SCHOOL OFNURSING

NCM 107 PEDIATRIC NURSING RESOURCE UNIT

Learning Objectives:

After the lecture, students will be able to:

1. Apply evidence-based practice in maternal and child health & discuss the immediate care of the
newborn.
2. Assess a newborn for normal growth and development
3. Nursing care planning: Interprofessional care maps
4. Filipino culture, values, & practices in relation to maternal & child care: nursing care planning to
respect cultural diversity.
5. Assess the normal growth and development of an infant.

Evidence-based Practice in Maternal and Child Health – Journal reading

Nursing Process Overview for Health Promotion of the Term Newborn: Immediate Care of the
Newborn
A. Assessment
Assessment of the newborn or neonate (a baby in the neonatal period, the first 28 days of life) includes:

1. Observe or assist with initiation of respirations.

2. Assess Apgar score.

3. Note characteristics of cry.

4. Monitor for nasal flaring, grunting, retractions, abnormal respirations.

5. Obtain vital signs.

6. Observe Newborn for signs of hypothermia or hyperthermia.

7. Assess for gross abnormalities

 Review of the mother’s pregnancy history.

 Physical examination of the infant.

 Analysis of the newborn’s laboratory reports such as hematocrit & blood type.

 Assessment of parent- child interactions to be certain bonding is beginning.

 Begins immediately after birth and is continued at every contact during the newborn’s hospital or
birthing center’s stay, early home visits, or well- baby clinic.
 Teaching parents to make assessment concerning their infant’s temperature, respiration and
overall health is crucial so they can continue to monitor their infant health at home.

B. Nursing Diagnosis

 Ineffective airway clearance related to mucus in airway

 Ineffective thermoregulation related to heat loss from exposure in birthing room
 Imbalanced nutrition, less than body requirements, related to poor sucking reflexes
 Readiness for enhanced family-coping related to birth of planned infant

C. Outcome Identification and Planning

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Take into account newborn needs during transition period & the mother’s need for adequate rest during
post-partum period includes:
 Helping them regulate body temperature
 Accustomed to breastfeed or bottle feeding

D. Implementation-

1. Role modeling to help new parents grow confident with their newborn.

2. Suction mouth, nares with bulb syringes when indicated.

2. Dry newborn & stimulate crying by rubbing back.

3. Maintain temperature stability; wrap newborn in warm blankets & place a bonnet/cap on newborn head.

4. Keep newborn with mother to facilitate bonding, mother’s breast if breastfeeding is planned, or place
on mother’s abdomen.

5. Place newborn in a warmer or drop light and position newborn on side or abdomen to keep warm.

6. Ensure newborn proper identification, footprint newborn & fingerprint mother on identification sheet, /
agency policies & procedures and place matching identification bracelets/ ID tags on mother & on
newborn’s ankle.

Apgar Scoring System

Apgar Score
 is an easy & quick assessment tool used to assess the status of a newborn after birth, discovered
by Dr. Virginia Apgar.
 Perform and record the Apgar score at 1 minute – done to determine the general condition of the
baby and at 5 minutes to determine how well the newborn is adjusting to extra uterine life.
 If score is less than 7 or 6 at 5 minutes, the Apgar score should be performed at 10 minutes.

Assess each 5 items to be scored, and assign value of 0 (very poor) to 2 (Excellent) for each item.
Add the points to determine the newborn total score.

Interventions Based on Score:

• A score of 7 to 10 indicates a healthy newborn- routine post- delivery care

• A score of 4 to 6 is considered moderately depressed- condition is guarded, dry quickly, suction,

maintain warmth, stimulate baby, rub back, give oxygen, ventilate 30 to 50x until heart rate is
above 100, color is pink, and spontaneous respiration begin, provide oxygen and careful
observation needed during the first days of life.

• A score of below 0-3 - is in serious danger, severely depressed, needs intensive

resuscitation, clear airway, insert endotracheal tube, use ambulatory bag if necessary, ventilate
with 100% oxygen at 40 to 60 breaths/ minute.
• Initiate full Cardio-Pulmonary Resuscitation as needed, maintain body temperature, support
parents.

Apgar Scoring

Criteria or Signs to Evaluate

Signs 0 1 2
1. Heart rate Absent or no heart Present, Less than More than 100bpm
rate 100
2. Respiratory Effort Absent or no Weak cry, slow, Strong vigorous cry
respiratory effort difficult respiration
3. Muscle tone Limp and Flaccid Minimal or some Maintains a position of
flexion of extremities flexion, with brisk
movements,
4. Reflex Irritability No response Grimace, when Cries or sneezes when
stimulation stimulated stimulated; good strong cry
5. Color Body and extremities Body pink, extremities Pink and extremities pink,
blue (cyanosis) or blue or pink all over
completely
pale(pallor)

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  The most critical observation is the heart rate.
 The general attitude of the newborn at birth is that of flexion.
 Body pink, extremities blue (called acrocyanosis) is normal during the first 24 hours of life.

Silverman-Anderson scale – index of respiratory distress (score of 10 is an indication of good

respiratory function)
 Grunting sound of air pushing past partially closed glottis, heard during inspiration.
 Retractions: sternal and intercostals; due to use of accessory muscles to aid in breathing.
 Flaring nares: due to newborn’s efforts to lessen resistance in narrow nasal passages.
 Seesaw respirations: Flattening of chest with inspiration and bulging of abdomen, caused by the
utilization of abdominal muscles during prolonged, forced respiration

Implementation
• Role modeling to help new parents grow confident with their newborn.
• Aware of how closely parents observe you for guidance in child care.
• Conserve newborn’s warmth & energy to help prevent hypoglycemia & respiratory distress.

Evaluation
• Parents are able to give beginning newborn care with confidence.
• Be certain that parents have made arrangements for continued health supervision for their
newborn.
• Infant establishes respirations of 30 to 60 breaths per minute.
• Infant maintains T at 97.8 degrees to 98.6 degrees F (36.5 to 37 degrees C)
• Infant breastfeeds for a minimum of 10 minutes every 3 hours.

Assessment of Gestational Age

 Obstetrical Method
 Mother’s LMP
 Fundic height
 Time quickening is first felt
 Time fetal heart sounds (first heard)

Clinical criteria for gestational age assessment in the newborn

Characteristics To 36 Weeks 37-38 weeks 39 weeks

Sole creases Anterior transverse Occasional creases, Sole covered with
crease only anterior two-thirds creases
Breast nodule 2 mm 4 mm 7 mm
diameter
Scalp hair Fine and fuzzy Fine and fuzzy Coarse and silky
Earlobe Pliable, no cartilage Some cartilage Stiffened by thick
cartilage
Testes and scrotum Testis in lower scrotal intermediate Testes pendulous;
sac; scrotum small, scrotum full; extensive

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 few rugae rugae

Identify the newborn.

 Identification of the neonate should be done in the delivery room before transferring to the
nursery.
 Footprints are said to be the best form, although identical ID bands for both baby and mother will
suffice.

Initial Physical Examination

General Guidelines
1. Keep Newborn warm during the examination.
2. Begin with general observations; then perform assessments that are least disturbing to the newborn
first.
3. Initiate nursing interventions for abnormal findings.
4. Document all abnormal findings.

Profile of the Newborn

A. Vital Statistics
1. Weight- 2.5 to 3.4 kg, (5.5 lbs- 7.5 lbs) – lower limit for all races. F white NB- 3.4 kg( 7.5 lb.), Male
White 3.5kg ( 7.7 lb).5lb.) loses wt. 5 to 10% of birth weight (6 to 10 oz) during the first few days of life.
• 75 to 90 % NB weight is fluid
• After 10 days, BF NB recaptures birth weight, Formula fed within 7 days, after that NB gains
weight
• Gain weight 2 lb/ mo. ( 6 to 8 oz/ week) for the first 6 mo. of life

Digital Weighing Scale in kilogram

2. Length- Average birth length of a mature female neonate (50 th%) is 53 cm (20.9 in), mature males 54
cm (21.3 in). Lower limit is 46 cm. (18 in). Rare- 57.5cm (23 in). 46 to 54 cm.

Measurement is done from the occiput down the heel.

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3. Head Circumference- mature NB- 34 to 35 cm. (13.5- 14 in) HC greater than 37 cm or less than
33cm.

Should be examined for neurological involvement.

Measured with a tape measure drawn across the center of the forehead & around the most prominent
portion of the posterior head (occiput).

Measuring the Head Circumference

4. Chest circumference- 32 to 33 cm, 2 cm less than HC (0.75 to 1 in), measured at the level of the
nipples.

Measuring the Chest Circumference

Measuring the Abdominal Circumference

Vital Signs

Heart Rate

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Fetal heart rate- 110-120 -160 inside the utero immediately.

Apical pulse after birth 180beats per minute

Within hour after birth -120-140bpm.

Sleep- 90-110bpm. degrees

(68-72 degrees F)- 21-22 C- DOH Delivery Room Temperature

Taking the Apical / Heart Rate

Taking the Respiration

Respirations: few minutes after birth- 80b/pm, 30 to 60 breaths / minute at rest, watching the rise and fall
of the abdomen because it involves the diaphragm and abdominal muscles. Coughing and sneezing
reflexes are present at birth to clear the airway, and newborn are nose-breathers.

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Taking the Axillary Temperature

Axillary Temperature- 99F (37.2 degrees C) just after birth because of heat loss & immature heat
regulating center, stabilizes 4 hours after birth 98.6 degrees F( 37 degrees C).

Taking the Rectal Temperature

Taking the Blood Pressure

Blood Pressure- 80/46mm Hg at birth, rises to 100/50mm Hg after 10 days

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4 Mechanisms of heat Loss

1. Convection- flow of heat from body surface to cooler surrounding air- drafts/ air conditioners

2. Conduction – transfer of body heat to a cooler solid object in contact with the baby – weighing scale

3. Radiation – transfer of body heat to a cooler solid object not in contact with the baby – cold window
surface or air conditioners.

4. Evaporation- loss of heat through conversion of a liquid to a vapor. NB are wet, loose a great deal of
heat as the amniotic fluid on the skin evaporates.

Brown fat- a special tissue found in mature NB helps to conserve or produce body heat by constricting
blood vessels by increasing metabolism.

Mechanical measures to conserve heat:

 Drying & wrapping

 Place in warm cribs

 Radiant warmer

 Kangaroo care- placing the NB against the mother’s skin and then covering the NB helps to
transfer heat from the mother to the NB, thus conserving heat loss.

Blood Values

 NB blood volume is 80 to 110 ml per kg of body weight, or about 300 ml.

 (RBC) Erythrocyte count is 6 million/ cubic millimeter.
 Hemoglobin level averages 17 to 18g/ 100 ml
 Hematocrit level is between 45 to 50%- warm the extremity by wrapping it in a warm cloth
increases circulation.

 Indirect bilirubin at birth is 1 to 4 mg/100ml – Any increase over this amount reflects the release of
bilirubin as excessive RBC begin to break down.

 White blood cell count (WBC) at birth-15,000 to 30,000 cells/ mm3

 WBC -40,000 cells/ mm3- seen if birth is stressful.

 Neutrophils account for a large part of leukocytosis but by the end of the first month lymphocytes
become predominant.

 Leukocytosis is a response to the trauma of birth & in non- pathogenic

 Signs of infection: pallor, respiratory difficulty, or cyanosis

Blood Coagulation

 Most NB are born with prolonged coagulation or prothrombin time because blood levels of
Vitamin K are lower than normal.
 Vitamin K synthesized through the action of intestinal flora, is necessary for the formation of
factor II (prothrombin), factor VII (proconvertin), factor IX (Plasma thromboplastin component),
and facto X (Stuart: Power Factor).
 A NB intestine is sterile at birth unless membranes were ruptured more than 24 hours for flora to
accumulate & for Vitamin K to be synthesized.
 All NB can be predicted to have diminished blood coagulation ability, Vitamin K ( Aquamephyton,
Konakion, Phytonadione) is given IM into the lateral anterior thigh after birth.

Respiratory System

 First breath of NB is initiated by a combination of cold receptors, lowered PO2(PO2, falls from
80mm Hg to as low as 15 mmHg), & increased PCO2( PCO2 as high as 70mm Hg).
 First breath requires a tremendous amount of pressure (40 to 70 cm. H2O).
 The presence of fluid in the lungs eases the surface tension on alveolar walls & makes breathing
easier than dry lung walls especially during vaginal delivery.
 Breathing becomes much easier for the baby once alveoli is inflated, requiring only about 6 to 8
cm H2O pressure.

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  10 to 12 hours of age, vital capacity is established at newborn proportions.
 Cesarean birth babies have less lung fluid, may have difficulty establishing effective respiration
(because excessive fluid blocks air exchange space).
 Newborns who are immature & whose alveoli collapse each time they exhale (because of the lack
of pulmonary surfactant) have trouble establishing effective residual capacity & respirations.

Gastro intestinal System

 Is usually sterile at birth, bacteria may be cultured with 5 hours, after birth, & babies at 24 hours
of life.
 Accumulation of bacteria in the GIT is necessary for digestion & for the synthesis of Vitamin K.
 NB stomach holds about 60-90 ml., limited ability to digest fats, regurgitates easily because of
immature cardiac sphincter between stomach & esophagus.
 Immature liver functions may lead to lowered glucose & protein serum.
 Stools- meconium is the first stool of the NB- a sticky, tarlike, blackish- green, odorless material
formed from mucus, vernix, lanugo, hormones & carbohydrates that are accumulated during
intrauterine life.
 Passed within 24 to 48 hours after birth, failure to pass should be examined for meconium ileus,
imperforate anus, & bowel extraction.
 2nd to third day, NB stool changes color & consistency- green, & loose called transitional stool,
resembles diarrhea.

 Bile duct obstruction- clay-colored (gray) stools, because bile pigments do not enter the intestinal
tract.

 Blood-flecked stools – anal fissure

 Apt test- dipstick to test for the presence of maternal blood from fetal blood.

Urinary System

 Average NB voids within 24 hours after birth a general rule. Failure to do so, examine for the
possibility of urethral stenosis or absent kidneys or ureters.

 Obstruction- Males & females- observe the force of the urinary stream

 Projecting urine farther than normal signal urethral obstruction.

 Males- voids with enough force to produce a small projected arc.

 Females- steady stream not just a continuous dribbling

 Color- light colored & odorless because kidneys do not concentrate urine well.

 Single voiding is 15 ml. Specific gravity- 1.008-1.010

 Urinary output daily is 30-60 ml total for the first 1 or 2 days.

 By week 1 total volume-300 ml.

 First voiding pink or dusky because of uric acid crystals that were formed in the bladder in utero.

 Small amount of Protein may normally be present for the first few days of life until kidney
glomeruli are fully mature.

Immune System

 Difficulty forming antibodies until 2 months of age – NB is prone to infection.

 At birth- the infant has passive antibodies (IgG) from mother that have crossed the placenta:
poliomyelitis, measles, diphtheria, pertussis, chicken pox, rubella & tetanus.

 Less natural immunity for herpes simplex

 Hepatitis B vaccine is given within 12 hours after birth.

The Neuromuscular System

Newborn Reflexes

1. Blink reflex

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  Mechanism: rapid eyelid closure when strong light is shone on eyes
 Purpose: protect the eyes from any object coming near them

 Age of disappearance: always present

2. Feeding reflexes

a. Rooting reflex- head will turn to the direction where cheek is stroked near the corner of the mouth

 Purpose: help infant find food

 Age of disappearance: 6 weeks

 Implication of disappearance: infant is already capable of seeing things past the visual midline

b. Sucking reflex--anything placed between the lips will be sucked

 Purpose: for feeding

 Age of disappearance: 6 months

 (IMPORTANT: The sucking reflex disappears immediately when not stimulated regularly.)

 Implication: Any infant put on NPO should be given a pacifier not only for psychological reasons
but also to prevent premature disappearance of the sucking reflex.

c. Extrusion reflex--anything placed on the anterior of the tongue will be spit out

 Purpose: prevent swallowing of inedible substance

 Age of disappearance: 4 months

 Implication of disappearance: infant is about ready for semi-solid or solid foods

d. Swallowing reflex--anything placed at the back of the tongue will be swallowed. Gag, cough, &
sneezing reflexes are present to maintain a clear airway.

 Age of disappearance: will never disappear

2. Tonic Neck reflex (TNR)/Fencing reflex/Boxer reflex--when on his back, if the newborn turns his
head to one side, the arm and leg on this side are extended, while the arm and leg on the opposite side
are flexed.

 Purpose: when incomplete, could mean paralysis of an extremity

 Age of disappearance: 2-3 month

3. Moro reflex--when head is allowed to drop backward in supine position (a change in the infant’s
equilibrium) or when the bassinet is jarred, abduction and then adduction of extremities is observed

 Purpose: The most significant singular reflex indicative of CNS status; its absence means
neurological damage. If asymmetric, implies injuries of the brachial plexus, clavicle or humerus &
Strong for the first 8 weeks

 Age of disappearance: 4 or 5 months can roll away from danger.

4. Babinski reflex--when side of the sole is stroked in an inverted “J” curve from the heel upward, the
infant fans his toes. Positive Babinski(adult-flexes /curve in his toes)

 Age of disappearance: starting 3 months

 Implication of disappearance: maturation of the CNS

5. Landau reflex--when on prone, the infant should demonstrate some muscle tone

 Purpose: to test spinal cord integrity

 Age of disappearance: 3 months

6. Palmar reflex--newborn has tendency to grasp an examiner’s finger when palm is stimulated

 Age of disappearance: 6 weeks to 3 months

7. Plantar Grasp reflex--newborn has tendency to curl toes downward when sole of foot is stimulated

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  Age of disappearance: lessens at 8 months

8. Step-in-place/Dancing/Walking reflex--newborn has tendency, when held upright, to take steps in

response to feet touching a hard surface

 Age of disappearance: 6 weeks

9. Magnet Reflex- if pressure is applied to the soles of the feet of a newborn lying in a supine position, he
or she pushes back against the pressure.

 Test for spinal cord integrity.

10. Crossed Extension Reflex- one leg of a newborn lying supine is extended & the sole of the foot is
irritated by being rubbed w a sharp object, such as a thumb nail. This causes the newborn to raise the
other leg & extend it as if trying to push away the hand irritating the first leg.

11. Trunk Incurvation Reflex- When newborns lie in a prone position & are touched along the
paravertebral area by a probing finger, they will flex their trunk & swing their pelvis toward the touch.

12. Deep tendon Reflex-

 A patellar reflex can be elicited in a newborn by tapping their patellar tendon w/ the tip of the
finger. The lower leg will move perceptibly if infant has an intact reflex.L2-14.

 Bicep reflex- place the thumb of your left hand on the tendon of the biceps muscle on the inner
surface of the elbow. Tap the thumb as it rests on the tendon. Feel the tendon contract than
observe movement. Test for spinal nerves C5 & C6.

Senses of the Newborn

Hearing

• Fetus is able to hear in utero.

• As soon as amniotic fluid drains or is absorbed from the middle ear by way of the eustachian
tube- within hours after birth- hearing in NB becomes acute.

• Calm in response to a soothing voice. Recognized mother’s voice immediately.

Vision

• NB see as soon as they are born & possibly have been seeing light & dark in utero for the last
few months of pregnancy as the uterus & the abdominal wall were stretched thin.

• Demonstrate sight at birth by blinking at a strong light( blink reflex).

• Or following a bright light or toy a short distance with their eyes, because they cannot follow past
the midline of vision, they lose tract of objects easily.

• Focus best on black & white objects at a distance of 9-12 inches. A pupillary reflex is present
from birth.

Touch

• Well developed at birth. Demonstrated by quieting at a soothing touch & by positive sucking &
rooting reflexes which are elicited by touch. React to painful stimuli.

Taste

• Has the ability to discriminate taste because taste buds are developed & functioning before birth.

• In the utero, fetus will swallow amniotic fluid more rapidly than usual if glucose is added to
sweeten its taste.

• Turns away from a bitter taste.

Smell - manifestation of rooting reflex.

• Is present in NB as soon as the nose is clear of mucus & amniotic fluid. Turn toward their
mother’s breast partly out of recognition of the smell of breast milk & partly.

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Physiologic Adjustment to Extrauterine Life

• Period of reactivity- the first phase lasts about half an hour . During this time, the baby is alert &
exhibits exploring, searching activity, often making sucking sounds.

• Heart rate & respiratory rate are rapid.

• Quiet Resting period- heart beat & respiratory rates slow; sleeps for about 90 minutes.

• Second period of reactivity, between 2 & 6 hours of life, occurs when baby wakes again, often
gaging, & choking on mucus that has accumulated in the mouth

• Alert, responsive & interested in surroundings.

• In the utero, fetus will swallow amniotic fluid more rapidly than usual if glucose is added to
sweeten its taste.

• Turns away from a bitter taste.

Smell - manifestation of rooting reflex.

• Is present in NB as soon as the nose is clear of mucus & amniotic fluid. Turn toward their
mother’s breast partly out of recognition of the smell of breast milk.

• Ability to respond odors can be used to document alertness.

Appearance of the Newborn

Skin

• Color- ruddy complexion because of the increased concentration of RBC in blood vessels & a
decreased amount of subcutaneous. Fat which makes the blood vessels more visible, slightly
fades over the first month. Pinkish red (light-skinned NB) to pinkish brown or pinkish yellow (dark-
skinned NB)

• Cyanosis-NB lips, hands & feet likely cyanotic from immature peripheral circulation. Common with
hypothermia, infection, and hypoglycemia, and with cardiac, respiratory, or neurological
abnormalities

• Acrocyanosis is a normal phenomenon in the first 24 -48 hours after birth due to compromised
peripheral circulation.

• Central cyanosis or cyanosis of the trunk –cause of concern indicates decreased oxygenation.
Result of temporary respiratory obstruction or underlying disease – Suction the mouth before the
nose.

Cyanosis - is the bluish or purplish discoloration of the skin or mucous membranes due to the tissues
near the skin surface having low oxygen saturation

Hyperbilirubinemia- leads to jaundice, or yellowish of the skin, occurs on the 2 nd or 3rd day of life, as a
result of the breakdown of fetal RBC (Physiologic jaundice).

• Skin & sclera of the eyes yellow as the high RBC count built up in utero is destroyed & heme &
globin are released.

• Globin is a protein component reused by the body not a factor in developing jaundice.

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 • Heme is further broken down into iron & Protoporphyrin- further broken down into indirect
bilirubin.

• Indirect bilirubin- is fat soluble & can’t be excreted by the kidneys, instead it is converted by liver
enzyme glucuronyl transferase into direct bilirubin, w/c is water soluble & is incorporated into
stool, & then excreted in the feces.

• Indirect bilirubin rises to 7 mg./100 ml, bilirubin permeates the tissue outside the circulatory
system & cause jaundice.

• Cephalhematoma – collection of blood under the periosteum of the skull bone- jaundice- RBC are
hemolyzed & indirect bilirubin is released.

• Transcutaneous bilirubinometry- a device to measure skin tone for jaundice & help in estimating
jaundice levels.

• Above 10-12 mg/ 100 ml, treatment will be considered.

• 20mg/100 ml, result in permanent cell damage called kernicterus- permanent neurologic effects
including cognitive challenge may result.

• Physiologic jaundice management: early feeding- speed passage of feces thru the intestine &
prevent reabsorption of bilirubin from the bowel. Phototherapy- exposure to light to initiate
maturation of liver enzymes.

Breastfed babies- more difficulty in because breast milk contains pregnanediol- a metabolite of
progesterone which depresses the action of glucuronyl transferase.

Pallor- result of anemia due to:

• Excessive blood loss when cord was cut

• Inadequate flow of blood from the cord into infant at birth

• Fetal-maternal transfusion

• Low iron stores caused by maternal nutrition during pregnancy

• Blood incompatibility in which large number of RBC were hemolyzed in utero

 Internal bleeding- blood in stool or vomitus

 Gray color- infection
 Infants w/ CNS damage- pale & cyanotic

Vernix caseosa: A white cheesy substance that covers and protects the skin of the fetus and is still all
over the skin of a baby at birth.

Acrocyanosis-bluish or purple coloring of the hands and feet caused by slow circulation.

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 • Assess skin turgor over the abdomen to determine hydration status

• Observe forceps marks

Harlequin Sign- due to immature circulation, NB lying on his side will appear red on the dependent side
of the body & pale on the upper side- fades immediately if position is changed.

Birthmarks

• Hemangiomas- vascular tumors of the skin.

3 Types:

 Strawberry hemangiomas- elevated areas formed by immature capillaries & endothelial cells,
appear up to 2 weeks after birth on term neonate. 7 years old 50-75% disappeared.

 Nevus Flammeus (Port-wine stain) a macular purple or dark red lesion because of its deep
color that is present at birth. Lesions generally appear on face, thighs., Those above the bridge of
nose fade. Laser or removed surgically.

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  Cavernous hemangiomas- dilated vascular spaces raised & resemble a strawberry appearance

 Stork beak mark (telangiectatic nevi)- lighter, pink patches at the nape of the neck.

Mongolian spots – collections of pigmentation cells (melanocytes) that appear as slate gray patches
across the sacrum or buttocks, arms & legs disappear by school age.

Appearance of the Newborn

HEAD

• Appears disproportionately large because it is ¼ of the total body length , adult 1/8 th of total height

• Forehead is large & prominent, chin appears to be receding, & quivers easily if startled or cries.

• Well -nourished have full -bodied hair, preterm have thin, lifeless hair.

 Anterior fontanels- soft, flat, diamond shaped 3-4 cm wide by 2 to 3 cm long closes between 12 to
18 months of age
 Posterior fontanels triangular 0.5 to 1 cm located between occipital and parietal bones, closes
between birth, and 2 to 3 months

 Molding: asymmetry of the head as a result of pressure in the birth canal; disappears in about 72
hours.

 Sutures- may override at birth because of extreme pressure exerted by passage through the

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 Birth canal

 .

Molding of the head

Masses from Birth Trauma:

a. Caput succedaneum: edema of the soft tissue over bone (crosses over suture line); subsides about the
3rd day of life.

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b. Cephalhematoma: Swelling caused by bleeding into an area between the bone and its periosteum
(does not cross over suture line); occurs 24 hours after birth. Usually absorbed within 6 weeks with no
treatment.

Craniotabes is a localized softening of the cranial bones. Caused by pressure of the fetal skull against the
mother’s pelvic bone. Normal in NB but would be pathologic in an older child (kidney dysfunction).

Head lag:

a. Common when pulling NB to a sitting position

b. When prone, NB should be able to lift the head slightly and turn the head from side to side

EYES

• Cry tearlessly because the lacrimal ducts are not fully mature until 3 months of age. Iris of the
eyes are blue or gray & the sclera blue due to its thinness. Assume permanent color between 3 &
12 months of age.

• Slate gray (light skin) or brown-gray (dark skin skin)

• Symmetrical and clear

• Pupils equal, round, react to light by accommodation

• Blink reflex present

• Eyes cross because of weak extraocular muscles

• Able to track and fixate momentarily

• Red reflex present

• Eyelids often edematous as a result of pressure during the birth process and the effects of eye
medication

• Appear clear without redness or purulent discharge’ Erythromycin ointment given at birth to
protect against Chlamydia infection as well as opthalmia neonatorum (gonorrheal conjunctivitis)
will cause purulent discharge for the first 24 hours of life.

• Subconjunctival hemorrhage- pressure during birth will rupture conjunctival capillary. No

treatment absorbed in 2 or 3 weeks.

• Cornea round & proportionate in size that of an adult eye. Larger than normal- congenital

EARS- not completely formed, pinna bend easily

• Symmetrical, Firm cartilage with recoil

• Pinna should be on or above line drawn from canthus of eye

• Low-set ears associated with Down’s syndrome

• Small tags associated w/ chromosomal abnormalities- ligate

• Hearing -Ring the bell about 6 inches from each ear

NOSE

• Flat, broad, in center, large for the face

• Obligatory nose breathing

• Occasional sneezing to remove obstruction

• Test for choanal atresia-blockage at the rear of the nose by closing the NB mouth & compressing
1 naris at a time w/ your finger. Note any discomfort / distress.

• Milia- pin point whitish spot due to unopened sebaceous gland.

MOUTH- Pink, moist gums

• Soft and hard palates intact, Epstein’s pearls (1 or 2 small, round, glistening, well circumscribe
white cysts) may be present on the hard palate

17
 • Open evenly when crying

• If one side of the mouth moves than the other, cranial nerve injury is suspected.

• Uvula in midline

• Tongue large & prominent, short, moves freely, is symmetrical, frenulum membrane is attached
close to the tip of the tongue

• Sucking and crying movements symmetrical

• Able to swallow, Gag reflex present

• Natal teeth- 1 or 2 teeth

NECK -Short and thick, not enough to support the weight, chubby with creased skin folds,

• Head held in midline, rotate freely, head lag,

• Trachea on midline

• Good range of motion (ROM) and is able to flex and extend

CHEST- small because the infant’s head is large in proportion. 2 years- chest measurement exceed the
head.

 Appears circular since anteroposterior and lateral diameters are about equal

• Respirations appear diaphragmatic- 30-60 bpm

• Bronchial sounds heard on auscultation

• Nipples prominent and often edematous

• Milky secretion (witch’s milk common

• Breast tissue present, Clavicles need to be palpated to assess for fractures

ABDOMEN- contour is slightly protuberant.

• Scaphoid or sunken indicate missing abdominal contents or diaphragmatic hernia.

• Bowel sounds present after an hour after birth.

• Edge of liver palpable 1 to 2cm below the right costal margin.

• Edge of spleen palpable 1 to 2 cm below the left costal margin.

• First hour after birth, umbilical cord appears as a white, gelatinous structure made up of
Wharton’s jelly, within the umbilical cord, with 3 blood vessels, 2 arteries and 1 vein, if fewer –
causes disease of the heart and kidney, notify the physician

• Small, thin cord may be associated with poor fetal growth

• Assess for intact cord, and ensure that clamp is secured

• Cord should be clamped for at least the first 24 hours after birth; clamp can be removed

when the cord is dried and occluded.

• Note any bleeding or drainage from the cord

• If symptoms of infection such as moistness, oozing, discharge, and a reddened base occur, notify
physician.

• Gastro intestinal tract

• Monitor cord for meconium staining

• Assess for umbilical hernia

• Note abdominal distention associated with obstruction, mass or sepsis

• First hour of life, cord begins to dry & shrink & turns brown .

• Second day or third day turns black.

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 • By sixth to tenth day, breaks free, leaving granulating area a few centimeters wide that heals
during the following week.

Umbilical hernia

• Monitor bowel sounds, which should occur within 1 to 2 hours after birth.

ANOGENITAL AREA

• Anal opening patent

• First stool of the baby which is sticky, tarlike, blackish- green, odorless material formed from
mucus, vernix, lanugo,, hormones and carbohydrates that accumulated during intra uterine life
which should be passed within 24 to 48 hours after birth.

GENITALS

Female

 Labia edematous, clitoris enlarged

 Smegma present (thick, white mucus discharge)

 Pseudomenstruation possible (blood-tinged mucus)

 Hymen tag may be visible

First voiding should occur within 24 hours

Male

 Prepuce(foreskin) covers glans penis

 Scrotum edematous

 Meatus at tip of penis

 Testes descended but may retract with cold

 Assess for hernia or hydrocele

 A hydrocele is a collection of fluid within the processus vaginalis (PV) that produces swelling in the
inguinal region or scrotum.

An inguinal hernia occurs when abdominal organs protrude into the inguinal canal or scrotum.

19
  First voiding should occur within 24 hours

SPINE

 Straight, posture flexed, supports head momentarily when prone, arms and legs flexed, chin
flexed on upper chest, sporadic movements that are well coordinated, a degree of hypotonicity or
hypertonicity is indicative of CNS damage

EXTREMITIES

 Flexed, full ROM; movements symmetrical, fists clenched, fingers and toes should be 10 each

number and separate, legs bowed, major gluteal folds even, creases on soles of feet, assess for fractures
(especially clavicle) or dislocations (hip)

 Assess for hip dysplasia-is an abnormality of the hip joint where the socket portion does not fully
cover the ball portion, resulting in an increased risk for joint dislocation.

 When thighs are rotated outward, no clicks should be heard, pulses palpable (radial, brachial,
femoral)

 Slight tremors are common but could be a sign of hypoglycemia or drug withdrawal

Club Foot-foot does not align or will not turn to a definite midline position.

• 160-170 degrees hip joint seems to be lock short of distance

• Talipes varus- turn inward

• Talipes valgus- turn outward

• 180degrees- both legs can be flexed & abducted, touch or nearly touch the surface of the bed

• Hip subluxation-a shallow & poorly formed acetabulum

• Ortolani’s sign a clunk of the femur head striking the shallow acetabulum

Checking Ortolani’s sign a clunk of the femur head striking the shallow acetabulum

20
Laboratory Studies

• Heel stick test for hematocrit, hemoglobin and random blood sugar

• Serum glucose less than 40mg/100 ml of blood (30mg/100 ml in the first 3 days of life) indicates
hypoglycemia. Intervention- feed the baby with oral glucose or breastfeed immediately.

Care of Newborn after Birth

Equipment needed:

• Radiant warmer or warmed bassinet

• warm soft blanket or cloth

• oxygen, resuscitation, suction

• eye care, vitamin K, hepatitis and BCG vaccine

• weighing scale, tape measure, thermometer and identification band

Newborn Identification:

• A number that corresponds to the mother’s hospital number

• The mother’s name

• Sex, date, and time of infan’ts birth

• 2 bands put on the legs

 Security band or bar code- prevent infant abduction

 Foot print

Birth Registration- the primary care provider who supervised the delivery is responsible for the registration
to Bureau of Vital Statistics.

 Infant’s name, mother’s name, father’s name, birth date, and birth place.

 Birth Documentation:

 Time of birth, time breastfed, respirations spontaneous or aided, Apgar Score at 1 minute & at 5
minutes, Eye prophylaxis, Vitamin K, Hepatitis & BCG Vaccine, General condition, Cord- number
of blood vessels, voided and defecated

Nursing Diagnosis

• Ineffective thermoregulation related to heat loss from exposure in the birthing room and transition
to extrauterine environment.

Plan & Intervention- Demonstrate techniques to correct underlying cause.

Intervention:

• Place on mother’s breast or abdomen for skin

• to skin contact for 90 minutes

• Dry baby immediately after birth & Put on the head cap,& cover the baby with dry cloth

• Swaddle baby after 90 minutes

21
 • Keep in radiant warmer or drop light.

Nursing Care of Newborn Post-partal Period:

Newborns are cared for either in birthing room or a transitional nursery for safety in the first few hours of
life.

Initial Feeding:

Baby –Friendly Hospital Initiative is a global program sponsored by WHO & the United Nations Children’s
Fund encourage hospitals & birthing centers to promote breastfeeding to all infants.

Feeding is per demand or feeding every 3 hours

Bathing:

Initial full bath is given 6hours after birth before feeding

Daily bath is done per sponge bath.

Sleeping position: SID’s - Sudden Infant Death Syndrome-sudden unexplained death to babies under 1
year old.

Prevention:

• Place baby on his back to sleep

• Use a firm sleep surface

• Avoidance of soft bedding, over heating;

• Avoidance to exposure to tobacco smoke, alcohol & illicit drugs

• Routine immunization

Diaper Area Care: Preventing diaper dermatitis or diaper rash:

• Change diapers frequently

• With each diaper change, wash the area with clear water & dry well.

• Nurse should wear gloves when doing the procedure.

Metabolic Screening Test: test for inherited disorders.

• Done routinely.

• A small blood sample by heel stick & dropped onto special filter paper. Baby should received
breastfeeding or formula 24 before the test for good results.

Hepatitis B vaccination:

• First vaccine given at birth or 12 hours after, 2nd dose at 1 month, 3rd dose at 6 months, dosage
is 0.5 ml at vastus lateralis IM.

Vitamin K Administration:

• Given at birth 0.5 to 1.0 mg IM vastus lateralis to prevent bleeding.

Essential Newborn Care Core Steps:

1. Immediate and thorough drying of the newborn prevents hypothermia which is extremely important to
newborn survival

2. Keeping the mother and baby in uninterrupted skin-to-skin contact prevents hypothermia,
hypoglycemia and sepsis, increases colonization with protective bacterial flora and improved
breastfeeding initiation and exclusivity

3. Properly timed cord clamping and cutting until the umbilical cord pulsation stops decreases anemia in
one out of every seven term babies and one out of every three preterm babies. It also prevents brain
(intraventricular) hemorrhage in one of two preterm babies.

4. Breastfeeding initiation within the first hour of life prevents an estimated 19.1% of all neonatal deaths.

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Care Prior to Discharge:

1. Examination of both mother and baby.

2. Advice to continue breastfeeding.

3. Check all vaccines needed for the newborn at birth was given.

4. Advice mother for follow-up check up-including the baby.,& Newborn screening done.

5. Advise when to claim birth certificate

6. Assess the preparedness of the family in the care of the newborn’s safety and develop a sense of
security.

7. Parents need to plan changes in their routine.

Evaluation

• Parents are able to give beginning newborn care with confidence.

• Infant establishes respirations of 30 to 60 breaths per minute.

• Infant maintains T at 97.8 degrees to 98.6 degrees F (36.5 to 37 degrees C)

• Infant breastfeeds for a minimum of 10 minutes every 3 hours.

Documentation:

All that has taken place from admission to discharge should be documented.

DAILY ROUTINE CARE OF NEONATES

• The major goal of nursing care of the newborn is to establish and maintain homeostasis.

1. WARMTH - by keeping the baby dry with adequate clothing. Baby should be kept to the side of the
mother, so that the mother’s body temperature can keep the baby warm.

• Baby can be placed in skin to skin contact with mother (kangarooing) to maintain temperature of
infant and facilitate breast feeding.

2. BREAST FEEDING - The baby should be put to mother’s breast within as soon as possible.

• Colostrum feeding must be offered.

• Mother should be informing about the importance and techniques of breast feeding.

• Demand feeding should be encouraged. Exclusive breastfeeding procedure should be explained

to the mother and family members.

• Exclusive breast feeding should be instructed, its advantages to both mother & baby.

Advantages of Breastfeeding to infants:

• Breast milk contains secretory immunoglobulin A (IgA), which binds molecules of foreign proteins,
including viruses & bacteria.

• Lactoferrin is an iron-binding protein that interferes with the growth of pathogenic bacteria.

• Enzyme lysozyme actively destroys bacteria by lysing (dissolving) their cell membranes,
increasing the effectiveness of antibodies.

• Macrophages, responsible for producing interferon (protein that protects against viruses), helps

• interfere with virus growth.

• The bifidus factor is a specific growth-promoting factor for the beneficial bacteria Lactobacillus
bifidus, interferes with colonization of pathogenic bacteria in the GIT, reducing diarrhea.

• Contains the ideal electrolyte & mineral composition for human growth. High in glucose, easily
digested sugar that provides ready glucose for rapid brain growth.

• Contains more linoleic acid, an essential fatty acid for skin integrity., less Na,K, Ca &
phosphorus.

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 • Better balance trace elements such as zinc.

• Exclusive breastfeeding reduces the incidence of certain allergies.

Advantages to Mother:

• Release of oxytocin from the posterior pituitary gland aids in uterine involution.

• Serve as protective function in preventing breast & ovarian cancer.

• Return to pre-pregnant state sooner, & if menstruation is delayed, may serve as temporary
Family Planning Method.

• Can have empowering effect because it is a skill only women can master.

• Reduces the cost of feeding & preparation time.

• Long- term effect is a decreased risk in fractures & osteoporosis.

• Provides a true symbiotic bond between mother & baby.

Nutritional Allowances for a Newborn:

CALORIES:

Due to rapid growth- an infant up to 2 months requires 119 to 120 calories / kg of body weight (50 to
55 kcal/lb. every 24 hours to provide adequate amount for maintenance & growth.

After 2 months amounts gradually decline s until the requirements at 1 year is 100 kcal/kg (45kcal/lb/
day.

Infant formula 20 calories/ oz. contain 9% to 12% CHON, 45 TO 55% CHO, 34 TO 46%) FAT

PROTEIN- high requirement CHON, 45 TO 55% CHO, 34 TO 46%) FAT

PROTEIN- high requirement necessary for the formation of new cells, to provide for rapid growth of
new cells as well as maintenance of existing cells.

First 2 months Protein requirement is 2.2 g / kg. body weight.

FAT- Linoleic acid, an essential fatty acid is necessary foe brain growth & skin integrity in infants.
When sufficient, the infant can manufacture docosahexaenoic acid (DHA), an omega-3 fatty acids &
an arachidonic acid (ARA), an omega -6 fatty a, contains a generous supply of fatty acids for rain
growth.

CARBOHYDRATE- Lactose, the disaccharide found in human milk, the most easily digested of the
CHO. Lactose improves calcium absorption & aids in nitrogen retention. Produces stools consisting
predominantly of gram – positive rather than gram negative thus decreasing GIT illness.

FLUID- maintains a sufficient fluid intake because metabolic rate is so high & metabolism requires
water. NB body surface area is large in relation to body mass.

30 to 35% of body weight is extracellular fluid, Adult 20%

NB needs 150 to 200 ml/kg (2.5 to 3.0 oz./lb) of water intake every 24 house, adult needs 2400 ml /
day or less than 1 oz/lb.

MINERALS:

Calcium- important because their skeleton grows rapidly.

Iron – (37 weeks or more gestation age) whose mother had adequate iron intake during pregnancy
will be born with iron stores will last first 3 months of life, until newborn begins to produce adult
hemoglobin.

Formula-fed infants to take iron-enriched formula the whole first year of life.

Fluoride- building sound teeth & preventing tooth decay, mother should take fluoridated water &
formula should be prepared w/ fluoridated water.

Fluoride supplement- 0.25 mg daily given till 6 months of age.

VITAMINS- supplement of 400 international units/ day of Vitamin D beginning in the first few days of
life.

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Formula Feeding:

Commercial Formulas: Available in 3 Types

• Modified milk based

• Soy based

• Elemental (fat, protein, & carbohydrate)

Modified milk-based formulas are used for the majority of newborns; lactose-free formulas are used
for newborns with lactose intolerance or galactosemia (inability to use sugars).

Soy formulas used for infants who are allergic to cow’s milk protein- although some may be given
casein hydrolysate formulas have protein particle but too small to be recognized by the immune
system.

Elemental formulas are used for infants with protein allergies or fat malnutrition.

Should purchase formula with added iron to prevent iron-deficiency anemia.

4 preparations of commercial formulas:

• Powder that is prepared by adding water as directed- least expensive

• Condensed liquid that is diluted with an equal amount of water

• Ready-to-feed which requires no dilution

• Individually prepacked & prepared bottles of formula- most expensive.

• Ready-to-feed which requires no dilution

• Individually prepacked & prepared bottles of formula- most expensive.

Calculating a Formula Adequacy

1.The total fluid ingested for 24 hours must be sufficient to meet the infant fluid needs: 75 to 90 ml
(2.5 to 3 oz) of fluid per pound of body weight (150 to 200 ml/kg/day.

2. the number of calories required per day is 50 to 55 pound of body weight (100 to 120 kcal/kg.

Ex. 7 lb infant needs 17.5 to 21 oz (7lb x 2.5 to 3 oz) of fluid /day, commercial formula contains 20
calories/ oz. this amount will also supply the infant’s calorie needs (350 to 420 calories / day). The
total volume can be divided into 6 feedings of 3 to 3.5 oz each. 9-lb need 22.5 to 27 oz of fluid / day
supplying 459 to 540 calories / day.

Quick formula- estimate how much an infant will drink at a feeding is to add 2 or 3 to the infant’s age
in months. After initially taking 0.5 to 1 oz for the first 2 days, a newborn (0 age) will take 2 to 3 oz
each feeding; 3- month-old- child 5 to 6 oz, 6 months 8 oz

months. After initially taking 0.5 to 1 oz for the first 2 days, a newborn (0 age) will take 2 to 3 oz each
feeding; 3- month-old- child 5 to 6 oz, 6 months 8 oz.

3. SKIN CARE AND BABY BATH

• The baby must be cleaned off blood, mucus and meconium.

• No vigorous attempts should be met to remove the vernix caseosa, as it provides protection to
the delicate skin.

• Full bath can be given in the hospital by using warm water in a warm room gently and quickly
after 6 hours.

• Daily care is done by sponge bath.

4. CARE OF EYES

• Eye should be cleaned at the birth and once every day using sterile cotton swabs soaked in
sterile water.

• Each eye should be cleaned using a separate swab.

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 • The eye should be observed for redness, discharge or the excessive tearing for early detection of
problems and prompt management.

5. CLOTHING OF BABY

• The baby should be dressed with loose, soft and cotton cloths.

• Large buttons synthetic frock and plastic or nylon napkin should be avoided.

• A triangular shaped soft, absorbent cloth should be used as napkin.

• The cloths should not be tight especially around the neck or abdomen.

GENERAL CARE:

• The new born should be kept with the mother for continues rooming in a well -ventilated room.

• Baby should be handled with gentle approach after hand washing.

• No infected person should take care or touch the baby.

• Baby should allow to sleep in a supine position which can prevent sudden infant death syndrome

• General cleanliness is to be maintained and surrounding to be kept clean.

• Wet nappies should be change immediately.

OBSERVATION.

• Temperature, pulse, respiration, feeding behavior, stool, urine and sleep pattern should be
assessed.

• Mouth, eyes, cord, and skin should be looked for any infections.

GROWTH AND DEVELOPMENT

Definition

A. Growth – denote an increase in physical size or quantitative change.

B. Development – denote an increase in skill or the ability to perform to function.(a qualitative

change)- observation on specific task

– psychosexual, psychosocial, physiological, moral & cognitive changes occurring over one’s life
span due to growth, maturation, & learning.

C. Maturation – synonym for development, physiological changes due to genetic inheritance.

 Psychosexual development- is a specific type of development that refers to developing instincts

or sensual pleasure (Freudian theory).

 Psychosocial development – refers to Erikson’s stages of personality development.

 Moral development is the ability to know right from wrong & to apply these to real –life situations.

 Cognitive development- refers to the ability to learn or understand from experience, to acquire &
retain knowledge, to respond to a new situation & to solve problems (intelligence; - Piaget theory
of cognitive development)

It is measured by intelligence tests & observing the child’s ability to function effectively in his /her
environment.

Principles of Growth & Development:

 Growth & development are continuous processes from conception until death.

Ex. Infant triples birth weight & increases height by 50%.

 Growth & development proceed in an orderly sequence.

Ex. Majority of children sit before they creep, creep before they stand

 Different children pass through the predictable stages at different rates.

26
 Ex. 2 kids of the same age, 1 begins to walk at 9 months, while the other walks at 14 mo.- follow the
predictable sequence; they are merely developing at different rates.

 All body systems do not develop at the same rate.

Ex. Neurological tissue experiences its peak growth during the first year of life, whereas genital tissue
grows little until puberty.

 Development is cephalocaudal: from head downward (areas closest to the brain/ head develop
first, followed by the trunk than the legs & feet).

Ex. A NB can lift only the head off the bed when he/she lies in prone position.

 Development proceeds from proximal to distal body parts.

From the inside out (controlled movements closest to the body’s center (trunk, arms)

develop before controlled movements distant to the body(fingers)

Ex. NB makes little use of arms & hands, except to put a thumb in the mouth,

 Development proceeds from gross to refined skills.

Ex. Child is able to control distal parts such as fingers, he/she is able to perform

Fine motor skill, like a 3- year- old colors best w/ large crayon.

 There is an optimum time for initiation of experiences or learning.

A child can’t learn tasks until his/her nervous system is mature enough to allow that particular
learning.

Ex. Child can’t learn to sit, until the nervous system has matured enough to allow back control.

 Neonatal reflexes must be lost before development can proceed.

An infant can’t grasp w/ skill until the grasping reflex has faded nor able to stand steadily until the
walking reflex has faded.

 A great deal of skill & behavior is learned by practice.

Infants practice over & over taking a first step before they accomplish this securely.

Factors Influencing Growth & Development:

 Genetic inheritance & Environmental influences

are the 2 primary factors in determining if a child will be able to reach his/her genetic potential.

Temperament – usual reaction pattern of an individual or an individual characteristic manner of thinking,

behaving or reacting to stimuli in the environment.

Genetics- eye color & height

Gender – girls are lighter & shorter than boys. Boys tend to be taller & heavier than girls.

Health – inherent a genetically transmitted disease may not grow rapidly or develop as fully as the
healthy child

Intelligence- children w/ high intelligence don’t generally grow faster physically than other children but
then tend to advance faster in skills.

Temperament

 Reaction Patterns- how children react

 Activity level- level of activity among children differs widely right after birth.

 Rhythmicity – manifests a regular rhythm in physiologic functions.

 Approach – refers to a child’s response on initial contact to a new stimulus.

 Adaptability – is the ability to change one’s reaction to stimuli over time.

 Intensity of reaction – meets new situations w/ their whole being.

27
  Distractibility – children who are easily distracted or who can easily shift their attention to a new
situation are easy to care for.

 Attention Span & Persistence – is the ability to remain interested in a project or activity for an
average length of time.

 Threshold of response- is the intensity level stimulation necessary to evoke a reaction.

 Mood Quality- a child who is always happy & laughing is said to have positive mood quality.

4 Categories of Temperament:

 The Easy Child- easy to care if they have a predictable rhythmicity, approach & adapt to new
situations readily, have a mild-to-moderate intensity of reaction, & have an overall positive mood
quality.

 The Intermediate Child- some characteristics of both easy & difficult groups are present.

 The Difficult Child –if they are irregular in habits, have a negative mood quality & withdraw rather
than approach new situations.

 Overall, they are fairly inactive, respond only mildly & adapt slowly to new situations & have a
general negative mood.

Environment –

 Environmental influences that affect growth & development:

 Socio-economic level

 The Parent- Child Relationship

 Ordinal position in the family

 Health

THE FAMILY WITH AN INFANT

Infancy- from birth to 1 year of age.

Growth & Development of the Infant

 Rapidly grow both in size & in their ability to perform tasks.

Physical Growth

 The physiologic changes that occur in the infant year reflect the increasing maturity & growth of
body organs.

Weight

 As rule most infants double their weight at 4 to 6 months & triple it by 1 year.

 During the first 6 months, infants average weight gain of 2 lb/month.

 Second 6 mo., weight gain is approximately 1 lb/ month.

 Average 1-year-old boy weighs 10kg, girl-9.5 kg

Height

 Infant increases in height during the first year by 50%, or grows from the average birth length of
20 inches to about 30 inches. Growth most apparent in the trunk during the early mo. During the
2nd half of the first year, more apparent of the legs.

Head Circumference

 Increases rapidly during the infant period, reflecting rapid brain growth. By the end of the first
year. Brain has already reached 2/3 of its adult size.

Body Proportion

28
  Changes during the first year from that of a NB to a more typical infant appearance. The mandible
becomes prominent as bone grows. By the end of infant period, lower jaw is prominent.

 Chest is generally less than that of the head at birth by about 2 cm.

 Abdomen remains protuberant until the child has been walking well, generally well in toddler
period.

 Lengthening of the lower extremities during the last 6 mo. of infancy readies the child for walking
& often changes from baby-like to toddler-like.

Body Systems

 Cardiovascular system, HR slows from 110 to 160b/m to 100 to 120 b/m by end of the first year.

 Bp slightly elevated from 80/40 to 100/60 mm Hg.

 Prone to develop physiologic anemia at 2 to 3 months of age. Occurs because fetal red blood
cells are destroyed (life is 4 months)

 Hemoglobin becomes totally converted from fetal to adult hemoglobin at 5 to 6 months of age.

 RR slows from 30 to 60 breaths/ min. by the end of first year.

 GIT- amylase necessary for the digestion of carbohydrates is deficient until approximately 3
months. Lipase necessary for the digestion of saturated fat, is decreased in amount during the
entire first year.

 Liver remains immature, causing inadequate conjugation of drugs, & inefficient formation of
carbohydrates, protein, & vitamins for storage.

 3-4 months, extrusion reflex prevents some infants from eating effectively.

 4 months drink from a cup w/ parental control.

 Independently drink from a cup by age 8 or 10 months.

 The immune system becomes functional by at least 2 months; the infant is able to produce both
IgG & IgM antibodies by 1 year of age.

 Immunoglobulins (IgA, IgE, & IgD) are not plentiful until preschool age, the reason why infants
need to be protected from infections.

 Ability to adjust to cold is mature by 6 months, infant can shiver in response to cold.

 Kidneys remain immature & not as efficient at eliminating body wastes as in adult.

 Endocrine system remains particularly immature in response to pituitary stimulation, such as

adrenocorticotropic hormone, insulin production from the pancreas.

 Extracellular fluid accounts for 35% of the infant’s body weight & intracellular fluid accounts for
40% at the end of first year, adult is 20% & 40%- diarrhea- dehydration.

Teeth

 First baby tooth (central incisor) usually erupts at 6 months Ff. by a new one monthly.

 Neonatal teeth- erupt in the first 4 weeks of life.

 Mandibular central incisors are the teeth frequently involved in this early growth.

 Deciduous teeth (temporary or baby teeth are essential for protecting the growth of the dental
arch.

Motor Development

 Average infant progresses through systematic motor growth during the first year

 that strongly reflects the principles of cephalocaudal development & gross to fine motor
development.

 Control proceeds from head to trunk to lower extremities in a progressive predictable sequence.

 Evaluate infant in 2 major areas of motor dev:

29
  1. gross motor development- ability to accomplish large body movements.

 2. fine motor dev. Measured by observing or

 Testing prehensile ability- ability to coordinate hand movements.

Gross Motor Development

 Observe infant in 4 positions:

Ventral suspension position- refers to the infant’s appearance when held in midair on a horizontal
plane, supported by a hand under the abdomen- allows head to hang down with little effort at control.

 1- month lifts head momentarily, the drops it again, may flex the elbows, extend the hips, & flex
the knees.

 2 months- hold their heads in the same plane as the rest of the body.

 3 months lifts & maintains the head well above the plane of the rest of the body in ventral
position.

 Landau reflex develops at 3 months.

 6-9 months- parachute reaction from ventral

 suspension position- suddenly lowered toward an examining table from ventral suspension, the
arms extend.

Prone position-

 1 month- infants lift their head & turn it easily to the side.

 2 months- can raise their head & maintain the position, but they can’t raise their chest high
enough to look around, head facing downward

Sitting position- when placed on his or her back & then pulled to a sitting position, 1 month old child has
gross head lag as in first days of life. In a sitting position, back is rounded & the infant demonstrates only
momentary head control.

 2 months- can hold his head fairly steady when sitting up- still w/ head lag.

 3 months- Slight head lag when pulled to sitting position.

 4 months- Reaches an important milestone by no longer demonstrating head lag when pulled to a
sitting position.

 5 months – can be seen to straighten his back when held or propped in a sitting position.

 6 months- sit momentarily w/out support. Anticipate being picked up & reach up with their hands
from this position. Limited ability to sit independently. Sit with their legs spread & their arms
stiffened between them.

 7 months- Sits alone, but only when the hands are held forward for balance.

 8 months- Sits securely w/out additional support, major milestone.

 9 months.- sit steadily that they can lean forward & regain their balance, may still lose their
balance if lean sideways.

Standing position- stepping reflex at 1 mo. In standing position, infant’s knees & hips flex rather than
support more than momentary weight.

 2 months- When held in standing position, holds

 head up w/ the same show of support as in a sitting position.

 3 months - Begins to try to support part of their body weight, stepping reflex begins to fade.

 4 months- Makes attempt to sustain their weight actively on their legs, successful because
stepping reflex faded.

 5 months- continue s the ability to sustain a portion of his weight. Tonic neck reflex should end &
Moro reflex is fading.

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  6 months - support nearly his full weight when in standing position.

 7 months – bounces w/ enjoyment in a standing position.

 9 months Can stand holding onto a table.

 10 months – can pull to a standing position by holding onto the side of a playpen but can’t let her
self- down again.

 11 months- learns to cruise or move about the crib rails, chairs walls.

 12 mo.- can stand alone at least momentarily. Until 22 month. To walk & still be w/in the normal
limit.

Fine motor development

 1 month - strong grasp reflex & hold hands in fists so tightly, it is difficult to hold to extend the
fingers. Grasping reflex begins to fade, 2 mo. will hold an object for a few min. before dropping it,
hands held open, not closed in fists.

 3 months- reach for attractive objects in front of them.

 4 months- bring hands together & pull at their clothes. Thumb opposition-ability to bring the thumb
& fingers together, is the beginning, but the motion is a scooping or raking one, not a picking-up
one, limited to handling large objects, palmar & plantar grasp reflexes have disappeared.

 5 months -accept an object that is handed to him & grasp the whole hand.

 6 months - grasping has advanced holding objects in both hands.

 Drop one toy when a second one is offered, hold spoon & start to feed themselves, w/ much
spilling. Moro, palmar, & tonic neck reflex faded.

 7 months - can transfer a toy from 1 hand to the other.

 8 months - random reaching & ineffective grasping have disappeared as a result of advanced
eye-hand coordination.

 10 months-pincer grasp reflex- ability to bring the thumb & first finger together- enables the child
to pick up small objects, offers toys to people but can’t release them.

 12 months- draw a semi-straight - line w/ a crayon, putting objects in containers & taking them out
again.

Developmental Milestones

 Language Development- begins to make small, cooing sounds by end of the first mo.

 2 months –differentiates a cry- hungry, or wet, ability to make throaty, gurgling or cooing sounds
increases.

 3 months- squeal w/ pleasure – more fun to be with.

 4 months- very talkative, cooing, babbling, & gurgling when spoken too.

 laugh aloud.

 5 months- simple vowel sounds-goo-goo, gah-gah

 6 months -learn the art of imitating- parents laugh

 7 months - talking increases, imitate vowel sounds well- oh-oh, ah-ah

 9 months- speaks a first word da-da, ba-ba., ma-ma.

 10 months- bye-bye or no.

 12 months- two words besides ma-ma, da-da, use 2 words w/ meaning.

Play

 1 mo.- interested in watching a mobile over their crib or play pen. Should be black & white or
brightly colored & light enough in weight so they move when someone walks by. Face down

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 toward the infant not sideways toward the adults standing beside the crib. Musical mobiles
provide extra stimulation.

 1 month - spend a great deal of time watching the parent’s face, appearing to enjoy this activity
so much that the face become their favorite toy.

Hearing a second sense that is a source of pleasure for the child in early infancy. Listens to sound of a
music box.

 2 months- will hold light, small rattles for a short period of time & then drop them.

 3 months- can handle small blocks or small rattles.

 4 months – need a play pen or a sheet spread on the floor so they have an opportunity to
exercise their knees skill of rolling over. Rolling all over is so intriguing, it may serve as a toy for
the entire month.

 5 months- ready for a variety of objects to handle, such as plastic rings, blocks, squeeze toys,
clothespin, rattles, & plastic keys.

 6 months- can sit steadily enough to be ready for bathtub such as rubber ducks or plastic boats.
Start to teethe, infants enjoy a teething ring to chew

 7 months- transfer toys interested in items such as blocks, rattles or plastic keys small enough to
be used. Become more interested to brightly colored balls, or toys that previously rolled out of
reach.

 8 months- sensitive to differences in texture. Enjoy having toys that have different feels

 such as velvet, fur, fuzzy, smooth or rough.

 9 months- needs the experience of creeping- time out to crib

 10 months- ready for a peek a boo

 11 months- learned to cruise or walk along low tables by holding on.

12 months- enjoy putting things in & taking things out of containers. As soon as will be able to
walk, interested in pull toys.

 Listen to nursery rhymes or music.

Development of Senses

Vision

 1 month – midline directly in-front of them about 18 inches away. Follow in a short distance.

 2 months- focus well at 6 weeks, & follow objects w/ the eyes not past midline, ability to follow &
focus is a milestone indicating that the infant has achieved binocular vision-ability to fuse 2
images into 1.

 3 months hold hands in-front of their face & study their fingers for long periods of time (hand
regard)

 4 months- recognizes familiar objects such as bottle, rattle or toy animal. Follow their parent’s
movements w/ their eyes eagerly.

 6 months- capable of organized depth perception, increases the accuracy of their reach for
objects as they begin to perceive distances accurately. Difficulty in establishing eye coordination.

 7 months- pat their image at the mirror, perform transferring of toys from hand to hand.

 10 months- looks under a towel or around a corner for a concealed object( beginning of
performance).

Hearing

 1 month- demonstrated who quiets momentarily at a distinctive sound such as a bell or a squeaky
rubber toy.

 2 months- becomes so acute that infants will listen or stop an activity at the sound of spoken
words.

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  3 months- turn their heads to attempt to locate a sound.

 4 months- hear a distinctive sound & turn toward the sound & look in that direction.

 5 months- demonstrate that they can localize sounds downward & to the side, by turning the head
& looking down.

 6 months- able to locate sounds.

 10 months- recognize their name & listen acutely when spoken to.

 12 months- can easily locate sounds in any direction & turn toward it.

Emotional Development

 1 month- can differentiate between faces & other objects by studying a face or the picture of a
face longer than other objects.

 Social smile- smiles in return at 6 mo.

 3 months. Demonstrate increased social awareness by readily smiling at the sight of a parent’s
face. Laughs aloud at a funny face.

 4 months –recognize their primary caregiver & prefer that person’s presence to others.

 5 months - show displeasure when object is taken away from them.

 6 months – increasingly aware of the difference between people who regularly care for them &
strangers.

 7 months- begin to show fear of strangers.

 Eight –month anxiety or stranger anxiety- fear of strangers

 9 months- very aware of changes of voice, cry when scolded.

 12 months.- overcome their fears of strangers, alert & responsive when approached.

Cognitive Development

 3rd months - Primary Circular Reaction- infant explores objects by grasping their hands or by
mouthing them.

 Secondary Circular Reaction

 6 months- Piaget –grasp the idea that their actions can initiate pleasurable sensations.

 Unaware of the permanence of objects.

Coordination of Secondary Schema

 10 months- discover object permanence, or become aware that an object out of sight still exists.

Theories of Child Development

 A theory is a systematic statement of principles that provides a framework for explaining a

phenomenon.
 Developmental theories are theories that provide road maps for explaining human development.
 Developmental tasks are a skill or a growth responsibility arising at a particular time in an
individual’s life, the achievement of which will provide a foundation for the accomplishment of
future tasks.

Freud’s Stages of Childhood Erickson’s Stages of Childhood

Stages Psychosexual Nursing Implication Developmental Nursing

Stage Task Implication
Infant Oral stage: child Provide oral To form a sense of Provide a primary
explores the world stimulation by trust vs. mistrust. caregiver. Provide
by using the mouth giving pacifiers: do Child learns to love experiences that
not discourage & to be loved. to security.
thumb sucking

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 Toddler Anal stage: Child Help children To form a sense of Provide
learns to control achieve bowel & autonomy vs. shame opportunities for
urination & bladder control & doubt. Child independent
defecation. without undue learns to be decision making,
emphasis on its independent & make such as choosing
importance. decisions for self. his own clothes.
Preschooler Phallic stage: Child Accept children’s To form sense of Provide new
learns sexual sexual interest initiative vs. guilt. things for
identity through such as fondling Child learns to do exploring new
awareness of genital his/her own things (problem places or
area. genitals, as normal solving & that doing activities. Allow
of exploration. things is desirable free form play.
School age Latent stage: Child’s Help children have To form a sense of Provide
personality positive industry vs. opportunities such
development experiences with inferiority. Child as allowing the
appears to be non- learning so their learns to do things child to assemble
active or dormant. self-esteem well. & complete a
continues to grow. short project.

Adolescent Genital Stage: Provide appropriate To form a sense of Provide

adolescent opportunities for identity vs role opportunities for
develops sexual the child to relate confusion. an adolescent to
maturity & learns to w/ opposite & own Adolescents learn discuss feelings
establish sex relationships who they are & what about events
satisfaction kind of person they important to him
relationships w/ will be. or her. Offer
others support & praise
for decision
making

Piaget’s Stages of Cognitive Development

Stages of Development Age Span Nursing Implication

Sensorimotor Neonatal
Reflex
Primary circular reactions
1 month Stimuli are assimilated into beginning mental
images. Behavior entirely reflexive.
1 -4 months Hand-mouth & ear coordination develop. Infant
spends much time looking at objects & separating
self from them. Beginning intention of behavior is
present (the infant brings thumb to mouth for a
purpose to suck it). Enjoyable activity for this period:
a rattle or tape of parent’s voice

Secondary circular reaction
4-8 months Infant learns to initiate, recognize, & repeat pleasure
experiences from environment. Memory traces are
present; infant anticipates familiar events (a parent
coming near him will pick him up). Good toy for this
period; mirror; good game; peek-a-boo.

Coordination of secondary
reactions
8-12 months Infants can plan activities to attain specific goals.
Perceives that others can cause activity & that
activities of own body ae separate from activity of
objects. Can search for & retrieve a toy that
disappears from view. Recognizes shapes & sizes
of familiar objects. Because of increased sense of
separateness, infant experiences separation anxiety
when primary caregiver leaves. Good toy for this
period: nesting toys (colored boxes)

Tertiary circular reaction 12-18 months Child is able to experiment to discover new
properties of objects & events. Good game for this
period: throw & retrieve.

Invention of new means thru 18-24 months Transitional phase to the preoperational thought

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 mental combination period, Good toys for this period: those w/ several
uses, such as blocks or colored plastic rings.

Preoperational thought
2-7 years Thought becomes symbolic; can arrive at answers
mentally instead of through physical attempt.
Comprehends simple abstractions but thinking is
basically concrete & literal. Child is egocentric
(unable to see the viewpoint of another). Displays
static thinking (inability to remember what they
started to talk about so at the end of a sentence
children are talking about another topic). Concept of
time is now, & concepts of distance is only as far as
they can see. Centering or focusing on a single
aspect of an object causes distorted reasoning. No
awareness of reversibility (for every action there is
an opposite action) is present.
Unable to state cause-effect relationships,
categories, or abstractions. Good toy for this period:
items that require imagination, such as modeling
clay.

Concrete operational 7-12 years concrete operations include systematic reasoning.

thoughts Uses memory to learn broad concepts(fruit) &
subgroups of concepts (apples, oranges).
Classifications involve sorting objects according to
attributes such as color: seriation, in which objects
are ordered according to increasing or decreasing
measures such as weight: & multiplication, in which
objects are simultaneously classified & seriated
using weight. Child is aware of reversibility, an
opposite or continuation of reasoning back to a
starting point (following a route through a maze &
then reverses steps). Understands conservation,
sees constancy despite transformation (mass or
quantity remains the same even if it changes shape
or position). Good activity for this period: collecting
& classifying natural objects such as native plants,
sea shells. Expose child to other viewpoints by
asking questions such as “ How do you

Think you’d feel if you were a nurse & had to tell a

boy to stay in bed?

Formal Operational Thought 12 years Can solve hypothetical problems w/ scientific

reasoning: understands causality & can deal w/ the
past, present & future. Adult or mature thought.
Good activity for this period: “talk time” to sort
through attitudes & opinions.

Kohlberg’s Stages of Moral Development

Age(Year Stage Description Nursing Implication

Preconventional (Level) Punishment/ obedience Child needs help to determine

2-3 1 orientation (heteronomous what are right actions. Give
morality). Child does right clear instructions to avoid
because a parent tells him or her confusion.
to & to avoid punishment.

4-7 2 Individualism. Instrumental Child is unable to recognize that

purpose & exchange. Carries out like situations require like
actions to satisfy own needs actions. Unable to take
rather than society’s. Will do responsibility for self-care,

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 something for another if that
person does something for the
child
Conventional 7- (Level II) 3 Orientation to interpersonal
10 relations of mutuality. Child
follows rules because of a need
to be a “good” person in own
eyes & eyes of others.
10-12 4 Maintenance of social order,
fixed rules and authority. Child
finds ff rules satisfying. Follows
rules of authority figures as well
as parents in an effort to keep
the “system”
Postconventional 5 Social contract utilitarian law-
(Level III) making perspectives. Follows
Older than 12 standards of society for the good
of all people.
6 Universal ethical principle
orientation. Follows internalized
standards of conduct.
Prepared by: Luz B. Ubana, R.N., M.A.N.
FACULTY
Approved by: Tita Yap Cruz, R.N., M.A.N., Ed.D.
Dean School of Nursing
Noted by: Floraine N. Saldana, R.N., M.A.N.
Level II Coordinator
because meeting own needs
interfere w/ this
Child enjoys helping others
because this is nice behavior.
Allow child to help w/ bed
making & other like activities.
Praise for desired behavior such
as sharing.
Child often asks what are the
rules & is something “right”. May
have difficulty modifying a
procedure because one method
may not be “right”. FF self-care
measures only if someone is
there to enforce them.
An adolescent can be
responsible for self-care
because he or she views this as
a standard of adult behavior.
Many adults do not reach this
level of moral development.
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