeding at all. and nutritional deficits. . To calculate this. The first trimester When you first encounter a patient in her early weeks of pregnancy. So. All require prompt reporting and intervention. Another major consideration during the first trimester is infection. a serious complication that involves weight loss. The second trimester During the second trimester. subtracting 3 months takes you to August. your priority will be to point out any danger signs – indications she must report to her provider because they might warrant intervention. for the first time. to meet your patient’s learning needs during its various trimesters. as it could be hyperemesis gravidarum. indeed. particularly as women feel their baby’s movement. Take the first day of the woman’s last menstrual cycle.Pregnancy Pregnancy is a time of profound physiological and emotional change. It is beyond the scope of this skills module to present a comprehensive review of pregnancy. these could indicate miscarriage or ectopic pregnancy.

and it will move forward across her lower abdomen. they will want to know how they can tell the difference between “true” and “false” labor. Once a woman is accustomed to the pattern and frequency of fetal movement. irritability. At this time. vision changes. Clammy pale skin. although they can be regular for short periods. During true labor. (These do not stop true labor. Walking and other activities will stop false labor. and edema. and headache. Either could be a fetal response to inadequate oxygenation. and lightheadedness are manifestations of hypoglycemia. rapid breathing. The third trimester During the third trimester. Abdominal pain or cramping can mean preterm labor. Instruct your patient to report the concurrent occurrence of flushed dry skin. with false labor. as will comfort measures and hydration. increased thirst and urination. With false labor. tremors. It is also important at this time to teach your patient about the benefits of breastfeeding and of taking childbirth preparation classes. however. especially of the face and hands. The previous danger signs still apply. ruptured membranes are likely to signal an imminent onset of term labor and not a danger sign of preterm labor. fruity breath. epigastric or abdominal pain. be sure to instruct your patient to report any indications that her blood pressure has risen and she has developed pre-eclampsia. she must report any significant increase or decrease. . and as the cervix dilates.The danger signs from the first trimester still apply. vaginal bleeding can also indicate placental problems such as placenta previa and abruptio placentae. She will feel the pain of true labor in her lower back. Gestational diabetes is another complication of pregnancy that manifests with specific warning signs.) And of course. when women are preparing for the birth of their baby. weakness. although after 37 weeks. in this trimester. the cervix does not dilate and it does not efface. These are manifestations of hyperglycemia. she will pass what is called a bloody show vaginally and feel the baby moving down into the birth canal. your patient will have regular contractions that gradually become stronger and closer together. contractions are usually irregular. Her cervix will dilate and efface. and a sudden gush of clear fluid from the vagina indicates a rupture of the amniotic membranes – a serious complication this early in pregnancy. Classic manifestations include headache.

then position the device at midline just above the symphysis pubis and apply firm pressure. usually around the 10th or 11th week of gestation. Count the fetal heart rate for 1 full minute. listening to its quality and rhythm as well. Rates outside of this reference range can indicate fetal distress. If you do not detect heart tones right away. . For optimal hearing later in the pregnancy. apply conductive gel to the patient’s skin. To auscultate fetal heart tones. A regular stethoscope or fetoscope can detect and transmit fetal heart sounds at 18 to 20 weeks and beyond. Inform the provider immediately if you cannot hear the fetal heart. move the device around the abdomen slowly until you hear them. it is possible to hear fetal heart tones with an ultrasound fetoscope or stethoscope. Placing the ultrasound device over the fetal back often improves the ability to hear the heart tones.Auscultating fetal heart tones Toward the end of the first trimester. use abdominal palpation (Leopold maneuvers) to determine the position of the fetus. Fetal heart tones are difficult to hear when a patient has an excessive amount of amniotic fluid (hydramnios) or excessive subcutaneous fat in the abdomen. The fetal heart typically beats from 120 to 160 times a minute.

or her knees in a flexed position. and ideally the same clinician should measure the fundus each time. From weeks 18 to 32. The duration of pregnancy at this time generally correlates with the height of the fundus above the symphysis pubis. Thus this measurement can help you assess fetal growth and estimate gestational age. Make sure the patient has emptied her bladder because a full bladder can change the measurement by as much as 3 cm. The result in centimeters is a rough estimate of gestational age. a miscalculation in due dates. Using a disposable metric tape measure. Be sure the patient’s position is the same for each fundal height measurement. it no longer reflects gestational age as the fetus is growing more in weight than in length. a development that makes it easy to assess fundal height. Have her lie supine with her head slightly elevated on a pillow. or both. or a multiple pregnancy. intrauterine growth restriction. note the distance from the symphysis pubis to the top of the fundus. or a fetal anomaly. . a large-for-gestational-age fetus. the uterus becomes part of the abdomen. the number of centimeters of fundal height is just about equivalent to the weeks of gestation. Measurements above the patient’s gestational age might indicate hydramnios. After 32 weeks. Fundal height measurements below the estimated gestational age might suggest a miscalculation in due dates.Measuring fundal height During the second trimester.

and the best location for auscultating fetal heart tones. stand on the patient's right side facing her. That location is the point of maximal intensity (PMI) of the fetal heart rate on the patient’s abdomen. the degree of the descent into the pelvis. the presenting part. will feel softer and less defined. Position a small rolled towel under one hip to shift her uterus away from large blood vessels and thus prevent supine hypotensive syndrome. If you are righthanded. that is. Leopold maneuvers comprise a stepwise method of abdominal palpation you can use to determine the number of fetuses. the buttocks and legs. consistency. Palpate for the fetal part that occupies the fundus to help identify fetal lie and presentation. cupping your hands around the fundus or the top of the uterus. face your patient and place both hands on her abdomen. The breech. The four Leopold maneuvers are:  Identifying the fetal part in the uterine fundus to determine fetal lie and the presenting  part Palpating the fetal back to identify fetal presentation  Determining which fetal part lies over the pelvic inlet to identify fetal attitude  Locating the fetal cephalic prominence to identify the attitude of the head Begin the procedure by asking your patient to empty her bladder so that she won’t feel any discomfort during palpation. The fetal head will feel firm and round. the fetal position. and mobility. For the first maneuver.Leopold maneuvers For your patients who are pregnant. Use the flat palmar surfaces of your fingers to perform Leopold maneuvers. . the fetal attitude. Feel for shape. the fetal lie.

use your right hand to grasp the lower section of the patient’s abdomen between your index finger and thumb and press inward over the inlet to the true pelvis. that is. and elbows. feet. Note any movement and determine whether the presenting part is soft or firm. whether the head is flexed or extended. If there is movement. and elbows. . If the head is the presenting part. feet. The fetal back will feel smooth and hard. determine fetal attitude. This also helps you identify the fetal presentation. Use the palmar surface of one hand to locate the fetal back and the various irregularities to identify hands. For the third maneuver. will feel like irregular nodules when you palpate them. The smaller fetal parts. the presenting part is not engaged. position the palms of your hands on the side of the patient’s abdomen.For the second maneuver. such as the hands.

. Outline the fetal head with your fingertips. the head is flexed and the vertex is presenting. Document the procedure and discuss the results with your patient’s provider. hands.For the fourth maneuver. face the patient’s feet and place both hands on both sides of her uterus. Do this by checking the fetal heart tones and by noticing any changes in fetal position. After the procedure. or brow. then the head is extended and the face is presenting. If you find the cephalic prominence on the same side as the back. and elbows. Palpate both sides of her abdomen to determine the cephalic prominence. Note that this maneuver applies only to cephalic presentations. assess the patient's response and then assess fetal well-being. If you find the cephalic prominence on the same side as the feet.

feet. . provide distraction. The rate is usually the same as with modified-paced breathing. she breathes faster – usually 32 to 40 breaths per minute. safe. involves manipulating energy fields to help reduce anxiety and pain during labor. Pattern-paced breathing requires more concentration as the patient sets up a pattern of breathing to help her through the final centimeters of cervical dilation.Nonpharmacological pain management Many patients base their perception of the birth experience not so much on the amount of pain they feel but on how well they achieve their goals for managing it. the patient returns to slow breathing. Massaging the patient’s head. and. The coach or the nurse uses the heel of the hand or a fist to achieve adequate counterpressure. One method is to make a “hee” or “hoo” sound in a pattern. but typically after the cleansing breath. They are simple. Slow-paced breathing is exactly that – the patient inhales slowly through the nose and exhales slowly through the mouth – usually six to nine times per minute and no fewer than three to four. This is especially helpful for patients who have pain and internal pressure in the lower back because the fetal head is in a posterior position. For those who have learned and practiced these strategies prior to labor. such as healing or therapeutic touch. hands. Energy work. Most expect some pain and will count on you to help minimize it. Counterpressure is steady pressure a support person applies to the sacral area of the patient’s back. Effleurage is light massage or stroking. Breathing techniques Breathing techniques promote relaxation. reminding her to use the cleansing breaths. usually on the patient’s abdomen in rhythm with breathing during contractions. and back provides comfort and communicates caring. The pattern may vary. the patient breathes in a 3-to-1 pattern – “pantpant-pant-blow” or “hee-hee-hee-hoo” throughout the entire contraction and ends with a cleansing or focused breath. The nurse and the support person can coach her by breathing with her. the patient breathes slowly in and out through her mouth. she takes quick panting breaths and then exhales or blows forcefully. Certified practitioners perform these techniques. Breathing in and out of her mouth. Touch Massage is an effective technique for enhancing relaxation and comfort. Nonpharmacologic methods of pain management are ideal for this purpose. The support person uses the fingertips with enough pressure to avoid tickling sensations. counting the breaths. As the contraction subsides. the chest and the thigh are appropriate alternatives. and making sure she takes even breaths to avoid hyperventilation. you can remind them to use them. For patients who have a monitoring belt across the abdomen. and improve coping during uterine contractions. They begin and end with a cleansing or focused breath – a slow. and easy for you to teach to your patients and their support people. as each contraction reaches its peak. With modified-paced breathing. relaxing breath in through the nose and gently out through the mouth.

and can provide some unique benefits for patients in labor. however. and sitting in a whirlpool bath can improve comfort. but as long as a patient in active labor has no contraindications for these techniques. Combining positions and activities like rocking and slow dancing with relaxation can help reduce pain perception. . and the patient’s preferences. Other therapies vary with the practice setting. Facility policies vary. Water therapy Showering. and transcutaneous electrical nerve stimulation. require trained practitioners and sometimes specialized equipment. the provider. acupressure. Recommendations for jet hydrotherapy are usually for 30 to 60 minutes. and make it easier for women in labor to cope with pain. such as biofeedback. Warm water can cause dizziness. imagery. soften perineal tissues. Some.Positioning Frequent position changes enhance comfort and relaxation and promote more effective contractions. require no special certification. Also be sure to provide a shower stool. so it is important to assist patients in and out of the shower or tub. improve circulation and oxygenation. and music therapy are easy to implement. Upright positions such as walking. hypnosis. heat and cold applications. acupuncture. bathing. provide a relaxing atmosphere. so they can sit down easily during showering. or squatting take advantage of gravity to encourage fetal descent. Others such as aromatherapy. she can generally stay in the bath for as long as she wishes. sitting.

This assessment information is essential because gestation relates directly to the likelihood of complications during the newborn period. scarf sign. popliteal angle. perform the examination within 96 hours of birth. At term. the hand should touch the wrist. the less flexion the newborn demonstrates. you’ll assess six neuromuscular and six physical characteristics. . Preterm newborns show lesser degrees of flexion: the younger the gestational age. perform the assessment sooner than 12 hours after birth. the New Ballard Score. Assess posture for the degree of flexion of the extremities. is appropriate for newborns from 20 to 44 weeks of gestation. Perform all assessments with the newborn lying supine. For newborns beyond 26 gestational weeks. resulting in a 0-degree angle. This assessment. Each parameter scores from minus 2 to 5. arm recoil. Commercially printed worksheets are available to use when performing this assessment. Measure the angle that forms where the hand meets the wrist. Overall. Timing of the gestational assessment influences the accuracy of its results. higher scores correlate with postmaturity. square window. it is best to perform the examination within 48 hours of birth. Refer to the scoring sheet to base the specific scores on your findings for each parameter. and heel to ear. Assess square window by grasping the newborn’s forearm and gently flexing the wrist toward the inner arm. For newborns younger than 26 gestational weeks. Do not allow rotation of the wrist. At term. with the characteristics to assess varying with the stage of maturity. The components of the neuromuscular assessment are posture. Lower scores correlate with prematurity. with the cumulative score correlating with a gestational age between 26 and 44 weeks.Gestational age assessment To determine the approximate gestational age of a newborn. a newborn’s legs and arms are moderately flexed at rest.

Very preterm newborns have an angle of wrist flexion of 90 degrees or more. Assess the scarf sign by grasping the newborn’s hand and attempting to cross the arm over his body at the neck. measure the popliteal angle by moving the foot gently toward the head until you meet resistance. Next. Measure the angle of flexion at the elbow to determine the arm recoil score. the leg straightens to a 180degree angle. measure the angle behind the knee in the popliteal area. while preterm newborns cross the elbow past midline. Term newborns are less flexible. the less flexibility at the wrist. At this point. With very preterm newborns.Preterm newborns show greater angles of flexion at the wrist: the younger the gestational age. Do not raise the newborn’s buttocks off of the examination surface. The arms of term newborns meet resistance before crossing midline. release the hands and allow the arms to recoil (return to flexion). Assess heel to ear by raising the newborn’s heel toward his head in an attempt to bring the foot to the ear. then extending the arms and hands fully at the newborn’s side. with about a 90-degree angle. With preterm . Measure arm recoil by first flexing and holding both forearms for 5 seconds. Term newborns demonstrate full recoil to a position of flexion while preterm newborns show less flexion. With the newborn’s thigh pressed against his abdomen. Stop when you meet resistance and measure the degree of extension of the leg.

and it is nearly absent in post-term newborns. Assess the skin for transparency. During the middle of the third trimester. Extremely premature newborns have none. you’ll come close to touching the heel to the ear. Base your scores for these parameters on your assessment findings. The pinna is less curved in preterm newborns. The eye/ear assessment is an analysis of the ear cartilage and shape of the pinna. cracks. Inspect the plantar surface of the foot for creases. while term newborns have a well-curved pinna with firm cartilage. and genitals. very preterm newborns may have fused eyelids. Physical maturity The components of the physical maturity assessment are skin. eye/ear.newborns. while the creases of a preterm newborn range from absent to faint red markings. Determine ear recoil by folding the pinna down and assessing how quickly it returns to its previous position. cracked. and wrinkled in post-term newborns. Also. most fetuses have plentiful lanugo. Term newborns have a raised to a full areola with breast buds that are 3 to 10 millimeters in diameter. and wrinkles. breast. lanugo. You’ll score the degree of fusion for these newborns. Closer to term. plantar surface. while you’ll meet resistance almost immediately with term newborns. this body hair begins to thin. The skin ranges from translucent and friable in preterm newborns to leathery. veins. Term newborns have creases over the entire plantar surface. . Inspect the breast to assess the size of the breast bud in millimeters and the development of the areola. peeling. Lanugo is very fine body hair. Terms newborns have very little. Preterm newborns lack developed breast tissue.

Palpate the testes to determine if they have descended and note the rugae. the testes usually descend near term and rugae (ridges or folds) are visible on the scrotum. Preterm newborns have a prominent clitoris and small labia minora. With extreme prematurity. the labia majora are larger than the clitoris and the labia minora. With female newborns at term. the scrotum is flat and smooth. With males. .Observe the genitals for physical maturity. Base your scores on the degree of development of the labia.

Regardless of the length of stay. Cleanse the penis with warm water and apply the diaper loosely. Administer acetaminophen (Tylenol) as needed for pain. parents must learn the skills of feeding. Umbilical cord care Teach parents to keep the newborn’s umbilical cord clean and dry. as it is part of the healing process. Early discharge is common. If bleeding continues or if they notice redness. with some women and newborns at low risk for complications leaving the hospital within 24 to 36 hours after an uncomplicated delivery. usually at about 24 hours of age. clothing. and protecting their infant before they leave. demonstration. Caution them about the yellow exudate they may see on the glans after 24 hours and for the next 2 to 3 days. purulent drainage. redness at the base of the stump. safety. Tell them they may control minor bleeding with gentle pressure from a sterile gauze pad. bathing. They should not remove it. With the Plastibell method. . feeding success. Demonstrate this for the parents. they should notify the provider. Let them know that the stump will probably fall off somewhere between 10 and 14 days after birth. Show them how to fold the upper edge of the front of the diaper down below the umbilicus so the stump remains exposed and dry. and a foul odor from the stump at each diaper change. pus. Some providers and facilities recommend soap and water. swelling. apply petroleum jelly to the penis for the first 24 hours to keep the diaper from adhering to the circumcision site.Newborn care When a patient and her newborn are ready to leave the facility varies with their physiologic status. then assure them that they may clean the stump with water as long as they allow it to dry afterward. federal legislation ensures that all health plans allow for a minimum of 48 hours of hospitalization after a vaginal birth and 96 hours after a cesarean birth. type of delivery. Circumcision care For newborns who have had a circumcision. and various other factors. You’ll ensure that they learn these skills with instruction. or a foul odor. and observation. Parents should watch for swelling. Observe the penis for bleeding and adequate urination. and make sure that understand that they should not use soap or commercial cleansing wipes until the circumcision has healed (about 5 or 6 days later). along with encouragement and support to help them develop confidence in their ability to care for their newborn. However. Remove the cord clamp when the cord is dry. petroleum jelly is unnecessary.

in fact. Clean the diaper area with each change. Wrap the infant in a blanket when washing the hair and scalp. inguinal folds. To treat diaper rash. pH-neutral soap. For excessive dryness. And do not expose the skin to direct sunlight. just gentle washing of the genital area. Newborn skin is fragile. not even for a second or two. To prevent heat loss. Signs of this type of diaper rash include severe erythema in the perianal area. Wash the tip (glans) with warm soap and water and replace the foreskin. Use soft. Do not rub it off. For girls. Wash the creases in the neck and under the arms and legs and in the groin as well as the rest of the body with soap and water. sweat. Go over the following instructions with them. the circumcised penis requires no special care. A good time for a bath is when the newborn awakes and before a feeding. or ointments routinely. which comprises the uppermost layer of the skin plus amniotic fluid. not cotton balls or swabs. If stool has dried on the skin.2° C (98° F to 99° F). powders. Diaper rash Bacteria that cause diaper dermatitis thrive in moist dark areas. apply a nonalcohol-based. Do not use creams. using separate parts of the washcloth for each eye.Bathing Bathing is an opportunity for interaction and bonding. Cleanse the eyes from the inner to the outer canthus. Suggest they use a bath thermometer to ensure that the water temperature is in the appropriate range: about 36. soak the area to make it easier to remove. Exposing the buttocks to air helps prevent bacterial growth. perform the bath quickly in a warm room. For infants prone to diaper rash or to help heal a rash. first with a demonstration and then with a return demonstration. Have parents start with a simple sponge bath. clean washcloths. Use one hand or a soft brush to wash the scalp with water and a mild. micro-organisms. Once healed. This and regular hair brushing prevent scalp desquamation. Dry the newborn thoroughly to prevent heat loss. A fungal rash from Candida albicans requires treatment with an antifungal ointment and possibly oral medication. For uncircumcised boys. and lower abdomen. unscented lotion.6° C to 37. and other metabolic products. unscented. excessive scrubbing can injure it. clean the area after each urination and bowel movement. Always rub gently and pat the skin dry. Then they may progress to tub baths. it can disrupt skin integrity and the acid mantle. superficial fat. Begin by washing the face with plain water. Daily bathing is unnecessary. gently retract the foreskin until you feel resistance. apply zinc oxide ointment to protect the skin. a practice they should continue periodically until the umbilical cord stump falls off. lotions. or cradle cap. Emphasize that parents must never leave an infant alone during bathing. gently separate the labia and carefully wash from the pubic area toward the anus. Be sure to wash between the fingers and toes. . exposing only a portion of the body at one time. Use corners of a washcloth to clean the ears and nose.

 To prevent suffocation.  Keep window cords out of reach. never expose an infant to tobacco smoke. A general guideline is to dress the newborn as warmly as the parents would dress themselves. throw.375 inches) apart and the mattress fits snugly against the sides. A mattress is too small if two adult fingers fit between it and the  sides of the crib.  Install smoke detectors and replace their batteries regularly. or other furniture. Make sure all clothing is flameretardant.Nail care It is not necessary to trim a newborn’s nails until they have grown long enough to extend beyond the skin of the tip of the fingers and toes. The best time to trim the nails is while the infant is sleeping.  Never leave an infant in a parked car. . or loose bedding in the crib  with an infant.  Use a firm mattress covered with a sheet. Then. parents should use manicure scissors or clippers to trim them straight across or use an emery board to file them and keep them short. A cap can help minimize heat loss and protect the infant from the sun. Pick an infant up gently and never swing.  Keep the crib away from heaters to prevent fire. do not place pillows.  Learn infant cardiopulmonary resuscitation.  Do not leave a bib or a pacifier with a string around an infant’s neck during sleep. table. Swaddling in a blanket provides a secure feeling and helps maintain body temperature. never on high places such as counters and beds. Safety Parents may not be aware of many potential dangers for their newborn. Test bath water temperature with a bath  thermometer.  Do not leave an infant alone on a bed.  Set the water heater to 49° C (120° F) or less. Position the crib on interior walls to prevent drafts.  Do not put an infant to sleep on a waterbed or in the same bed with sleeping adults. Clothing Parents should dress the infant for comfort and security.  Place infant carriers on the floor. Avoid overdressing the newborn. Provide instructions such as these to promote safety. Use a sleep sack to keep the infant warm instead of loose bedding or comforters. or shake him.  Make sure crib slats are no more than 6 cm (2.  Position the infant supine to reduce the risk of sudden infant death syndrome.  To prevent respiratory illnesses. stuffed animals.

to provide toys and mobiles with black and white contrasting designs. Many local agencies offer car seat information and actual installation and verification of adherence to safety regulations. playing music. Caution parents to use only safety-tested commercial pacifiers. Comforting techniques Newborns use nonnutritive sucking to self-soothe. and walking using a stroller into their daily routines. illness. is quite common. Encourage parents to hold their infant close while face to face. . massaging. Encourage parents to interpret what a cry means and respond accordingly. During these times comforting measures may not help. rear-facing car seat and secure it in the rear seat of the vehicle. discomfort. back rubbing. These include swaddling. Signs of illness Make sure parents know when to contact their provider. frequent vomiting. and to incorporate singing. Make sure the harness is snug and the clip is at axillary level and not across the infant’s neck or abdomen. Sensory stimulation Sensory stimulation promotes development. decreased urination or bowel movements. eye drainage. Instruct parents who give their newborn a pacifier to clean it and replace it regularly and not to coat it with sweet solutions. Provide parents with education about techniques to quiet their infant. or bleeding from the umbilical cord or circumcision. It is likely that the infant will fuss until he releases enough energy to fall asleep. Outings in a stroller or a motor-vehicle often help. cyanosis. for example. soothing noise. breathing difficulties. A fussy period each day. Advise women who breastfeed to delay the use of a pacifier until breastfeeding is well established (generally about 1 month). They may cry only a few minutes or for 2 hours or more. diarrhea. or other mild rhythmic movement such as with a cradle or a rocking chair. patting. skin-to-skin contact. for significantly high or low axillary temperatures. poor feeding. They suck on their own fingers and some use a pacifier. Follow federal and state regulations for age and weight parameters for car seat types and positions. lethargy. inconsolable crying.Car seats Use only a federally approved. and boredom. Infants cry to communicate hunger. usually in the late afternoon or evening.

offer them evidence-based information about the nutritional needs of newborns. Each ounce of breast milk and of formula contains about 20 kcal. as they have little tolerance for fluctuations in fluid balance. newborns need 60 to 80 mL of fluid per kilogram (kg) of body weight per day. and the potential risks of formula feeding. including enhanced immunity. including rooting. Increases in a newborn’s appetite generally correlate with growth spurts. sucking motions. infants require 110 kcal/kg/day. maturation of the gastrointestinal tract. It is essential to monitor their intake and output carefully. and 6 months of age. 6 weeks. promotion of postpartum weight loss. Putting the newborn and the mother in direct skin-to-skin contact (kangaroo care) facilitates the first breastfeeding experience for the mother-infant pair. the benefits of breast milk. followed by a combination of solid foods and human milk until 12 months of age. and hand-to-hand or hand-to-mouth movements. Feeding also provides an opportunity for parents to bond with their newborn. During these times. assess the newborn for feeding-readiness cues. they need 120 to 180 mL/kg/day. . and reduced risks of diabetes mellitus and childhood obesity. Caloric intake. and metabolic function. 3 months. Advantages for the mother include reduced risks of ovarian and breast cancer. they should increase the frequency or duration of feedings to accommodate their infant’s nutritional needs. convenience. Parents usually notice these changes at 10 days. Current recommendations are for exclusive breastfeeding for the first 6 months of life. Breastfeeding Human milk offers many health benefits for newborns. For the next 4 days. The optimal time for initiating breastfeeding is immediately after an uncomplicated birth. 3 weeks. physical activity.Nutritional needs of newborns Optimal nutrition during the neonatal period supports newborn growth and development. Fluid and calories For their first 2 days. For the first 3 months of life. They lose fluid through urination and respiration. provides energy for growth. measured in kilocalories (kcal). For the remainder of their first month. To help parents make an informed decision. When helping a patient get started with breastfeeding. and minimal cost. It is important to initiate breastfeeding when the newborn demonstrates these cues rather than waiting until he is sleeping or crying. they need 100 to 150 mL/kg/day. Parents may also choose to feed their newborn commercially prepared formula.

that is. and you can hear him swallow.Common positions for breastfeeding are the cradle. parents should attempt feedings every 3 to 4 hours. a seal between the newborn’s mouth over the nipple. Encourage your patient to use a position she finds comfortable and easily achieves latch. The duration of feedings also varies. have her position him on her breast.  Sit him upright. Although newborns are often sleepy during the first few days. his cheeks are rounded and not dimpled. have her support the breast with one hand while bringing the baby’s mouth to it with the other hand. make sure your patient alternates breasts from feeding to feeding.  Change his diaper. not pain. areola. some newborns feed from one breast per feeding. his chin. The breast(s) will feel softer. . Tell them to look for the following signs of adequate nutrition. cheeks. These cues help parents determine the appropriate duration of feedings. the football or clutch hold. Suggest that she gently stimulate the newborn’s lower lip with her nipple to prompt him to open his mouth. Teach parents how to determine when the newborn is finished feeding.  Unwrap the newborn’s blanket. The newborn’s jaw should also move smoothly when he sucks. Be sure his mouth covers the nipple and an area about 2 to 3 cm (1 inch) around the nipple. As he does this and his tongue moves down. Parents are often concerned that their infant isn’t receiving enough nourishment from breastfeeding.  Stroke the soles of his feet and the palms of his hands. when their newborn is feeding regularly and gaining weight. but in general. Then. Also. the newborn will suck slowly or release the breast. After this initial period. and he will appear content or will fall asleep. His mother should feel a tugging sensation. they should breastfeed eight to 12 times in each 24 hour period. For parents who need to wake their newborn for feedings or during feedings. and tip of the nose all touch the breast. Encourage the patient to express colostrum to spread over her nipple. For those who do not resume sucking when moved to the other breast. and breast that creates enough suction to remove breast milk. the modified cradle or across-the-lap. and the side lying position. When the newborn has latched on and is sucking effectively. while others switch easily during a feeding. Breastfeeding patterns vary among newborns. it is appropriate for them to shift to on-demand feedings.  Speak to him. suggest these strategies.  Massage his chest or back.

concentrate. The newborn has returned to his birth weight by 10 to 14 days. Have them hold the bottle so that the nipple is filled with fluid. it is important to make sure parents understand how to use them.  The newborn feeds eight to 12 times in 24 hours. They should use commercially prepared formula. They may store breast milk in the freezer of a twodoor refrigerator for up to 6 months and in a separate freezer up to 12 months. and loss of interaction opportunities. Although manufacturers of infant formula provide detailed instructions for using these products. and the mother feels the let-down. to prepare feedings for others to give the newborn. Have them hold their newborn in a semi-reclining position for all feedings. Breasts are full before  feedings. They should also avoid the use of pacifiers for at least 1 month. Tell the parents not to feed their newborn formula or water unless there is some medical indication for it. Cues that the newborn is . sensation during feedings.  The newborn has at least one wet diaper and one stool per day for the first 3 days. The milk supply is “in” by the newborn’s third or fourth day. then  six to eight wet diapers and at least three stools every 24 hours. or milk ejection. Periods of contentment after feedings alternate with periods of wakefulness. when breastfeeding is well established. for all feedings. they should store only 60 to 120 mL (2 to 4 oz) in each container and should use the oldest milk first.  The newborn latches on easily and swallows audibly. This is also appropriate when the infant is premature or unstable and must remain in a neonatal intensive or special care unit after the mother goes home. or ready-to-feed type. and to thaw frozen breast milk in running water or in their refrigerator. Bottle feeding Parents of formula-fed newborns also need education and support for their choice and about the feeding process. Expressing and storing breast milk Some patients wish to pump and store breast milk because of engorgement. Tell them to place breast milk containers in the middle or the rear of the refrigerator or freezer. with a manual pump. They may keep freshly expressed breast milk at room temperature for up to 8 hours and in a refrigerator up to 8 days. To prevent waste. Instruct these patients to store their breast milk in glass containers or plastic containers or bags free of bisphenol A (a chemical that hardens plastics) with the collection date on the label. or because they will be away from the newborn. Mothers can express breast milk by hand. tooth decay. or with an electric pump. never in a microwave oven. not air. Propping of bottles during feedings can result in choking. either the powder.

They do not need to boil them unless there are environmental risks. stopping sucking. such as an issue with safety of the water supply. with six to eight feedings in each 24-hour period. During the first 24 hours of life. Make sure they understand that they must discard any formula that remains in the bottle after a feeding. The amount gradually increases during the first week. Instruct parents to wash bottles in warm soapy water using a bottle and nipple brush and then to rinse them thoroughly. parents should facilitate burping because newborns swallow air during bottle feeding. Teach parents to recognize these cues to help prevent overfeeding and obesity. .satisfied after feeding include turning his head away. During and after each feeding. Parents should feed them every 3 to 4 hours. newborns usually drink 15 to 30 mL of formula at each feeding. or falling asleep.

suggest warm compresses or a warm shower before breastfeeding to stimulate milk flow. respiration. and bleeding. bladder. warmth is helpful for promoting circulation and healing. suggest that your patient compress or tighten her buttocks just before sitting. If the fundus is boggy. suggest she pump her breasts to relieve discomfort. you can place between the fundus and the umbilicus above or below it. fundus. and consistency. you’ll assess your patient’s vital signs.Postpartum assessment During postpartum. apply cold during the first 24 hours. Or. if her newborn isn’t emptying both breasts. inspect and gently palpate her breasts for redness. For perineal pain. and pain level. Also. check your patient’s fundus. Temperature may rise due to the dehydration that can accompany labor and sometimes as a result of epidural anesthesia. but this does vary. If she is breastfeeding and her breasts are engorged. The uterus descends into the pelvis approximately 1 to 2 cm per day. and severity. cracks. lochia. About a week after delivery. First. At 12 hours after delivery. Determine the fundal height by placing one hand at the base of the uterus and the other at the umbilicus. After the first 24 hours. the fundus should be halfway between the umbilicus and the symphysis pubis. the time between delivery and the return of the reproductive system to its pre-pregnancy state. and hypertension may persist in women who have had pre-eclampsia. then the fundus is at the umbilical level. After the first 24 hours. Measure vital signs with the frequency your facility’s policies specify or according to the provider’s prescription. Hypotension can indicate hemorrhage. perineum. suggest ice packs to help suppress milk production and reduce discomfort. gently massage . Measure how many fingerbreadths. assess whether the fundus is boggy or firm. Assess uterine height. elevations in temperature warrant further investigation as they suggest infection. A sustained rapid pulse can indicate hemorrhage. Administer pain medication to keep the patient’s pain at a manageable level. Inspect the nipples for redness. This helps reduce swelling and irritation. heart rate. If she is not breastfeeding. Include temperature. Orthostatic hypotension is common after delivery. Respiratory rates may be low after epidural anesthesia and after a cesarean birth but should gradually return to the expected range. however. breasts. type. the fundus is typically 1 cm above the umbilicus. Assist her to a supine position. blood pressure. Next. and any incisions. including location. This reduces pressure on healing perineal tissues. and engorgement. Pulse rates may be somewhat elevated but should return to their pre-pregnant status gradually. which are roughly equivalent to centimeters. pain. including cool sitz baths. If none. location. Encourage your patient to urinate prior to assessing her fundus. To help reduce pain from sitting down. Assess your patient’s pain. quality. legs.

and severe hemorrhaging could result. Determine the amount of saturation as scant.the uterus with a rotating motion while supporting the lower uterine segment until it feels firm. insertion of a straight urinary catheter may become necessary. the uterus could invert. encourage the patient to urinate and monitor her fluid intake and output. Be sure to check under the patient’s buttocks to be sure blood is not pooling beneath her. Determine whether the fundus is at midline in the pelvis or displaced laterally due to a full bladder. . Without stabilization of the lower segment. Lochia rubra is typical 1 to 3 days following delivery. heavy. Assess and palpate the bladder at this time as well. For that finding as well as for numerous large clots or a foul odor. moderate. light. notify the provider immediately. Examine the patient’s perineal pad for bleeding. noting the character. presence of clots. the patient will soak an entire perineal pad within 15 minutes or so. For some patients. and small clots are common. quantity. If bleeding is excessive. and odor. or excessive. If the bladder is full. Lochia typically increases with breastfeeding and ambulation.

Finally. and ecchymosis. the face. tenderness. edema. ecchymosis. and approximation of its edges. or redness. Also check her rectum for hemorrhoids and assess bowel function by auscultating bowel sounds. Check for edema of the hands. assess your patient’s comfort level and emotional status. have her lie on her side and assess the episiotomy incision for approximation. drainage. edema. Assess for thrombophlebitis by checking the patient’s calves for pain. and the lower extremities. If the patient has had an episiotomy. . examine the incision for redness. Notify the provider immediately if you find any of these.If the patient has had a cesarean delivery.