CARE OF THE NEWBORN

1. Discuss why intrapulmonary fluid and fetal breathing movements are important for
normal pulmonary function.
 The amniotic fluid plays an important role in fetal lung development. Inhalation of
the amniotic fluid into the lungs helps to promote growth and differentiation of the
lung tissue.
 Fetal breathing movements (FBMs) can be observed by ultrasonography as early
as 11 weeks of gestation. The breathing movements serve as an important
mechanism that helps to develop the muscles of the chest wall and the diaphragm.
 The absorption of fetal lung fluid is accelerated during labor and delivery and for
up to a few hours after birth. This fluid shift constitutes an important physiologic
event: it assists in reducing the pulmonary resistance to blood flow (necessary
while in utero) and facilitates the initiation of air breathing.

2. Explain why surfactant is important for respirations and identify two prenatal conditions
that may be associated with a decrease in surfactant production.
 Surfactant causes a decreased surface tension within the alveoli, which allows for
alveolar re-expansion after each exhalation. Under normal circumstances, by the
34th to 36th weeks of gestation, surfactant is produced in sufficient amounts to
maintain alveolar stability.
 Surfactant production is decreased in infants of diabetic mothers (classes A, B,
and C),
infants with hemolytic disorders (e.g., erythroblastosis fetalis), and in multiple
gestations.

3. Describe the four factors that are essential for the initiation of respirations.
1. Chemical Factors
 Chemical factors that initiate respirations are hypercarbia, acidosis, and hypoxia.
These conditions, brought about by the stress of labor and birth, stimulate the
respiratory center in the brain to initiate breathing.
2. Sensory Factors
 The newborn experiences a vast amount of stimuli when leaving a familiar,
comfortable, warm environment to enter into an extremely sensory overloaded one
—filled with a multitude of tactile, visual, and auditory stimuli. These sensory
experiences aid in the initiation of respirations
3. Thermal Factors
 After months of development in a warm (98.6ºF [37ºC]) fl uid-fi lled environment,
the newborn abruptly enters into a thermal environment that ranges from 70 to
75ºF (21 to 23.9ºC). The drastic change in temperature helps to stimulate the
initiation of respirations.
4. Mechanical Factors
 Removal of fluid from the lungs with the subsequent replacement of air constitutes
the primary mechanical factors involved in the initiation of respirations
4. Explain characteristics of periodic breathing in the neonate.
 The breathing pattern is often shallow, diaphragmatic, and irregular. Abdominal
movements should be synchronous with the chest movements. The breathing
pattern may include brief pauses that last 5 to 15 seconds. Termed periodic
breathing, this pattern is usually not associated with any change in skin color or
heart rate and it has no prognostic significance

5. Identify when the ductus venosus functionally closes.

 Because of unequal pressures within the heart, the foramen ovale is functionally
closed within 1 to 2 hours after birth.

6. Describe the physiological event that causes closure of the foramen ovale.
 The right-to-left shunting ceases once the umbilical cord has been clamped. The
ventricular and aortic pressures in the left side of the heart rise. The systemic
vascular resistance increases while pressure in the right side decreases. The
pulmonary blood vessels respond to the increase in PO2 during lung expansion
and aeration with vasodilation and a decrease in pulmonary vascular resistance.
These changes cause an increase in blood flow through the pulmonary veins to the
left atrium and lead to an increased left atrial pressure that results in closure of the
foramen ovale. Since the foramen ovale is capable only of shunting from right to
left, this physiological event closes the shunt.
7. Define nonshivering thermogenesis and discuss its effect on thermoregulation in the
newborn.
 Unlike children and adults, newborns are unable to shiver to generate heat.
Instead, they must produce heat via NST and this process becomes the key
mechanism for maintaining a neutral thermal environment.
 Nonshivering thermogenesis utilizes the newborn’s stores of brown adipose tissue
(BAT) to provide heat in the cold-stressed newborn.
8. Identify three nursing interventions to prevent heat loss by evaporation and convection
after birth.
 The nurse can help minimize neonatal heat loss through convection by preventing
drafts in the birth area (e.g., no ceiling fans) and by placing the newborn away
from doors or windows.
 Nursing interventions geared toward preventing evaporative heat loss include
thoroughly drying the neonate after birth, promptly removing wet linens, and
immediately placing a hat on the head to prevent evaporation through the scalp.

9. Explain how depletion of brown adipose tissue stores places the term newborn at risk of
respiratory distress.
 Utilization of the brown fat stores places the infant at risk for metabolic acidosis.
Decreased oxygen causes peripheral vasoconstriction and increases the likelihood
of respiratory distress. Peripheral vasoconstriction can lead to increased
pulmonary vascular resistance and a return to fetal circulation as a compensatory
mechanism.
10. Identify two factors that may place an infant at risk for physiological jaundice.
 There is a decreased reabsorption of bilirubin from the intestines. This is related to
the decreased caloric intake common in most infants during the first few days of
life. When the caloric intake is inadequate, the production of hepatic binding
proteins is decreased and the levels of bilirubin rise.
 There is an increased amount of bilirubin presented to the liver. This is related to
an increase in blood volume (following a delay in cord clamping) and accelerated
RBC destruction due to their shortened life span. Newborns produce and break
down two to three times more bilirubin than do adults.
11. Discuss why delayed cord clamping at birth can affect that development of jaundice.
 Perinatal events, such as delayed clamping of the umbilical cord, increase the
volume of circulating erythrocytes and predispose the neonate to an increased
breakdown of RBCs and the subsequent development of jaundice.

12. Describe the fetal to newborn transition process that takes place in the gastrointestinal
tract.
 The neonate’s stomach capacity is approximately 6 mL/kg at birth and by the end
of the first week of life, the capacity has increased to hold approximately 90 mL.
In utero, the fetal gastrointestinal system reaches maturity around 36 to 38 weeks
of gestation when there is sufficient enzymatic activity for digestion and the
transport of nutrients throughout the body. To nutritionally thrive, newborns must
be able to digest essential carbohydrate disaccharides that include lactose, maltose
and sucrose. Lactose, the primary carbohydrate in breast milk, is easily digested
and readily absorbed
 Fetal peristalsis can be influenced by anoxia, which triggers the expulsion of
meconium into the amniotic fluid. Immediately after birth, air enters the stomach
and reaches the small intestine within 2 to 12 hours. Bowel sounds are present
within the first 15 to 30 minutes of life due to the air that has entered the stomach
and small intestines.

13. Identify the enzymes that aid in digestion and those that are deficient at birth.

 Deficiency of pancreatic amylase, the only enzyme lacking at birth and during the
first few months of life

14. Identify when bowel sounds become present in the newborn.

 Bowel sounds are present within the first 15 to 30 minutes of life due to the air
that has entered the stomach and small intestines.
15. Identify three physiological factors that enable the newborn’s kidneys to produce and
excrete urine.
 The nephrons are fully functional by 34 to 36 weeks of gestation.
 The glomerular filtration rate is lower than that of the adult.
 There is a limited capacity for the reabsorption of HCO3 – and H+.
16. Explain the origin and significance of “brick dust spots” in the neonate’s urine.
 Since the kidneys have difficulty concentrating urine and removing waste products
from the blood immediately after birth, small amounts of protein and glucose are
frequently present in the urine. Urate crystals, which are pink-red in color, are
excreted in the urine and can be mistaken for blood. The crystals (sometimes
referred to as “brick dust spots”) disappear after the first few days of life as kidney
function matures

17. Describe what is meant by “humoral immunity.”

 Humoral immunity is important in protecting the newborn against bacterial and
viral infections. Low levels of immunoglobulins and immature leukocyte function
in destroying pathogens render the newborn especially vulnerable to infections

18. Discuss the psychosocial adaptation in the newborn.

The First Period of Reactivity
 This stage is the first period of active, alert wakefulness that the infant displays
immediately after birth. It may last from 30 minutes to 2 hours and is a wonderful
time for parents to get to know their baby, and to perform their first full
“inspection” of their infant.
The Period of Inactivity and Sleep
 After being awake and alert for the first 30 minutes to 2 hours after birth, the
neonate settles in to the sleep phase.
The Second Period of Reactivity
 At this time, the newborn awakens and becomes alert once again. Most infants
show signs for feeding readiness (e.g., sucking, rooting) and are eager to begin
feeding if not previously fed.

19. Discuss the components of the neonate’s initial adaptation.

 Respirations Rate 30–60 breaths per minute, irregular No retractions or grunting.
Apical pulse Rate 120–160 beats per minute. Temperature 97.8°F (36.5°C). Skin
color Pink body, blue extremities. Umbilical cord Contains two arteries and one
vein. Gestational age Full term: 37 completed weeks (should be 38–42 weeks to
remain with parents for an extended time period) Weight 2500–4300 grams
Length 45–54 cm.

20. Describe how the infant should be positioned to prevent SIDS.

 All newborns should be put to sleep on their backs; avoid placing the infant in a
prone position.
 When using a side-lying position, place the infant’s dependent arm forward to
lessen the likelihood that the infant will roll into a prone position
21. Name three nursing actions that should be used to assess the infant’s true skin color.
 Use a variety of light sources (helps to ascertain the “true” color).
 Examine the infant’s entire skin surface.
 Carefully inspect the palms, soles of the feet, lips, and areas behind the ears.
 Gently palpate bony prominences (nose, sternum, sacrum, wrists, ankles).
22. Describe how to obtain neonatal body measurements.
 the neonate’s actual body measurements are correlated with a development graph
to ascertain appropriateness of the physical size. As a component of the visual
inspection, the nurse confirms that the infant’s head appears to be the largest body
part.
 The recumbent length is recorded on a regular basis until the infant reaches 24
months of age. Normal length parameters for newborns are approximately 18 to 22
inches (45 to 55 cm).
 To obtain the head circumference, the tape measure is placed on the area
immediately above the eyebrows and pinna of the ears and then wrapped around to
the occipital prominence at the back of the head.
 To obtain the chest measurement, the paper tape measure is placed on the nipple
line and then wrapped around the entire thoracic area.
 The abdominal circumference may be obtained by encircling the infant’s body
with the paper tape measure placed directly above the umbilicus
23. Identify two maturity components that are assessed in the Ballard tool.
 Includes a neuromuscular maturity and a physical maturity component.
24. Describe when and why the Ballard assessment tool should be performed.
 The scoring system is designed to identify the decreased levels of muscle and joint
flexibility characteristic of the premature infant, as well as the mature term
infant’s ability to return to the original position after movement.
 The nurse usually performs this assessment within the first 12 hours of the infant’s
life. The Ballard scoring system is more accurate when conducted on term infants
who are between 10 and 36 hours of life.

25. Discuss whether or not the Ballard maturity score should be identical to the gestational
age of the neonate.
 Gestational age maturity may occur at different rates among the various
categories. It is important to remember that the infant’s maturity scoring does not
directly translate to the gestational age in weeks. a score of 4 (full maturity) in one
category does not indicate that all subsequent categories must also reflect a score
of 4. “Half-scores” are often recorded if the examiner believes that the infant
exhibits a characteristic that falls between two scoring options during the
assessment.

26. Describe the location of the fontanels. Explain why it is important to assess them.
 The anterior fontanel is readily identifiable as a diamond-shaped open space
formed by the anterior–posterior sagittal and frontal sutures and the lateral coronal
suture. The posterior fontanel, located toward the back of the cranium, is a small,
triangular-shaped space formed by the sagittal suture and the posterior lateral
suture.
 Assessment of the fontanels for intracranial pressure is an important component of
the examination. Normal intracranial pressure is characterized by a finding of
fontanel fullness without bulging, either on visual inspection or palpation.
Bulging, tense fontanels in an infant with a large head circumference are
indicative of increased intracranial pressure, often associated with hydrocephalus.
27. Differentiate between caput succedaneum and cephalhematoma and discuss how each is
treated.
 Caput succedaneum is diffuse edema that crosses the cranial suture lines and
disappears without treatment during the first few days of life. Cephalhematoma, a
more serious condition, results from a subperiosteal hemorrhage that does not
cross the suture lines. It appears as a localized swelling on one side of the infant’s
head and persists for weeks while the tissue fluid is slowly broken down and
absorbed.
28. Identify the major and minor reflexes
 minor reflexes (finger grasp, toe grasp, rooting, sucking, head righting, stepping
and tonic neck).The major reflexes include the gag, Babinski, Moro, and Galant
reflexes.
 POSTPARTUM CARE

1. Describe the expected vital sign findings during the postpartum period.
 Temperature- During the first 24 hours postpartum, some women experience an
increase in body temperature up to 100.4°F (38°C).
 Pulse Heart rates of 50 to 70 beats per minute (bradycardia) commonly occur
during the first 6 to 10 days of the postpartum period.
  Blood Pressure Postpartal blood pressure values should be compared with blood
pressure values obtained during the first trimester. Decreased blood pressure may
result from the physiological changes associated with the decrease in intrapelvic
pressure, or it may be indicative of uterine hemorrhage. An increase in the
systolic blood pressure of 30 mm Hg or 15 mm Hg in the diastolic blood pressure,
especially when associated with headaches or visual changes, may be a sign of
gestational hypertension.
 Respirations The respiratory rate should remain within the normal range of 12 to
20 respirations per minute.
2. Discuss the BUBBLE-HE MNEMONIC postpartum assessment guide.
 To assist with the postpartum assessment, the mnemonic BUBBLE-HE is
commonly used to guide nursing practice. BUBBLE-HE reminds the nurse to
assess the breasts, uterus, bladder, bowel, lochia, and episiotomy.

3. Explain the REEDA acronym to facilitate the perineal assessment.

 REEDA guides the nurse to assess for Redness, Edema, Ecchymosis, Drainage or
discharge, and Approximation of the episiotomy if present.

4. Explain normal breast changes that occur during the first few postpartal days.
 During the first 2 postpartal days, the breast tissue should feel soft to the touch.
By the third day,
the breasts should
begin to feel firm
and warm. This
 change is described as “filling.” On the fourth and fifth days postpartum,
breastfeeding mothers’ breasts should feel firm before infant feeding, then
become soft once the baby is satiated.
5. Explain what is meant by involution.
 Involution is a term that describes the process whereby the uterus returns to the
nonpregnant state.
6. Identify the three types of lochia and explain the characteristics and duration of each.
 During the first few days postpartum, the lochia consists mostly of blood, which
gives it a characteristic red color known as lochia rubra. After 3 to 4 days, the
lochia becomes the pinkish brownish lochia serosa. Lochia serosa contains blood,
wound exudates, erythrocytes, leukocytes, and cervical mucosa. After
approximately 10 to 14 days, the uterine discharge has a reduced fluid content and
is largely composed of leukocytes. This combination produces a white or yellow-
white thick discharge known as lochia alba. Lochia alba also contains decidual
cells, mucus, bacteria, and epithelial cells. It is present until about the third week
after childbirth but may persist for 6 weeks.
7. Describe nursing interventions to promote healing, enhance comfort, and prevent
infection in the patient with an episiotomy.
 The nurse should apply an ice bag or commercial cold pack to the perineum
during the first 24 hours after childbirth.
 Application of cold provides local anesthesia and promotes vasoconstriction while
reducing edema and the incidence of peripheral bleeding
 The nurse encourages the use of moist heat (sitz bath) between 100 and 105 F
(37.8–40.5 C) for 20 minutes three to four times per day
8. Discuss the nurse’s role in pain assessment of the postpartal patient.
 The nurse assesses and documents the patient’s pain behavior regarding the:
• Location of the pain
• Type of pain: stabbing, burning, throbbing, aching
•Duration of pain: intermittent or continuous
 Nursing interventions include the administration of analgesics and patient
education about other measures to promote comfort.
9. Discuss the physiological and psychological changes that occur in the postpartal woman.
 NEUROLOGICAL SYSTEM-Fatigue and discomfort are common complaints
after childbirth. The demands of the newborn frequently create altered sleep
patterns that contribute to increased maternal fatigue. Anesthesia and analgesia
received during labor and birth may cause transient maternal neurological changes
such as numbness in the legs or dizziness.
 RENAL SYSTEM, FLUID, AND ELECTROLYTES-The renal plasma fl ow,
glomerular fi ltration rate (GFR), plasma creatinine and blood urea nitrogen
(BUN) return to pre-pregnant levels by the second to third month after childbirth.
Urinary glucose excretion increases in pregnancy by 100-fold over nonpregnant
values.
 INTEGUMENTARY SYSTEM-Changes in the skin during pregnancy and in the
postpartum period are related to the major alterations in hormones. Most
pregnancy-related skin changes disappear completely during the postpartum
 period although some, such as striae gravidarum (stretch marks) fade but may
remain permanently.
 RESPIRATORY SYSTEM-Respiratory alkalosis and compensated metabolic
acidosis occur during labor and may persist into the postpartum period.
 HEMATOLOGICAL AND METABOLIC SYSTEMS-During the immediate
postpartum period, a decrease in blood volume correlates with the blood loss
experienced during delivery. During the next few days after childbirth, the
maternal plasma volume decreases even further as a result of diuresis.
 GASTROINTESTINAL SYSTEM-Owing to hormonal effects, gastric motility is
decreased during pregnancy. It is further decreased during labor and in the first
few postpartal days due to decreased abdominal wall tone.
 IMMUNE SYSTEM- The WBC count is increased during labor and birth and
remains elevated during the early postpartum period, gradually returning to
normal values within 4 to 7 days after childbirth.
 REPRODUCTIVE SYSTEM- The uterus undergoes a rapid reduction in size
(involution) and returns to its pre-pregnant state in about 3 weeks.
 MUSCULOSKELETAL SYSTEM During the first few days after childbirth, the
woman may experience muscle fatigue and general body aches from the exertion
of labor and delivery of the baby.

10. Identify factors that determine how quickly patients should return to the pre-pregnant
weight.
 Factors associated with weight changes during the postpartum period include
gestational weight gain, frequency of exercise, dietary intake, and breastfeeding
for longer than 1 year.

11. Describe the essential components of patient teaching about perineal care.
 Hand washing before and after perineal care (“pericare”)
 The nurse instructs the patient to gently rinse her perineum with fresh warm water
after use of the toilet and before a new perineal pad is applied.
 The patient is taught to fill the peri-bottle (hand-held squirt bottle) with warm tap
water and gently squirt the water toward the front of the perineum and allow the
water to flow from front to back.
 Consistent use of the peri-bottle is soothing, cleansing, and helps to relieve
discomfort.
 Peri-pads should be changed often and secured in the underwear to allow for free
drainage of the lochia.
12. Describe the four stages involved in the process of lactation.
 The initiation of milk production is divided into three stages. Stage 1 occurs in
late pregnancy and is characterized by the maturation of the alveoli, the
proliferation of the secretory alveoli ductal system, and the increase in size and
weight of the breast. Stage 2 begins during the postpartum period. Reduced
plasma progesterone levels lead to an increase in prolactin levels that cause a
copious milk production by the fourth to fifth postpartal day. Stage 3, the
establishment and maintenance of the milk supply, is governed by a principle of
“supply and demand” and continues until breastfeeding ceases. The “weaning”
 stage, sometimes referred to as “Stage 4,” begins when breast stimulation ceases.
This stage is characterized by a significant reduction in milk volume.
13. Discuss techniques the breastfeeding mother can use to promote proper “latch-on”.
 The mother should hold the baby so that his nose is aligned with the nipple and
watch for an open mouth gape. At the height of the gape, when the mouth is open
widest, the mother should aim the bottom lip as far away as possible from the
base of the nipple.
 the infant’s mouth should be placed 1 to 2 inches beyond the base of the nipple
14. Explain what the mother should be taught regarding the infant’s weight.
 Any infant who loses more than 7% of his birth weight should be carefully
evaluated to make sure that the he is being fed frequently enough and that the
feeding technique is effective in transferring milk from the mother’s breast.
 Once the mother’s milk production increases and the volume of milk consumed
increases, most infants begin to gain 15 to 30 g or 1/2 to 1 oz. per day
15. Discuss four common breastfeeding positions.
 Common positions for breastfeeding. A. Cradle hold position. B. Football hold
position. C. Side-lying position.
 In the cradle hold position, the infant is cradled, in the arm, close to the maternal
breast. The infant’s abdomen is placed against the mother’s abdomen with the
mother’s other hand supporting the breast.
 The cross cradle hold is similar to the cradle hold, although in this hold, the infant
is laying in the opposite direction.
 football hold, the infant’s back and shoulders are held in the palm of the mother’s
hand.
 the side-lying position, both the mother and the infant lay on their sides.
16. Explain what the breastfeeding mother should be taught about pumping and storing breast
milk.
 Freshly pumped breast milk can be safely stored at room temperature for four
hours or refrigerated at 34 to 39°F (0°C) for 5 to 7 days after collection.
 The oldest milk should be used first, unless the pediatrician recommends the use
of recently expressed milk.
 Women should be taught to thaw breast milk by placing the collection container
in the refrigerator.
 Breast milk should not be allowed to thaw at room temperature, in very hot water,
or in the microwave oven.
 After the feeding, any milk that remains in the feeding container should be
discarded and not saved for a later feeding.
17. Discuss appropriate cleaning techniques for bottles and nipples,
 Wash thoroughly/sterilize all equipment used to prepare the infant formula and
use a bottle and nipple brush to remove milk residue.
 Replace the nipples regularly.
 Bottles and nipples must be thoroughly washed in hot soapy water with
dishwashing detergent and then rinsed in hot clean water. They may also be
cleaned in an automatic dishwasher.
  The items are then well rinsed in hot, clean water, placed in a pot filled with
enough water to cover the equipment and boiled for 5 to 10 minutes.
18. Describe special precautions to be used with powdered formula.
 Poorly prepared formula that is too concentrated (from adding an incorrect
amount of water) may result in infant hypernatremia and dehydration.
 Formula that is too dilute may cause the infant to demonstrate symptoms of
undernourishment and water intoxication.
 Parents should also be advised to read and follow the manufacturer’s instructions
explicitly when preparing the formula.
19. Identify and describe the Rubin’s three phases associated with assuming the mothering
role.
 In the first day or two after birth, the mother is exhausted and should be
encouraged to rest. During this time, she is reflecting and clarifying, or “taking-
in” her birth experience.
 As the mother’s physical condition improves, she begins to take charge, and
enters the taking-hold phase where she assumes care for herself and her infant.
 In the letting-go phase, seen later in the mother’s recovery, the woman begins to
see the infant as an individual separate from herself. At this point, she can leave
the baby with a sitter, set aside more time for herself, become more involved with
her partner, and begin adapting to the realities of parenthood.
20. Describe strategies to facilitate maternal and paternal bonding.
 a positive mother–child relationship begins in the delivery/birthing room when the
infant is placed directly on the mother’s chest and is held skin-to-skin.
 The nurse should encourage the mother to initiate early eye contact during the
first 30 minutes after childbirth when both the mother and her baby are alert. This
special quiet time provides an opportunity for connecting and communicating
with one another.
 Early initiation of breastfeeding for mothers who wish to breastfeed and utilizing
a rooming-in protocol are important nursing interventions that contribute to a
positive maternal-child relationship
 Allowing fathers in the delivery room and encouraging early contact with the
infant have all been instrumental in promoting and fostering early paternal–infant
bonding.
 Fathers should be encouraged to assume an active role in infant bonding by
participating in the care giving activities.

21. Discuss five specific activities that parents can use to help older siblings adjust to the
newborn.
 Talk with the child(ren) about their feelings regarding the new baby. Listen and
validate their feelings.
 Teach the older sibling how to play with the new baby; encourage gentleness.
 Help develop the child’s self-esteem by giving him/her special jobs, for example,
bringing the diaper when you are changing the baby. Praise each contribution.
 Praise age-appropriate behaviors and do not criticize regressive behaviors.
 Set aside a special time each day for you to be alone with the older child; remind
the child that he/she is loved very much.