CARE OF MOTHER, CHILD, ADOLESCENT | NCM 107

IMMEDIATE NEWBORN CARE

RELATED TERMINOLOGIES NEONATAL TRANSITION PERIOD

APGAR SCORING • The newborn’s transition from intrauterine to extrauterine life
• Method of evaluating/monitoring cardiovascular adaptation of is marked by a series of rapid and complex physiologic
the baby. changes.
• The Apgar score is a test given to newborns soon after birth. • Your assessment of these changes begins in the delivery room
• This test checks a baby's heart rate, muscle tone, and other and continues through the infant’s hospital stay.
signs to see if extra medical care or emergency care is needed. • During the birth process, fluid is squeezed from the fetal lungs.
• The test is usually given twice: once at 1 minute after birth, • As the chest emerges, most healthy newborns will take their
and again at 5 minutes after birth. first breaths spontaneously.
• The onset of respiration stimulates a series of
ACROCYANOSIS cardiopulmonary changes as the infant makes the transition
• Bluish discoloration of body and extremities. from fetal to neonatal circulation.
HARLEQUIN’S SIGN VITAL STATISTICS
• Dependence sign; reddish on one side of the baby. • Newborns may look alike, but each has their own physical
• Harlequin colour change appears transiently in approximately attributes and personalities.
10% of healthy newborns. • Some newborns are fat and short while some are long and
• This distinctive phenomenon presents as a well-demarcated thin.
colour change, with one half of the body displaying erythema • There are newborns who never give a fuss whenever they are
and the other half pallor. changed or cuddled, but some can cry in high decibels
MILIA whenever you lift them from their cradles.
• Pinpoint whitish structures on baby’s nose, forehead and chin • The weight of newborns varies according to their race,
genetics, and nutritional factors.
MOTTLING
• The hue and color patterns of a newborn's skin may be PARAMETER
startling to some parents. ANTHROPOMETRIC AVERAGE
• Mottling of the skin, a lacy pattern of small reddish and pale MEASUREMENT
areas, is common because of the normal instability of the WEIGHT 6.5 to 7.5 lbs (2.9 kg to 3.4 kg)
blood circulation at the skin's surface. LENGTH 50 cm (20 in)
HEAD CIRCUMFERENCE 33 to 35 cm (13 to 13.7 in)
LANUGO
31 to 33 cm or 2cm less than
• Downy hair of newborn; anterior shoulder, buttocks, scapular CHEST CIRCUMFERENCE
head circumference
region, forehead.
ABDOMINAL CIRCUMFERENCE 31 to 33 cm
MONGOLIAN SPOTS
IMMEDIATELY AT
• Bluish discoloration in lumbar region and buttocks. VITAL SIGN
BIRTH
AFTER BIRTH
• Mongolian blue spots, also known as slate gray nevi, are a type TEMPERATURE 36.5 to 37.2 Celsius
of pigmented birthmark. 120-140
• They’re formally called congenital dermal melanocytosis. PULSE 180 beats/minute
beats/minute ave.
• These marks are flat and blue-gray. 30-50
• They typically appear on the buttocks or lower back, but may RESPIRATION 80 breaths/minute
breaths/minute
also be found on the arms or legs. 100/50 mmHg (by
• They’re generally present at birth or develop soon after. BLOOD PRESSURE 80/46 mmHg
10th day)
• These birthmarks are noncancerous and present no health
danger.
• However, your child’s pediatrician should examine the marks to
confirm the diagnosis.
• There’s no recommended treatment for Mongolian blue spots.
• They usually fade before adolescence.
VERNIX CASEOSA
• Also known as vernix, is the waxy or cheese-like white
substance found coating the skin of newborn human babies.
• It is produced by dedicated cells and is thought to have some
protective roles during fetal development and for a few hours
after birth.
NEWBORN CARE
• The care is performed immediately after birth through the first
28 days of life, making the transition to extra uterine life
smoothly easy in promoting the physical well-being of the
newborn and supporting the establishment of a well-
functioning family unit.

LAMAGON | BSN 2A
 CARE OF MOTHER, CHILD, ADOLESCENT | NCM 107
IMMEDIATE NEWBORN CARE

• The infant is weighed nude at approximately the same time NEONATAL REFLEXES
each day. Newborn loses 5% to 10% of birth weight days after • Also known as developmental, primary, or primitive reflexes.
birth due to: • They consist of autonomic behaviors that do not require higher
o No longer under the influence of salt-fluid retaining level brain functioning.
maternal hormones • They can provide information about lower motor neurons and
o Adjustment in breastfeeding muscle tone.
HEAD CIRCUMFERENCE • They are often protective and disappear as higher-level motor
• Proceeds from cephalocaudal principle: head longer than the functions emerge.
rest of the body; head: 33-35 cm using a tape. NEUROMUSCULAR SYSTEM
• Measurement above head just above eyebrows and pina ears, 1. BLINK REFLEX
resting on occipital regions.
• May be elicited by shining a strong light on an eye.
• If above 33-35 cm, suspect hydrocephalus.
• To protect eyes from any object coming near it.
• For accurate measurement, the tape is placed over the most
prominent part of the occiput and brought to just above the 2. ROOTING REFLEX
eyebrows. • Serves to help the NB find food.
• The circumference of the newborn’s head is approximately 2 • When cheek is stroked near the corner of the mouth, a NB will
cm greater than the circumference of the newborn’s chest at turn the head in that direction.
birth. • Reflex disappears 6 wks. of life.
CHEST CIRCUMFERENCE • At this time, NB eyes can focus steadily so food source can be
seen.
• Chest circumference should be taken with the tape measure at
the lower edge of the scapulas and brought around anteriorly 3. SUCKING REFLEX
directly over the nipple line. • This reflex helps the NB find food.
LENGTH • When NB’s lips are touched, the baby makes a sucking motion.
• The length of the newborn is difficult to measure because the • Begins to diminish at 6 months of age.
legs are flexed and tensed. 4. SWALLOWING REFLEX
• To measure length, start from the crown of the newborn’s • Food that reaches the posterior portion of the tongue is
head following the conjunction of the spine/back then the automatically swallowed.
buttocks, thigh down to the heel of the foot. 5. EXTRUSION REFLEX
• Other way of measuring the length, the nurse should place the
• Prevents swallowing of inedible substances.
newborn’s flat on their backs with legs extended as much as
• Disappears in 4 months.
possible.
• Extrudes any substance placed on anterior portion of the
TEMPERATURE tongue.
• If the newborn’s temperature does not stabilize shortly after
6. PALMAR GRASP
birth, the cause needs to be investigated to rule out infection.
• Disappears in 6 wks. - 3 months.
PULSE
• Elicited by the examiner placing his finger on the palmar
• Transient murmurs surface of the infant’s hand and the infant’s hand grasps the
o Result from incomplete closure of fetal circulation shunts finger.
• During crying • Attempts to remove the finger result in the infant tightening
o May rise to 180 bpm the grasp.
• During sleep • Grasps meaningfully at 3 months of age.
o 90 – 110 bpm
• Palpate for femoral pulses 7. STEP (WALK)-IN-PLACE
o Absence suggests coarctation (narrowing) of the aorta. • NBs who are held in a vertical position with their feet touching
a hard surface will take a few quick, alternating steps.
RESPIRATION
• Disappears by 3 months of age
• Coughing & sneezing present to clear the airway.
• Maybe as high as 90 breaths per minute right after birth but 8. PLACING REFLEX
will settle to an average 0f 30- 60 breaths per minute. • Similar to step-in-place reflex
• NBs are obligate nose-breathers. • Elicited by touching the anterior surface of the lower part of
o Show signs of distress if nostrils become obstructed. the NB’s leg against a hard surface.
o Edge of table or bassine
BLOOD PRESSURE
• At birth 9. PLANTAR GRASP
o 80/46 mmHg • When an object touches the sole of a NB’s foot at the base of
• By 10th day the toes, the toes grasp in the same manner as do the fingers.
o 100/50 • Disappears at 8 – 9 months of age in preparation for walking.
CREDE’S PROPHYLAXIS
• Crede’s prophylaxis and apply terramycin eye ointment on
both eyes.
• Retract lower eyelid outward to instill ¼ inch strand of
ointment along the conjunctival surface.

LAMAGON | BSN 2A
 CARE OF MOTHER, CHILD, ADOLESCENT | NCM 107
IMMEDIATE NEWBORN CARE
10. TONIC NECK (FENCING POSTURE)
• Elicited by rotating the infant’s head from midline to one side.
• The infant should respond by extending the arm on the side to
which the head is turned and flexing the opposite arm.
• The lower extremities respond similarly.
• Disappears between 2 – 3 months of life.
11. MORO REFLEX
• The examiner holds the infant so that one hand supports the
head and the other supports the buttocks. The reflex is elicited
by the sudden dropping of the head in her hand. The response
is a series of movements: the infant’s hands open and there is
extension and abduction of the upper extremities. This is
followed by anterior flexion of the upper extremities and
audible cry.
• Their fingers assume a typical “C” position.
• Fades by end of 4-5 months.
• An absent or inadequate Moro response on one side:
o Hemiplegia, brachial plexus palsy, or a fractured clavicle
• Persistence beyond 5 months of age:
o Indicate severe neurological defect
12. BABINSKI REFLEX
• Elicited when the sole of the foot is stroked in an inverted “J”
curve from the heel upward. The infant responds by plantar
flexion and either flexion or extension of the toes (fans the
toes).
• Remains positive until 3 months of age.
13. MAGNET REFLEX
• If pressure is applied to the sole of the feet of the NB lying in
supine position, he/she pushes back against the pressure.
14. CROSSED EXTENSION REFLEX
• If one leg of the NB lying supine is extended, and the sole of
that foot irritated by being rubbed with a sharp object
(thumbnail), the infant raises the other leg and extends it, as if
trying to push the hand away.
15. TRUNK INCURVATION
• When NB lies prone and is touched along the paravertebral
area by a probing finger, they flex their trunk and swing their
pelvis toward the touch.
16. LANDAU REFLEX
• A NB who is held in prone position with a hand underneath
supporting the trunk, should demonstrate some muscle tone.
MUSCLE TONES
• Muscle toned is determined by evaluating the degree of
flexion and resistance of the extremities.
1. SQUARE WINDOW SIGN
• Is elicited by gently flexing the newborn’s hand towards the
ventral forearm until resistance is felt.
• The angle formed at the wrist is measured.
2. ARM RECOIL
• Is elicited when the newborn is in supine position, the forearm
is fully flexed for 5 seconds then fully extend by pulling the
hands and release.
3. POPLITEAL ANGLE (DEGREE OF KNEE FLEXION)
• Is determined with the newborn flat on his or her back. Flex
the thigh on the abdomen and chest, place the index finger of
the other hand behind the newborn’s ankle to extend the
lower leg until resistance is met, and measure the angle form.
• Results vary from no resistance in the very immature newborn
to an 80-degree angle in a term newborn.
4. SCARF SIGN
• Is elicited by placing the newborn supine and drawing an arm
across the chest toward the newborn’s opposite shoulder until
resistance is met.
• Note the location of the elbow in relation to the midline of the
chest.
5. HEEL-TO-EAR EXTENSION
• Is performed by placing the newborn in a supine position and
then gently drawing the foot toward the ear on the same side
until resistance is felt. Allow the knee to bend during the test.
6. ANKLE DORSIFLEXION
• Is determined by flexing the ankle on the shin. Use a thumb to
push on the sole of the newborn’s foot while the fingers
support the back of the leg. Then measure the angle form by
the foot and the interior leg.
• Intrauterine position and congenital deformities can influence
the sign.
7. HEAD LAG (NECK FLEXOR)
• Is measured by pulling the newborn sitting position and noting
the degree of head lag. Total lag is common in newborns up to
43 weeks gestation, whereas post term newborn (42+ weeks)
holds their heads in front of their body lines.
• Full – term newborns can support their heads momentarily.
8. VENTRAL SUSPENSION (HORIZONTAL POSITION)
• Is evaluated by holding the newborn prone on the hand and
noting the position of the head and the back and degree of
flexion and the arms and legs.
NEWBORN CARE COMPETENCIES
• Dry the baby for at least 30 seconds, wipe eyes, face, head,
front, back, arms and legs.
• Remove the wet cloth.
• Check breathing. Do not ventilate unless not breathing and do
not suction unless with secretions but first suction the mouth
first.
• Do APGAR scoring immediately then after 5 minutes.
• If the baby is breathing and crying, position the baby prone on
the mother’s abdomen then cover with cloth, cover the head
with bonnet and place ID band on ankle.
• Remove the first set of gloves then when the umbilical
pulsation is gone, clamp the cord using sterile clamp at 2cm
from the umbilical base then clamp again at 5cm from the base
then cut the cord close to the clamp.
• Check for presence of 2 arteries and one vein.
• Then allow skin to skin contact with the mother, observe
feeding cues and encourage the mother to feed the baby
through her breast.
• After the first full breastfeeding, proceed to weighing, eye
care, injection of Vitamin K and examination.
• Check temperature per rectum for patency.
LAMAGON | BSN 2A
 CARE OF MOTHER, CHILD, ADOLESCENT | NCM 107
IMMEDIATE NEWBORN CARE

EYE CARE/CREDE’S PROPHYLAXIS ✓ Receiving blanket

✓ Digital Thermometer
✓ Baby’s cap
✓ Weighing scale
✓ Goose neck lamp
▪ Vicente Sotto Memorial Medical Center (VSMMC)
✓ Cord clamp
✓ Sterile OC (3-4 pcs)
✓ Sterile cotton balls (2-3 pcs)
✓ Cord cuter
✓ Tape measure
✓ Vitamin K ampule
✓ Terramycin eye ointment tube
✓ ICC Syringe
✓ Baby diaper
✓ ID band – Blue (male), Pink (female)
• Do Crede’s prophylaxis and apply terramycin eye ointment on ✓ Receiving blanket
both eyes. ✓ Digital Thermometer
• Retract lower eyelid outward to instill ¼ inch strand of ✓ Baby’s cap
ointment along the conjunctival surface. ✓ Weighing scale
• Record observation done and medications given. ✓ Goose neck lamp
• Report for any abnormalities noted. 2. Prepare the room temperature of the delivery room. Room
INJECTION OF VITAMIN K temperature should be 25-28 C.
• Is synthesized through the action of intestinal flora and is 3. Notify appropriate staff.
responsible for the formation of clotting factors. 4. Arrange needed supplies in linear fashion.
• Newborns have less coagulation ability so vitamin K is usually 5. Check resuscitation equipment.
administered to prevent bleeding. 6. Wear a face mask and bonnet properly.
• Vitamin K: 7. Wash your hands with clean water and soap.
o Term: 0.1 ml 8. Don’t double glove just before delivery.
o Premature: 0.05 ml 9. Within first 30 seconds:
▪ Dry the newborn thoroughly for at least 30 seconds.
INJECTION OF VITAMIN K ON THE VASTUS LATERALIS ▪ Do a quick check of breathing while drying. (do not suction
• Cleanse the area thoroughly with alcohol swab and allow skin unless the mouth/nose are blocked with secretions or
to dry. other materials)
• Bunch the tissue of the upper thigh (vastus lateralis muscle) ▪ Wipe the eyes, face, head, front and back, arms and legs.
and quickly insert a 25G 5/8-inch needle at 90 degrees angle (DO NOT wipe off the vernix caseosa)
to the thigh. ▪ Remove the wet cloth.
• Aspirate and then slowly inject the solution to distribute the 10. After 30 seconds, if newborn is breathing and crying,
medication evenly. ▪ Position the newborn prone on the mother’s abdomen or
• Remove the needle and do not massage the site. chest.
HEPATITIS B VACCINE ▪ Cover the newborn’s back with a dry blanket.
• 0.5ml ▪ Cover the newborn’s head with a bonnet/cap.
• Vaccine must be given within 12 hrs. after birth 11. After 1-3 minutes, properly time cord clamping.
• 2nd dose at 1 month ▪ Remove the first set of gloves.
• 3rd dose at 6 months ▪ After the umbilical pulsations have stopped, lamp the cord
• Infants with mothers positive for HepB surface antigen using a sterile plastic clamp at 2cm from the base.
(HBsAg) should also receive Hep B immunuglobulin (HBIG) ▪ Do not milk the cord towards the baby.
▪ Clamp again at 5 cm using Kelly forceps from the base.
PROCEDURE
▪ Cut the cord close to the plastic clamp.
1. Prepare all equipment.
12. Place the identification band on ankle (not wrist) of
▪ Cebu Puericulture Center and Maternity Inc. (CPCMHI)
corresponding gender.
✓ Cord clamp
▪ CPCMHI – left ankle
✓ Sterile OC (3-4 pcs)
▪ VSMMC – both ankles
✓ Sterile cotton balls (2-3 pcs)
▪ Leave the newborn in skin-to-skin contact.
✓ Mayo Scissors
▪ Observe for feeding cues, including tonguing, licking,
✓ Bulb Syringe
rooting.
✓ Tape measure
▪ Point these out to the mother and encourage her to
✓ Vitamin K ampule
nudge.
✓ Terramycin eye ointment tube
13. After 90 minutes, remove the newborn from mother’s
✓ ICC Syringe
abdomen.
✓ Baby diaper
14. Transfer the newborn to the work table.
✓ ID band – Blue (male), Pink (female)
15. Weigh the newborn to the work table.

LAMAGON | BSN 2A
 CARE OF MOTHER, CHILD, ADOLESCENT | NCM 107
IMMEDIATE NEWBORN CARE

16. Perform physical assessment of the newborn and do APGAR

scoring.
▪ Perform Anthropometric measurement
▪ Head circumference
▪ Chest circumference
▪ Mid-arm
▪ Body length
17. Take the rectal temperature
18. Inject Vitamin K
▪ CPCMHI – left thigh
▪ VSMMC – right thigh
19. Apply eye prophylaxis.
20. Put on baby’s clothes.
21. Wrap the baby with baby’s blanket
22. Obtain heart rate and respiratory rate.
23. Show the baby to the mothers. Latch on the baby to the
mother’s breast.
24. Documentation immediately after cord care and latch on.
25. Do after care.

LAMAGON | BSN 2A