Professional Documents
Culture Documents
The Neonate
From birth through the first 28 days of life
Also called “the newborn period”
2/3 of all deaths that occur during the 1st year of life occur during this period; more than half occur
in the 1st 24 hours after birth---an indication of how hazardous this time is for an infant
How well a NB makes major adjustments depends on his or her:
o Genetic composition
o The competency of the recent intrauterine environment
o The care received during the neonatal period
PRINCIPLES IN IMMEDIATE NEW BORN CARE
1st day of life
1. initiation and maintenance of respiration (used bulb syringe initiate a/w)
2. establishment of extra uterine circulation
3. control of body temp
4. intake of adequate nourishment
5. establishment of waste elimination
6. prevention of infection
7. establishment of an infant parent relationship
8. dev’t care that balances rest and stimulation or mental dev’t
Immediate care of the newborn.
A-airway (most neonatal deaths with in 24 h caused by inability to initiate a/w, lung function begins after birth only)
B-body temperature
C-check/asses the newborn
D-determined identification
I. Establish and Maintain a Patent Airway / Effective Respiration
Nursing Interventions:
1. Wipe the mouth and nose secretions after delivery of the head
2. Suction secretions from the mouth and nose properly.
Catheter Suctioning
1.) Place head to side to facilitate drainage
2.) Suction mouth 1st before nose
-neonates are nasal breathers
3.) Period of time
-5-10 sec suctioning, gentle and quick
Prolonged and deep suctioning can lead to hypoxia, laryngo spasm, brady cardia due to stimulation vagal nerve
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“If not effective, requires effective laryngoscopy to open a/w. After deep suctioning an endotracheal tube can be
inserted and oxygen can be administered by an (+) pressure bag and mask with 100% oxygen at 40-60b/m.”
Nsg alert:
No smoking
Always humidify to prevent drying of mucosa
Over dosage of oxygen can lead to scarring of retina leading to blindness ( retro lentalfibrolasia or retinopathy of
prematurity)
When mecomium stained (greenish) never administer oxygen with pressure ( O2 pressure will push mecomium
inside)
3. Stimulate the baby to cry if baby does not cry spontaneously or if baby’s cry is weak.
“A crying infant is a breathing infant. Effective cry means effective breathing”
Do not slap the buttocks but rub the soles of the feet
Do not stimulate the NB to cry unless the secretions have been suctioned to prevent
aspiration
The normal infant cry is loud & lusty. Observe for the ff. abnormal cry:
High-pitched cry : hypoglycemia, increased ICP
Weak cry: prematurity
Hoarse cry: laryngeal stridor
4. Oral mucus may cause the NB to choke, cough or gag during the first 12 to 18 hours of life.
Place the neonate in a position that would promote drainage of secretions
Trendelenburg (contraindicated to Increased ICP)
Side-Lying
5. Keep the nares patent. Remove mucus and other particles w/c can cause obstruction as newborns
are “obligatory nasal breathers” until they are about 2-3 weeks old.
6. Give O2 as needed. Oxygen should be given for 20-30 minutes when the neonate remains
cyanotic or tachycardic after initial suctioning and stimulation.
* asphyxiation → hypoxia → hypercapnia(↑ CO2) → acidosis → coma → death
• Observe precaution in giving oxygen
• Do not give more than 40% O2 as this may lead to retrolental fibroplasia (blood vessels of the eyes
become spastic leading to blindness)
• Use pulse oximeter and monitor O2 concentration every hour
7. If the heart rate falls below 60 bpm, cardiac massage may need to be carried out.
II. Maintain Appropriate Body Temperature
Temp Regulation
goal in temp regulation is to maintain it not less than 97.7% F (36.5 C)
maintenance of temp is crucial on preterm and SGA (small for gestational age) - babies prone
to hypothermia or cold stress
o Neonates have “physiologic resilience” wherein they tend to adopt or take temperature of
their own environment. (poikilothermic)
“cold stress (hypothermia) is more dangerous than hyperthermia”
Effects of cold stress
Cold stress metabolic acidosis CNS depression Coma Death
o Every NB is born slightly acidotic. Any new build-up of acid may lead to life-threatening
metabolic acidosis, which can be lethal even to normal newborn infants.
o The average NB temp.@ birth is around 37.2°C.
o NB lose heat easily because:
They have immature temp.-regulating system
Of very little amount of subcutaneous fat to provide heat
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They have a larger body surface area that results in more heat loss
They have little ability to conserve heat by changing posture and no ability to adjust its
own clothing
Methods of Heat Loss in Newborn
• Convection – the flow of heat from the NB’s body surface to cooler surrounding air; ex:
windows, air conditioners
• Conduction- the transfer of a body heat to a cooler solid object in contact with a baby; ex:
baby placed on a cold counter
• Radiation – the transfer of body heat to a cooler solid obj. not in contact with a baby; ex: cold
window or air con
• Evaporation – loss of heat through conversion of a liquid to a vapor; ex: after delivery,
newborns are wet, with amniotic fluid on their skin, tsb
Effects of Hypothermia
( Cold stress)
To Prevent Hypothermia
1. Dry and wrap baby
2. Mechanical pressure – radiant warmer
pre-heated first isolette (or square acrylic sided incubator)
3. Prevent an necessary exposure – cover baby
4. Cover baby with tin foil or plastic
5. Embrace the baby- kangaroo care
6. Delay initial bath until temp. has stabilized for at least 2 hours.
7. Maintain ambient temp. of nursery at 24°C or 75°F.
8. Perform any extensive examination or procedure under radiant heat to prevent heat loss and expose only the part of the
body to be examined.
9. Note the presence of any cyanosis:
2 types of cyanosis: a.) central cyanosis
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b.) peripheral cyanosis hands & feet are cyanotic, due to cold environment and poor circulation
Axillary temperature measurement. The thermometer should remain in place for 3 minutes. The nurse presses the
newborn’s arm tightly but gently against the thermometer and the newborn’s side, as illustrated
Ophthalmia neonatorum
Any conjunctivitis with discharge occuring during the first two weeks of life. It typically appears 2-5 days after
birth, although it may appear as early as the first day or as late as the 13th.
silver nitrate (used before) – 2 drops lower conjunctiva (not used now)
A irway
B ody temperature
C heck/ assess the newborn
D etermine identification
Stimulate & dry infant
Assess ABCs
Encourage skin-to-skin contact
Assign APGAR scores
Give eye prophylaxis & Vit. K
Keep newborn, mother, & partner together whenever
Physical Assessment
Temperature - range 36.5 to 37 axillary
Common variations
o Crying may elevate temperature
Stabilizes in 8 to 10 hours after delivery
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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 - coartation of aorta
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
Tachypnea - respirations > 60
Persistent irregular breathing
Excessive mucus
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Skin
o Skin reddish in color, smooth and puffy at birth
o At 24 - 36 hours of age, skin flaky, dry and pink in color
o Edema around eyes, feet, and genitals
o Venix Caseosa -whitish, cheese-like substance, covers the fetus while in utero and
lubricates the skin of the NB. The skin of the term or postterm nb has less vernix and is
frequently dry; peeling is common, esp. on the hands & feet
o Lanugo -moderate in full term; more in preterm; absent in postterm; shed after 2 weeks
in time of desquammation
o Turgor good with quick recoil Skin color
blue – cyanosis or hypoxia
o Hair silky and soft with individual strands White – edema
o Nipples present and in expected locations Grey – inf
Yellow – jaundice , carotene
o Cord with one vein and two arteries
o Cord clamp tight and cord drying
o Nails to end of fingers and often extend slightly beyond
Acrocyanosis
o Bluish discoloration of the hands and feet maybe present in the first 2 to 6 hours after birth
o This condition is caused by poor peripheral circulation, w/c results in vasomotor instability &
capillary stasis, esp. when the baby is exposed to cold.
Mongolian Spots
Mottling
Physiologic Jaundice
o Hyperbilirubinemia not associated with hemolytic disease or other pathology in the newborn.
Jaundice that appears in full term newborns 24 hours after birth and peaks at 72 hours.
Bilirubin may reach 6 to 10 mg/dl and resolve in 5 to 7 days.
o If jaundice occurs within 2 days – pathologic jaundice
o If jaundice occurs at 3rd-7th days of life – physiologic jaundice
o Jaundice is first detectable on the face (where skin overlies cartilage) and the mucus
membranes of the mouth and has a head-to-toe progression.
o *Evaluate it by blanching the tip of the nose, the forehead, the sternum, or the gum line. This
procedure must be done with appropriate lighting. Another are to assess is the sclera.
o Jaundice maybe related to breastfeeding, hematomas, immature liver function, bruises from
forceps, blood incompatibility, oxytocin induction or severe hemolysis process
Nsg Resp:
1. cover eyes – prevent retinal damage
2. cover genitals – prevent priapism –
painful continuous erection
3. change position regularly – even
exposed to light
4. increase fld intake – due prone to
dehydration
5. monitor I&O – weigh baby
6. monitor V/S – avoid use of oil or lotion
due- heat at phototherapy
= bronze baby syndrome-
transient S/E of phototherapy
Exchange Transfusion
o Is the withdrawal and replacement of newborn’s blood with donor blood.
Milia
Milia which are exposed to sebaceous
glands, appear as raised white spots on
the face, esp. across the nose.
No treatment is necessary, bec they will
clear within first month.
Infants of African heritage have a
similar condition called transient
neonatal pustular melanosis.
Erythema toxicum
Harlequin Sign
o The color of the newborn's body appears to be half red and half pale. This condition is
transitory and usually occurs with lusty crying. Harlequin Coloring may be associated with to
an immature vasomotor reflex system.
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.
3 types Hemangiomas
a.) Nevus Flammeus – port wine stain – macular purple or dark red lesions seen on face or thigh.
NEVER disappear. Can be removed surgically
b.) Strawberry hemangiomas – nevus vasculosus – dilated capillaries in the entire dermal or subdermal
area. Enlarges, disappears at 10 yo.
c.) Cavernous hemangiomas – communication network of venules in SQ tissue that never disappear
with age.
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HEAD
o Head circumference should be 2 cm greater than chest circumference
o Assess fontanelles and sutures - observe for signs of hydrocephalus and evaluate
neurologic status
o Craniosynostosis
o Microcephaly
o macrocephaly
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o Pseudomenstruation: the discharge w/c can become tinged w/ blood and is caused by withdrawal of
maternal hormones
o Smegma: a white cheeselike substance is often present between labia. Removing it may traumatize
tender tissue
o Phimosis : tight foreskin or prepuce; w/c sometimes lead to early circumcision
o Cryptoorchidism: undescended testes ;if the testes did not go down
o Orchidopexy: repair of undescended testes before 2 y/o
o Penis: urethra should be at the tip of the penis
o Hypospadias : if the opening is at the ventral surface
o Epispadias: if the opening is at the dorsal surface
o Hydrocele – swelling due to accumulation of serous fluid in the tunica vaginalis of the testis or in the
spermatic cord
Anus
o Inspect anal area to verify that it is patent and has no fissure
o Digital exam by physician or nurse practitioner if needed
o Note passage of meconium
Extremities
o Tic dwarfism : very short arms
o Amelia : absence of arms
o Phocomelia : absence of long arm
o Polydactilism: more fingers; extra digits on either hands or feet
o Syndactilism: webbing; fusion of fingers or toes
o *Inspect the hands for normal palmar creases. A single palmar crease called SIMIAN line is frequently
present in Down’s syndrome
o Adactyl : no foot
o Down’s syndrome: inward rotation of little fingers
o Clubfoot/ talipes deformity – inward rotation of foot fingers.
o Erb-Duchenne paralysis (Erb’s palsy) : resulting from injury to the 5th and 6th cervical roots of the
brachial plexus; usually from a difficult birth; it occurs commonly when strong traction is exerted on
the head of the NB in an attempt to free a shoulder lodged behind the symphysis pubis in the presence
of shoulder dystocia.
A, The asymmetry of gluteal and thigh fat folds seen in infant with left B, Barlow's (dislocation) maneuver. Baby's thigh is grasped and
developmental dysplasia of the hip. adducted (placed together) with gentle downward pressure.
Clubfoot
Nursing Role
Be knowledgeable about normal newborn variations and responses that indicate further investigation
o Respiratory distress
o Central cyanosis
o Thermoregulation problems
o Dehydration
Teaching
During physical and behavioral assessment, identify family's need for teaching
o Involve family early in care of infant
o Process establishes uniqueness and allays concern
Teaching TALIPES – “clubfoot”
o Feeding cues a.) Equinos – plantar flexion – horsefoot
o Alert state b.) Calcaneous – dorsiflexion – heal
lower that foot anterior posterior of
o Cord care foot flexed towards anterior leg
o Sleeping c.) Varus- foot turns in
Neurological Status d.) Valgus- foot turns out
Assessment begins with period of observation Equino varus- most common
Observe behaviors - note:
o State of alertness
o Resting posture
o Cry
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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””
BABINSKI reflex
Grasp reflex
Moro reflex
Step reflex -
Rooting Reflex
Suck reflex -
Female genitals
B, The clitoris is still visible.The labia C, The term newborn has well-developed, large
minora are now covered by the larger labia majora that cover both clitoris and labia
labia majora. Score 2. The gestational minora. Score 3.
age is 36 to 40 weeks
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Neuromuscular Components
Scarf sign
BIRTHMARKS:
1. Mongolian spots – stale gray or bluish discoloration patches commonly seen across the sacrum or buttocks due to
accumulation of melanocytes. Disappear by 1 yr old
2. MIlla – plugged or unopened sebaceous gland . white pin point patches on nose, chin or cheek.
3. Lanugo – fine, downy hair – common preterm
4. Desquamation – peeling of newborn, extreme dryness that begin sole and palm.
5. Stork bites (Talengeictasi nevi) – pink patches nape of neck
hair will grow as child grows old
6. Erythema Toxicum – (flea bite rash)- 1st self limiting rash appear sporadically & unpredictably as to time & place.
7. Harlequin sign – dependent part is pink, independent part is blue
(side lying – bottom part is dependent pink)
8. Cutis Marmorato – transitory mottling of neonates skin when exposed to cold.
9. Hemangiomas – vascular tumors of the skin
3 types Hemangiomas
a.) Nevus Flammeus – port wine stain – macular purple or dark red lesions seen on face or thigh. NEVER disappear. Can
be removed surgically
b.) Strawberry hemangiomas – nevus vasculosus – dilated capillaries in the entire dermal or subdermal area. Enlarges,
disappears at 10 yo.
c.) Cavernous hemangiomas – communication network of venules in SQ tissue that never disappear with age. - MOST
DANGERIOUS – intestinal hemorrhage
Skin color blue – cyanosis or hypoxia
White – edema
Grey – inf
Yellow – jaundice , carotene
Vernix Caseosa – white cheese like for lubrication, insulator