Chapter 18
Nursing Care of a Family with a New Born
By Thea Yu
Neonatal period - time from birth through the first 28 days of life
*encourage pregnant women to continue breastfeeding through
the first 6 months of life
*advise parents of the advantages of placing infants on their
backs to sleep
Nursing process overview
Assessment
 Review of mother’s pregnancy history
 Physical examination of the infant
 Analysis of lab reports (hematocrit, blood type)
 Assessment of parent-child interaction
Diagnosis
 Ineffective airway clearance r/t mucus in the airway
 Ineffective thermoregulation r/t heat loss from exposure in
the birthing room
 Imbalanced nutrition, less than body requirements, r/t poor
sucking reflex
 Readiness for enhanced family coping r/t birth of planned
infant
 Health-seeking behaviors r/t newborn needs
 *Parental fear r/t hemangioma on left thigh of newborn
Planning
Implementation
Evaluation
 Infant’s RR= 30 - 60 breaths/min
 Infant’s temperature= 97.8-98.6
 Mother demonstrates competence in caring for newborn
 Infant breastfeeds well with strong sucking reflex
THE PROFILE OF A NEW BORN
Vital Statistics
- Weight (2.5-3.4 kg)
Varies depending on racial, nutritional, intrauterine,
and genetic factors present during conception and
pregnancy
- Length (46-54 cm)
 Mature female neonate is 53 cm (20.9 in)
 Mature male neonate is 54 cm (21.3 in)
 Lower limit of normal length is 46 cm (18 in)
 Lengths as great as 57.5 cm (24 in)
- Head circumference (34-35 cm)
Measured across the center of the forehead and
around prominent portion of posterior head
(occiput)
- Chest circumference (32-33cm)
Measured at the level of the nipples
Vital sign
- Temperature (97.6-98.6)
Cause of heat loss
 Convection-sflow of heat from baby’s body
surface to cooler surrounding air
 Radiation- transfer of body heat to cooler solid
object not in contact with the baby
 Conduction- transfer of body heat to cooler
solid object in contact with the baby
 Evaporation- loss of heat through conversion
of a liquid to a vapor
- Pulse (120-140 bpm)
The heart rate of a newborn often remains
slightly irregular because of immaturity of the
cardiac regulatory center in the medulla.
newborn’s heart rate is always determined
by listening for an apical heartbeat for a full
minute
absence of femoral pulse suggests possible
coarctation (narrowing) of the aorta
- Respiration (30-60 breaths/min)
 periodic respirations, are normal
 Newborns are obligate nose-breathers
- Blood Pressure (80/46 mmHg)
By the 10th day, it rises about 100/50 mmHg
Physiologic Functions
- Cardiovascular System
 The peripheral circulation of a newborn
remains sluggish for at least the first 24
hours.
 It is common to observe cyanosis in the
infant’s feet and hands (acrocyanosis) and
for the feet to feel cold to the touch at this
time.
 Blood values
o Blood volume is 80 to 110 mL
o Hemoglobin level averages 17 to 18
g/100 mL of blood
o Hematocrit is between 45% and 50%
o RBC count, about 6 million cells per
cubic millimeter
o indirect bilirubin level at birth is 1 to 4
mg/100 mL
o WBC count at birth, about 15,000 to
30,000 cells/mm3
leukocytosis- response to the trauma of birth
and is nonpathogenic
*Before obtaining a blood specimen from a heel, warm
the foot by wrapping it in a warm cloth
 Blood coagulation
Newborns have prolonged coagulation or
prothrombin time because of low level of
Vitamin K
Vitamin K (AquaMEPHYTON)- necessary
for the formation of:
o Factor II (prothrombin)
o Factor VII (proconvertin)
 o Factor IX (plasma thromboplastin
component)
o Factor X (Stuart-Prower factor)
-route: intramuscularly into the Left
lateral anterior thigh (Vastus Lateralis)
- Respiratory System
 First breath - requires a tremendous amount
of pressure (about 40 to 70 cm H2O)
- GI System
 Stool - passed within 24 hours after birth
- consists of Meconium (sticky, tarlike,
blackish-green, odorless material
formed from mucus, vernix, lanugo,
hormones, and carbohydrates that
accumulated during intrauterine life)
- If newborn does not pass a
meconium stool by 24 to 48 hours
after birth, suspect for meconium
ileus, imperforate anus, or
volvulus.
transitional stool- second or third day of
life, stool changes in color and
consistency, becoming green and loose.
By the fourth day of life, breastfed babies
pass three or four light yellow stools per
day. They are sweet-smelling, because
breast milk is high in lactic acid,
Newborns with bile duct obstruction have
clay-colored (gray) stools, because bile
pigments are not entering the intestinal
tract. Blood-flecked stools usually indicate
an anal fissure.
swallowed some maternal blood during
birth and either vomits fresh blood
immediately after birth or passes a black
tarry stool after 2 or more days.
If the stools remain black or tarry, intestinal
bleeding should be suspected. If mucus is
mixed with stool or the stool is watery and
loose, a milk allergy, lactose intolerance,
or some other condition interfering with
digestion or absorption should be
suspected.
Dipstick Apt test- differentiate Maternal
blood from fetal blood
- Urinary System
possibility of obstruction in the urinary tract can
be assessed by observing the force of the urinary stream
newborn urine usually light-colored and odorless
A single voiding in a newborn is only about 15
mL
Specific gravity ranges from 1.008 to 1.010
daily urinary output for the first 1 or 2 days is
about 30 to 60 mL total
By week 1, total daily volume rises to about 300
mL
*first voiding may be pink or dusky because of uric
acid crystals that were formed in the bladder in utero; this is
an innocent finding
- Immune System
born with passive antibodies (immunoglobulin G)
from their mother that crossed the placenta
Newborns are routinely administered hepatitis B
vaccine during the first 12 hours after birth
- Neuromuscular System
 Blink reflex
-to protect the eye from any object
coming near it by rapid eyelid closure
-elicited by shining a strong light into an
eye
 Rooting reflex
-to help new born find food
-disappears at about 6th week of life
-if newborn’s cheek is brushed or
stroked near the corner of the mouth,
infant will turn head in that direction
 Sucking reflex
-helps newborn find food
-diminishes at about 6 months of age
-when newborns lips are touched, the
baby makes a sucking motion
 Swallowing reflex
-food that reaches the posterior portion
of the tongue is automatically
swallowed
-gag, cough, sneeze reflex are present
to maintain a clear airway
 Extrusion reflex
-prevent swallowing of inedible
substances
-newborn extrudes any substance that
is placed on the anterior portion of the
tongue
 Palmar grasp reflex
-newborns grasp an object placed in
their palm by quickly closing their
fingers on it
-disappears at about 6 weeks to 3
months of age
 Step (walk)-in place reflex
-newborns who are held in a vertical
position with their feet touching a hard
surface, will take a few quick alternating
steps
-disappears by 3 months of age
 Placing reflex
-elicited by touching the anterior surface
of the lower part of the newborns’ leg
against a hard surface
 Plantar grasp reflex
-when an object touches the sole of a
newborn’s foot at the base of the toes,
the toes grasp in the same manner as
the fingers
-disappears at about 8-9 months of age
 Tonic neck reflex
-if you turn a newborns head to the
opposite side he or she will often
change the extension and contraction of
legs and arms
-sometimes called “boxer” or “fencing”
reflex
-stimulates someone preparing to box
or stab
-disappears between the 2nd and 3rd
months of life
 Moro reflex
-initiated by startling a newborn with a
loud noise or by jarringte bassinet
-strong for first 8 weeks of life and fades
by the end of the 4th or 5th month
 Babinski reflex
-when the sole of the newborn’s foo is
stroked ina n inverted “J” curvefrom the
heel upward, anewborn fans the toes
-remains positive until 3 months of age
 Magnet reflex
-test of spinal cord integrity
-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
 Crossed extension reflex
-test of spinal cord integrity
-when a newborn is lying supine, if one
leg is extended and the sole of that foot
is irritated by being rubbed with sharp
object, the infant raises the other leg
and extends it as if trying to push away
the hand irritating the first leg
 Trunk incurvation reflex
-test of spinal cord integrity
-When newborns lie in a prone position
and are touched along the paravertebral
area by a probing finger, they flex their
trunk and swing their pelvis toward the
touch
 Landau reflex
-newborn who is held in a prone
position with a hand underneath,
supporting the trunk, should
demonstrate some muscle tone.
  Deep tendon reflexes

-patellar reflex

- elicited in a newborn by tapping the

patellar tendon with the tip of the finger.

-test for spinal nerves L2–L4

-biceps 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.

-test for spinal nerves C5 and C6

- The sense
 Hearing

A fetus is able to hear in utero even

before birth.

 Vision

Newborns see as soon as they are born

and possibly

have been “seeing” light and dark in

utero for the last few months of
ASSESSMENTS FOR WELL-BEING
pregnancy
Apgar Scoring

Newborns demonstrate sight at birth by

blinking at a strong light (blink reflex) or
by following a bright light or toy a short
distance with their eyes.

 Touch

Newborns demonstrate this by quieting

at a soothing touch and by sucking and
rooting reflexes

 Taste

Newborn has the ability to discriminate

taste, because taste buds are
developed and functioning even before
birth.

 Smell

Present in newborns as soon as the

nose is clear of lung and amniotic fluid

The Physiologic Adjustment to Extrauterine Life

Heart rate
Respiratory effort
Muscle tone
Reflex irritability
Color

Respiratory Evaluation

Assessment of gestational age

Dubowitz Maturity Scale
Brazelton Neonatal Behavioral Assessment Scale
Health History
Physical Examination
Appearance of a newborn
Skin
 Color

Ruddy complexion because of the increased concentration of red (C) Strawberry hemangiomas consist of dilated capillaries in
blood cells in blood vessels and fades slightly over the first entire dermal and subdermal layers. They continue to enlarge
month. after birth but usually disappear by age 10 years.

Pale and cyanotic- Infants with poor central nervous system

control may appear
(D) Cavernous hemangiomas consist of a communicating
Gray color- indicates infection network of venules in subcutaneous tissue and do not fade with
age.
Cyanosis

Acrocyanosis is a normal phenomenon in the first Vernix Caseosa

24 to 48 hours after birth; however, central
cyanosis, or cyanosis of the trunk, is always a Vernix caseosa is a white, cream cheese–like
cause for concern
substance that serves as a skin lubricant in utero
Central cyanosis indicates decreased oxygenation.
Hyperbilirubinemia leads to jaundice, or yellowing Lanugo
of the skin.
Lanugo is the fifine, downy hair that covers a
Cephalhematoma- collection of blood under the
periosteum of the skull bone. newborn’s shoulders, back, and upper arms.

Kernicterus permanent cell damage By 2 weeks of age, it has disappeared

Pallor Desquamation

-usually the result of anemia and internal bleeding

Within 24 hours after birth, the skin of most
-may be caused by:
newborns has

(a) excessive blood loss when the cord was cut become extremely dry. The dryness is particularly
evident on
(b) inadequate flow of blood from the cord into the
infant at birth
the palms of the hands and soles of the feet.
(c) fetal–maternal transfusion
Milia
(d) low iron stores caused by poor maternal
nutrition during pregnancy, All newborn sebaceous glands are immature. At least
one pinpoint white papule (a plugged or unopened
(e) blood incompatibility in which a large number of
RBCs were hemolyzed in utero. sebaceous gland)can be found on the cheek or across
the bridge of the nose of almost every newborn.
Harlequin Sign
Disappear by 2 to 4 weeks of age
-Occasionally, because of immature circulation, a newborn who
has been lying on his or her side appears red on the dependent
side of the body and pale on the upper side
Erythema Toxicum

Birthmarks This usually

Hemangiomas. The hemangiomas are vascular tumors of
appears in the fifirst to fourth day of life but may
the skin. appear up to

2 weeks of age. It begins with a papule, increases in

severity
(A) Nevus flammeus (port-wine stain) formed of a plexus of

newly formed capillaries in the papillary layer of the corium. It is to become erythema by the second day, and then
deep red to purple, does not blanch on pressure, and does not disappears
fade with age.

by the third day. It is sometimes called a flflea-bite

rash
(B) A telangectasia or stork’s beak mark, commonly occurring on
the nape of the neck. It blanches on pressure; although it does caused
not fade, it is not noticeable as it becomes covered by hair.
by a newborn’s eosinophils reacting to the • General condition of the infant
environment as
• Number of vessels in the umbilical cord

the immune system matures. • Whether cultures were taken (they are taken if at some

Forceps Marks point sterile birth technique was broken or the mother has

leave a circular or linear contusion matching the rim a history of vaginal or uterine infection)
of the blade of the forceps on the infant’s cheek (Fig.
• Whether the infant voided and whether he or she passed a
18.13).
stool (this information is helpful if, later on, the diagnosis
Disappears in 1 to 2 days
of bowel obstruction or absence of a kidney is considered)
Skin Turgor

NURSING CARE OF A NEWBORN AND FAMILY IN THE

If a fold of the skin is grasped between the thumb and POST PARTAL PERIOD
fifingers, it should feel elastic. Initial feeding
Bathing
Sleeping position
Head Diaper area care
Metabolic screening tests
A newborn’s head appears disproportionately large Hepatitis B vaccination
Vitamin K Administration
because it is about one fourth of the total body length Circumcision

THE ASSESSMENT OF A FAMILY’S READINESS TO CARE

It FOR A NEWBORN AT HOME

is diamond shaped and measures 2 to 3 cm (0.8 to 1.2

SUMMARY
in) in THE PROFILE OF A NEW BORN
Vital Statistics
width and 3 to 4 cm (1.2 to 1.6 in) in length. - Weight
- Length
- Head circumference
- Chest circumference
Vital sign
- Temperature
- Pulse
Fontanelles - Respiration
Sutures - Blood Pressure
Molding Physiologic Functions
Caput Succedaneum - Cardiovascular System
Cephalohematoma - Respiratory System
Craniotabes - GI System
Eyes - Urinary System
Ears - Immune System
Nose - Neuromuscular System
Mouth  Blink reflex
Neck
 Rooting reflex
Chest
 Sucking reflex
Abdomen
Anogenital area  Swallowing reflex
Male genitalia  Extrusion reflex
Female genitalia  Palmar grasp reflex
Back  Step (walk)-in place reflex
Extremities  Placing reflex
 Plantar grasp reflex
CARE OF THE NEWBORN AT BIRTH  Tonic neck reflex
Newborn identification and registration  Moro reflex
Identification banding  Babinski reflex
Birth registration  Magnet reflex
 Crossed extension reflex
• Time of birth  Trunk incurvation reflex
 Landau reflex
• Time the infant breathed  Deep tendon reflexes
- The senses
 Hearing
• Whether respirations were spontaneous or aided
 Vision
 Touch
• Apgar score at 1 minute and at 5 minutes of life  Taste
 Smell
• Whether eye prophylaxis was given The Physiologic Adjustment to Extrauterine Life

• Whether vitamin K was administered ASSESSMENTS FOR WELL-BEING

Apgar Scoring
Heart rate
 Respiratory effort
Muscle tone
Reflex irritability
Color
Respiratory Evaluation
Assessment of gestational age
Dubowitz Maturity Scale
Brazelton Neonatal Behavioral Assessment Scale
Health History
Physical Examination
Appearance of a newborn
Skin
Color
Birthmarks
Vernix Caseosa
Lanugo
Desquamation
Milia
Erythema Toxicum
Forceps Marks
Skin Turgor
Head
Fontanelles
Sutures
Molding
Caput Succedaneum
Cephalohematoma
Craniotabes
Eyes
Ears
Nose
Mouth
Neck
Chest
Abdomen
Anogenital area
Male genitalia
Female genitalia
Back
Extremities

CARE OF THE NEWBORN AT BIRTH

Newborn identification and registration
Identification banding
Birth registration

NURSING CARE OF A NEWBORN AND FAMILY IN THE

POST PARTAL PERIOD
Initial feeding
Bathing
Sleeping position
Diaper area care
Metabolic screening tests
Hepatitis B vaccination
Vitamin K Administration
Circumcision

THE ASSESSMENT OF A FAMILY’S READINESS TO CARE

FOR A NEWBORN AT HOME