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

5 – 21 inch or 47.take it once only.46 to 54 cms (19 . bulging and tense fontanel 3. give 2 breathsambu bag  1 yr old. atretic – no anal opening 2. projective vomiting.)  Length range . increase BP and widening pulse pressure 4.5 – 53. 13 oz.4000 gms (5 lbs.21 inches)  Normal length.newborn – to rule out imperforate Anus .lazy eyes 7. 1 inch insertion Imperforate anus 1. abnormally large head 2.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 .sure sign of cerebral irritation 6. high deviation – diplopia – sign of ICP older child a.>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.normal eye deviation b. 4-6 months. . If absent COA  Respiration .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 .Maternal and Child Health Nursing Newborn Assessment Newborn Assessment and Nursing Care Temperature .respirations > 60 Persistent irregular breathing Excessive mucus Persistant fine crackles Stridor Breathing ( ventilating the lungs)  check for breathlessness  if breathless. membranous – has opening Earliest sign: 1.mouth to mouth.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 36.35 cm or 13 – 14 “ Hydrocephalus . no mecomium 2. 8oz. High pitch shrill cry-late sign of ICP Newborn Assessment Abejo . abd destention 3. Decreased RR. foul odor breath 4. decreased PR 5.75cm. >6 months. vomitous of fecal matter 5.range 36. stenos – has opening 4. agenetialism – no genital 3.5 Temp: rectal. 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 . If present PDA Femoral pulse – normal present. average 50 cm  Head circumference 33.8 lbs. 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 .19.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.

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

(18-22 inches) HEAD Head circumference = 33-35 cm (2-3 cm.7 – 55.Maternal and Child Health Nursing Newborn Assessment HEPATIC Liver responsible for changing Hgb into conjugated bilirubin. 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. and unable to shiver to increase body heat. 13 oz.asymmetry of head as a result of pressure in birth cana Newborn Assessment Abejo . 8oz.9 cm. 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.Increased metabolic rate and activity Axillary temperature: 96. giving a jaundiced or yellow appearance to these tissues HEAT PRODUCTION in newborn accomplished by: a. Metabolism of “ BROWN FAT” . which is further changed into conjugated (water soluble) bilirubin that can be excreted Excess unconjugated bilirubin can permeate the sclera and the skin.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.) Length= 45.A special structure in NB is a source of heat . – 8 lbs.

permanent color established w/in 3-12 mos.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 .Maternal and Child Health Nursing Newborn Assessment EYES Blue/ gray d/t scleral thinness. Lacrimal glands immature at birth. NOSE MOUTH Nose breathers for first few months of life Scant saliva with pink lips Epstein’s Pearls . 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. 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. Unequal size should be reported immediately. This indicates that the light is shining onto the retina.

in cord. thin cord may be associated with poor fetal growth Assess for intact cord.Maternal and Child Health Nursing Newborn Assessment ABDOMEN Cylindrical with some protrusion. 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. 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. 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 . if fewer than three vessels are noted notify the physician Small. when thighs are rotated outward. two arteries and one vein.

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

Cause is unknown and no treatment necessary Acrocyanosis versus Central Cyanosis  Acrocyanosis involves the extremities of the neonate.  Central cyanosis. VERNIX CASEOASA Should not be removed by oil or hand lotion. Milia are blocked sebaceous glands located on the chin and the nose of the infant. tongue and trunk indicating HYPOXIA which needs further assessment by the nurse. and it disappears after birth. and consist of a white or pale yellow papule or pustule w/ an erythematous base. Newborn Assessment Abejo . 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. which involves the lips. Never remove it with alcohol or cotton balls. usually over the trunk and diaper area and is frequently widespread. The peak incidence is 24-48 hours of life.Maternal and Child Health Nursing Newborn Assessment Erythema toxicum       Is an eruption of lesions in the area surrounding a hair follicle that are firm. . because it is a protective layer of the neonate after birth. 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.

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

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. vaginal opening can be seen Fewer shallow rugae on the scrotum Soles are smoother. sneezing. yawning. Others are responses to certain actions. 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. The neonate turns the head in the direction of the stroking. Some reflexes occur only in specific periods of development. 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. others stimulate interaction o Assess for CNS integration Protective reflexes are blinking. This reflex disappears between ages 6 and 9 months. Reflexes help identify normal brain and nerve activity.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. coughing. 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 . occurring as part of the baby's usual activity. The palmar grasp reflex is elicited by placing an object in the palm of a neonate. looking for food. some aid in feeding. the neonate's fingers close around it. 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.

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

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

The normal range for blood glucose level in a preterm baby is 40 to 60 mg/dl. The normal specific gravity for a preterm baby is 1.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.) 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. Cardinal signs Abnormal laboratory values      Best procedure  Newborn Assessment Abejo .020. Resuscitation NOTE: resuscitation becomes important for infant who fails to take first breath or difficulty maintaining adequate respiratory movements on his own.

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. tachycardia Surfactan ( Survanta) Nature of the drug:  Lung surfactant to improve lung compliance Side effect:  Transient bradycardia. Newborn Assessment . irritability. head is in neutral position. rales Vitamin K (Aquamephyton)  Use for prophylaxis to treat hemorrhagic disease of the newborn. 3. 2.5% Ilotycin. Intubations NOTE: head of the infant in neutral position with towel under shoulder. 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.  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. Best position for suctioning:  Infant on the back and slide a folded towel or pad under shoulders to rise. Necrotizing enterocolitis Bedside equipment Preterm size laryngoscope ET tube Suction catheter with synthetic surfactant Isolettes (incubator) Drug study 1.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. Naloxone (Narcan) Nature of the drug:  Narcotic antagonist Side effects:  Hypertension. Nursing diagnosis 1. Side effects:  Hyperbilirubinuria Eye prophylaxis (Erythromycin 0.

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

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. Suctioning NOTE: allows removing mucus and prevents aspiration of any mucus and amniotic fluid present in the mouth and nose of the newborn. dehydrations and chronic hypoxia “old man faces’ Long & thin with cracked skin which is loose. seizure activity and cold stress. wrinkled and strained greenish yellow. 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. with no vernix nor lanugo Long nails with firm skull Wide eyed alertness of one month old baby Increased total no. To establish clear airway. congenital anomalies.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. Other common problems include Meconium aspiration syndrome. 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. 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.) Mother’s with diabetes mellitus Congenital abnormalities such as omphalocele. polycythemia. Intubations NOTE: head of the infant in neutral position with towel under shoulder. Body is covered with lanugo Old man facies Intrauterine weight loss. Newborn Assessment Abejo .

depth and rhythm. anticipate the need for CPAP or PEEP Continue to assess the newborn’s respiratory status closely. 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. Meconium aspiration blocks the air flow to the alveoli. Risk for fluid volume deficit related to insensible water loss at birth 3. Vitamin K (Aquamephyton)  Use for prophylaxis to treat hemorrhagic disease of the newborn Side effects:  Hyperbilirubinuria 2. Auscultate lung sound. 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. Ineffective infant feeding pattern  Assess newborn’s respiratory rate. Kept the infant under a radiant heat warmer to preserve energy Monitor baby’s weight. the infant will not inhale and aspirate meconium in the upper respiratory tract. Keep a restful environment. note proper positioning of the infant. provide feedback and assistance as needed Suggest mother to monitor infants weight periodically Nursing interventions                   Newborn Assessment Abejo . therefore increasing the risk of inadequate oxygen circulation to the fetus   Bedside equipment ET tube Suction catheter Drug study 1.Maternal and Child Health Nursing Newborn Assessment NOTE: The patient with post-term pregnancy is at high risk for decreased placental functioning.5% Ilotycin. As long as the chest is compressed in the vagina. leading to potentially life threatening respiratory complications. Encourage as much parental participation in the newborn’s care as condition allows Administer IV fluids after birth to provide Glucose to prevent hypoglycemia. Suction every 2 hours or more often as necessary Position newborn on side or back with the neck slightly extended Administer O2. Monitor mother’s effort. 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. “latching on” technique. monitor closely the infusion rate. Anticipate the infants need to be breastfeed Demonstrate technique for feeding to mother. Ineffective airway breathing 2. 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. Eye prophylaxis (Erythromycin 0.

Sign up to vote on this title
UsefulNot useful