Maternal and Child Health Nursing

Newborn Assessment

MATERNAL and CHILD HEALTH NURSING

NEWBORN ASSESSMENT
Lecturer: Mark Fredderick R. Abejo RN, MAN
______________________________________________________________________

Newborn Assessment

Newborn Assessment

Abejo

Maternal and Child Health Nursing

Newborn Assessment

Newborn Assessment and Nursing Care

Temperature - range 36.5 to 37 axillary

Common variations
o Crying may elevate temperature
Stabilizes in 8 to 10 hours after
delivery
o Temperature is not reliable indicator
of infection
A temperature less than 36.5
Temp: rectal- newborn to rule out imperforate
Anus
- take it once only, 1 inch insertion
Imperforate anus
1. atretic no anal opening
2. agenetialism no genital
3. stenos has opening
4. membranous has opening
Earliest sign:
1. no mecomium
2. abd destention
3. foul odor breath
4. vomitous of fecal matter
5. can aspirate resp problem
Mgt: Surgery with temporary colostomy

Heart Rate
range 120 to 160 beats per minute
Common variations
Heart rate range to 100 when sleeping
to 180 when crying
Color pink with acrocyanosis
Heart rate may be irregular with
crying
Although murmurs may be due to
transitional circulation-all murmurs
should be followed-up and referred for
medical evaluation
Deviation from range
Faint sound

Cardiac rate: 120 160 bpm newborn

Apical pulse left lower nipple
Radial pulse normally absent. If present PDA
Femoral pulse normal present. If absent COA

Respiration
- range 30 to 60 breaths per minute
Common variations
Bilateral bronchial breath sounds
Moist breath sounds may be present
shortly after birth
Signs of potential distress or deviations
from expected findings
Asymmetrical chest movements
Apnea >15 seconds
Diminished breath sounds
Seesaw respirations
Grunting
Nasal flaring
Retractions
Deep sighing

Newborn Assessment

Tachypnea - respirations > 60

Persistent irregular breathing
Excessive mucus
Persistant fine crackles
Stridor

Breathing ( ventilating the lungs)

check for breathlessness
if breathless, give 2 breathsambu bag
1 yr old- mouth to mouth, pinch nose
< 1 yr mouth to nose
force different between baby &
child
infant puff
Circulation
Check for pulslessness :carotidadult
Brachial infants
CPR breathless/pulseless
Compression inf 1 finger breath
below nipple line or 2 finger breaths
or thumb
CPR inf 1:5
Adults 2:30

Blood Pressure - not done routinely

Factors to consider
Varies with change in activity level
Appropriate cuff size important for accurate
reading
65/41 mmHg

General Measurements
Head circumference - 33 to 35 cm
Expected findings
Head should be 2 to 3 cms larger than the
chest
Abdominal circumference 31-33 cm
Weight range - 2500 - 4000 gms (5 lbs. 8oz.
- 8 lbs. 13 oz.)
Length range - 46 to 54 cms (19 - 21 inches)
Normal length- 19.5 21 inch or 47.5
53.75cm, average 50 cm
Head circumference 33- 35 cm or 13 14
Hydrocephalus - >14
Chest 31 33 cm or 12 13
Abd 31 33 cm or 12 13

Signs of increased ICP

1. abnormally large head
2. bulging and tense fontanel
3. increase BP and widening pulse pressure
4. Decreased RR, decreased PR
5. projective vomiting- sure sign of cerebral
irritation
6. high deviation diplopia sign of ICP older
child
a. 4-6 months- normal eye deviation
b. >6 months- lazy eyes
7. High pitch shrill cry-late sign of ICP

Abejo

Maternal and Child Health Nursing

Newborn Assessment

Head to Toe Newborn Assessment

CIRCULATORY
STATUS

UMBILICAL VEIN and DUCTUS VENOSUS constrict after cord id clamped

DUCTUS ARTERIOSUS constrict with establishment of respiratory function
FORAMEN OVALE closes functionally as respirations established, but anatomic or
permanent closure may take several months
HEART RATE averages 140 b.p.m.
BP 73/55 mmHg
PERIPHERAL CIRCULATION acrocyanosis within 24 hours
RBC high immediately after birth; falls after 1 st week
ABSENCE/ NORMAL FLORA INTESTINE Vitamin K

RESPIRATORY
STATUS

Adequate levels of surfactants (Lecithin and spingomyelin) ensure mature lung

function; prevent alveolar collapse and respiratory distress syndrome
RR = 30-80 breaths /minutes with short periods of apnea (< 15 seconds) = assess for
1 full minute change noted during sleep or activity
NOTE: Periodic apnea is common in preterm infants. Usually, gentle stimulation is
sufficient to get the infant to breathe

RENAL SYSTEM

Urine present in the bladder at birth but NB may not void doe 1st 12-24 hours
Later pattern is 6-10 voidings/ day indicative of sufficient fluid intake
Urine is pale and straw colored initial voidings may leave brick-red spots on
diaper ( d/t passage of uric acid crystals in urine)
Infant unable to concentrate urine for the 1st 3 months

DIGESTIVE
SYSTEM

IMMATURE CARDIAC SPHINCTER may allow reflux of food, burped,

REGURGITATE- placed NB right side after feeding
Newborn cant move food from lips to pharynx. Insert nipple well to mouth
FEEDING PATTERS vary
- Newborns may nurse vigorously immediately afterbirth or may need as long as
several days to suck effectively
- Provide support and encouragement to new mothers during this time as infant
feeding is very emotional doe most mothers
NOTE: Distinguishing Neonatal Vomiting from Regurgitation
Vomiting is usually sour, looks like curdled milk due to HCL, with a sour odor, while
regurgitation has no sour odor or curdling of milk, or occurs during or immediately
after feeding.
IMPORTANT CONSIDERATIONS:
Breastfeeding can usually begin immediately after birth; bottle-fed newborns
may be offered few milliliters of sterile water or 5% dextrose 1 to 4 hours after
birth prior to a feeding with formula
An infant with gastrostomy tube should receive a pacifier during feeding
unless contraindicated to provide normal sucking activity and satisfy oral
needs.
At age4-6 months, an infant should begin to receive solid food foods one at a
time and 1 week apart.
FIRST STOOL is MECONIUM
- Black, tarry residue from lower intestine
- Usually passed within 12-24 hours after birth
If the amniotic fluid shows evidence of meconium staining, the physician most likely do
immediately after delivery is to suction the oropharynx immediately after the head is
delivered and before the chest is delivered.
TRANSITIONAL STOOLS thin, brownish green in color
After 3 days MILK STOOLS are usually passed
a. MILK STOOLS for BF infant loose and golden yellow
b. MILK STOOLS for FORMULATED FED- formed and pale yellow

Newborn Assessment

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Maternal and Child Health Nursing

Newborn Assessment

HEPATIC

TEMPERATURE

Liver responsible for changing Hgb into conjugated bilirubin, which is further
changed into conjugated (water soluble) bilirubin that can be excreted
Excess unconjugated bilirubin can permeate the sclera and the skin, giving a jaundiced
or yellow appearance to these tissues
HEAT PRODUCTION in newborn accomplished by:
a. Metabolism of BROWN FAT
- A special structure in NB is a source of heat
- Increased metabolic rate and activity
Axillary temperature: 96.8 to 99F
Newborn cant shiver as an adult does to release heat
Newborns are unable to maintain a stable body temperature because they have an
immature vasomotor center, and unable to shiver to increase body heat.
NBs body temperature drops quickly after birth after stress occurs easily
Body stabilizes temperature in 8-10 hours if unstressed
Cold stress increases o2 consumption may lead to metabolic acidosis and
respiratory distress

IMMUNOLOGIC

NB develops own antibodies during 1st 3 months but at risk for infection during the
first 6 weeks
Ability to develop antibodies develops sequentially

Neonatal Physical Assessment

Birth weight=2500-400 grams (5 lbs. 8oz. 8 lbs. 13 oz.)
Length= 45.7 55.9 cm. (18-22 inches)
HEAD

Head circumference = 33-35 cm (2-3 cm. Greater than chest circumference)

Anterior fontanel (diamond shape) = closes 12-18 months
Posterior fontanel (triangle shape)= closes 2-3 months
NOTE: The posterior fontanel is located at the intersection of the sagittal and
lambdoid suture is the space between the pariental bones; the lambdoid suture
separates the two parietal bones and the occipital bone
Molding- asymmetry of head as a result of pressure in birth cana

Newborn Assessment

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Maternal and Child Health Nursing

Newborn Assessment

EYES

Blue/ gray d/t scleral thinness; permanent color established w/in 3-12 mos.
Lacrimal glands immature at birth; tearless cry up to 2 months
Absence of tears is common because the neonates tear glands are not yet fully
developed
Transient strabismus
Dolls eye reflex persist for about ten days
Red Reflex: A red circle on the pupils seen when an ophthalmoscopes light is shining
onto the retina is a normal finding. This indicates that the light is shining onto the
retina.
CONVERGENT STRABISMUS (CROSS EYED)
It is common during infancy until age 6 months because of poor oculomotor
coordination

NOTE : Congenital Glaucoma

It is due to increased intraocular pressure caused by an abnormal outflow or
manufacturing of normal eye fluid.
Unequal size should be reported immediately.

NOSE
MOUTH

Nose breathers for first few months of life

Scant saliva with pink lips
Epsteins Pearls - small shiny white specks on the neonates gums and hard palate
which are normal

EARS

Incurving of pinna and cartilage deposition

NECK

Short and weak with deep fold of skin

CHEST

Characterized by cylindrical thorax and flexible ribs

NOTE:
appears circular since anteroposterior and lateral diameters are about equal
Respirations appear diaphragmatic
Nipples prominent and often edematous
Milky secretion (witch's milk) common ( effect of estrogen)

Newborn Assessment

Abejo

Maternal and Child Health Nursing

Newborn Assessment

ABDOMEN

Cylindrical with some protrusion; scaphoid appearance indicates diaphragmatic hernia

Umbilical cord is white and gelatinous with two arteries and one vein and begins to dry
within 1-2 hours after delivery
NOTE: Umbilical cord
Three vessels, two arteries and one vein, in cord; if fewer than three vessels
are noted notify the physician
Small, thin cord may be associated with poor fetal growth
Assess for intact cord, and ensure that damp is cured
Cord should be clamped for at least the first 4 hours after birth; clamp can
be removed hen the cord is dried and occluded
Umbilical clamp can be removed after 24 hours

GENITALIA

MALE: includes rugae on the scrotum and testes descended into the scrotum
Urinary meatus:
Hypospadias (ventral surface)
Epispadias (dorsal surface)

NOTE:
Meatus at tip of penis
Testes descended but may retract with cold
Assess for hernia or hydrocele
First voiding should occur within 24 hours
FEMALE: labia majora cover labia minora and clitoris
Pseudomenstruation possible (blood-tinged mucus) effect of estrogen
First voiding should occur within 24 hours
EXTREMITIES

All neonates have bowlegged and flat feet

NOTE NORMAL FEATURES:
Major gluteal folds even
Creases on soles of feet
Assess for fractures (especially clavicle) or dislocations (hip)
Assess for hip dysplasia; when thighs are rotated outward, no clicks should be
heard
Some neonates may have abnormal extremities:
Polydactyl (more than 5 digits on extremity)
Syndactyl (two or more digits fused together)

Newborn Assessment

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Maternal and Child Health Nursing

Newborn Assessment

Polydactyl

Syndactyl

SPINE

Should be straight and flat

Anus should be patent without any fissure
Dimpling at the base is associated with spina bifida
A degree of hypotonicity or hypertonicity is indicative of central nervous system (CNS
damage)

SKIN

Assessment for Jaundice

The #1 technique is to blanch the skin over the bony prominence such as the
forehead, chest or tip of the nose.
NOTE: Jaundice starts at the head first, spreads to the chest, then the abdomen, then the
arms and legs, followed by the hands and feet, which are the last to be jaundiced.
Jaundice in the first 24 hours after the birth is a cause for concern that requires
further assessment. Possible causes of early jaundice are blood incompatibility,
oxytocin induction, and severe hemolytic process.
Mongolian Spots
Gary, blue or black marks that are frequently found on the sacral area, buttocks, arms
shoulders or other areas.

Harlequins Sign
Occurs on one side of the body turns deep red color. It occurs when blood vessels on
one side constrict, while those on the other side of the body dilate.

Newborn Assessment

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Maternal and Child Health Nursing

Newborn Assessment

Erythema toxicum

Is an eruption of lesions in the area surrounding a hair follicle that are firm, vary
in size from 1-3 mm, and consist of a white or pale yellow papule or pustule w/ an
erythematous base.
It is often called newborn rash or flea-bite dermatitis
The rash may appear suddenly, usually over the trunk and diaper area and is
frequently widespread.
The lesions do not appear on the palms of the hands or soles of the feet.
The peak incidence is 24-48 hours of life.
Cause is unknown and no treatment necessary

Acrocyanosis versus Central Cyanosis

Acrocyanosis involves the extremities of the neonate, for example bluish hands
and feet due to neonates being cold or poor perfusion of the blood to the
periphery of the body.
Central cyanosis, which involves the lips, tongue and trunk indicating
HYPOXIA which needs further assessment by the nurse.

.
Milia are blocked sebaceous glands located on the chin and the nose of the infant.

VERNIX CASEOASA
Should not be removed by oil or hand lotion, because it is a protective layer of the
neonate after birth, and it disappears after birth. Never remove it with alcohol or
cotton balls, unless meconium skinned.

Newborn Assessment

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Maternal and Child Health Nursing

Newborn Assessment

BIRTH MARKS
Telangiectatic nevi (stork bites)
Appear as pale pink or red spots and are frequently found on the eyelids, nose,
lower occipital bone and nape of the neck
These lesions are common in NB w/ light complexions and are more noticeable
during periods of crying. These areas have no clinical significance and usually
fade by the 2nd birthday

Hemangioma is benign vascular tumor that may be present on the newborn

3 types Hemangiomas
1. Nevus Flammeus port wine stain macular purple or dark red lesions seen
on face or thigh. NEVER disappear. Can be removed surgically
2. Strawberry hemangiomas nevus vasculosus dilated capillaries in the
entire dermal or subdermal area. Enlarges, disappears at 10 yo.
3. Cavernous hemangiomas communication network of venules in SQ tissue
that never disappear with age.

Nevus Flammeus (port-wine stain)

A capillary angioma directly below the epidermis, is a non-elevated, sharply

demarcated, red-to-purple area of dense capillaries.
Macular purple
The size & shape vary, but it commonly appears on the face. It does not grow in
size, does not fade in time and does not blanch. The birthmark maybe concealed by
using an opaque cosmetic cream.
If convulsions and other neurologic problem accompany the nevus flammeus,---5th cranial nerve involvement.

Nevus vasculosus (strawberry mark)

A capillary hemangioma, consists of newly formed and enlarged capillaries in the
dermal and subdermal layers.
It is a raised,clearly delineated, dark-red, rough-surfaced birthmark commonly
found in the head region.
Such marks usually grow starting the second or third week of life and may not
reach their fullest size for 1 to 3 months; disappears at the age of 1 yr. but as the
baby grows it enlarges.
Providing appropriate information about the cause and course of birthmarks often
relieves the fears and anxieties of the family. Note any bruises, abrasions,or
birthmarks seen on admission to the nursery.

Newborn Assessment

Abejo

Maternal and Child Health Nursing

Newborn Assessment

GESTATIONAL ASSESSMENT
PARAMETER

BREAST TISSUE
FEMALE GENITALIA

NURSING
ACTION
Fold the pinna
(auricle) forward
Measure it
Observe

MALE GENITALIA

Observe

HEEL CREASES

Observe

EAR

TERM born between

37-42 weeks gestation
Pinna recoils (springs
back)
3 mm
Labia majora cover
labia minora
Scrotal sac very
wrinkled
Extend 2/3 of the way
from the toes to the heel

PRETERM born before 37 weeks

gestation
Pinna opens slowly or stays folded
in very premature infants
Less than 3 mm
Labia minora are more prominent;
vaginal opening can be seen
Fewer shallow rugae on the scrotum
Soles are smoother, creases extend
less than 2/3 of the way from the
toes to the heel

NEWBORN REFLEXES

Immature central nervous system (CNS) of newborn is characterized by variety of reflexes

o Some reflexes are protective, some aid in feeding, others stimulate interaction
o Assess for CNS integration
Protective reflexes are blinking, yawning, coughing, sneezing, drawing back from pain
Rooting and sucking reflexes assist with feeding

What reflexes should be present in a newborn? Reflexes are involuntary movements or actions. Some movements
are spontaneous, occurring as part of the baby's usual activity. Others are responses to certain actions. Reflexes
help identify normal brain and nerve activity. Some reflexes occur only in specific periods of development. The
following are some of the normal reflexes seen in newborn babies

PALMAR GRASP
REFLEX

ROOTING
REFLEX

SUCKING
REFLEX

Newborn Assessment

Newborns fingers curl around the examiners fingers and the newborns toes
curl downward.
The palmar grasp reflex is elicited by placing an object in the palm of a
neonate; the neonate's fingers close around it. This reflex disappears between
ages 6 and 9 months.
Palmar response lessens within 3-4 months
Palmar response lessens within 8 months

The rooting reflex is elicited by stroking the neonate's cheek or stroking near
the corner of the neonate's mouth.
The neonate turns the head in the direction of the stroking, looking for food.
This reflex disappears by 6 weeks.

The sucking reflex is seen when the neonate's lips are touched
Lasts for about 6 months

Abejo

Maternal and Child Health Nursing

Newborn Assessment

MORO REFLEX

Symmetric & bilateral abduction & extension of arms and hands

Thumb & forefinger form a C
EMBRACE reflex
Present at birth, complete response may occur up to 8 weeks
A persistent response lasting more than 6 months may indicate the occurrence
of brain damage during pregnancy

A normal reflex in a young infant caused by a sudden loud noise. It results in drawing
up the legs, an embracing position of the arms, and usually a short cry.

BABINSKI SIGN

Beginning at the heel of the foot, gently stroke upward along the lateral aspect of
the sole; then the examiner moves the fingers along the ball of the foot
The newborns toes hyperextend while the big toe dorsiflexes
Absence of this reflex indicates the need for a neurological examination
The Babinski reflex is elicited by stroking the neonate's foot, on the side of the
sole, from the heel toward the toes.
A neonate will fan his toes, producing a positive Babinski sign, until about age 3
months

STEPPING OR
WALKING
REFLEX

The newborn simulates walking, alternately flexing and extending the feet
The reflex is usually present 3-4 months

TONIC NECK
REFLEX

While the newborn is falling asleep or sleeping, gently and quickly turn the head
to one side
As the newborn faces the left side, the left arm & leg extend outward while the
right arm & leg flex
When the head is turned to the right side, the right arm & leg extend outward while
the left arm & leg flex
Usually disappears within 3-4 months

Newborn Assessment

Abejo

Maternal and Child Health Nursing

Newborn Assessment

CRAWLING

Place the newborn on the abdomen

The newborn begins making crawling movements with the arms and legs
The reflex usually disappears after about 6 weeks

BASIC TEACHING NEEDS OF NEW PARENTS

CORD CARE

Cleanse the cord with alcohol and sometimes triple dye once a day
Keep the area clean and dry
Keep the newborns diaper below the cord to prevent irritation
Signs of infection: redness, drainage, swelling, odor
Notify physician for signs of infection
NOTE:
Note any bleeding or drainage from the cord
Triple dye may be applied for initial cord care because it minimizes
microorganisms and promotes drying; use a cotton-tipped applicator to paint
the dye, one time, on the cord on 1 inch of surrounding skin
Application of 70% isopropyl alcohol to the cord with each diaper change and
at least two r three times a day to minimize microorganisms and promote
drying.
NOTE: The skin is surrounded with alcohol which promotes drying and cleans the area.
The umbilical cord dries and falls off about 14 days. Peroxide and lanolin promote
moisture, which can inhibit drying and allow growth of bacteria. Water doesnt
promote drying.
It is best to care for the neonates umbilical cord area by cleaning it with cotton
pledgets moistened with alcohol. The alcohol promotes drying and helps decrease the
risk of infection. An antibiotic ointment maybe used instead of alcohol, because there
are a lot of bacteria which is resistant against some bacteria. Other agents such as
wipes, sterile water and soap & water are not as effective as alcohol.

CIRCUMCISION
CARE
BONDING

Observe for bleeding, first urination

Apply diaper loosely to prevent irritation
Notify physician for signs of infection
Encourage parent to talk to, hold, and sing to infant
Promotes skin-to-skin contact between parent and infant
Feedings are opportunities for parent-infant bonding
Notify physician for signs of infection
NOTE: Sense of Touch
The most highly developed sense at birth that is why, neonates responds well to
touch.

Newborn Assessment

Abejo

Maternal and Child Health Nursing

Newborn Assessment

PRE TERM INFANT ( PREMATURE INFANT)

Definition

PRE TERM INFANT

A neonate born before 38 weeks age of gestation

Synonym

Low birth weight

Contributing factors

Cardinal signs

Low socioeconomic level

Poor nutritional status
Lack of pre natal care
Multiple pregnancy
Prior previous early birth
Race (non whites have a higher incidence of prematurity than
whites)
Cigarette smoking
The age of the mother ( the highest incidence is in mothers
younger than age 20.)
Order of birth ( early termination is highest in first pregnancies
and in those beyond the forth )
Closely spaced pregnancies
Abnormalities of the reproductive system such as intrauterine
septum
Infections ( specially urinary tract infections)
Obstetric complications such as premature rupture of membranes
or premature separation of the placenta
Early induction of labor
Elective cesarian birth
Appears small and underdeveloped
The head is disproportionately large ( 3 cm or more greater than
chest size)
Skin is thin with visible blood vessel and minimal subcutaneous
fat pads
Vernix caseosa is absent
Both anterior and posterior fontanelles are small

Abnormal laboratory values

Decreased RBCs
Decreased serum glucose
Increased concentration of indirect bilirubin
Decreased serum albumin
NOTE:
The normal range of urine output for a preterm
baby is 1 to 2ml/kg/day. The normal specific gravity for a
preterm baby is 1.020. The normal range for blood glucose
level in a preterm baby is 40 to 60 mg/dl.

Best procedure

Resuscitation
NOTE: resuscitation becomes important for infant who fails to
take first breath or difficulty maintaining adequate
respiratory movements on his own.

Newborn Assessment

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Maternal and Child Health Nursing

Newborn Assessment

Best position

Suctioning
NOTE: allows removing mucus and prevents aspiration of any
mucus and amniotic fluid present in the mouth and
nose of the newborn to establish clear airway.

Intubations
NOTE: head of the infant in neutral position with towel under
shoulder.

Positioning the infant on the back with the head of the mattress
elevated approximately 15 degrees to allow abdominal contents to
fall away from the diaphragm affording optimal breathing space.

Best position for suctioning:

Infant on the back and slide a folded towel or pad under shoulders
to rise, head is in neutral position.

Anemia of prematurity
Hyperbilirubinemia/ kernicterus
Persistent patent ductus arteriosus
Periventricular / intraventricular hemorrhage
Respiratory distress syndrome
Retinopathy of prematurity
Retrolental fibroplasias are a complication that occurs if the
infant is overexposed to high oxygen levels.
Necrotizing enterocolitis

Bedside equipment

Preterm size laryngoscope

ET tube
Suction catheter with synthetic surfactant
Isolettes (incubator)

Drug study

1.

Naloxone (Narcan)
Nature of the drug:
Narcotic antagonist
Side effects:
Hypertension, irritability, tachycardia

2.

Surfactan ( Survanta)
Nature of the drug:
Lung surfactant to improve lung compliance
Side effect:
Transient bradycardia, rales

3.

Vitamin K (Aquamephyton)
Use for prophylaxis to treat hemorrhagic disease of the
newborn.
Side effects:
Hyperbilirubinuria

4.

Eye prophylaxis
(Erythromycin 0.5% Ilotycin, Tetracycline 1%
Silver Nitrate 1% ( not already used causes chemical
conjunctivitis)
Prophylactic measure to protect against Neisseria
gonorrhoeae and Chlamydia trachomatis
Side effects:
Silver nitrate can cause chemical conjuctivitis

Complications

Nursing diagnosis

1.
2.

Newborn Assessment

Impaired gas exchange related to immature pulmonary

functioning
Risk for fluid volume deficit related to insensible water loss at
birth and small stomach capacity
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Maternal and Child Health Nursing

Newborn Assessment

3.
4.

5.
6.

Nursing intervention

Newborn Assessment

Risk for aspiration related to weak or absent gag reflex a nd/or

administration of tube feedings
Hypothermia related to lack of subcutaneous and brown fat
deposits, inadequate shiver response, immature
thermoregulation center, large body surface area in relation to
body weight, and/or lack of flexion of extremities toward the
body.
Risk for infection related to immature immune response, stasis of
respiratory secretions, and/ or aspiration
Imbalanced nutrition: less than body requirements related to
lack of energy to suck and/or weak or absent sucking reflex
The nurses first priority in preparing a safe environment for a
preterm newborn with low Apgar scores is to prepare
respiratory resuscitation equipment. Airway maintenance is the
first priority.
Give the mother oxygen by mask during the birth to provide the
preterm infant with optimal oxygen saturation at birth ( 85-90%).
Keeping maternal analgesia and anesthesia to a minimum also
offers the infant the best chance of initiating effective respiration.
Bedside larngyoscope, endotracheal tube, suction catethers and
synthetic surfactant to be administered by the endotracheal tube.
Infant must be kept warm during resuscitation procedures so he
or she is not expending extra energy to increase the metabolic
rate to maintain body temperature.
Observe for changes in respirations, color and vital signs
Check efficacy of Isolette: maintain heat, humidity and oxygen
concentration, administer oxygen only if necessary
Maintain aseptic technique to prevent infection
Adhere to the techniques of gavage feeding for safety of infant
Observe weight-gain patterns
Determine blood gases frequently to prevent acidosis. Institute
phototherapy when hyperbilirubinemia occurs
Support parents by letting them verbalize and ask questions to
relieve anxiety.
Provide liberal visiting hours for parents, allow them to
participate in care.
Arrange follow-up before and after discharge by a visiting nurse.

Abejo

Maternal and Child Health Nursing

Newborn Assessment

POST TERM INFANT

POST TERM INFANT

A neonate born after 42 weeks age of gestation

Definition

Contributing factors

Classic signs

Intrauterine weight loss, dehydrations and chronic hypoxia old

man faces
Long & thin with cracked skin which is loose, wrinkled and
strained greenish yellow, with no vernix nor lanugo
Long nails with firm skull
Wide eyed alertness of one month old baby

Increased total no. of RBCs

Increased hematocrit level
Decreased serum glucose

Sonogram

Resuscitation
NOTE: resuscitation becomes important for infant who fails to take
first breath or difficulty maintaining adequate respiratory
movements on his own.

Suctioning
NOTE: allows removing mucus and prevents aspiration of any
mucus and amniotic fluid present in the mouth and nose of the
newborn.
To establish clear airway.

Intubations
NOTE: head of the infant in neutral position with towel under
shoulder.

Positioning the infant on the back with the head of the mattress
elevated approximately 15 degrees to allow abdominal contents

Meconium aspiration syndrome

Respiratory distress syndrome

Abnormal
values

laboratory

Screening test

Best procedure

Best position

Complications

Low socioeconomic level

Poor nutritional status
Lack of pre natal care
Multiparous mothers
Cigarette smoking
The age of the mother (the highest incidence is in mothers younger
than age 20.)
Mothers with diabetes mellitus
Congenital abnormalities such as omphalocele.
Body is covered with lanugo
Old man facies

NOTE: Post mature neonates have difficulty maintaining glucose

reserves. Other common problems include Meconium aspiration
syndrome, polycythemia, congenital anomalies, seizure activity and cold
stress.
NOTE: The infant who are exposed to high blood-glucose levels in
utero may experience rapid and profound hypoglycemia after birth
because of the cessation of a high in-utero glucose load. The small-forgestational-age infant has use up glycogen stores as a result of
intrauterine malnutrition and has blunted hepatic enzymatic response
with which to carry out gluconeogenesis.

Newborn Assessment

Abejo

Maternal and Child Health Nursing

Newborn Assessment

NOTE: The patient with post-term pregnancy is at high risk for

decreased placental functioning, therefore increasing the risk of
inadequate oxygen circulation to the fetus

Bedside equipment

ET tube
Suction catheter

Drug study
1. Vitamin K (Aquamephyton)
Use for prophylaxis to treat hemorrhagic disease of the newborn
Side effects:
Hyperbilirubinuria
2. Eye prophylaxis
(Erythromycin 0.5% Ilotycin, Tetracycline 1% Silver Nitrate 1%
Prophylactic measure to protect against Neisseria gonorrhoeae and
Chlamydia trachomatis
Side effects:
Silver nitrate can cause chemical conjuctivitis
Nursing diagnoses

Nursing interventions

1. Ineffective airway breathing

2. Risk for fluid volume deficit related to insensible water loss at birth
3. Ineffective infant feeding pattern

Assess newborns respiratory rate, depth and rhythm. Auscultate

lung sound.
Note: Meconium stained syndrome of POST MATURE neonates
Aspiration of meconium is best prevented by suctioning the neonates
nasopharynx immediatelt after the head is delivered and before the
shoulders and chest are delivered. As long as the chest is
compressed in the vagina, the infant will not inhale and aspirate
meconium in the upper respiratory tract. Meconium aspiration
blocks the air flow to the alveoli, leading to potentially life
threatening respiratory complications.

Suction every 2 hours or more often as necessary

Position newborn on side or back with the neck slightly extended
Administer O2, anticipate the need for CPAP or PEEP
Continue to assess the newborns respiratory status closely.
Encourage as much parental participation in the newborns care as
condition allows
Administer IV fluids after birth to provide Glucose to prevent
hypoglycemia, monitor closely the infusion rate.
Kept the infant under a radiant heat warmer to preserve energy
Monitor babys weight, serum electrolytes and ensure adequate
fluid intake
Measure urine output by weighing diapers
Check for blood stools to evaluate for possible bleeding from
intestinal tract.
Keep a restful environment.
Anticipate the infants need to be breastfeed
Demonstrate technique for feeding to mother, note proper
positioning of the infant, latching on technique, rate of delivery
of feeding and frequency of burping
Provide a relaxed environment during feeding
Adjust frequency and amount of feeding according to infants
response
Alternate feeding procedure (nipple and gavage feeding) according
to infants ability.
Monitor mothers effort, provide feedback and assistance as needed
Suggest mother to monitor infants weight periodically

Newborn Assessment

Abejo