➢ Assess characteristic of cry (strong and lusty)
THE NURSES’ ROLE IN MATERNAL CHILD CARE
➢ Physical Assessment of the NB
○ Transitional - immediately after birth (initial
/ EINC)
○ physiologic adaptation
➢ Physical/ Behavior
➢ Promote parent-infants bonding
○ be alert in any problems in attachment
○ check OB profile
➢ Prepares the family for discharge
○ demonstrate physical care of the NB
○ provide health /discharge
teaching/information,
○ anticipatory guidance
Immediate Care of the Newborn (EINC)
1. Dry and provide warmth to the newborn
immediately after delivery (1st 30 secs).
2. Clear airway PRN
3. Assess baby’s response to birth
4. Check APGAR score
5. Facilitate bonding between the mother and her
newborn through skin to skin contact
6. Clamp and cut the cord after the cord
pulsations have stopped (1-3 mins).
7. Facilitate early initiation to breastfeeding
8. Give Crede’s prophylaxis (1 hour post
delivery)[erythromycin or terramycin ointment ]
9. Ensure proper identification of the newborn
Non-immediate Care of the Newborn (EINC)
➢ These interventions are usually given 6 hours after
birth and should never be made to compete with
time-bound interventions / immediate interventions.
1. Administer medications:
a. Give Vitamin K (IM)
b. Inject Hepatitis B vaccine (IM)
c. Inject BCG (ID)
2. Dress the umbilical cord
3. Take vital signs, anthropometric, and physical
assessment of the NB
4. Swaddle the baby (PRN) and place it in
side-lying the lying position
5. Give a full bath once stable or after 24 hours
(follow hospital protocol)
Dry and provide warmth to the newborn
➢ Wipe and dry using clean warmed blankets
➢ Place baby in a radiant warmer
➢ Remove wet linens
➢ Rub/flick soles of NB (+ stimulation is required as
needed)
➢ Do not slap buttocks (no beneficial effect)
➢ Stimulate baby to breathe
➢ Stimulate crying by gentle friction
➢ Provide patent airway
➢ Newborn are obligate nasal breather
➢ Assess for nasal flaring, retractions and abnormal
respiration
Factors Predisposing the Newborn to Excessive Heat
Loss
➢ Large surface area results in heat loss to
environment
➢ Newborn’s thin layer of adipose is poor
insulator
➢ Newborn cannot shiver to increase heat
production
➢ Metabolizes brown fat stores to generate heat
Maintain Stable Body Temperature
➢ Mechanism of NB heat loss:
○ Evaporation
○ Radiation
○ Conduction
○ Convection
The APGAR SCORE
➢ Developed by Virginia Apgar (1950),
American anesthesiologist
➢ Purpose:
1. A scoring system that helped to
evaluate a newborn’s physical
condition after birth. It help to
determine any urgent need for
emergency or extra medical care
(e.g. acidosis, CPR)
2. To evaluate how well the newborn
adjusts to extra uterine life
3. Assess newborn’s response to birth
4. Performed and record at 1, 5 minutes
and 10 minutes as needed
➢ APGAR SCORE INTERPRETATION:
○ 7-10 - indicates healthy newborn
1
 ○ very good; rarely needs
resuscitation The CORD
○ 3-6 - moderately depressed ➢ Apply cord clamp 1 inch from the base then cut
○ - fair, it requires above the cord clamp
resuscitation suctioning ➢ Cord is pearly white gelatinous
signify moderate difficulty ➢ Assess for the presence of the BV (2 Arteries, 1
needs further assessment vein) = AVA
and medical intervention ➢ Assess for intact cord and ensure that clamp is
○ 0-2 - severely depressed secured
○ poor, requires intensive ➢ Cord should be clamped for at least the 1st 24
resuscitation needs hours after birth. Clamp can be removed when
intensive medical intervent cord is dried.
➢ If score is less than 7 at 5 minutes, the score ➢ Note for any bleeding or drainage from the cord.
should be performed in 10 minutes. ➢ Note for any foul odor from the cord.
➢ Monitor cord meconium staining
ENSURE NEWBORN’S PROPER IDENTIFICATION
1. Check identification band
○ name of baby (e.g. Bb boy Fernando
○ name of mother
○ date and time of delivery
○ Doctors (OB and Pedia)
2. Foot Prints (no longer required but depends on the
hospital)
3. Baby tag and crib tag. Check always and should
match at all times.
4. Take fingerprint of mother (as per agency) Picture A: cord a few days after birth
○ R.A. 7600 (The Rooming and Breastfeeding
Act of 1992)

Identification of the Newborn

➢ Safety concerns related to newborn identification
procedures
➢ Specify facility procedures
➢ NCMEC: National Center for Missing and Exploited
Children
➢ “Profile” of abductor Picture B: cord right after birth (<24 hrs)

Take Vital Signs ADMINISTER MEDICATIONS

➢ Maintain stable body temperature 1. Crede’s Prophylaxis
○ N.V. 36.5 – 37.5◦C (99.7-99.5◦ F) 2. Vitamin K
○ Axillary 36.5 – 37.6◦ C (97.7-99.7◦ F) 3. Hepatitis B Vaccination
○ Rectal more accurate ○ HBIG - mother + for HBSAG
➢ RR 30-60 breaths per minute 4. BCG Vaccine
➢ CR 120-160 bpm(apical) 100 asleep; 180 crying
➢ BP seldom taken CREDE’S PROPHYLAXIS
➢ Maintain temperature stability: ➢ Application of ophthalmic medication =
○ Wrap the newborn in a warm blanket and put a prevention of OPHTHALMIA NEONATORUM -
stockinette cap on the newborn's head. infectious conjunctivitis in newborn; contracted in
(Usually unstable and takes 6-8 hours to the birth canal of mother w/ gonorrhea or
stabilize) chlamydia
○ Observe for hypothermia/ hyperthermia ➢ Given 1st hour after birth
○ Check S/S of: infection, dehydration, ➢ Rx: ophthalmic ointment or drops
inadequate clothing, prematurity ○ Erythromycin (0.5%)
○ Tetracycline (1%) / Gentamicin
The Anthropometric Measurements:
➢ HC 33 -35 cm (13-14 in) occipito-frontal APPLICATION OF CREDE’S PROPHYLAXIS
➢ CC 31- 33 cm measure at nipple line 1. Child is placed in supine position:
➢ AC 31-33 cm a. EYE DROPS
➢ Birth length 48-53 cm (19-21 inches) ○ Lower lid is pulled to form a pocket
➢ Birth weight 2700 - 4000 grams (2.7 – 4 kgs / 6-9 and the solution is dropped into the
lbs) pocket.

2
 b. EYE OINTMENT
○ Applied from inner canthus to outer
canthus.
➢ TAKE NOTE: Make sure that the tip of the
tube/dropper does not touch the eye.
Vitamin K injection
➢ Aquamephyton, Phytonadione
➢ Route: IM (single dose)
➢ Site: Vastus lateralis (Rectus Femoris)
○ Dose: 0.5 to 1 mg
○ 0.1 ml (term)
○ 0.05 ml (preterm)
➢ Given prevent hemorrhagic bleeding
➢ Catalyze the synthesis of prothrombin in the liver
which is needed for blood clotting and coagulation
Hepatitis B Vaccine
➢ recommended by CDC all NB before they
leave the hospital
➢ decrease the incidence HBV in children and its
serious consequences (e.g cirrhosis/ Ca)
➢ given IM
➢ if infant is born to HBsAg + they should be
immunized w/ HBIG w/in 12 hours.
BCG
➢ BCG can be given in the hospital
➢ It depends on the policy of the institution
Swaddle the Baby
➢ Place right side-lying to drain out secretions
➢ Swaddling the baby will keep them from
hypothermia
Bath
➢ Give full bath
○ To clean the baby and remove blood and
mucus
○ Use lukewarm water and anti microbial
soap that is hypo allergenic
○ Take note: full bath should be done under
radiant warmer and when temperature is
already stable
Physical Assessment (PA)
➢ Basic Principles:
1. Review perinatal history.
2. Keep newborn warm during the examination.
3. Begin with the general observations. Then
perform assessment that are least disturbing
a. assess the NB’s color.
b. auscultate only in a quiet
environment
4. Take note of the life threatening conditions.
5. Calm the infant before doing the examination
6. Have the necessary tools at hand
7. Handle the infant gently
8. Initiate nursing interventions for abnormal
9. findings. Assess for gross anomalies
10. Document all findings (normal / abnormal)
○ for legal purposes
○ document what is really been done
Anthropometric Measurements
➢ Birthweight (BW)
○ 2700 – 4000 g (6 – 9 lbs)
○ average weight 3400 g (7.5 lbs)
➢ weight is taken soon after birth.
➢ WEIGHT LOSS occurs rapidly after birth
➢ NEONATE weight LOSSES about 10 % of the
BW by 3 -4 days of life but usually regained
by the 10th day of life.
➢ Head circumference (HC)
○ 33-35 cm (13-14 inch)
(occipitofrontal)
➢ Chest circumference (CC)
○ 31-33 cm (nipple line)
➢ Abdominal circumference (AC)
○ 31-33cm
➢ Birth length (BL)
○ 48-53 cm (19-21 inches)
➢ BW & BL are very important because they
provide a baseline for assessment of future
growth
● Assess for:
○ SGA (small for gestation age)
○ AGA (appropriate for gestational age)
○ LGA (large for gestational age)
Vital Signs
➢ Measure VS when the infant is still quiet
➢ CR,RR,BP fluctuates with stress, crying,
movements and sleep wake cycles
Temperature
➢ Temp 36.5-37.5 ◦ C
➢ Axillary is the preferred site
➢ But rectal temperature more accurate.
➢ Temperature is taken per anal INITIALLY TO
CHECK FOR PATENCY OF ANUS! (Insert 1
in)
➢ ROUTINE USE OF RECTAL TEMP IS
AVOIDED
➢ May also cause vagal nerve stimulation
➢ Succeeding temperature is taken by axillary
➢ Other sites of temperature:
○ Tympanic
○ Skin - 36.5 – 37 C
(using probe; slightly lower than the
core)
➢ Temp stabilizes in 8 – 10 hours after birth
➢ VS taken q 15 mins during the first hour and
hourly during the next few hours then q4 (
depend on hospital policy ) thereafter if it
remains stable.
Heart Rate (HR/CR)
➢ 120-160 bpm (apical)
➢ Low & high (rapid / irregular, with slight
murmur)
➢ Count for 1 full min. (due to some
irregularities)
➢ Auscultation of heart sounds difficult
3
 ○ Murmurs
○ S1, S2 should be clear
➢ PMI: Point of maximum impulse
○ Rhythm regular at 4th to 5th ICS
○ Slightly left of midclavicular line
Heart
➢ Murmur normal (only during the 1st few DOL)
○ Foramen Ovale still open
○ adjustment period
➢ Tachycardia - RDS
➢ Bradycardia - CHD
➢ Pulses sites: apical, brachial, femoral,
pedal
○ check for equality and strength
○ femoral –check if absent , COA
➢ Dextrocardia – heart on right side
Respiratory Rate
➢ 30-60 breaths / minute. Count for 1 full minute
➢ Irregular,abdominal, shallow, quiet,unlabored,
symmetrical
➢ With short periods of apnea (5- 10 secs), with
slight retractions
➢ Breath sounds present, equal,clear
➢ Diaphragmatic and abdominal
➢ Check and observe RR and effort
➢ Bradypnea – Narcosis fr analgesics,
anesthetics, trauma
➢ Tachypnea – RDS, MAP, CHD
➢ hypertonic – NAS,CNS damage
➢ jitteriness/tremors – low glucose / low calcium
➢ opisthotonos, seizure, stiff neck – CNS
damage
B. Behavior
○ observe and monitor for
alertness,drowsiness and irritability
(common signs of neurologic
problems)
➢ some questions may be ask:
a. Is the infant awakened easily by loud
noise?
b. is the infant comforted by rocking,
sucking ,cuddling?
c. Does there seem to be pds of deep &
light sleep?
d. Does infant seems to be satisfied
after feeding?
e. What stimuli elicit responses from the
infant?
Skin
C. Check color
○ Inspect and palpate. Use natural light
○ generally pinkish,velvety smooth and puffy
○ depends on the race, ethnic and familial
background
○ Observe color in relation to activity,position
and temperature changes
○ with acrocyanosis (normal / chilled)

Blood Pressure Skin color

➢ Systolic 60-80 mm Hg / diastolic 40- 50 ➢ Check for cyanosis:
mm Hg A. Circum-oral cyanosis
○ at 10th DOL systolic 95 – 100 ○ cyanosis of mouth & central areas
mm Hg diastolic slightly increased ○ (requires suctioning)
➢ Not routinely checked in healthy newborn B. Acrocyanosis/peripheral
➢ Only if cardiac problem is suspected ○ due to cold environment
○ e.g COA – all 4 extremities BP is C. Cyanosis are also seen
taken ○ Infection, hypoglycemia, cardiopulmo,
➢ Varies with changes in NB’s activity and blood cardiac ds.
vol.
➢ More accurate if NB is resting Other skin colors
➢ Use special bp app for neonate ➢ Dark red (phletora) – premature
➢ Pallor – CV, CNS, blood dyscrasia, blood loss,
General Appearance twin to twin, nosocomial infection
➢ Yields valuable clues to the physical status of ➢ Petechiea
infant ➢ Ecchymoses
A. Posture: ➢ Gray – hypotension, poor perfusion, infection
○ infant assume a well flexed position ➢ Yellowish discoloration – jaundice
(normal position in utero)
○ Most NB are born in a vertex General Assessment
presentation ➢ (should be performed in cephalocaudal
○ Flexion decrease area of skin manner)
exposed to environment , thereby ➢ Newborn Head:
reducing heat lost a. 25% of the body length . Largest part
➢ Arms are flexed,fists clenched, movement of infant’s body
symmetrical b. bones of cranium are not fused (6
➢ w/ slight tremors during crying cranial bones)
➢ Check for: hypotonic, limp, flaccid, “ floppy” or c. sutures – palpable; may override
rigid extremities - seen in preterm, hypoxia, (only at birth)
excessive medications, CNS trauma d. assess for head circumference

4
 ○ microcephaly (e.g. cranial synostosis)
○ macrocephaly (e.g. hydrocephalus)
○ anencephaly
Newborn Head
➢ Assess contour of head (e.g molding)
➢ Assess fontanels—anterior, posterior
➢ Degree of head control/head lag
➢ Result of birth trauma
○ Caput succedaneum
○ Cephalhematoma
○ Physiologic craniotabes
Molding
➢ Asymmetry of the head as a result of pressure
in the birth canal
➢ Disappear in 72 hours
Fontanels
Newborn Head
➢ Separating lines of the skull, may override at
the birth because of extreme pressure exerted
by the passage through the birth canal, sort of
overlap.
➢ Palpate the skull for all sutures
Sutures
➢ Separating lines of the skull, may override at
birth because of extreme pressure exerted by
the passage through the birth canal, sort of
overlap.
➢ Palpate the skull for all sutures
Anterior Fontanel
➢ at the junction of 2 parietal bones and the 2
fused frontal bones
➢ felt as soft spot, flat diamond shape
➢ 4-5 cm (about 2 inches) at widest point
➢ It closes at 12 to 18 months
➢ if > 5cm maybe a sign of HYDROCEPHALUS
and CRETINISM
Posterior Fontanel
➢ Located between occipital and parietal bone
➢ Triangular, 0.5 cm to 1 cm (.5 in) wide
➢ Small, not readily felt
➢ Closes between birth and 2-3 months
Caput Succedaneum
➢ Edema of the scalp
➢ This is due to the pressure of the presenting
part during labor
➢ Disappear after 3 days
Cephalhematoma
➢ Rupture of periosteal capillary of the skull.
➢ This is due to pressure in birth canal
➢ Usually absorbed in 6 weeks without treatment
5
 Coloboma
Craniotabes
➢ Localized softening of the cranial bones
➢ Can be indented by pressure of a finger
➢ Correct itself without treatment after some
months
➢ More common among 1st born because of
early lightening

Exotropia Strabismus

Face
➢ Check for symmetry
➢ No bell’s palsy (facial nerve paralysis/drooping
of mouth to one side)
➢ Due to use of forceps/birth trauma
○ Permanent
○ Temporary
➢ Check for delivery history
➢ Facial Paralysis:

Ears
➢ Pinna
➢ Canals
➢ Tympanic membrane
➢ Startle reflex
➢ Otoacoustic Emission (OAE)
Eyes ➢ Auditory ability (ABR testing)
➢ Newborn tend to keep their eyes tightly closed ➢ Well formed notch of ears on straight line with
➢ Slate gray (light skin) or brown-gray (dark skin) outer canthus of the eye (pinna aligned with
➢ PERRLA - no keyhole (coloboma) outer canthus)
➢ Symmetrical and clear ➢ Symmetrical
➢ Sclera white and clear ➢ Firm cartilage with recoil
➢ Cornea should be round and adult sized ➢ Can hear once amniotic fluid has been
➢ May have subconjunctival hemorrhage (small absorbed (e.g. Startle Reflex)
broken tiny capillaries on sclera) ➢ Assess for low set ears
➢ Eyelids edematous for first days of life
➢ Tearless/no drainage/no purulent discharge
➢ Able to track and fixate momentarily
➢ Eye crosses because of weak extraocular
muscles (normal strabismus)
➢ Nystagmus/Strabismus
➢ Corneal reflex
➢ Red reflex
➢ Blink reflex present

6

Ears (PINNA) assessment
➢ Note: of ears set lower - abnormal
○ Chromosomal defects - Down
syndrome
○ Kidney Ds.
○ Patau syndrome
○ Edward Disease
○ Kidney defects
○ Craniofacial defects
Nose
➢ Patency of nasal canals / no discharge
➢ Structure: flat, broad, at the center
➢ Obligatory nasal breather
➢ Occasional sneezing common
➢ Check for congenotal anomaly (deviated
septum/choanal atresia)
➢ Monitor for flaring, observe for RDS
Mouth and throat
➢ Pink moist gums
➢ Tongue moves freely, symmetrical
➢ Sucking and crying movements symmetrical
➢ Able to swallow - do test feeding (E. atresia)
➢ Should open mouth evenly when crying
➢ Check for oral thrush - not common
➢ Soft and hard palates intact (e.g. cleft palate)
➢ Epstein pearls
➢ Frenulum and lingual frenulum (tongue tie)
➢ Reflexes: sucking, rooting, gag, swallowing
➢ Uvula - at midline (check during crying)
➢ Natal teeth/neonatal teeth no common
Craniofacial defect
Cleft palate
Neck
➢ Short and thick neck
➢ Head held at midline
➢ Good ROM and is able to extend
➢ Freely movable
➢ Thyroid gland is not palpable
➢ Reflex present: Tonic - neck reflex (Fencer
position)
Chest
➢ Circular with equal anteroposterior and lateral
diameter
➢ With bilateral chest expansion
➢ Respirations diaphragmatic abdominal
➢ Bronchial sounds heard on auscultations (BS
clear)
➢ Clavicles straight and intact
➢ Observe for abnormalities (appearance, BS)
➢ Chest AP and lateral diameters are equal
➢ Ribs flexible - observe for S/S of RDS
➢ Breasts:
○ Nipples prominent and often
edematous
○ Observe for size, shape, location,
number, and formation
○ Supernumerary nipples
○ “Witch’s milk”
7
 Abdomen Imperforate Anus
➢ Soft, dome shaped, round, some laxness of
muscles, moves with respirations
➢ Contour - cylindric with visible veins
➢ Bowel sounds present
➢ Liver, spleen, and kidneys palpable at birth
➢ Umbilical cord - white gelatinous with 2
arteries and 1 vein, no foul odor
➢ Femoral pulses palpable and equal, no bulges
or nodes along bilateral inguinal areas

Gastrointestinal
➢ Assess for abnormalities
○ Hernia Female Genitalia
○ Omphalocele ➢ Labia majora - edematous, clitoris enlarged
○ Gastroschisis ➢ Labia minora - may have vernix caseosa and
○ Scaphoid - diaphragmatic hernia smegma
➢ Assess for abdominal distention associated ➢ Laboa majora nor,ally covers the minora and
with obstruction, mass, or sepsis clitoris
➢ Monitor bowel sounds - occur within 1-2 hours ➢ Hymenal tah maybe visible/fistula
after birth ➢ Vaginal discharge/pseudomenstruation
(blood-tinged mucus) may be present
➢ Note: In preterm babies, appearance is
Omphalocele
different - clitoris and minora are larger than
majora

Male Genitalia
➢ Scrotum edematous, pendulous with rugae
➢ Testes should be present and descended into
scrotum
○ Assess for cryptorchidism
➢ Urinary meatus at tip of penis
○ Epispadia / hypospadia
➢ Foreskin (prepuce) covers the glans penis and
Gastroschisis should be retracted
○ Check for phimosis
➢ Check for any abnormalities
○ Hydrocele / hernia
➢ Smegma

Hypospadias

Anus
➢ Check for anal opening
➢ Should be patent and well places
➢ Check for imperforate anus
➢ Meconium should pass within 24 hours
➢ Check for fistula
➢ Note: Strict monitoring of I&O is important and
should be well-documented
Genital ‘cont
➢ Take note: Preterm male – appearance
different
○ small penis, lack for rugae on
scrotum
➢ For both male and female 1st voiding should
➢ occur within 24 hours of life.
➢ Check for ambiguous genitalia:

8
 ○ Hermaprodite
○ Klinefelter’s syndrome Extremities and Trunk
➢ Trunk - short, flexed, synchronized movements
Cryptorchidism ➢ Trunk incurvature reflex (Galant Reflex)
➢ Extremities - (Upper)
○ Flexed with good muscle tone
○ Full ROM; movements symmetrical
○ Fist clenched
○ Equal in length
○ Grasp reflex present
○ Five digits on each hands with palmar
creases, nail present, separated and
in correct formation
○ Assess for polydactyly and
syndactyly
Hydrocele ○ Reflex: Grasp, Moro
➢ Check for fracture/Erb’s Palsy:
○ Erb Duchenne Paralysis/Erb’s Palsy -
Newborn is unable to move upper
arm or asymmetric moro response
may be caused by damage in the 5th
and 6th cervical roots of the brachial
plexus

Erb’s Palsy

Back (spine)
➢ Spine
○ Sacral dimple
○ Sacral tuft
○ Pilonidal sinus/cyst
○ Spina bifida (occulta)
➢ Straight and flexible
➢ Posture well flexed
➢ Movements is well coordinated
➢ No opening or felt on vertebral column
➢ Pilonidal cyst/sinus - A small dimple at the
base of the spine no connection with spinal
cord
➢ Check for neural tube defect (Spina Bifida)

Spina Bifida

➢ Lower Extremities - Legs

○ Equal in length, bowed, well flexed
○ Symmetric skin folds (major gluteal
folds is even)
○ Creases on soles of feet
○ Pulses present (radial, brachial,
femoral)
○ Assess for fractures (E.g. Hip
dislocation)
➢ Ortolani’s sign / Barlow’s test
○ Slight tremors are common, but could
be signs of hypoglycemia or drug
withdrawal

9
 Hip Dislocation/Dysplasia Phocomelia

Ortolani Test

Vernix Caseosa
➢ white cheesy substance seen in areas like
back, armpit, inguinal, and buttocks
➢ serves as skin lubricant, protection from
infection and acts as insulator
➢ Seen 2-3 days of life

Allis/Galeazzi

Lanugo
➢ fine downy hair
➢ seen upper arm, shoulder, back ,forehead and
ears
➢ Disappear in 2 weeks
➢ common characteristic of premature babies

Feet
➢ Creases on soles
➢ May have “positional clubfoot” caused by
intrauterine position should be able to turn
toward midline
➢ Reflexes present: plantar grasp, babinski

Equinovarus
➢ Club foot
➢ Characterized by:
○ Plantar flexion ( toes pointing down )
○ Inversion ( toes pointing inward )
➢ Other types:
○ Eversion ( toes pointing outward )
○ Calcaneus ( toes pointing upward )
Milia
➢ white ,pinpoint spots seen on the cheek and
bridge of nose caused by immature sebaceous
glands
➢ disappears in 2-4 weeks as sebaceous glands
mature and drain

10
 Erythema Toxicum
➢ pink papules with superimposed vesicles
➢ common at the face, back and buttocks
➢ self limiting

TELANGIECTASIS NEVI
➢ Pale pink or red dilated capillaries on eyelids,
nose, lower occipital bone and nape of the
neck
Newborn rash/Flea bite rash (Erythema Toxicum)
➢ Disappear at 2 years of age

Erythema Toxicum Portwine Stains (Nevus Flammeus)

➢ a macular purple or dark red lesion or patches
➢ Non elevated, sharply demarcated, red to
purple, dense areas of capillaries
➢ Can be seen face, buttocks, thigh and genitals
➢ Does not fade in time
➢ May require surgery (cosmetic) in the future

➢ Assess skin turgor over the abdomen to

determine hydration status
➢ Observe for forceps marks
➢ Observe also for birthmarks:
○ Telangiectatic nevi
○ nevus flammeus (port –wine stain) Mongolian spot
○ nevus vasculosus (strawberry mark) ➢ Bluish, greenish black, gray patches caused
○ mongolian spots by accumulation of melanocytes
➢ seen at shoulder, upper arm, back and
Strawberry marks (Nevus vasculosus) buttocks
➢ Elevated areas formed by immature capillaries ➢ disappears at in a year ( white skinned )
and endothelial tissues ➢ pre-school ( dark skinned )
➢ Capillary hemangioma, raised clearly
delineated dark red with rough surface
➢ Common in head part
➢ Disappears at 7-9 years old

11
 Common marks (not to be used in ID)
➢ Mongolian spots

Clinical Assessment of Gestational Age

➢ Important criterion because perinatal morbidity
& mortality r/t gestational age & BW
➢ Ballard Scoring Tool / (Dubowitz scale)
➢ Maturity Rating
○ an assessment that evaluates 6
○ Preterm = below 37 weeks
neuromuscular and 6 physical
○ Term = 37-42 weeks
characteristics during the 1ˢᵗ few
○ Post = above 42 weeks
hours of birth.
○ a score of 1 to 5 is assigned to each
characteristics

Ballad Scoring
➢ Neuromuscular maturity
○ during the 1ˢᵗ 24 hrs the Nervous
system is unstable
○ reflexes and assessments dependent
on his or her brain centers.
○ maybe unreliable and need to be
repeated in 24 hrs
○ Components: Posture, Square
window, Arm recoil, popliteal angle,
scarf sign, heel to ear extension

➢ Physical Maturity
○ Not influenced by labor and birth and
do not
○ change significantly within the 1ˢᵗ 24
hours after birth.
○ Components: Skin, Lanugo, Plantar
surface, Breast, Eye/ear, male
genitalia/ female genitalia

Pre-term (36 weeks & below)

➢ SKIN: Gelatinous , transparent, with visible BV
➢ EAR CARTILAGE:Absent / Pliable
➢ BREAST NODULE: 1-2 mm
➢ GENITALS:

12
 ○ MALE: ○ Fetal lung fluid removal
○ TESTES- undescended ○ Compression of chest with
○ SCROTUM- Less swollen, passage through birth canal
few rugae ○ Lymphatic vessels and
○ FEMALE: pulmonary capillaries
○ Clitoris and minora- ○ Expansion of alveoli
PROMINENT ○ Occurs with initiation of
➢ SOLE CREASES: Anterior transverse breathing
➢ LANUGO: abundant ○ Role of surfactant in keeping
➢ SCALP HAIR: Fine & Fussy alveoli expanded
Term (37-40 weeks) ➢ Sensory Factors
➢ SKIN: Smooth,pink, superficial, cracking, less ○ Tactile
visible veins ○ Auditory
➢ EARS: Formed and firm with instant recoil ○ Olfactory
➢ BREAST NODULE: 3-5 mm ○ Nurses hold, dry and place
➢ GENITALS: infant skin to skin
○ MALE: Partially descended, more ○ with the mother
swollen & rugae ○ Wrap in a blanket
○ FEMALE: Partially covered by
majora Newborn Circulation
➢ SOLE CREASE: 2/3 of the sole w/ creases ➢ Circulatory changes allow blood to flow
➢ LANUGO: Less through lungs
➢ Pressure changes in heart, lungs, and vessels
Post term (42 weeks & above) ➢ Functional closure of fetal shunts
➢ SKIN: Parchment,deep cracking, ○ Foramen ovale
desquamates, no visible BV ○ Ductus arteriosus
➢ EARS: thick cartilage and stiff ○ Ductus venosus
➢ BREAST NODULE: 6 TO 10 mm
➢ GENITALS: Sequential Circulatory Changes in the Newborn
○ MALE: Fully descended, pendulous, ➢ Inspired oxygen dilates pulmonary vessels
marked swollen ; extensive rugae ➢ Pulmonary vascular resistance decreases and
○ FEMALE: Majora completely covers pulmonary blood flow increases
minora and clitoris ➢ As the lung receives blood, the pressure in Rt
➢ SOLE CREASE: ENTIRE SOLE ➢ Atrium, Rt Ventricle, and pulmonary arteries
➢ LANUGO: None decreases
➢ Gradual increase in systemic vascular and
Weight Related to Gestational Age increase blood volume as a result of cord
➢ Birth weight is poor indicator of gestational and clamping.
fetal maturity
➢ Gestational age reflects fetal maturity Further Circulatory Changes in the Newborn
➢ AGA: growth between 10th and 90th ➢ LA pressure > RA pressure leads to closure of
percentile foramen ovale
➢ SGA: <10th percentile ➢ Increase of pulmonary blood flow and dramatic
➢ LGA: >90th percentile reduction of pulmonary vascular resistance
begins to close the ductus arteriosus
Adjustment to Extrauterine Life
➢ Respiratory System Typical Times for Newborn Circulatory Changes
○ Transition from fetal /placental ➢ Foramen ovale: functional closure soon after
circulation to independent respiration birth
○ Chemical factors stimulate breathing ➢ Ductus arteriosus: functional closure in about
○ Hypoxemia 4 days after birth in well neonate.
○ Hypercarbia ➢ Closure may delay in ill or preterm infants
○ Low pH (acidosis) ➢ Reversible blood flow through DA result in
➢ Thermal Factors functional murmur occasionally heard
○ Newborn leaves warm environment ➢ Failed closure of the above shunts takes blood
to relatively cooler atmosphere. away from newborn’s pulmonary circulation
Sensory impulses to the skin are ➢ Ductus Venosus closes (FC, shunts Arterial
transmitted to respiratory center in Blood into IVC), shunts perfusion of the liver
the medulla.
○ Initiation of respiration thru tactile
stimulation
➢ Mechanical Factors

13

Physiological Changes
➢ Before birth:
○ small fraction of fetal blood passes
through fetal lungs.
○ Fetal lungs do not function as a
source for O2 or as a route to excrete
CO2
○ The fetal lungs are expanded in
utero, but the potential air sacs are
filled fluid, rather than air.
○ The BV that perfuse and drain the
fetal lungs are markedly constricted.
○ Most of the blood from the right side
of the heart can not enter the lungs
because of constricted blood vessels
in the fetal lungs.
○ Instead, most of this blood flows
through the ductus arteriosus into the
aorta.
➢ After birth:
○ Newborn will no longer be connected
to the placenta and will depend on
the lungs as the only source of O2
○ Over a matter of seconds, the lungs
must fill with O2 and the BV in the
lungs must relax to perfuse the
alveoli and to absorb O2 and carry it
to the rest of the body
3 Major changes w/in 3 secs after birth
1. The fluid filled in the alveoli is absorbed into
the lung tissue and replaced by air. The O2 in
the lungs is then able to diffuse into the blood
vessels that surround the alveoli
2. The umbilical arteries and veins are clamped.
This removes the low resistance placental
circuit and increases systemic BP
3. As a result of gaseous distention and
increased O2 in the alveoli, the blood vessels
in the lung tissue relax
➢ The relaxation together with increased in
systemic BP, creates a dramatic increase in
pulmonary blood flow and decrease in flow
through D. arteriosus
➢ The O2 from the alveoli is absorbed by the
increased pulmonary blood flow, and the O2
enriched blood returns to the left side of the
heart where it is pumped to the tissues of the
newborn’s body
➢ As blood levels of O2 increase and pulmonary
blood vessels relax, the ductus arteriosus
begins to constrict
➢ Blood previously diverted through the ductus
arteriosus now flows through the lungs, where
it picks up more O2 to transport to tissues
throughout the body
➢ Initial cry and deep breaths help move fluid
from airways
Cardiovascular System
➢ Take note of the physiologic changes
○ Fetal - neonatal circulation
➢ Observe for cardiac distress in newborn
○ E.g. During feeding
➢ Blood values are high in NB as a response
to the pulmonary circulation. A high WBC
during the newborn period is not a sign of
infection. Further assessment is needed
Hemopoietic System
➢ Blood volume depends on the amount of blood
transferred via the placenta before clamping
the cord
➢ Full-term newborn blood volume is
approximately 80-85 mL/kg body weight
➢ Average total blood volume for newborn =
300 mL +/- 100 mL
Fluid and Electrolytes
➢ Newborn’s body weight is 73% fluid (Adult
is 58% fluid)
➢ Infant has higher ratio of ECF than adult
➢ Infant has higher level of total body Na++ &
Cl+
➢ Infant has lower level of total body K+, Mg++,
and phosphate+
GI System
➢ Newborn has deficiency of pancreatic lipase
which limits fat absorption
➢ This makes cow’s milk indigestible
➢ Human milk despite its high fat content is easy
to digest and absorb because it has lipase
➢ Stomach capacity varies from 5 ml to about
60 ml on Day 3
➢ Colon has small volume leading to frequent
stooling
➢ Rapid intestinal peristalsis (empty time 2.5 - 3
hrs)
➢ Progressive changes in stool pattern in NB
➢ Observe for feeding reflexes:
○ Rooting, sucking, swallowing
➢ Assist mother with breastfeeding or formula
feeding
➢ Burp newborn during and after feeding
➢ Assess for regurgitation and vomiting
➢ Position newborn on the right side after
feeding
➢ Observe for passage of stool
Liver
➢ Liver is very immature in newborn
➢ Immature liver affects conjugation of bilirubin
and contributes to physiologic jaundice
➢ Liver is deficient in forming plasma proteins in
newborns (edema results)
➢ Prothrombin and other coagulation factors
are low at birth
➢ Liver stores of glycogen are lower at birth than
later in life.
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 ➢ Newborn is at risk for hypoglycemia
(importance of frequent feedings)
➢ Liver controls the amount of circulating
unconjugated bilirubin ( a pigment derived
from Hgb )
➢ Unconjugated bilirubin can leave the vascular
system permeate other extravascular tissues
(skin,sclera, etc) resulting to icterus (jaundice)
➢ Types of jaundice:
1. Physiologic
2. Pathologic
3. Breastfeeding assoc jaundice (early
onset)
4. Breast Milk jaundice (late onset) -
presence of pregnanediol
Bilirubin Values
A. Unconjugated bilirubin:
○ 0.2 – 1.4 mg/dl - normal value
○ 5 mg/dl - jaundice observable
B. Kernicterus
Other jaundice parameters
1. Timing of the appearance of jaundice
2. Gestational age
3. Age in days since birth (DOL)
4. Family Hx (e.g. maternal Rh factor)
5. Evidence of Hemolysis
6. Feeding method
7. Infant’s physiologic status
8. Progression of serial serum bilirubin
Jaundice
➢ First void should occur w/in 24 hrs after
birth
➢ Newborns may void 10-20 times/day
➢ Has immature kidneys – unable to concentrate
urine
➢ GFR (reabsorption & filtration) low
➢ NB may tend to reabsorb sodium and excrete
large amount of water
➢ Decrease ability to excrete drugs and
excessive fluid loss which can lead to acidosis
and fluid imbalance
➢ Uric acid crystals may cause reddish stain
the diaper
➢ Nursing intervention:
○ Weigh newborn daily.
○ Monitor I & O. Weigh diaper prn.
○ Assess for signs of dehydration
Implications
➢ Rate of fluid exchange in newborn much faster
than in adult
➢ Rate of metabolism in newborn twice as great
related to body weight
➢ Acid forms quickly, leading to rapid
development of acidosis
➢ Immature kidney cannot concentrate urine to
conserve body fluid
Newborn Resultant Problems
➢ Prone to dehydration
➢ Prone to acidosis
➢ Prone to overhydration/fluid overload

Newborn Skin
➢ Immature integumentary function in newborn
➢ Active sebaceous glands
➢ Eccrine (sweat) glands
➢ Apocrine glands small and nonfunctional
➢ Hair follicles
➢ Amount of melanin low at birth—lighter skin
➢ than in later life; UV susceptibility

Phototherapy Skin
➢ The more mature the NB, the more mature
➢ the skin and more likely will be protected from
➢ heat loss and infection.
➢ Skin color depends on activity level,
➢ temperature, hematocrit levels and race.

Renal System
➢ Functional deficiency in kidney’s ability to
concentrate urine
➢ Total volume of UO per 24 hours is 200-300 ml
by the end of first week
➢ Normal newborn urine production 1-2 mL/kg/hr
➢ Bladder capacity approximately 15-30 mL
Musculoskeletal System
➢ Skeletal system contains more cartilage than
➢ ossified bone
➢ Rapid ossification in first year of life
➢ Muscular system almost completely formed at
➢ birth
➢ Muscle growth by hypertrophy rather than
➢ Hyperplasia
Immune System
➢ Skin and mucous membranes are first line of
defense from invading organisms

15
 ➢ Second line of defense: cellular elements of ○ last 2-4 hours
the immunologic system: neutrophils, ○ HR,RR decrease temperature
eosinophils, lymphocytes continue to fall
➢ Third line of defense: formation of antibodies ○ in a state of sleep and relatively calm
○ Breastmilk provides passive immunity ○ any attempt to stimulate elicits
(IgG) minimal response
➢ Passive immunity via placenta (IgG) 3. Second Period of Reactivity
➢ Passive immunity via colostrum (IgA) ○ awakes from deep sleep, last about
➢ Increased IgM indicates infection in utero 2-5 hours
➢ Observe aseptic technique when caring for ○ provides for NB and parents to
the NB interact
➢ Observe universal precautions when ○ NB alert and responsive
handling the NB ○ HR, RR increase
○ Gag reflex active
Endocrine System ○ Close observation required for
➢ Endocrine system well developed in newborns changes in VS and color.
➢ but function is immature
➢ ADH (vasopressin) production is limited, Behavioral Assessment
inhibits diuresis ➢ Brazelton Neonatal Behavioral Assessment
○ Risk of dehydration Scale (BNBAS)
➢ Effects of maternal sex hormones in newborns ➢ Interactive examination that assess infant’s
response
Neurologic System ➢ Areas of behavior:sleep,wakefulness,activity
➢ Reflexes ➢ Patterns of sleep and activity
➢ Posture, tone, head control, body movement ○ State modulation
➢ Behavioral response to care ➢ Cry
○ Consolability ○ Communication of the newborn
○ Cry: frequency and pitch ○ Variations and meanings
➢ At birth the nervous system is incompletely
integrated Assessment of Attachment Behaviors
➢ Primitive reflexes ➢ Emotional bonding between parents and
➢ Autonomic nervous system crucial during newborn
transition because it stimulates initial ➢ En face position
respiration. ➢ “Falling in love” with the newborn
➢ Myelination of nerves follows cephalocaudal ➢ Absence of attachment behaviors
and proximodistal progression ○ Effect on newborn
○ Effect on relationship with parents
Sensory Functions
➢ Vision Family Involvement
○ Pupils react to light ➢ Family-centered maternity care
○ Blink reflex responsive to minimum ➢ Fathers
stimulus ○ Cultural influences on fathering
○ Corneal reflex activated by light touch behaviors
○ Tear glands minimal function until 2-4 ○ “Paternal engrossment” concept
wks age ➢ Siblings
➢ Hearing ➢ Grandparents/extended family
➢ Smell ➢ Community
➢ Taste
➢ Touch Preparation for Discharge and Newborn Care at Home
➢ Mom/infant “dyad” concept
Transitional Assessment: Periods of Reactivity ➢ “Couplet care”
➢ 6-8 hours after birth ➢ Discharge teaching
➢ Period of Reactivity: ➢ Teachable moments
1. First Period of Reactivity ➢ Follow-up care
○ During the first 30 mins after birth ➢ Car seat safety
○ awake, alert and cries vigorously
○ sucks his fingers or fist and appears Stool Patterns in Newborns
interested in the environment ➢ Meconium
○ Eyes are usually open (excellent ○ First stool;should occur within 24-48
opportunity to hrs after birth
○ see one another) ○ Description: green, black, sticky
2. First Reactive period odorless, passed 4x/day

16
➢ Transitional stools
○ Usually appear by 3rd day of life after
the initiation of feeding
○ Transition from meconium to milk
○ Description: yellowish-green, slimy 6x
or more
➢ Milk stools (regular stool)
○ Usually appear by 4th DOL
○ Differ in breasted and formula fed
baby
Breast Fed Baby Stool
➢ Characteristic:
○ Golden yellow (mustard)
○ Mushy and soft
○ Sweet odor – due to lactic acid ,high
(sour milk)
○ Passed every after breastfeeding (3-4
x a day)
Bottle Fed Baby Stool
➢ Characteristic:
○ Pale yellow
○ Formed
○ Offensive (foul odor)
○ Passed once/day (depends)
Reflexes
Blinking Reflex (Corneal Reflex)
➢ Infants blinks at sudden appearance of bright
light or at approach of object toward cornea.
➢ Persist throughout life
Babinski Reflex
➢ Stroking outer sole of foot upward from heel
and upward and across the ball of foot causes
toes to hyperextend and hallux to dorsiflex
➢ Disappear at 1 year of age.
Galant Reflex (Trunk Incurvation)
➢ Stroking infant’s back alongside spine causes
hips to move toward stimulated side
➢ Disappear by age 4 weeks
Grasp Reflex
➢ Touching palms or soles near base of digits
causes flexion of hands or toes
➢ Palmar grasp lessens at 3 months to be
replaced by voluntary movement plantar grasp
lessens by 8 months of age
Sucking Reflex
➢ Infant begins strong sucking in response to
stimulation, persist throughout infancy
Rooting Reflex
➢ Touching or stroking the cheeks alongside of
mouth causes the infant to turn head toward
that side, and begin to suck
➢ Should disappear at 3-4 months but may
persist up to 12 months
Extrusion Reflex
➢ When tongue infant responds by forcing it
outward
➢ Disappear at 4 months
Gag Reflex
➢ Stimulation of posterior pharynx by food,
suction or passage of tube causes infant to
gag
➢ Persist throughout life
Moro Reflex
➢ Sudden jarring or change in equilibrium
causes sudden extension and abduction of
extremities and fanning of fingers, with index
finger and thumb forming C shape followed by
adduction of extremities
➢ Disappear at 3-4 months
Startle Reflex
➢ Sudden loud noise causes abduction of arms
with flexion of elbows, hands remain clenched
➢ Disappear at 4 months
Newborn Screening
➢ A screening/test for genetic/congenital
disorder
➢ Mandated by law R.A. 9288 (NBS Law)
➢ Simple procedure to find out if baby has a rare
metabolic disorder
➢ Baby may look healthy at birth
➢ If left untreated, may lead to MR
➢ Done on 3rd DOL
➢ Test for:
○ Congenital Hypothyroidism
○ CAH
○ Galactosemia
○ PKU
○ G6PD
○ Maple Urine Syrup Disorder
Breastfeeding
➢ Advantage/disadvantages
➢ Cultural perspectives on infant feeding
➢ Need for support, encouragement, and
assistance
➢ Human milk in the preferred form of nutrition
for newborn
➢ WHO promotion of breastfeeding worldwide
➢ Baby Friendly Hospital Initiative (BFHI)
➢ Economical
➢ Always available
➢ Breast cancer incidence significantly lower in
women who have breastfed
➢ May also offer protection to child from obesity,
allergy, diabetes, atherosclerosis
Purposes
1. Promotes bonding
2. Facilitates release of colostrum and breast
milk
17
3. Stimulates production od prolactin and
oxytocin
4. Prevent jaundice
Physiologic Benefits of Human Milk
➢ Species-specific food for newborn humans
➢ Digestibility
➢ Immunologic properties cannot be duplicated
in commercial formulas
➢ Availability/Infection control
Promotion of Successful Breastfeeding
➢ Frequent and early breastfeeding (within first
hour of life is important)
➢ Promotion of skin-to-skin contact
➢ Feeding on demand schedule
➢ Careful control of drugs (maternal and
newborn)
➢ Significance of nurses in breastfeeding
success
Keys to Breastfeeding Success
➢ Correct sucking technique
➢ Correct positioning of infant at breast
➢ Absence of a rigid feeding schedule
Commercial Formulas
➢ Lactose based
➢ Lactose-free
➢ Soy based
➢ Other specialty formulas
➢ Calorie content of formula
➢ Preparation of formula
Bottle Feeding
➢ Techniques
➢ Equipment
➢ Positions
➢ Preparation of formula
➢ Feeding schedules
➢ Behaviors during feeding
Infant Stimulation
➢ Newborn prefers human face for stimulation
➢ Visual benefit of black and white objects for
newborn stimulation
➢ Stimulation of human voice
➢ Importance of tactile stimulation
Common Problems
➢ Regurgitation
➢ Common in newborn due to multiple factors
○ Intestine longer in relation to body
size than adult
○ Rapid peristaltic waves and
simultaneous nonperistaltic waves
along esophagus
○ Decreased sphincter tone in lower
esophagus
GI Problems
➢ Constipation
○ More common among bottle fed
infants
○ Mngt: Offer fluids in between
feedings
➢ Loose Stools
○ Careful Hx taking
○ Management depends on the cause
➢ Colic
○ paroxysmal abdominal pain common
in infants below 3 months of age.
○ Causes: overfeeding, gas distention,
too much CHO in MF, tense and
unsure mother
Mngt:
1. Give feeding per demand.
2. Tell mother to burp the baby at least
2x during feeding.
3. Feed baby upright position. Burp.
Place on right side-lying position.
4. Change MF per doctor’s order
5. Reduce sugar content of formula.
➢ Spitting Up
○ due to poorly developed cardiac
sphincter .
○ common among bottle fed.
Mngt:
1. Feed the baby upright. Burp
2. Position in right side lying.
➢ Skin Irritation
○ May be due to either poor hygiene or
irritation from urine, feces, and some
laundry products.
Mngt:
1. Expose to air – most important
2. Careful hand washing and rinsing
away of irritating soap from skin
3. Starch bath if it is due to
miliaria(prickly heat)
➢ Seborrheic dermatitis / cradle cap
○ involves the sebaceous glands due to
poor hygiene.
➢ Clothing
○ Rule of thumb. If mother feels warm
keep baby cool; if the mother feels
cold keep the baby warm.
➢ Sleeping pattern
○ Sleep varies it grows. Babies 16-20
hours day.
18
 Newborn Care and Hygiene
➢ Bathing
○ can be done any time of the day that
is convenient for the mother. Bathe
the baby in a warm room, do it before
feeding.
○ All equipment needed should be
prepared prior to activity.
○ Make bathing enjoyable for both the
infant and mother.
➢ Umbilical cord care (Routine)
➢ Initial Cord Care
➢ Routine Cord Care:
1. Teach mother how to perform cord
care
2. Keep cord care clean and dry after
each
3. diaper change. Use water only.
Expose to air
4. Assess the cord for odor, swelling or
discharge.
5. Sponge bath the NB until cord falls
off.
➢ Circumcision (optional)
➢ Not routinely done. Done per request of the
parents
➢ Procedure:
○ Infant is restrained. Penis is cleansed
with soap and water. Betadine
applied. Yellen clamp or Gomco
clamp is used. A petrolatum gauze
dressing is applied to prevent
adherence of the circumcised site to
the diaper while applying pressure to
prevent bleeding
➢ Nursing Care:
a. Check hourly for bleeding (common
complication during the 1st day).
b. If a small amount of bright red is
present apply gentle pressure to the
area w/ a sterile gauze.
c. Do not attempt to remove exudates
which persist for 2-3 days. Just wash
with warm water.
d. Diapers must be pinned loosely
during the 1st 2-3 days when the
base of the penis is tender.
➢ Skin care and skin concerns

19