SIGN 0 1 2

Heart Rate absent Slow ˂ 100 ˃ more than 100

bpm/min bpm/min

Respiratory absent Irregular, slow, Good, strong cry

effort weak. cry

Muscle tone limp Some flexion of Well flexed

extremities

Reflex irritability No response grimace Cry, sneeze

Color Blue, pale Body pink, Completely pink

extremities blue

I. Health Promotion of the Newborn and Family

An important consideration in the physiologic change required of the

newborn is transition from fetal or placental circulation to independent respiration.
There is no more placental connection so the loss of complete metabolic support like
supply of oxygen and removal of carbon dioxide.

There are immediate adjustments in the different systems:

1. Respiratory System

a. The most critical and immediate physiologic change required is the onset of
breathing. Chemical factors in the blood (low oxygen, high carbon dioxide, and low
pH) initiate impulses that excite the respiratory center in the medulla.
b. Tactile stimulation may assist in initiating respiration. Descent through the birth
canal and normal handling during the delivery, such as drying the skin, help
stimulate respiration in uncompromised students. Acceptable methods of tactile
stimulation include slapping or flicking the soles of the feet or gently rubbing the
newborn’s back, trunk or extremities
c. In the alveoli the fluid’s surface tension is reduced by surfactant, a substance
produced by the alveolar epithelium that coats the alveolar surface.

2. Circulatory System
a. Circulatory changes allow blood to flow through the lungs and these occur
gradually and are the result of pressure changes in the heart, lungs and major
vessels.

Physiologic Status of other systems:

1. Thermoregulation
a. heat regulation is most critical to the newborn’s survival.
Factors that predispose the newborn to excessive heat loss
 newborn’s large surface area relative to his or her weight facilitates heat loss
to the environment
 newborn’s thin layer of subcutaneous fat
 newborn’s mechanism for producing heat

2. Hemopoietic System
a. the blood volume of the newborn depend s on the amount of placental transfer of
blood.
The blood volume of the full-term infant is about 80 to 85 ml/kg of body weight

3. Fluid and Electrolyte Balance

a. Changes occur in the total body water volume, extracellular fluid volume, and
intracellular volume during the transition from fetal to postnatal life.
b. The rate of fluid exchange is seven times greater in the infant than in the adult,
and the infant’s rate of metabolism is twice as great in relation to body weight

Gastrointestinal System
The newborn’s ability to digest, absorb, and metabolized food is adequate but limited
in certain functions. Enzymes are available to catalyze protein s and simple
carbohydrates but deficient production of pancreatic amylase Impairs utilization of
complex carbohydrates
The liver is the most immature of the gastrointestinal organs
Some salivary glands are functioning at birth, but the majority do not begin to secrete
saliva until about age 2 to 3 months.

Renal System
a. All structural components are present in the renal system but the kidney has a
functional deficiency in its ability to concentrate urine and to cope with fluid and
electrolyte fluctuations, such as dehydration or a concentrated load.

b. total volume output- 200 to 300ml per 24 hours at the end of the first week
the bladder involuntarily empties when stretched by a volume of 15 ml resulting in as
many as 20 voiding per day.

Change in Stooling Patterns of Newborns

Meconium
o This is the infant’s first stool, composed of amniotic fluid and its
constituents, intestinal secretions, shed mucosal cells, and possibly blood
(ingested maternal blood or minor bleeding of alimentary tract vessels).
o Passage of meconium should occur within the first 24 to 48 hours although
it may be delayed up to 10 days in in very-low-birth-weight infants
Transitional stools
o These usually appear by the third day after initiation of feeding , they are
greenish brown, thin, and less sticky than meconium and may contain some
milk curds
Milk Stools
o These usually appear by fourth day
o In breast-feeding infant’s stools are yellow to golden, are pasty in
consistency, and have an odor similar to that of sour mil
 o In formula-feeding infants stools are pale yellow to light brown, are firmer in
consistency , and have a more offensive odor

Integumentary System
a. At birth all the structures within the skin are present but many of the functions of
the integument are immature. The two layers of the skin (epidermis and dermis) are
loosely bound to each other and are very thin.

Musculoskeletal System
a. at birth the skeletal system contains large amount of cartilage than ossified bone ,
although the process of ossification is fairly rapid during the first year.

Defenses against infection

1. skin and mucous membranes which protect the body from invading organism
2. the cellular elements of the immunologic system which produces several types of
cells capable of attacking a pathogen.
3. formation of specific antibodies to an antigen

Endocrine System
a. the newborn’s endocrine system is adequately developed but its functions are
immature

Neurologic system
a. at birth the nervous system is incompletely integrated but sufficiently developed to
sustain extra uterine life in most neurologic function are primitive reflexes

Sensory Functions
a. Vision
 at birth the eye is structurally incomplete. The pupils react to light,
the blink reflex is responsive to minimum stimulus and the corneal
reflex is activated by a light touch. Tear glands usually do not begin
to function until 2 to 4 weeks of age.
b. Hearing
 Once the amniotic fluid is drained from the ears the infant probably
has auditory acuity similar to that of an adult. The infant is able to
detect a loud sound of about 90 dB and reacts with a startle (Moro)
reflex.
c. Smell
 newborns react to strong odors such as alcohol or vinegar by
turning their heads away. Breast-fed infants are able to smell
breastmilk and will cry for their mothers when the breasts are
leaking
d. Taste
 The newborn can distinguish between tastes and various types of
solutions elicit differing facial reflexes. A tasteless solution elicits no
facial expression; a sweet solution elicits an eager suck and a look
of satisfaction; a sour solution causes the usual puckering of lips
and a bitter liquid produces an angry upset expression
e. Touch
  The newborn perceives tactile sensation in any part of the body,
although the face hands soles of the feet seem to be most
sensitive. Sufficient evidence shows that touch and motion are
essential components in the attachment process and in normal
growth and development.

Nursing Care of the Newborn and Family

Physical Assessment after delivery can be divided into four phases
1. the initial assessment – which includes the Apgar scoring system
2. transitional assessment during periods or reactivity
3. assessment of gestational age
4. comprehensive, systematic physical examination

a. Initial Assessment Apgar scoring

the most frequently used method to assess the newborn’s immediate adjustment to
extra uterine life. The score is based on observation of heart rate, respiratory effort,
muscle tone, reflex irritability, and color.

b. Transitional Assessment: Periods of Reactivity

The newborn exhibits behavioral and physiologic characteristics that can at first
appear to be signs of stress. A newborn’s initial 24 hours’ changes in heart rate,
respiration, motor activity, color, mucus production and bowel activity occur in an
orderly, predictable sequence, which is normal and indicates lack of stress.
Distressed infants also progress through these stages but a slower rate
a. for 6-8 hours after birth the newborn is in the 1st period of reactivity. 1st 30 minutes
the infant is alert, cries vigorously, may suck his/her fingers, thus it is best to begin
breastfeeding, then 2 to 4 hrs. infant is in a state of sleep and relative calm.
b. for 2 to 5 hours is the 2nd period of reactivity and usually begins when the infant
wakes from this deep sleep

Behavioral Assessment
Infants behavior help shape their environment and their ability to react to various
stimuli affects how others relate to them.
The principal areas of behavior for newborns are sleep, wakefulness, and activity
such as crying
Brazelton Behavior Assessment Scale – one method of systematically assessing the
infant’s behavior wherein there is an interactive examination parent-child
relationship; to help identify caregivers who may benefit from a role model and to
guide parents, helping them focus on their infant’s individuality and develop a deeper
attachment.

Patterns of Sleep and Activity

a. newborns begin life with a systematic schedule of sleep and activity that is initially
evident during the periods of reactivity. The next 2 to 3 days most infants sleep
almost constantly to recover from exhausting birth process
b. infants have six distinct sleep-wake states, which represent a particular form of
neural control.

States of sleep and Activity

State and Behavior
Deep Sleep (Quiet)
Closed eyes, regular breathing
No movement except for occasional
sudden bodily twitch no eye movement
Light Sleep (Active)
Closed eyes irregular breathing slight
muscular twitching of body
Rapid eye movements under closed
eyelids
,may smile
Drowsy
Eyes may open irregular breathing
active body movement variable, with
occasional mild startles
Quiet Alert focuses attention to stimuli
Eyes wide open and bright responds to
environment by active body movement
and staring at close-range objects
minimum body activity regular breathing
Active alert
May begin with whimpering and slight
body movement
Eyes open irregular breathing
Crying
Progresses to strong, angry crying and
uncoordinated thrashing of extremities
eyes open or tightly closed, grimaces
irregular breathing
Implications for parenting
Continue usual house noises because
external stimuli do not arouse infant
External stimuli that did not arouse
infant during regular sleep may
minimally arouse child Periodic
groaning or crying is usual; do not
interpret as indication of pain or
discomfort
Most stimuli arouse infant, but infant
may return to sleep rate
Satisfy infant’s needs such as hunger or
nonnutritive sucking
Place infant in area of home where
activity is continuous
Remove intense internal or external
stimuli because of increases sensitivity
to stimuli
Comforting measures that were
effective during alert state are usually
ineffective rock and swaddle to
decrease crying
Intervene to reduce fatigue, hunger or
discomfort

Physical Assessment of the newborn

Usual Findings
General a. head circumference: - 33-35 cm (13-14 in); about 2-3cm (1
Measurements in) larger than chest circumference
b. chest circumference: 30.5- 33 cm (12-13 in)
c. crown-to-rump length: 31-35 cm (12.5-14 in) approximately
equal to head circumference
d. head to heel length: 48-53 cm (19-21 in)
e. birth weight: 2700-4000 g (6-9 lb.)
Vital signs a. temperature: axillary 36.5˚C- 37˚C (97.9˚F-98˚F)
b. heart rate: apical 120-140 beats/min
c. respiration 30-60 beats/min
d. blood pressure oscillometric 65/41 mmHg in arm and calf
General a. posture, flexion of head and extremities, which rest on chest
Appearance and abdomen
Skin a. at birth, bright red, puffy, smooth
b. 2nd -3rd day, pinky, flaky dry
c. vernix caseosa
d. lanugo
 e. edema around eyes, face, legs, dorsa of hands, feet and
scrotum or labia
f. acrocyanosis of hands and feet
g. cutis marmorata – transient mottling when infant is exposed
to decreased temperature
Head a. anterior fontanelle: diamond shaped; size varies from barely
palpable to 4-5 cm (0.5-2 in)
b. posterior fontanelle: triangular, 0.5-1 cm
c. fontanels flat, soft, and firm
d. widest part of fontanel measured from bone to bone not
suture to suture
Eyes a. lids usually edematous
b. color: slate gray, dark blue, brown
c. absence of tears
d. presence of red reflex
e. corneal reflex in response to touch
f. pupillary reflex in response to light
g. blink reflex in response to light or touch
h. rudimentary fixation on objects and ability to follow to
midline
ears a. position: top of pinna on horizontal line with outer canthus of
eye
b. startle reflex elicited by loud, sudden noise
c. pinna flexible , cartilage present
nose a. nasal patency
b. nasal discharge: thin white mucous
c. sneezing
Mouth and throat a. intact, high-arched palate
b. uvula in midline
c. frenulum of tongue
d. frenum of tongue
e. sucking reflex, strong and coordinated
f. rooting reflex
g. gag reflex
h. extension reflex
i. absent or minimum salivation
j. vigorous cry
neck a. short, thick, usually surrounded by skinfolds
b. tonic neck reflex
chest a. anteroposterior and lateral diameters equal
b. slight sternal retractions evident during inspiration
c. xiphoid process is evident
d. breast enlargement
lungs a. respirations chiefly abdominal
b. cough reflex absent at birth, present by 1-2 days
c. bilateral equal bronchial breath sounds
heart a. apex 4th-5th intercostal space, lateral to left sternal border
b. S2 slightly sharper and higher in pitch than S1
Abdomen a. cylindric in shape
b. liver: palpable 2-3 cm below right costal margin
 c. spleen: tip palpable at end of 1st week of age
d. kidney: palpable 1-2 cm above umbilicus
e. umbilical cord: bluish white at birth with 2 arteries and 1 vein
f. femoral pulse equal bilaterally
Female genitalia a. labia and clitoris usually edematous
b. urethral meatus behind clitoris
c. vernix caseosa between labia
d. urination within 24 hours
Male genitalia a. urethral opening at the tip of the glans penis
b. testes palpable in each scrotum
c. scrotum usually large, edematous, pendulous, and covered
with rugae, usually deep pigmented in dark skinned ethnic
groups
d. smegma
e. urination within 24 hours
Back and a. spine intact, no openings, masses, or prominent curves
rectum. b. trunk incurvation reflex
c. anal reflex
d. patent anal opening
e. passage of meconium within 48 hours
extremities a. 10 fingers and toes
b. full range of motion
c. nail beds pink, with transient cyanosis immediately after birth
d. creases on anterior 2/3 of sole
e. symmetry of extremities
f. equal bilateral brachial pulses
Neuromuscular a. extremities usually in some degree of flexion
system b. head lag while sitting, but momentary ability to hold head
erect
c. ability to turn head from side to side when prone
d. ability to hold head in horizontal line with back when held
prone

Maintain a Patent Airway

1. Establishing a patent airway is the primary objective in the delivery room

2. The American Academy of Pediatrics recommends the supine position during
sleep for all newborns
3. Suctioning maybe done if needed with a bulb syringe and replaced every 24 hours
in the hospital. Mechanical suction can be used if more forceful removal of
secretions is needed
a. gentle suctioning is necessary to prevent laryngospasm, reflex bradycardia, and
other cardiac arrhythmias from vagal stimulation
b. oropharyngeal suctioning is performed for up to 5 seconds with sufficient time
between each attempt to allow to infant to reoxygenate
c. nasal suctioning must be done after oral suctioning to minimize the possibility of
aspiration of oropharyngeal contents

Maintain a stable body temperature

1. conserving the newborn’s body heat is an essential nursing goal
2. at birth a major cause of heat loss is evaporation, the loss of heat through
moisture
3. another source of heat loss is radiation, the loss of heat to cooler solid objects in
the environment that are not in the direct contact with the infant.
4. Heat loss can also occur through conduction and convection. Conduction involves
loss of body heat from direct skin contact with a cooler solid object and convection is
similar to conduction, except the heat loss is aided by surrounding air currents

Protection from infection and injury

1. Identification
Proper identification of the newborn is essential. The nurse must verify that
identifying bands are securely fastened on the newborn and verify the information
(name, sex, mother’s admission number, date and time of birth) against the birth
records and the child’s actual gender.

2. Eye care
Prophylactic eye treatment against opthalmia neonaturum, infectious conjunctivitis of
the newborn, includes the use of silver nitrate solution, erythromycin ophthalmic or
drops tetracycline ophthalmic ointment or drops

3. Vitamin K administration
Shortly after birth Vitamin K is administered as a single intramuscular dose of 0.5 to
1 mg to prevent hemorrhagic disease of the newborn

4. Hepatitis B vaccination
To decrease the incidence of hepatitis B virus in children and its serious
consequence, cirrhosis and liver cancer, in adulthood, the first of 3 doses of HBV
vaccine is recommended between birth and 2 months of age for all newborns and
given in vastus lateralis muscle

5. Newborn Screening
A large of number of congenital disorders can be detected in the newborn period by
blood sampling so that early intervention can take place.

6. Universal Newborn Hearing Screening

It has been estimated that screening children for hearing loss by risk factors alone
fails to identify approximately 50% of all newborns with a congenital hearing loss.
Infants who are hard of hearing or deaf yet receive intervention before the age of 6
months maintain appropriate language development matching their cognitive abilities
through the age of 5 years.
It is now recommended the universal hearing screening of all newborns before
discharge from the birthing hospital by auditory brainstem response or evoked
optoacoustic emission

7. Bathing
Bath time is an excellent time for observing the infant’s behavior, state of arousal,
alertness and muscular activity
Bathing is usually performed after the vital signs have stabilized, especially the
temperature.
8. Care of the umbilicus
The umbilicus stump is an excellent medium for bacterial growth. One way of
preventing the infection is by cleaning the stump with alcohol.

9. Circumcision
It is the surgical removal of the foreskin on the glans penis is usually done in the
hospital although it is not common practice in most countries

10. Provide optimum Nutrition

Breastfeeding

Contraindications to breastfeeding
 Maternal chemotherapy – antimetabolites and
certain antineoplastic drugs
 Active tuberculosis not under treatment in
mother
 HIV in mother
 Galactosemia in infant
 Maternal herpes simplex lesion on a break
 cytomegalovirus
 maternal substance abuse
 Human t cell leukemia virus type 1
 Mothers receiving diagnostic or radioactive
isotopes or who have exposure to radioactive
materials

Intervention to promote breastfeeding

 Frequent and early breast-feeding especially during the first hour of life:
immediate skin to skin contact; rooming-in and feeding on demand
 Direct modeling of the importance of breastfeeding by health care providers,
such as implementing demand nursing with no formula supplementation and
decreased emphasis on infant formula products
 Increased information and support to mother s after discharge, especially
follow-up
 Early breast pumping every 2 to 3 hours for 20 minutes bilaterally if the
newborn is unable to nurse immediately

Bottle feeding
This refers to the use of bottles for feeding commercial or evaporated milk formula
rather than using the breast, although in some instances human milk maybe
expressed and feed with a bottle.

Propping the bottle is discouraged

1. it denies the infant the important components of close human contact
2. the infant may aspirate formula into the trachea and lungs while sleeping
3. it may facilitate the development of middle ear infection
4. it encourages continuous pooling of formula in the mouth, which can lead to caries
when the teeth erupt.

Feeding Schedules
Feeding schedules should be determined by the infant’s hunger. Demand feedings
are given when the infant signals readiness. Some hospitals routinely feed infant
every 3 to 4 hours which is suitable for bottle-fed infants. Breastfed infants tend to be
hungry every 2-3 hours because of the easy digestibility of the milk
Supplemental feedings should not be offered to breastfeed infants before lactation is
well established because they may satiate the infant and may cause nipple
preference
Supplemental water is not needed in breastfeed infants even in hot climate