NEWBORN CARE (continuation) SILVERMAN-ANDERSEN INDEX

1. IMMEDIATE ASSESSMENT OF THE - An assessment of respiratory function is a

NEWBORN priority = ongoing assessment

APGAR
 Dr. Virginia Apgar
 Taken on 1st and 5th minutes at birth
 1st minute – neonate’s initial adaptation to
extrauterine life and necessity for
resuscitation
 5th minute – more reliable picture of
neonate’s overall status
MUSCLE TONE (ACTIVITY) – resistance to
extension
HEART RATE (PULSE RATE) – apical pulse or
pulsation from umbilical cord
REFLEX IRRITABILITY (GRIMACE)– suction
catheter; slapping of the soles of the Feet
COLOR (APPERANCE) – Pink; *acrocyanosis ASSESSMENT OF GESTATIONAL MATURITY
RESPIRATORY EFFORT – regular at 1 minute;  Not routinely done = UTZ
*analgesia / anesthetic  Ballad or Dubowits Assessment Scale
 Page 439 book
INTERPRETATION OF APGAR RESULT:
 Total score has corresponding age in weeks
0-3 = baby is in serious danger and needs
PROPER IDENTIFICATION OF NEWBORN
immediate resuscitation
FOOT PRINT
4-6 = the baby’s condition is guarded and may
need more extensive clearing of the airways and  The infant’s foot should be clean and dry
supplementary oxygen and must be pressed firmly on the ink pad
and then gently on the footprint from
7-10 = is considered good and in the best possible
beginning in the heel (upward motion)
health
ID BRACELETS

 Mother’s full name

 Date and time of delivery
 Hospital or admission number that
corresponds with the mother
 Gender of the baby
DOCUMENT IN THE BIRTH RECORD
 Time of birth
 Time the infant breastfed
 Whether respirations were spontaneous or
aided
 APGAR score at 1 and 5 minutes
 Whether eye prophylaxis and Vit. K were
given

CJBS KBBS BSN 2-C

  General condition of the infant
 Number of vessels in umbilical cord
 Whether cultures were taken (lab)
 Whether the infant voided and passed a
stool
PROBLEMS FOR NEWBORN
 Risk for Ineffective Thermoregulation
r/t newborn’s Transition to
extrauterine life
- Mother abdomen for skin to skin
contact
- Gently rubbing
 Risk for Ineffective airway Clearance
- Record 1st cry
- Crying baby is breathing baby
- More forcefully cry = breathing
deeply and forcefully
- Mucus = suction mouth using
bulb syringe, before laid to mother’s
abdomen (to avoid aspiration)
 SUCTION QUICKLY AND GENTLY –
prolong and deep during 5-10 mins
(stimulates vagus nerves)
 SUCTION THE MOUTH THEN THE
NOSE – if the nose is suctioned first, the
stimulation of the nasal mucosa will
cause reflex inhalation of pharyngeal
material into the trachea and bronchi
causing aspiration
 CARE OF UMBILICAL CORD
- Inspect for the presence of AVA
- Continue to pulsate after infant is born
- 2 clamps (8 inch above abdomen)
- Clamp applies half inch from the
abdomen
- The corm stump usually dries and fall off
within 7 to 10 days
- Avoid wetting the cord – fold the diaper
below
- Keep cord dry – DON’T apply anything
on the cord
- NO tub bathing until cord falls off
- Alcohol 1x-2x daily (hasten drying) but
now we use Betadine
- Leave cord exposed to air
 CREDES PROPHYLAXIS
- Allow parents to interact with infant
before giving
- Given during 1st 24 hours
- Wipe the face dry
- One eye at a time
- Apply ointment from inner to outer
canthus of the lower lid
- Massage eyelid gently to distribute the
ointment
- Wipe excess ointment after one minute
with sterile cotton balls moistened with
sterile water
NURSING CARE OF THE NEWBORN IN THE
POST-PARTAL PERIOD
 Initial Feeding
- Written breastfeeding policy
- Educate all staff with skills
- Inform about benefits of
breastfeeding
- Initiate BF within 1st hour
- X pacifiers, X food other than breast
milk
 Bathing
- Sponge bath after 2-4 hrs post birth
(NO need to remove vernix)
- Face, diaper area, and skin fold
- Use Gloves
- Bathe from feeding (Vomiting –
Aspiration)
 Cleanest to dirtiest
- Warm room (24C) to prevent
chilling
- Wash clothes, towels, comb, clean
diaper, shirt,
- NO soap, powder, lotion
 Position in Sleeping
- Sleep on their back (to prevent
SIDS)
- Room sharing without bed sharing
 DIAPER AREA CARE
- Changes diaper as frequent
 Metabolic Screening Test
- Single drop of blood (newborn
screening)
CJBS KBBS BSN 2-C
 - Best result (feed for 24 hours)  Eosinophils reacting to rough sheets and
- If NOT performed on the 1st day, = clothing
can be 2 to 3 days’ time  Begins with a papule, ^ severity to become
 Hep. B Vaccination erythema by the second day; x 3rd day
 X clinical significance; lacks pattern,
- 1st vaccine within 12 hours after
sporadic
birth (1 month, 6 months)  X treatment
- In mother (+), infant receives HBIg
 Administration of Vit.K LANUGO
- Aquamephyton (Phytonadieone)  Fine downy hair may be noted over the
S1mg injected IM into the Lateral aspect face, shoulders and back, upper arms,
(vastus lateralis) to prevent forehead and ears
bleeding disorder Hemorrhagic Disease  Absent in postterm
of Newborn (HDN)  X 2 weeks of age

HARLEQUIN SIGN MONGOLIAN SPOTS

 red on the dependent side and pale on the
upper side; due to immature circulation
DESQUAMATION
 first 2-4 weeks of life
 skin becomes dry and it will peel
 palms, soles of feet
 apply lotion
 Gray patches across the sacrum or
buttocks and consist of collection of pigment
cells (melanocytes)
 Arms and legs; x school age w/o treatment
 Asian, Southern European, African ethnicity
BIRTHMARKS
HEMANGIOMAS

SKIN TURGOR  Vascular tumors of the skin

 good elasticity (well-hydrated) a. NEVUS FLEMMEUS

 skin is grasped between the thumb and
1. PORTWINE STAIN
finger -> released: skin should fall back to
form smooth surface  macular purple or dark red lesions;
 check on the sternum / abdomen doesn’t blanch
 poor S.T. indicates dehydration  face and thighs
 sunken fontanels – dehydration  fades spontaneously; may be removed by
 bulging fontanels – increased ICP laser
VERNIX CASEOSA 2. STORK BITES / TELANGIECTASIA
 white, cream-cheese like substance that  lighter pink patches; blanches
serves as a skin lubricant  nape of the neck
 skin folds  males; x fade; covered by hairline
 document color
 permanent
 DO NOT rub harshly (break in skin integrity)
 If meconium stained, wipe off b. STRAWBERRY HEMANGIOMAS
MILIA  elevated areas formed by immature
capillaries and endothelial cells
 Pinpoint white papule; distended
 rough texture
sebaceous glands; cheek; bridge of nose
 continue to enlarge up to 1 year of age
 Disappears 3-4 weeks of age
 absorbed and shrink in size; 7 y/o = 70%
 DO NOT scratch off or squeeze -> may
disappear; 10 yrs = x
become a portal of entry for microorganisms
 scalp, face, neck
ERYTHEMA TOXICUM / FLEA BITE RASH
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  X surgery (complication); steroids; laser  Supine position and lift the head to open his
therapy / her eyes
 Rare tears (mature lacrimal @ 3 mos.)
c. CAVEROUS HEMANGIOMAS  Iris is gray or blue (permanent color @ 3-
 Dilated vascular spaces 12 mos.)
 Raised and irregular in shape; permanent - Check for symmetry in size and shape
marks (should be symmetric, x tears)
 Smooth texture - Check eyelids for size, movements, blink (

FORCEPS MARKS THE EARS

 Circular or linear contusion matching the rim  Not completely formed

of the blade of the forceps on the infant’s
cheeks; disappears in 1-2 days along with
the edema
 Assess the facial nerve while the newborn is
at rest or during crying episodes
THE HEAD
 Forehead of newborn is large (1/4 of height)
and prominent, chin appears to be receding
and quivers easily if infant is startled or cries
FONTANELLES
 Spaces / openings where the skull bones
join
 Anterior = diamond; indented (DHN); bulge
(^ ICP)
 Posterior = triangle
CAPUT SUCCEDANEUM
 Edema of the scalp on the presenting part
 Gradually absorbed; x 3rd day of life
 NO treatment needed
 Tissue trauma
CEPHALHEMATOMA
 Collection of blood between the periosteum
of the skull bone and the bone itself; black
/ blue underneath
 NO treatment needed; weeks absorbed
 Observe for jaundice
CRANIOTABES
 Localized softening of the cranial bones
caused by pressure of the skull against the
mother’s pelvic bone
 Skull is soft
 It corrects after few months (Calcium on
milk). No treatment needed
THE EYES
o Term = strong and recoils
 External ear at level with outer canthus
(abnormal: chromosomal abnormality)
 Small tag in front (chromosomal
abnormality; kidney dse)
o Observe pinpoint opening
 Hearing screening
 Small bell 6 inches away –
blink, startle
NOSE
 Covered with milia; larger for the face
 Assess for choanal atresia
o Close mouth and compress one
naris at a time with finger, note
discomfort or distress w/ breathing
 Midline; apparent lack of bridge, flat, broad
 Some mucus but no drainage
 Preferential nose breather; sneezing to
clear nose
MOUTH
 Symmetry of lip movement; (Facial nerve
injury) – inspect and palpate; check
placement on face; assess lips for color,
configuration, movement)
 Pink gums; presence of natal teeth
(evaluate for stability) unusual teeth one or
two erupted – check gums
 Short; tongue tied (ineffective
breastfeeding)
 Tongue not protruding; freely movable;
symmetric in shape – assess tongue for
attachment, mobility, movement, size
 Soft and hard palates intact; uvula in midline
 Presence of Epstein pearls disappears
within 1 week
 Distinguish from candida (tongue sides of
cheek) – assess palate (soft and hard) and
uvula
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  Distinct chin – assess chin
 Reflexes present – check reflexes (rooting,
sucking, extrusion)
NECK
 Short, thick, surrounded by skin folds, often
chubby
 Assess for nuchal rigidity
o Congenital torticollis (SCM injury)
o Meningitis (rupture membranes > 24
hrs)
 Head lag (not strong enough to support total
weight of head
CHEST
INSPECT AND PALPATE SHAPE
 Almost circular; appear small in proportion
to head (2cm smaller)
 No retractions (drawing in of the chest wall
w/ inspiration) strong force to pull air into
respi tract -> oxygen needed
CHECK RESPIRATORY MOVEMENT
 Symmetric chest movement, chest and
abdominal movements synchronized during
respirations; rhonchi
EVALUATE CLAVICLES
 Clavicles intact; crepitus (Fracture)
ASSESS RIBS
 Rib cage symmetric; intactl moves with
respiration
 Rhonchi vs. grunting and stridor
ASSESS NIPPLES FOR SIZE, PLACEMENT, AND
NUMBER
ABDOMEN
 Slightly protruded
o Slightly appearance – missing
abdominal contents or
diaphragmatic hernia
 Bowel sounds = within 1 hr after birth;
meconium stool = 24-48 hours after birth
 Inspect cord (color, odor, di ko natapos
kasalanan to ni carl chika nya aq)
GENITALIA
FEMALE
 Vulva may be swollen
 Pseudomenstruation (blood-tinged mucus
vaginal discharge); disappears 1-2 days
MALE
 appears small, meatus at tip of penus
(epispadias; hypospadias)
 Prepuce (foreskin) covering glans penis and
it is not stenosed
 Edematous and rugaeted scrotum; deeply
pigmented
 Palpable testicles on each side
(cryptorchidism)
o press inguinal ring PRIOR to
assessment (if not supported,
testicles might ascend)
 positive cremasteric reflex
DEFECTS: ANOGENITAL AREA
Imperforated anus – covered by membrane
Cryptorchidism – absence of one or both testicle
Ectopic testes – testes cannot enter the scrotum
the opening of scrotal sac is closed
Undescended testes – vas deferens is too short to
allow the testes to descend
Epispadias – malformation of the penis in which
the urethra ends in an opening on the upper aspect
(the dorsum) of the penis
Hypospadias – urethra opens anywhere along a
line running from the tip along the underside
(ventral aspect) of the shaft to the junction of the
penis and scrotum or perineum
BACK AND EXTREMITIES
 spine straight and easily flexed infant able
to raise and support head momentarily
when prone
 shoulders, scapular, and iliac crests lining
up in same place
 arms and legs appear short in newborn
period
 symmetric movement
 five fingers on each hand; fist often
clenched with thumb under fingers
 palm of hands have three creases
 soles of feet appear flat
 intact femur
 major gluteal folds even
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 PHYSIOLOGIC FXN / SYSTEMIC EVALUATION
CARDIOVASCULAR SYSTEM
- when cord is clamped, neonate is forced to
take in O2 through the lungs
1. Closure of the foramen ovale (fossa ovalis) by
the 3rd month of life to 1 year
2. Change of the ductus arteriosus into a mere
ligament (ligamentum arteriosum) when the infant
is several weeks to 4 months
3. Ductus venosus becomes a mere ligament
(ligamentum venosum) as well as due to decrease
pressure on the right side of the heart by 2 months
4. Arteries and umbilical veins atrophied and
degenerate by 2-3 months since no more blood
goes through these vessels
FETAL AND NEONATAL CIRCULATION
FETAL
 constricted with very little blood flow (^
pulmonary vascular resistance)
 lungs not expanded
 Fluid filled lungs
Systemic blood vessels
 Dilated with decreased resistance
 Blood mostly in placenta
Ductus arteriosus
 large with no tone
 blood flow from PA to aorta
 right to left shunting
foramen ovale
 patent
 increased blood flow from R-L atrium
NEONATAL
 Vasodilation and increased blood flow (v
pulmonary
Systemic blood vessels
 Increased arterial pressure (cord clamping)
with loss of placenta
 Increased systemic blood volume
Ductus arteriosus
 Reversal of blood flow
 PA to lungs
 Left to right shunting
 Increased atrial pressure and increased
systemic vascular pressure
Foramen ovale
 Increased pressure in left atrium attempts to
reverse blood flow
 One way valve
BLOOD VALUES
A. BLOOD VOLUME – 80-110 ml/kg of weight or
about 300 Ml
B. ERYTHROCYTES COUNTS – increased, 6
million/mm3
C. HGB LEVEL – 17-18g/100 mL of blood
D. HCT LEVEL – 45%-50%
E. WBC – 15,000 to 30,000 cells/mm3 (PRC)
* assess for other signs of infection (pallor, DOB,
cyanosis, increased temp = infection
F. BILIRUBIN LEVEL – 1-4 mg/100 mL
RESPIRATORY SYSTEM
A. The first breath (about 50-70 cm H2O)
* combination of cold receptors a decreased PO2
(15 mmHg) and an increased PO2 (rises as high as
70 mmHg)
B. Fluid in the lungs = decreased surface tension
on alveolar walls (easier breathing)l 1/3 drained
through vaginal delivery; rest absorbed by lung BV
and lymphatics after 1st breath
* CS = <fluid expel -> fluid blocks air; preterm =
lacks surfactant
GASTROINTESTINAL SYSTEM
a. Sterile at birth
b. Most bacteria enter (NB’s mouth from airborne
sources, vaginal secretions at birth, from hospital
bedding, and from contact at the breast)
* necessary for Vit. K synthesus
c. Newborn’s stomach holds about 60-90 ml at birth
(size of a calamansi)
d. Decreased pancreatic enzymes (lipase and
amylase) first few months
e. Immature cardiac sphincter -> regurgitation
CJBS KBBS BSN 2-C
f. Immature liver – decreased glucose and protein
serum level
STOOLS
a. Meconium – 1st stool of the newborn
 usually passed within 24 hours
 a sticky, tarlike, blackish-green, odorless
material formed from mucus, vernix, lanugo,
hormones, and CHO
* meconium ileus, imperforate anus, volvulus
b. Transitional stool – occurs on the 2nd or 3rd day
of life
 becomes green and loose
 resembles diarrhea to the untrained eye
By the fourth day of life, stool depends on the type
of feeding:
a. Breast-fed babies – light yellow, mushy, more
frequent and sweet smelling (high in lactic acid –
not foul smelling)
b. Bottle-fed babies – bright yellow, firm, less
frequent and foul-smelling
c. Under phototherapy (jaundice) – bright green
stools
d. Bile duct obstruction – clay colored (gray)
stools
e. Anal fissure – blood flecked
f. Bleeding (swallowed maternal blood during
delivery / GI) – black, tarry stools
+ Apt Downey Test -> remains black -> GI bleeding
g. Milk allergy, lactose intolerance, digestion
problems – mixed with mucus; watery and loose
URINARY SYSTEM
 Voids within 24 hours after birth
 Urine is odorless and light in color
 Daily urine output for the first 1-2 days of life
is 30-60 mL AND MAY INCREASE TO
ABOUT 300 Ml AFTER 1 WEEK
 Specific gravity is 1.008-1.010; may have
small amount of protein
 First voiding may be pink or dusky
 Female = strong stream when voiding; Male
= small projected arc when voiding, if NOT -
> urethral obstruction
 Weigh diapers to determine amount of
voiding
IMMUNE SYSTEM
 Able to produce own by 2 months
 Born with passive natural immunity (IgA and
IgG)
 Newborns have antibodies from mother
against poliomyelitis, diphtheria, tetanus,
pertussis, rubella, measles, and chickenpox
SENSES
a. Hearing
 able to hear in utero (25-27 weeks AOG)
 respond to sound through generalized
activity to a specific sounds
 difficulty locating where sound is coming
from
 recognize mother’s voice = calms
b. Vision
 positive pupillary reflex
 focus best on black and white objects at 9-
12 inches
 positive vision
c. Touch
 most developed sense
 quieting at a soothing touch
 positive sucking and rooting reflexes
(elicited by touch)
 reacts to pain stimuli
d. Taste
 ability to discriminate taste (taste buds are
developed and functioning even before
birth)
e. Smell
 present when nose is clear of mucus and
amniotic fluid
 turn towards mother’s breast partly out of
recognition of the smell of breastmilk and as
manifestation of rooting reflex
NEUROMUSCULAR SYSTEM
 Demonstrates neuromuscular function
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 DISCHARGE INSTRUCTIONS
FEEDING
Breastfeeding
 Preferred method of feeding a newborn
 Remains the ideal nutritional source for
infants through the first year of life
 Done on the 48th hour or at least 24 hours
from birth
 * < 24 hours – some disorders are
undetected
 Screening again after 2 weeks for more
accurate results
BRIEF DECRIPTION OF THE DISORDERS

Bottle feeding CONGENITAL HYPOTHYROIDISM

 Infants routinely receives an initial feeding - Lack or absence of thyroid hormone, which
about 1 oz of sterile water at 4-6 hours of is essential to growth of the brain and the
age body
 To be certain the infant can swallow without CONGENITAL ADRENAL HYPERPLASIA
gagging and aspirating
 Fed every 4 hours - Endocrine disorder that causes severe salt
loss, DHN, and abnormally high levels of
BATHING
 May be given anytime convenient for
parents; not within 30 mins after feeding
 * increased handling can cause
regurgitation
 Sponge bath done until the cord falls off (7th
– 14th day)
 Wash infant’s hair daily with the bath. First
soap the hair with the baby lying on the
bassinet. Then hold the infant on one arm
over the basin of water (foot ball hold)
 Body 1st then head
SLEEPING PATTERNS
 Sleeps 16-20 hours / day
CORD CARE
 Use rubbing alcohol 70% 2 or 3x a day for
faster drying
 Fold down diapers so that cord does not get
wet during voiding
 Small pink granulating area may be seen on
the day the cord falls off
DIAPER CARE
 After each change, wash area with clear
water and dry well
 * to prevent ammonia
NEWBORN SCREENING
 Procedure to find out congenital metabolic
disorder that may lead to mental retardation
and even death if left untreated

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