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 .19. 8oz.>14” Chest 31 – 33 cm or 12 – 13” Abd 31 – 33 cm or 12 – 13”  Cardiac rate: 120 – 160 bpm newborn Apical pulse – left lower nipple Radial pulse – normally absent. stenos – has opening 4.range 36. foul odor breath 4. 13 oz. decreased PR 5. 1 inch insertion Imperforate anus 1.5 – 53. bulging and tense fontanel 3.newborn – to rule out imperforate Anus . If present PDA Femoral pulse – normal present.5 Temp: rectal.8 lbs. >6 months. increase BP and widening pulse pressure 4.5 – 21 inch or 47.mouth to mouth.75cm. agenetialism – no genital 3. 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 .normal eye deviation b. give 2 breathsambu bag  1 yr old. abd destention 3. . abnormally large head 2. High pitch shrill cry-late sign of ICP Newborn Assessment Abejo . 4-6 months.lazy eyes 7. If absent COA  Respiration . vomitous of fecal matter 5.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 Signs of increased ICP 1.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 . projective vomiting.4000 gms (5 lbs.sure sign of cerebral irritation 6. atretic – no anal opening 2. Decreased RR.take it once only.33 to 35 cm  Expected findings  Head should be 2 to 3 cms larger than the chest  Abdominal circumference – 31-33 cm  Weight range .46 to 54 cms (19 . average 50 cm  Head circumference 33.)  Length range .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. membranous – has opening Earliest sign: 1.2500 . 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        Tachypnea . high deviation – diplopia – sign of ICP older child a.respirations > 60 Persistent irregular breathing Excessive mucus Persistant fine crackles Stridor Breathing ( ventilating the lungs)  check for breathlessness  if breathless.35 cm or 13 – 14 “ Hydrocephalus . no mecomium 2.21 inches)  Normal length.

Usually. or occurs during or immediately after feeding. brownish green in color After 3 days MILK STOOLS are usually passed a. 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. BP 73/55 mmHg PERIPHERAL CIRCULATION acrocyanosis within 24 hours RBC high immediately after birth. tarry residue from lower intestine . At age4-6 months.Newborns may nurse vigorously immediately afterbirth or may need as long as several days to suck effectively . looks like curdled milk due to HCL.p. 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 IMMATURE CARDIAC SPHINCTER – may allow reflux of food.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. an infant should begin to receive solid food foods one at a time and 1 week apart.m. MILK STOOLS for FORMULATED FED. FIRST STOOL is MECONIUM . MILK STOOLS for BF infant – loose and golden yellow b. burped. 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.Black. Insert nipple well to mouth FEEDING PATTERS vary . 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.placed NB right side after feeding Newborn can’t move food from lips to pharynx.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. while regurgitation has no sour odor or curdling of milk. with a sour odor. IMPORTANT CONSIDERATIONS: Breastfeeding can usually begin immediately after birth.Usually passed within 12-24 hours after birth If the amniotic fluid shows evidence of meconium staining.formed and pale yellow RESPIRATORY STATUS DIGESTIVE SYSTEM Newborn Assessment Abejo . but anatomic or permanent closure may take several months HEART RATE averages 140 b. REGURGITATE. TRANSITIONAL STOOLS thin. falls after 1 st week ABSENCE/ NORMAL FLORA INTESTINE Vitamin K Adequate levels of surfactants (Lecithin and spingomyelin) ensure mature lung function.

Metabolism of “ BROWN FAT” .) Length= 45. 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. 8oz.A special structure in NB is a source of heat .7 – 55.asymmetry of head as a result of pressure in birth cana Newborn Assessment Abejo .8 to 99F Newborn can’t 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. – 8 lbs.Increased metabolic rate and activity Axillary temperature: 96. giving a jaundiced or yellow appearance to these tissues HEAT PRODUCTION in newborn accomplished by: a.9 cm. which is further changed into conjugated (water soluble) bilirubin that can be excreted Excess unconjugated bilirubin can permeate the sclera and the skin. the lambdoid suture separates the two parietal bones and the occipital bone Molding. (18-22 inches) HEAD Head circumference = 33-35 cm (2-3 cm. 13 oz. NB’s 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 TEMPERATURE 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.Maternal and Child Health Nursing Newborn Assessment HEPATIC Liver responsible for changing Hgb into conjugated bilirubin.

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.Maternal and Child Health Nursing Newborn Assessment EYES Blue/ gray d/t scleral thinness. tearless cry up to 2 months Absence of tears is common because the neonate’s tear glands are not yet fully developed Transient strabismus Doll’s eye reflex persist for about ten days Red Reflex: A red circle on the pupils seen when an ophthalmoscope’s light is shining onto the retina is a normal finding. Lacrimal glands immature at birth.small shiny white specks on the neonate’s gums and hard palate which are normal EARS NECK CHEST Incurving of pinna and cartilage deposition Short and weak with deep fold of skin 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 . permanent color established w/in 3-12 mos. NOSE MOUTH Nose breathers for first few months of life Scant saliva with pink lips Epstein’s Pearls . Unequal size should be reported immediately. This indicates that the light is shining onto the retina.

two arteries and one vein. and ensure that damp is cured Cord should be clamped for at least the first 4 hours after birth. thin cord may be associated with poor fetal growth Assess for intact cord. 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. if fewer than three vessels are noted notify the physician Small. when thighs are rotated outward.Maternal and Child Health Nursing Newborn Assessment ABDOMEN Cylindrical with some protrusion. 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. 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 Abejo . in cord.

Maternal and Child Health Nursing Newborn Assessment Polydactyl SPINE Syndactyl 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) Assessment for Jaundice The #1 technique is to blanch the skin over the bony prominence such as the forehead. SKIN Harlequins Sign Occurs on one side of the body turns deep red color. which are the last to be jaundiced. arms shoulders or other areas. Newborn Assessment Abejo . oxytocin induction. while those on the other side of the body dilate. It occurs when blood vessels on one side constrict. blue or black marks that are frequently found on the sacral area. spreads to the chest. NOTE: Jaundice starts at the head first. followed by the hands and feet. then the arms and legs. chest or tip of the nose. Mongolian Spots Gary. and severe hemolytic process. Jaundice in the first 24 hours after the birth is a cause for concern that requires further assessment. then the abdomen. Possible causes of early jaundice are blood incompatibility. buttocks.

and it disappears after birth. VERNIX CASEOASA Should not be removed by oil or hand lotion. . because it is a protective layer of the neonate after birth. Never remove it with alcohol or cotton balls. tongue and trunk indicating HYPOXIA which needs further assessment by the nurse. usually over the trunk and diaper area and is frequently widespread.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. 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. Milia are blocked sebaceous glands located on the chin and the nose of the infant. Cause is unknown and no treatment necessary Acrocyanosis versus Central Cyanosis  Acrocyanosis involves the extremities of the neonate. The peak incidence is 24-48 hours of life. The lesions do not appear on the palms of the hands or soles of the feet. unless meconium skinned. It is often called “newborn rash” or “flea-bite” dermatitis The rash may appear suddenly. Newborn Assessment Abejo . and consist of a white or pale yellow papule or pustule w/ an erythematous base. which involves the lips.

 Providing appropriate information about the cause and course of birthmarks often relieves the fears and anxieties of the family. is a non-elevated. Nevus Flammeus – port wine stain – macular purple or dark red lesions seen on face or thigh. Can be removed surgically 2. abrasions. Newborn Assessment Abejo . Enlarges. If convulsions and other neurologic problem accompany the nevus flammeus. rough-surfaced birthmark commonly found in the head region. consists of newly formed and enlarged capillaries in the dermal and subdermal layers. red-to-purple area of dense capillaries. but it commonly appears on the face. but as the baby grows it enlarges. 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. Macular purple The size & shape vary. Strawberry hemangiomas – nevus vasculosus – dilated capillaries in the entire dermal or subdermal area. dark-red.or birthmarks seen on admission to the nursery. NEVER disappear.---5th cranial nerve involvement. 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. The birthmark maybe concealed by using an opaque cosmetic cream. 3.clearly delineated. does not fade in time and does not blanch. Nevus vasculosus (strawberry mark)  A capillary hemangioma. nose. Note any bruises. It does not grow in size. sharply demarcated.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. disappears at 10 yo.  It is a raised. disappears at the age of 1 yr. Nevus Flammeus (port-wine stain)     A capillary angioma directly below the epidermis. Cavernous hemangiomas – communication network of venules in SQ tissue that never disappear with age.  Such marks usually grow starting the second or third week of life and may not reach their fullest size for 1 to 3 months.

the neonate's fingers close around it. Reflexes help identify normal brain and nerve activity. some aid in feeding. sneezing. looking for food. 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. Others are responses to certain actions.Maternal and Child Health Nursing Newborn Assessment GESTATIONAL ASSESSMENT PARAMETER EAR BREAST TISSUE FEMALE GENITALIA MALE GENITALIA HEEL CREASES NURSING ACTION Fold the pinna (auricle) forward Measure it Observe Observe Observe ‘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. yawning. vaginal opening can be seen Fewer shallow rugae on the scrotum Soles are smoother. others stimulate interaction o Assess for CNS integration Protective reflexes are blinking. coughing. occurring as part of the baby's usual activity. Some movements are spontaneous. The neonate turns the head in the direction of the stroking. Some reflexes occur only in specific periods of development. The following are some of the normal reflexes seen in newborn babies””   Newborn’s fingers curl around the examiner’s fingers and the newborn’s toes curl downward. 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. The palmar grasp reflex is elicited by placing an object in the palm of a neonate. This reflex disappears by 6 weeks. SUCKING REFLEX   The sucking reflex is seen when the neonate's lips are touched Lasts for about 6 months Newborn Assessment Abejo . This reflex disappears between ages 6 and 9 months. Palmar response lessens within 3-4 months Palmar response lessens within 8 months PALMAR GRASP REFLEX ROOTING REFLEX    The rooting reflex is elicited by stroking the neonate's cheek or stroking near the corner of the neonate's mouth.

 A neonate will fan his toes. from the heel toward the toes. It results in drawing up the legs. then the examiner moves the fingers along the ball of the foot  The newborn’s 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. gently and quickly turn the head to one side  As the newborn faces the left side. BABINSKI’ SIGN  Beginning at the heel of the foot.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. on the side of the sole. and usually a short cry. the right arm & leg extend outward while the left arm & leg flex  Usually disappears within 3-4 months Newborn Assessment Abejo . 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. an embracing position of the arms. producing a positive Babinski sign. until about age 3 months STEPPING OR WALKING REFLEX  The newborn simulates walking. gently stroke upward along the lateral aspect of the sole. the left arm & leg extend outward while the right arm & leg flex  When the head is turned to the right side.

It is best to care for the neonate’s umbilical cord area by cleaning it with cotton pledgets moistened with alcohol. use a cotton-tipped applicator to paint the dye. sterile water and soap & water are not as effective as alcohol. drainage. The umbilical cord dries and falls off about 14 days. first urination Apply diaper loosely to prevent irritation Notify physician for signs of infection Encourage parent to talk to. Other agents such as wipes.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 newborn’s diaper below the cord to prevent irritation Signs of infection: redness. neonates responds well to touch. 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. Newborn Assessment Abejo . 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. Peroxide and lanolin promote moisture. The alcohol promotes drying and helps decrease the risk of infection. NOTE: The skin is surrounded with alcohol which promotes drying and cleans the area. Water doesn’t promote drying. An antibiotic ointment maybe used instead of alcohol. because there are a lot of bacteria which is resistant against some bacteria. swelling. which can inhibit drying and allow growth of bacteria. one time. 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. CIRCUMCISION CARE BONDING Observe for bleeding. hold.

The normal range for blood glucose level in a preterm baby is 40 to 60 mg/dl.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 Low birth weight                     Synonym Contributing factors 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 mother’s younger than age 20. The normal specific gravity for a preterm baby is 1. Cardinal signs Abnormal laboratory values      Best procedure  Newborn Assessment Abejo . Resuscitation NOTE: resuscitation becomes important for infant who fails to take first breath or difficulty maintaining adequate respiratory movements on his own.020.) 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 Decreased RBC’s 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.

head is in neutral position. tachycardia Surfactan ( Survanta) Nature of the drug:  Lung surfactant to improve lung compliance Side effect:  Transient bradycardia.5% Ilotycin. Intubations NOTE: head of the infant in neutral position with towel under shoulder. Nursing diagnosis 1. Best position for suctioning:  Infant on the back and slide a folded towel or pad under shoulders to rise. Side effects:  Hyperbilirubinuria Eye prophylaxis (Erythromycin 0. rales Vitamin K (Aquamephyton)  Use for prophylaxis to treat hemorrhagic disease of the newborn. 4.            Complications 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. irritability. 3.Maternal and Child Health Nursing Newborn Assessment  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. Newborn Assessment . 2. 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. 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 Impaired gas exchange related to immature pulmonary functioning Risk for fluid volume deficit related to insensible water loss at birth and small stomach capacity Abejo 2.  Best position  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.

Institute phototherapy when hyperbilirubinemia occurs Support parents by letting them verbalize and ask questions to relieve anxiety. Bedside larngyoscope. Risk for infection related to immature immune response. inadequate shiver response. humidity and oxygen concentration. Keeping maternal analgesia and anesthesia to a minimum also offers the infant the best chance of initiating effective respiration. immature thermoregulation center. Nursing intervention Newborn Assessment Abejo . color and vital signs Check efficacy of Isolette: maintain heat. and/or lack of flexion of extremities toward the body. suction catethers and synthetic surfactant to be administered by the endotracheal tube. 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. stasis of respiratory secretions.Maternal and Child Health Nursing Newborn Assessment 3. Observe for changes in respirations. Provide liberal visiting hours for parents. 4. endotracheal tube. 5. Give the mother oxygen by mask during the birth to provide the preterm infant with optimal oxygen saturation at birth ( 85-90%). 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. Airway maintenance is the first priority. large body surface area in relation to body weight. 6. Arrange follow-up before and after discharge by a visiting nurse. allow them to participate in care. and/ or aspiration Imbalanced nutrition: less than body requirements related to lack of energy to suck and/or weak or absent sucking reflex The nurse’s first priority in preparing a safe environment for a preterm newborn with low Apgar scores is to prepare respiratory resuscitation equipment. 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.

Other common problems include Meconium aspiration syndrome. Body is covered with lanugo Old man facies Intrauterine weight loss.Maternal and Child Health Nursing Newborn Assessment POST TERM INFANT Definition POST TERM INFANT  A neonate born after 42 weeks age of gestation           Low socioeconomic level Poor nutritional status Lack of pre natal care Multiparous mother’s Cigarette smoking The age of the mother (the highest incidence is in mother’s younger than age 20.) Mother’s with diabetes mellitus Congenital abnormalities such as omphalocele. 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. dehydrations and chronic hypoxia “old man faces’ Long & thin with cracked skin which is loose. polycythemia. Positioning the infant on the back with the head of the mattress elevated approximately 15 degrees to allow abdominal contents Best procedure    Best position   Complications Meconium aspiration syndrome Respiratory distress syndrome NOTE: Post mature neonates have difficulty maintaining glucose reserves. Intubations NOTE: head of the infant in neutral position with towel under shoulder. To establish clear airway. Newborn Assessment Abejo . 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. congenital anomalies. Suctioning NOTE: allows removing mucus and prevents aspiration of any mucus and amniotic fluid present in the mouth and nose of the newborn. of RBC’s Increased hematocrit level Decreased serum glucose Contributing factors Classic signs     Abnormal values laboratory      Screening test Sonogram Resuscitation NOTE: resuscitation becomes important for infant who fails to take first breath or difficulty maintaining adequate respiratory movements on his own. 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. seizure activity and cold stress.

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. provide feedback and assistance as needed Suggest mother to monitor infants weight periodically Nursing interventions                   Newborn Assessment Abejo . Monitor mother’s effort. As long as the chest is compressed in the vagina. Ineffective infant feeding pattern  Assess newborn’s respiratory rate. Encourage as much parental participation in the newborn’s care as condition allows Administer IV fluids after birth to provide Glucose to prevent hypoglycemia. therefore increasing the risk of inadequate oxygen circulation to the fetus   Bedside equipment ET tube Suction catheter Drug study 1. Kept the infant under a radiant heat warmer to preserve energy Monitor baby’s weight. Anticipate the infants need to be breastfeed Demonstrate technique for feeding to mother. 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 1. monitor closely the infusion rate. Auscultate lung sound. Vitamin K (Aquamephyton)  Use for prophylaxis to treat hemorrhagic disease of the newborn Side effects:  Hyperbilirubinuria 2. Ineffective airway breathing 2. note proper positioning of the infant. “latching on” technique. Suction every 2 hours or more often as necessary Position newborn on side or back with the neck slightly extended Administer O2. the infant will not inhale and aspirate meconium in the upper respiratory tract. 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. anticipate the need for CPAP or PEEP Continue to assess the newborn’s respiratory status closely. Risk for fluid volume deficit related to insensible water loss at birth 3. Meconium aspiration blocks the air flow to the alveoli.Maternal and Child Health Nursing Newborn Assessment NOTE: The patient with post-term pregnancy is at high risk for decreased placental functioning. Keep a restful environment. leading to potentially life threatening respiratory complications. Eye prophylaxis (Erythromycin 0.5% Ilotycin. Note: Meconium stained syndrome of POST MATURE neonates Aspiration of meconium is best prevented by suctioning the neonate’s nasopharynx immediatelt after the head is delivered and before the shoulders and chest are delivered. depth and rhythm.