860 SIX THE NEWBORN
Early discharge has affected both the timing of newborn
Figure 30–12 ● Infant car restraint for use from birth to about 12
months of age.
children up to the age of 4 is mandatory. In some states such
as California the age is 6. Nurses need to ensure that all par-
ents are knowledgeable about the benefits of child safety seat
use and proper installation.
NEWBORN SCREENING AND IMMUNIZATION
PROGRAM
Before the newborn and mother are discharged from the
birthing unit, the nurse informs the parents about newborn
screening tests and tells them when to return to the
birthing center or clinic if further tests are needed. The
disorders that can be identified from a drop of blood
obtained by a heel stick are cystic fibrosis, galactosemia,
congenital adrenal hyperplasia, hypothyroidism, biotini-
dase deficiency, phenylketonuria (PKU), and hemoglo-
binopathies. Early newborn discharge puts infants at risk
for delayed or even missed diagnosis of PKU and congeni-
tal hypothyroidism because of decreased sensitivity of
screening prior to 24 hours of age. Newborns should be
retested by 2 weeks of age if the first test was done prior to
24 hours of age.
Immunization programs against the hepatitis B virus dur-
ing the newborn period and infancy are in place in many
states, at least 20 countries, and high-incidence areas such as
Alaska and American Samoa. Universal vaccination of in-
fants is recommended. Infants should receive the first dose
of hepatitis B (Hep B) vaccine at birth to 2 months of age.
The second dose should be at least one month after the first
dose. The third dose should be administered at least 4
months after the first dose and at least 2 months after the
second dose, but not before 6 months of age (Centers for
Disease Control, 2003). See the Drug Guide: Hepatitis B
Vaccine. Parents need to be advised whether their birthing
center provides newborn hepatitis vaccination so that an ad-
equate follow-up program can be set in motion.
metabolic screening tests and the acquisition of subsequent
immunization. For example, the accuracy of the test for
PKU is directly related to the newborn’s age. The likelihood
of detecting PKU increases as the infant grows older, and the
infant must be at least 24 hours old for a valid test. A second
test is required in most states, usually between one week and
one month of age, to minimize the chance of a positive child
going undetected.
The nurse should teach the family all necessary care-
giving methods before discharge. A checklist may be help-
ful to determine whether the teaching has been completed
and to verify the parents’ knowledge on leaving the
birthing unit (Figure 30–13 ●). The nurse needs to review
all areas for understanding or any outstanding questions
with the mother and father, without rushing, taking time
to answer all queries. Any concerns of the parents or nurse
are noted.
COMMUNITY-BASED NURSING CARE
The nurse discusses with parents ways to meet their new-
born’s needs, ensure safety, and appreciate the newborn’s
unique characteristics and behaviors. By assisting parents
in establishing links with their community-based health-
care provider, the nurse can get the new family off to a
good start. Parents also need to know the signs of illness,
how to reach the pediatrician or after-hours clinic, and the
importance of follow-up after discharge. See Table 30–4 ●.
Parents should also check with their clinician for advice
about over-the-counter medications to be kept in the med-
icine cabinet.
The family should have the care provider’s phone number,
address, and any specific instructions. Having the birthing
unit or nursery phone number is also reassuring to a new-
WHEN PARENTS SHOULD CALL THEIR
HEALTHCARE PROVIDER
Temperature above 38.4C (101F) rectally or 38C (100.4F) axillary or below
36.1C (97F) rectally or 36.6C (97.8F) axillary
Continual rise in temperature
More than one episode of forceful vomiting or frequent vomiting over a 6-
hour period
Refusal of two feedings in a row
Lethargy (listlessness), difficulty in awakening baby
Cyanosis with or without a feeding
Absence of breathing longer than 15 seconds
Inconsolable infant (quieting techniques are not effective) or continuous
high-pitched cry
Discharge or bleeding from umbilical cord, circumcision, or any opening
(except vaginal mucus or pseudomenstruation)
Two consecutive green, watery stools
No wet diapers for 18 to 24 hours or fewer than six to eight wet diapers per
day after 4 days of age
Development of eye drainage