Chapter-18 - maternal and child chapter 18
CHAPTER 18: NURSING CARE OF A FAMILY WITH NEWBORN
NEWBORN – undergo physiologic changes at the moment of
birth (and, probably psychological changes as well) as they are
released from a warm, snug, dark, liquid-filled environment that
has met all of their basic needs into a chilly,
unbounded, brightly lit, gravity-based, outside world.
How well a newborn makes these major adjustments depends on
their:
 Genetic composition
 Competency of the recent intrauterine environment
 Gestational duration
 Presence/absence of fetal anomalies
 The care received during labor and birth
 The care received during the newborn or neonatal period
(neonatal period: time from birth through the first 28
days of life)
The assessment of a newborn includes:
 Review of the birthing parent’s pregnancy history
 A physical examination of the infant
 An analysis of laboratory reports such as hematocrit,
bilirubin, blood type
 Assessment of parent-child interactions to be certain
bonding is beginning
This assessment begins immediately after birth and is continued
at every contact during a newborn’s birthing center stay, at early
home visits, and at well-baby and sick baby visits.
THE PROFILE OF A NEWBORN
A. Vital statistics
B. Vital signs
C. Physiologic functions
A. VITAL STATISTICS
Vital statistics measured for a newborn is consist of:
 Weight
 Length
 Head circumference
 Chest circumference
 Abdominal circumference
 Mid-upper arm circumference
WEIGHT: 2.5-3.4 KG
 As long as newborns are breathing well, they are
weighed nude and without a blanket soon after birth in
the birthing room
 A newborn’s weight is important because it helps to
determine maturity as well as establish a baseline
against which all other weights can be compared.
 Weight below 2.5kg is considered as low birth weight. If
a term newborn weighs more than 4.5kg (4.7kg), the
baby is said to be MACROSOMIC—a condition that
usually occurs in conjunction with a maternal illness
such as gestational diabetes. The baby is delivered in a
cesarean section.
 Large for Gestational Age (LGA) - a term used to
describe babies who are born weighing more than the
usual amount for the number of weeks of pregnancy.
 SECOND-BORN CHILDREN usually weigh more than
first-born ones. Birth weight tends to increase with each
succeeding child in a family.
 During the first few days after birth, a newborn loses 5%-
10% of their birth weight. This weight loss occurs
because a newborn is no longer under the influence of
hormones that can cause salt and fluid retention.
 BREASTFED NEWBORN usually recaptures birth
weight within 10 days; a FORMULA-FED INFANT may
accomplish this gain within 7 days. After this, all infants
begin to gain about 2lb per month (5 to 8 oz per week)
for the first 6 months of life.
 Abnormal loss of weight may be the first indication that
a newborn has an inborn error of metabolism, such as
adrenocortical insufficiency (salt-dumping type) or is
becoming dehydrated.
LENGTH: 46-54 CM
 Filipino babies are usually within 50-52cm.
 A newborn’s length at birth in relation to weight is a -
second important determinant used to confirm that a
newborn is healthy.
 A baby’s length from the top of the head, to the bottom
of one of their heels. It is the same as their height.
HEAD CIRCUMFERENCE: 34-35 CM
 Is measured with a tape measure drawn across the
center of the forehead and then around the most
prominent portion of the posterior head (occiput).
CHEST CIRCUMFERENCE: 32-33 CM
 Is measured at the level of the nipples.
 Chest circumference is lower than head circumference
because of the cephalocaudal development.
Sometimes, there are babies that have equal HC and
CC measurements.
 If a large amount of breast tissue/edema of the breasts
is present, this measurement will not be accurate until
the edema has subsided.
ABDOMINAL CIRCUMFERENCE:
 Is measured at the level of the umbilicus.
 Usually lower of less 1-2 cm compared to chest
circumference.
B. VITAL SIGNS
TEMPERATURE: 97.6°F-98.6°F axillary
 Watch out for heat loss. Immediate and thorough
drying (for 30 seconds) is important to prevent heat
loss. The priority is drying the baby not suction.
 If the baby came out weak (lupaypay), the first thing
(first nursing intervention) to do is drying less than 30
seconds or 10 seconds, but the best nursing
intervention is to suction and resuscitate the baby.
 Skin-to-skin contact for 60-90 minutes is essential.
Covering the hair with a cap after drying further reduces
the possibility of evaporation cooling. Careful when
weighing the newborn, especially the weighing scale is
metal and cold, do not put the baby immediately (direct
contact) to the metal weighing scale because the baby
will lose its heat, resulting to hypothermia.
 BROWN FAT is a special tissue found in mature
newborns, apparently helps to conserve or produce
body heat by increasing metabolism as well as
regulating body temperature similar to that of a
hibernating animal. KICKING & CRYING are also ways
to increase the newborn’s metabolic rate and can
produce more heat.
Heat Loss in the Newborn: 4 Mechanisms
1. Convection – is the flow of
heat from the newborn’s body
surface to cooler surrounding air.
Eliminating drafts, such as from air
MJ - CH. 18
conditioners, is an important way to reduce convection
heat loss.
2. Radiation – is the transfer of body heat
to a cooler solid object not in contact with
the baby, such as a cold window or air
conditioner. Moving an infant as far from
the cold surface as possible helps reduce
this type of heat loss.
3. Conduction – is the
transfer of body heat to
a cooler solid object in
contact with the baby.
For example, a baby
placed on the cold base
of a warming unit quickly loses heat to the colder metal
surface. Covering surfaces with a warmed blanket or
towel is necessary to help minimize conduction in heat
loss.
4. Evaporation – is loss of heat through
conversion of a liquid to a vapor.
Newborns are wet when born, so they
can lose a great deal of heat as the
amniotic fluid on their skin evaporates.
Top prevent this type of heat loss, lay a newborn on the
parent’s abdomen immediately after birth and cover with
a warm blanket for skin-to-skin contact.
PULSE RATE: 120-140 BEATS/MIN
 The heart rate of a fetus in utero averages 110-160 bpm.
The heart rate of a newborn often remains slightly
irregular because of immaturity of the cardiac regulatory
center in the medulla.
 FEMORAL PULSES in a newborn are best palpated
when the infant is quiet. Radial and temporal pulses are
more difficult to palpate accurately. A newborn’s HR is
best determined by listening for an APICAL
HEARTBEAT for a full minute rather than assessing a
pulse in an extremity or over the carotid artery.
 Always palpate for femoral pulses and document that
these are present because absence suggests possible
coarctation (narrowing) of the aorta, which is a
cardiovascular abnormality.
RESPIRATORY RATE: 30-60 BREATHS or CYCLES /MIN
 Respiratory depths, rate, and rhythm are likely to be
irregular; and short periods of apnea (up to 10 seconds
and without cyanosis), sometimes called PERIODIC
RESPIRATIONS, are also common and normal during
this time.
 Respiratory rate can be observed most easily by
watching the movement of a newborn’s abdomen
(babies are abdominal breathers) because breathing
primarily involves the use of the diaphragm and
abdominal muscles.
BLOOD PRESSURE: 80/46 mmHg
 By the 10th day, it rises to about 100/50 mmHg and
remains at that level for the infant year.
 For an accurate reading, the cuff width, used must be no
more than two-thirds the length of the upper arm or thigh
C. PHYSIOLOGIC FUNCTIONS
I. CARDIOVASCULAR SYSTEM
 After birth, the lungs are responsible for oxygenating
blood that was formerly oxygenated by the placenta. As
soon as the umbilical cord is clamped, which stimulates
a neonate to take in oxygen through the lungs, fetal
cardiovascular shunts (foramen ovale, ductus
arteriosus, ductus venosus) begin to close.
 The peripheral circulation of a newborn remains sluggish
for at least the first 24 hours, which can cause cyanosis
in the infant’s feet and hands (peripheral acrocyanosis)
and for a newborn’s feet to feel cold to the touch. The
easiest way to asses central acrocyanosis is to check
the tongue or mouth or lips.
BLOOD VALUES
 The newborn has more RBCs than the average adult.
Capillary heel sticks may reveal a falsely high
hematocrit or hemoglobin value because of sluggish
peripheral circulation.
 CAPILLARY HEEL STICK is a procedure in which a
baby's heel is pricked with a lancet and then a small
amount of the blood is collected in a narrow-gauge
capillary glass tube or on a filter paper. This is also used
for newborn screening to check if there are congenital
metabolic problems. Before obtaining a blood specimen
from the heel, warm the foot by wrapping it in a warm
cloth to increase circulation and improve the accuracy of
this value.
 At birth, the indirect bilirubin level is between 1 and 4 mg
per dL (1 and 3 mg/dL sa book). Also, a newborn has a
corresponding high WBC count, this is not evidence of
infection but reflects how stressful an event birth is for
fetus.
BLOOD COAGULATION
 Vitamin K is synthesized thru the action of intestinal
flora, is responsible for the formation of factor II
(prothrombin), factor VII (proconvertin), factor IX
(plasma thromboplastin component), and factor X
(Stuart-Prower factor) in the clotting sequence.
 Because a newborn’s intestine is sterile at birth, it will
take about 24 hours for flora to accumulate and for
ongoing Vitamin K to be synthesized. Vitamin K 0.1 mL
(phytonadione, AquaMEPHYTON) is usually
administered intramuscularly into the LATERAL
ANTERIOR THIGH (VASTUS LATERALIS), the
preferred site for all injections in newborns, immediately
after birth.
II. RESPIRATORY SYSTEM
 A first breath is a major undertaking because it requires
a tremendous amount of pressure (about 40-70 cm H2O)
for a newborn to be able to inflate alveoli for the first time.
 Some fluid present in the lungs from te intrauterine life
makes a newborn’s first breath possible because of the
fluid eases surface tension on alveolar walls and allows
alveoli to inflate more easily than if the lungs were dry.
About one-third of this fluid is forced out of the lungs by
the pressure of vaginal birth. In CS, intervention done is
by suctioning to remove excess fluid in the lungs.
III. GASTROINTESTINAL SYSTEM
 At birth, GI tract is sterile. Bacteria may be cultured from
the tract in most babies within 5 hours of birth and from
all babies at 24 hours of life. The accumulation of
bacteria is helpful because bacteria in the GI tract are
necessary for digestion through probiotics and for the
synthesis of Vitamin K.
STOOLS
 The first stool of a newborn is usually passed within 24
hours of birth. It consists of MECONIUM—a sticky,
tarlike, blackish-green, odorless material formed from
MJ - CH. 18
the mucus, vernix, lanugo, hormones, and
carbohydrates that accumulated in the bowel during
intrauterine life.
 If a newborn does not pass a meconium stool by 24 to 8
hours after birth, the possibility of some problem such as
meconium ileus, imperforate anus, or volvulus
should be suspected.
 TRANSITIONAL STOOL – is a newborn stool usually in
the second or third day, bowel contents appear both
loose and green; bowel movements may resemble
diarrhea.
 Fourth day of life, BREASTFED babies pass three or
four LIGHT YELLOW stools per day that have soft
consistency. These stools are not foul smelling because
breast milk is high in lactic acid, w/c reduces the amount
of putrefactive organisms in the stool. FORMULA-FED
babies pass two or three BRIGHT YELLOW stools a
day of soft consistency. These have a more noticeable
odor.
 A newborn placed under phototherapy lights as
therapy for jaundice will have bright green stools
because of increased bilirubin excretion.
 Newborns with bile duct obstruction have clay-
colored (gray) stools because bile pigments cannot
enter the intestinal tract.
 Blood-flecked stools usually indicate an anal fissure
 Occasionally, a newborn has swallowed some
maternal blood during birth and either vomits fresh
blood immediately after birth or passes a black tarry
stool after two or more days. Whether bleeding is caused
by ingestion of maternal blood at birth or newborn
bleeding may be differentiated by a DIPSTICK APT-
DOWNEY TEST. If stools remain black or tarry, this
suggests newborn intestinal bleeding rather than
swallowed blood.
 If mucus is mixed with stool or the stool is watery and
loose, a milk allergy—LACTOSE INTOLERANCE, or
other condition interfering w/ digestion is suspected.
IV. URINARY SYSTEM
 The average newborn voids within 24 hours of birth. A
newborn who does not take in much fluid for the first 24
hours may void later than this, but the 24-hour point is a
general rule. Newborns who do not void within this time
need to be assessed for the possibility of urethral
stenosis or absent kidneys or ureters.
 The kidneys of newborns do not concentrate urine well,
making newborn urine usually light colored and
odorless.
 A single voiding in a newborn is only about 15 mL and
may be easily missed in an absorbent diaper. Specific
gravity ranges from 1.008 to 1.010. The 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. The
first voiding may be pink or dusky because of uric acid
crystals that were formed in the bladder in utero.
Diapers can be weighed to determine the amount and
timing of voiding, which is done when there is a concern.
V. IMMUNE SYSTEM
 Newborns have limited immunologic protection at birth
because they are not able to produce antibodies until
about 2 months (the reason most immunizations are not
administered until 2 months of age).
 Newborns are born with passive antibodies
(immunoglobulin G) passed to them from their birthing
parent that crossed the placenta. These include
antibodies against poliomyelitis, measles, diphtheria,
pertussis, chickenpox, rubella, and tetanus.
 Because the newborn has little natural immunity against
herpes simplex, healthcare personnel with herpes
simplex eruptions (cold sores) should not care for
newborns until the lesions have crusted
VI. NEUROMUSCULAR REFLEX
1. BLINK reflex
A blink reflex in a newborn serves the same purpose as
it does in an adult—to protect the eye from any object coming
near it by rapid eyelid closure. It may be elicited by shining a
strong light such as a flashlight into an eye. A sudden
movement toward the eye sometimes can elicit the blink
reflex, but this is not as reliable
2. ROOTING reflex
Newborn's cheek is brushed or stroked near the corner
of the mouth; the infant will turn the head in that direction.
This reflex serves to help a newborn find food; when a breast
brushes the newborn's cheek, the reflex causes the baby to
turn toward the breast.
Disappears: about 6th week of life
3. SUCKING reflex
When a newborn's lips are touched, the baby makes a
sucking motion. Like the rooting reflex, this reflex also helps
a newborn find food. Disappears: 6 months
4. SWALLOWING reflex
The swallowing reflex in a newborn is the same as in the
adult. Food that reaches the posterior portion of the tongue
is automatically swallowed. Gag, cough, and sneeze reflexes
also are present in newborns to maintain a clear airway.
5. EXTRUSION reflex
In order to prevent the swallowing of inedible
substances, a newborn extrudes any substance that is
placed on the anterior portion of the tongue.
Disappears: at 4 months, it will look as if they are rejecting
the food.
6. PALMAR GRASP reflex
Newborns grasp an object placed in their palm by quickly
closing their fingers on it. Mature newborns grasp so strongly
that they can be raised from a supine position and
suspended momentarily from an examiner's fingers.
Disappears: at 6 weeks to 3 months of age.
7. 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: 3 months of age.
8. PLACING reflex
The placing reflex is elicited by touching the anterior
lower leg against a surface such as the edge of a table. The
newborn makes a few quick lifting leg motions, as if to step
onto the table.
9. PLANTAR GRASP reflex
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.
This reflex disappears at about 8 to 9 months of age in
preparation for walking.
10. TONIC NECK reflex
Arm and leg extend on the side toward which the head
is turned, and the opposite arm and leg contract. This
posture is most evident in the arms but should not be totally
absent in the legs. It is also called a "boxer" or "fencing
reflex." The reflex typically disappears between the 2nd & 3rd
months of life.
11. MORO reflex
A Moro (startle) can be elicited with a loud noise or by
jarring the bassinet. The most accurate method of eliciting
the reflex is to hold a newborn in a supine position and then
allow the head to drop backward about 1 in. In response to
this sudden backward head movement, the newborn first
extends arms and legs, then swings the arms into an
embrace position, and pulls up the legs against the abdomen
(Schor, 2020). The reflex simulates the action of someone
trying to ward off an attacker and then covering up to protect
the body. It is strong for the first 8 weeks of life and
Disappears: 4th or 5th month.
MJ - CH. 18
12. BABINSKI reflex  Increase the percentage of healthy full-term infants who
When the sole of a newborn's foot is stroked in an are put to sleep on their backs from a baseline of 69%-
inverted "J" curve from the heel upward, a newborn fan the 75.9%.
toes (positive Babinski sign). The reflex remains positive o Sudden Infant Death Syndrome (SIDS)
(toes fan) until at least 3 months of age, when it is  Reduce the proportion of young children aged 3-5 years
supplanted by the downturning response. with dental caries in their primary teeth (which could
13. MAGNET reflex originate from nighttime bottle feeding) from a baseline
If pressure is applied to the soles of the feet of a newborn of 33.3%-30%
lying in a supine position, they push back against the  Reduce the perinatal mortality rate to no more than 5.9
pressure. This and the two following reflexes are tests of per 1000 live births from a baseline of 6.6 per 1000 live
spinal cord integrity. births.
14. CROSSED EXTENSION reflex
When a newborn is lying supine, if one leg is extended ASSESSING A NEWBORN
and the sole of that foot is irritated by being rubbed with a
sharp object, such as a thumbnail, the infant raises the other
leg and extends it as if trying to push away the hand irritating APGAR SCORING
the first leg. Apgar scoring is done at 1 and 5 minutes after birth. The newborn
15. TRUNK INCURVATION reflex is considered to be "VIGOROUS" if the initial scores are 7 and
When a newborn lies in a prone position and is touched above. If the 5-minute score is less than 7, scoring is done every
along the paravertebral area on the back by a probing finger,
5 minutes thereafter until the score reaches 7. The numbers in
the newborn flexes the trunk and swings the pelvis toward
the touch the left-hand column represent the number of points that are
16. LANDAU reflex signed to each parameter when the criteria in the corresponding
When a newborn is supported in a prone position by a column are met.
hand, the newborn should demonstrate some muscle tone.
A newborn may not be able to lift the head or arch the back
in this position but neither should the infant sag into an
inverted "U" position. The latter response indicates extremely
poor tone, which needs to be investigated.
17. DEEP TENDON reflex
Both a patellar and a biceps reflex are intact in a
newborn

VII. THE SENSES

1. HEARING
By 25 to 27 weeks gestation, hearing is functional and
the fetus can hear the birthing parent's heartbeat and voice.
As soon as amniotic fluid drains or is absorbed from the
middle ear by way of the Eustachian tube within hours of
birth, hearing becomes acute. Newborns respond with
generalized activity to a sound such as a bell. They appear
to have difficulty locating where a sound is coming from. ASSESSMENT OF GESTATIONAL AGE
2. VISION
A pupillary reflex or ability to contract the pupil is present
from birth. The fetus has a blink or squint reflex in response
to a bright light in utero by 26 weeks gestation; newborns
demonstrate they can see by blinking at a strong light (blink
reflex) or by following a bright light or toy a short distance
with their eyes. Newborns have the ability to fixate on close
objects that are about 8 to 10 in. away (9-12 in). Newborns
are also only able to detect light and dark (black and white
objects).
3. TOUCH
The sense of touch is also well developed at birth.
Newborns quiet down at a soothing touch, cry at painful
stimuli, and show sucking and rooting reflexes that are
elicited by touch. Newborns also feel secure when they are
swaddled.
4. TASTE
A newborn has the ability to discriminate taste, because
MATURITY RATING: BALLARD OR DUBOWITZ TEST
taste buds are developed and functioning even before birth.
Swallowing decreases if a bitter flavor is added. After birth, a
baby continues to show a preference for sweet over bitter
tastes.
5. SMELL
The sense of smell is present in newborns as soon as
the nose is clear of lung and amniotic fluid. Newborns
probably turn toward their parents' breasts partly out of
recognition of the smell of breast milk and partly as a
manifestation of the rooting reflex.

2020 National Health Goals Related to the Newborn Period

 Increase the proportion of mothers who breastfeed their
babies in the early postpartal period from a baseline of
74%-81.9%.
 Increase the proportion of mother who continue
exclusive breastfeeding until their babies are 3 months
old from a baseline of 33.6%-46.2%
MJ - CH. 18
1. Any complications of pregnancy such as gestational
diabetes, hypertension, premature rupture of
membranes, serious falls, or other injuries
2. Length of pregnancy and length of labor
3. Type of birth (vaginal or cesarean) and whether the
infant breathed spontaneously or needed assistance at
birth

THE PHYSICAL EXAMINATION

The Ballard or Dubowitz test may be performed if the mother did

not have prenatal care or if there is another question regarding
maturity of the newborn. Using this standard method to rate
maturity helps detect infants who were thought to be term but
instead are actually preterm because of a miscalculated due date
and who need additional observation and perhaps high-risk care.

THE BRAZELTON NEONATAL BEHAVIORAL ASSESSMENT

SCALE
The Brazelton Neonatal Behavioral Assessment Scale is a
rating scale of six different categories of behavior:
1. Habituation
2. Orientation
THE APPEARANCE OF A NEWBORN
3. Motor maturity
4. Variation This includes the general inspection of the newborn’s (1) skin, (2)
5. Self-quieting ability, and birthmarks, (3) head, (4) eyes, (5) ears, (6) nose, (7) mouth, (8)
6. Social behavior neck, (9) chest, (10) abdomen, (11) anogenital area, (12) back,
A total evaluation takes 20 to 30 minutes to complete. Unlike (13) extremities.
many assessment scales, the infant is scored on best
performance rather than on average performance. A. THE SKIN
General inspection of a newborn’s skin includes color, any
GRADING OF NEONATAL RESPIRATORY DISTRESS birthmarks, and general appearance.

COLOR
 Most term newborns have a RUDDIER COMPLEXION
for their first month because of the increased
concentration of red blood cells in their blood vessels
and a decrease in the amount of subcutaneous fat,
which makes blood vessels more visible.
 Infants with poor central nervous system control or
respiratory difficulty may appear PALE AND
CYANOTIC.
 In darker skinned newborns, cyanosis may appear as
DUSKY GREY or WHITISH around the child’s mouth
CYANOSIS
 Generalized mottling of the skin is a common finding in
newborns. The lips, hands, and feet are likely to appear
blue from immature peripheral circulation (termed
ACROCYANOSIS). Acrocyanosis is a normal finding at
birth through the first 24 to 48 hours after birth.
 CENTRAL CYANOSIS or cyanosis of the trunk, is
always a cause for concern. It indicates decreased
oxygenation that could be occurring as the result of a
temporary respiratory obstruction and also could reflect
a serious underlying respiratory or cardiac disease.
 Mucus obstructing a newborn’s respiratory tract causes
THE HEALTH HISTORY sudden cyanosis and apnea, but this can be relieved by
The history of a newborn is obtained from examination of the suctioning the mucus from the mouth and nose. In
mother’s pregnancy record if this is available, her labor and birth newborns, always suction the mouth before the nose
record, and an interview with the mother. Important information because suctioning the nose first may trigger GASP
to gather includes:
MJ - CH. 18
REFLEX, possibly leading to aspiration if there is mucus  Internal bleeding. To detect this, a baby who appears
in the posterior throat. pale should be watched closely for signs of blood in the
HYPERBILIRUBINEMIA stool or vomitus.
 Hyperbilirubinemia is caused by the accumulation of HARLEQUIN SIGN
excess bilirubin in blood serum. The skin and sclera of  Because of immature blood circulation, a newborn who
the eyes begin to appear noticeably yellow on the 2nd or has been lying on his or her side appears red on the
3rd day of life as a result of a breakdown of fetal red dependent side of the body and pale on the upper side,
blood cells (called PHYSIOLOGIC JAUNDICE). as if a line had been drawn down the center of the body
 This occurs because, as the high red blood cell count  Odd coloring fades immediately if the infant’s position is
built up in utero is being reduced, HEME and GLOBIN changed or kicks or cries.
are released.
• HEME is further broken down into iron (which is reused B. BIRTHMARKS
and not involved in the jaundice) and protoporphyrin.
• PROTOPORPHYRIN is then broken down into indirect HEMANGIOMAS
bilirubin, a compound which is fat-soluble and therefore  are vascular tumors of the skin and occur in three distinct
cannot be excreted by the kidneys. In order to be types.
removed from the body, it must be converted by the
LIVER enzyme glucuronyl transferase into direct
bilirubin, which is water-soluble, and is then incorporated
into the stool and excreted as FECES.
 Carefully observe infants who are prone to extensive
bruising (large, breech, or preterm babies) for jaundice
because bruising leads to hemorrhage of blood into the
subcutaneous tissue or skin; this blood then has to be
broken down so can add to the amount of indirect
bilirubin accumulating. A CEPHALOHEMATOMA is a
collection of blood under the periosteum of the skull
bone caused by pressure at birth. As the red blood cells
in this type of lesion are hemolyzed, additional indirect
bilirubin is also released and so can be yet another
cause of jaundice.
 Another reason indirect bilirubin levels can increase is if
a newborn has an intestinal obstruction because stool
cannot be evacuated. Intestinal flora in the bowel then
breaks down bile into its basic components, one of which
is indirect bilirubin. Early feeding of newborns promotes
intestinal movement, excretion of meconium and helps
prevent indirect bilirubin buildup from this source.
 Acute Bilirubin Encephalopathy or KERNICTERUS
results to permanent neurologic damage, including
cognitive, vision, and hearing problems. This occurs
when there’s an above normal indirect bilirubin levels
(about 20 mg/100 ml) leaves the bloodstream interferes
with the chemical synthesis of brain cells, resulting in
permanent cell damage.
 Intervention: promote early breastfeeding and
phototherapy (exposure of the infant to light to initiate
maturation of liver enzymes) to speed the passage of
meconium.
 Formula-fed babies, a small proportion of breastfed
babies may have more difficulty converting indirect
bilirubin to direct bilirubin because breast milk contains
PREGNANEDIOL (a metabolite of progesterone), which VERNIX CASEOSA
depresses the action of glucuronyl transferase.
 is the white, cream cheese–like substance that serves
 Breastfeeding alone rarely causes enough jaundice to as a skin lubricant in utero. It is typically noticeable on a
warrant therapy and in most cases, healthcare providers term newborn’s skin, at least in the skin folds, at birth.
should promote breastfeeding in infants with jaundice Document the color of any vernix present because it
PALLOR takes on the color of the amniotic fluid
 Usually occurs as the result of anemia, which may be o YELLOW vernix implies the amniotic fluid was
caused by a number of circumstances such as: stained from excessive bilirubin or a blood
 Low iron stores caused by poor maternal nutrition during dyscrasia may be present;
pregnancy. o GREEN vernix suggests meconium was
 Blood incompatibility in which a large number of red present in the amniotic fluid
blood cells were hemolyzed in utero.  Handle newborns with gloves to protect yourself from
 Fetal–maternal transfusion. exposure to vernix. Remove only the vernix that is
 Inadequate flow of blood from the cord into the infant contaminated by meconium or blood.
before the cord was cut.
 Excessive blood loss when the cord was cut.
MJ - CH. 18
LANUGO
 is the fine, downy hair that covers a term newborn’s
shoulders, back, upper arms, and possibly also the
forehead and ears.
 POSTTERM INFANTS (born after more than 42 weeks
of gestation) rarely have lanugo. Babies born at 37 to 39
weeks, in contrast, have a generous supply of lanugo.
By 2 weeks of age, it has usually totally disappeared.
DESQUAMATION
 Within 24 hours after birth, the skin of most newborns
begins to dry. The dryness is particularly evident on the
PALMS of the hands and SOLES of the feet and results
in areas of peeling similar to those caused by sunburn.
This is a reaction to suddenly living in an air-filled rather
than a liquid-filled environment.
 Newborns who are POSTTERM and have suffered
INTRAUTERINE MALNUTRITION may have such
extremely dry skin that it has a leathery appearance and
there are actual cracks in the skin folds.
MILIA
 Sebaceous glands in a newborn are immature, so at
least one pinpoint white papule (a plugged or unopened
sebaceous gland) is usually found on a cheek or across
the bridge of the nose of every newborn. Disappear by 3
to 4 weeks of age as the sebaceous glands mature
 Milia are unopened sebaceous glands frequently found
on the nose, chin, or cheeks of a newborn
ERYTHEMA TOXICUM
 The rash usually appears in the 1st – 4th day of life but
may appear as late as 2 weeks of age.
 It is sometimes called a FLEA-BITE RASH because the
lesions are so minuscule. One of the chief
characteristics of the rash is its lack of pattern. It occurs
sporadically and unpredictably and may last hours or
days. It is probably caused by the newborn’s
eosinophils reacting to the rough environment of
sheets and clothing rather than a smooth liquid against
the skin.
FORCEPS MARKS
 Forceps are rarely used for birth today, but if they are
used, they may leave a circular or linear contusion
matching the rim of the forceps blade on the infant’s
cheek
 The mark disappears in 1 to 2 days.
 Closely assess the face of a newborn with a forceps
mark especially during a crying episode to be certain the
infant’s mouth is symmetrical, to detect any potential
facial nerve injury
SKIN TURGOR
 Grasp a fold of the skin between your thumb and fingers
and evaluate if it feels elastic. When released, the skin
should fall back to form a smooth surface. If severe
dehydration is present, the skin will not smooth out again
but will remain as an elevated ridge. Poor turgor is seen
in newborns who suffered malnutrition in utero, difficulty
sucking at birth, or who have certain metabolic disorders
such as adrenocortical insufficiency.
C. THE HEAD
Appears disproportionately large because it is about one fourth
of the total body length compared with an adult, whose head is
one eighth of total height. Other features include:
 The forehead appears large and prominent.
 The chin appears to be receding, and it quivers easily if
the infant is startled or cries.
 If a newborn has hair, the hair should look full bodied;
both poorly nourished and preterm infants have thin,
lifeless hair.
 If internal fetal monitoring was used during labor a
newborn may have a pinpoint ulcer at the point where
the monitor was attached.
FONTANELLES
 Are the spaces or openings where the skull bones join.
 ANTERIOR fontanelle is located at the junction of the
two parietal bones and the two fused frontal bones. It is
diamond-shaped and measures 2-3 cm (0.8 to 1.2 in.)
in width and 3-4 cm (1.2 to 1.6 in.) in length.
o The anterior fontanelle can be felt as a soft spot.
It should not appear indented (a sign of
dehydration) or bulging (a sign of increased
intracranial pressure) when the infant is held
upright. Closes at 12-18 months of age.
 POSTERIOR fontanelle is located at the junction of the
parietal bones and the occipital bone. It is triangular and
measures about 1-2 cm (0.4 to 0.7 in.) in length
o Closes by the end of the 2nd month.
SUTURES
 The separating lines of the skull, may override at birth
because of the extreme pressure exerted on the head
during passage through the birth canal. The overriding
subsides in 24 to 48 hours.
 Suture lines should never appear widely separated in
newborns. WIDE SEPARATION suggests increased
intracranial pressure because of abnormal brain
formation, abnormal accumulation of CSF in the cranium
(hydrocephalus), or an accumulation of blood from a
birth injury such as subdural hemorrhage. FUSED
SUTURE LINES also are abnormal; they require X-ray
confirmation because this will prevent the head from
expanding with brain growth.
MOLDING
 The part of the infant’s head that engaged the cervix
(usually the vertex) molds to fit the cervix contours
during labor. After birth, this area appears prominent and
asymmetric.
CAPUT SUCCEDANEUM
 Is edema of the scalp that forms on the presenting part
of the head. It occurs in
cephalic births and can
either involve wide
areas of the head or be
so confined that it’s the
size of a large egg.
CEPHALOHEMATOMA
 A collection of blood between the periosteum of a skull
bone and the bone itself, is caused by rupture of a
periosteal capillary because of the pressure of birth
CRANIOTABES
 Is a localized softening of the cranial bones probably
caused by pressure of the fetal skull against the mother’s
pelvic bone in utero. It is more common in FIRST-BORN
INFANTS because of the lower position of the fetal head
in the pelvis during the last 2 weeks of pregnancy in
primiparous women.
 The skull is so soft that the pressure of an examining
finger can indent it. The bone then returns to its normal
contour after the pressure is removed.
 Craniotabes is an example of a condition that is normal
if seen in a newborn but would be pathologic in an older
child or adult because then it probably would be the
result of faulty calcium metabolism or kidney dysfunction
D. EYES
To inspect the eyes of a newborn, lay the infant in a supine
position and lift the head. It’s rare to see tears in a newborn
not fully mature until about 3
MJ - CH. 18
months of age. Almost without exception, the irises of the eyes
look gray or blue; the surrounding sclera may appear light blue
due to its thinness. The iris will assume its permanent color
between 3 and 12 months of age. Eyes should appear clear,
without redness or purulent discharge.
 Pressure during birth sometimes ruptures a conjunctival
capillary of the eye, resulting in a small
SUBCONJUNCTIVAL HEMORRHAGE on the sclera.
This appears as a red spot on the inner aspect of the
eye, or as a red ring around the cornea. The bleeding is
slight, requires no treatment, and is completely
absorbed within 2 or 3 weeks.
 Slight edema is often present around the orbit or on the
eyelids and remains for the first 2 or 3 days until the
newborn’s kidneys are capable of evacuating fluid more
efficiently.
 CONGENITAL GLAUCOMA - Cornea that appears
larger than usual. Glaucoma’s effect is IOP (increased
ocular pressure)
 COLOBOMA - An irregularly shaped pupil or discolored
iris that may denote a congenital formation.
 A white pupil suggests the presence of a congenital
cataract, glaucoma, retinoblastoma, or other eye
disorder and should be reported
E. EARS
In a term newborn, however, the pinna should be strong enough
to recoil after bending. The level of the top part of the external ear
should be even to a line drawn from the inner canthus to the outer
canthus of the eye and back across the side of the head
 Ears that are set lower than this are found in infants with
certain chromosomal abnormalities, particularly trisomy
18 and 13
 Hearing screening is done with a reliable standardized
method such as the optoacoustic emissions test or
automated auditory brainstem response test. While
waiting for a hearing examiner, infants can be tested by
ringing a small bell held about 6 in. from each ear. A
hearing infant will blink, attend to the bell’s sound, and
possibly startle.
F. NOSE
 A newborn’s nose usually has milia and appears large
 Always test for choanal atresia (blockage at the rear of
the nose) when examining a newborn by closing the
infant’s mouth while compressing one naris at a time
with your fingers
G. MOUTH
A newborn’s mouth should open evenly when he or she cries.
 The tongue may appear short or “tongue tied” because
the frenulum membrane is attached close to the tip.
 Inspect the palate of a newborn to be certain it is intact.
Occasionally, one or two small round, glistening, well-
circumscribed cysts (Epstein pearls) can be seen on the
palate from extra calcium that was deposited in utero.
these pearl-like cysts are insignificant, require no
treatment, and will disappear spontaneously within a
week.
 ORAL THRUSH or Candida infection, which appears on
the tongue and sides of the cheeks as white or gray
patches and requires treatment with an antifungal drug
such as nystatin
 It is highly unusual for a newborn to have teeth, but
sometimes one or two (called NATAL TEETH) will have
erupted. Any teeth that are present must be evaluated
for stability. If loose, they are usually extracted to prevent
possible aspiration during feeding.
H. NECK
The neck of a newborn appears short with creased skin folds.
The head should rotate or turn freely on it.
 If the neck is rigid, congenital torticollis, caused by injury
to the sternocleidomastoid muscle during birth, might be
present
 In newborns whose membranes were ruptured more
than 24 hours before birth, nuchal rigidity may be an
early sign of meningitis
 Trachea usually appears prominent on the front of the
neck. The thymus gland appears enlarged because of
the rapid growth of glandular tissue early in life. Thymus
appears to be enlarged and bulging, it is rarely a cause
of respiratory difficulty; it plays a critical a role in
providing immunity
I. CHEST
The chest in most newborns looks small because the head is so
large in proportion to it (an important finding at birth so the largest
diameter of the baby is born first). The chest averages 2 cm (0.75
to 1 in.) smaller in circumference than the head, and symmetrical
 The clavicles should appear straight and feel smooth. A
CREPITUS (crackling) or an actual separation of one
or both clavicles suggest a fracture occurred during birth
(can happen with large infants).
 A SUPERNUMERARY NIPPLE (usually found below
and in line with the normal nipples) may be present.
 Female and male infants, the breasts may be engorged
because of the influence of maternal hormones during
pregnancy. the breasts may secrete a thin, watery fluid
popularly termed WITCH’S MILK; disappears in 1 week.
 Respirations are normally rapid (30-60 breaths/min) but
not distressed. RETRACTION (drawing in of the chest
wall with inspiration) should not be present.
 GRUNTING, suggests respiratory distress syndrome,
and a HIGH, CROWING SOUND on inspiration
suggests stridor or immature tracheal development
J. ABDOMEN
The contour of a newborn abdomen looks slightly protuberant.
 A scaphoid or sunken appearance suggests missing
abdominal contents or DIAPHRAGMATIC HERNIA
(bowel or other abdominal organs positioned in the chest
instead of the abdomen).
 For the first hour after birth, the stump of the umbilical
cord appears as a white, gelatinous structure marked
with the blue and red streaks of the one umbilical vein
and the two arteries. After the first hour of life, the cord
will begin to dry, shrink, and turn brown. By the 2nd or 3rd
day, it will have turned black. On day 6 to 10, it breaks
free, leaving a granulating area a few centimeters wide
that will heal during the following week.
 A moist or odorous cord suggests INFECTION, requiring
immediate antibiotic therapy to prevent the infectious
organisms from entering the newborn’s bloodstream and
causing septicemia.
 Moistness at the base of the cord also may indicate a
PATENT URACHUS (a narrow opening that connects
the bladder and the umbilicus), w/c requires surgical
repair
K. ANOGENITAL AREA
Test for anal patency and that the anus is not covered by a
membrane (imperforate anus) by gently inserting the tip of your
gloved and lubricated little finger. If a newborn does not do so in
the first 24 hours, there may be an anatomical or physiologic
problem
MJ - CH. 18
MALE GENITALIA
 The scrotum in most male newborns is edematous and
has rough rugae on the surface. It may be deeply
pigmented in dark-skinned newborns. Both testes
should be palpable in the scrotum.
 CRYPTORCHIDISM – one/both testicles are not
present. This condition could be caused by agenesis
(absence of the testes), ectopic testes (the testes are
present in the abdomen but cannot enter the scrotum
because the opening to the scrotal sac is closed), or
undescended testes (the vas deferens or artery is too
short to allow the testes to descend).
 Always elicit a cremasteric reflex by stroking the
internal side of the thigh while inspecting testes (as the
skin on the thigh is stroked, the testis on that side moves
perceptibly upward). The response is indication that
spinal nerves T8 through T10 are intact
 The penis of newborns appears small, approximately 2
cm long. Inspect the tip of the penis to be certain the
urethral opening is at the tip of the glans, not on the
dorsal surface (EPISPADIAS) or on the ventral surface
(HYPOSPADIAS).
FEMALE GENITALIA
The vulva in female newborns may appear swollen because of
the effect of maternal hormones during intrauterine life.
 PSEUDOMENSTRUATION – Where some female
newborns also have a mucus vaginal secretion,
sometimes blood tinged, which is also caused by
maternal hormones; disappears in 1 or 2 days.
 Preterm – prominent clitoris, and less labia majora; Term
– more appearance of labia major; less clitoris
L. BACK
 A newborn normally assumes the position maintained in
utero for days after birth, with the back rounded and
arms and legs flexed across the abdomen and chest. A
child who was born in a frank breech position tends to
straighten the legs at the knee and bring them up next to
the face. The position of a baby with a face presentation
sometimes simulates opisthotonos (backward arching of
the spine) for the first week because the curve of the
back is concave.
M. EXTREMITIES
 The arms and legs of a newborn appear short in
proportion to the trunk. The hands seem plump and are
typically clenched.
 Test the upper extremities for muscle tone by unflexing
the arms for approximately 5 seconds then letting them
return to their flexed position (which typically occurs
immediately if muscle tone is good). Next, hold the arms
down by the sides and note their length. The fingertips
on both sides should reach as far as the mid-thigh.
Unusually short arms may signify achondroplasia
(dwarfism) and would require further evaluation.
 Observe for curvature of the little finger, and inspect the
palm for a simian crease (a single palmar crease).
Although curved fingers and simian creases can occur
normally, they are commonly seen in children with Down
syndrome
 Asymmetry suggests birth injury, such as injury to a
clavicle or to the brachial or cervical plexus or fracture of
a long bone. Assess for webbing (SYNDACTYLY)
between fingers as well as missing or extra fingers
(POLYDACTYLY).
 Check for ankle clonus by supporting the lower leg in
one hand and dorsiflexing the foot sharply two or three
times by pressure on
hand. After the dorsiflexion, one or two continued
movements are normal. Rapid alternating contraction
and relaxation (clonus) is not normal and suggests
neurologic or calcium insufficiency.
 If a foot does not align readily or will not turn to a definite
midline position, a talipes deformity (clubfoot) may be
present
 Clubfoot, also known as Congenital Talipes
Equinovarus, is a complex, congenital deformity of the
foot, it is defined as a deformity
characterized by complex, malalignment
of the foot involving soft and bony
structures in the hindfoot, midfoot and
forefoot.
o “Tali” means Ankle,
o “Pes” means Foot
o “Equinus” means foot pointing down
(like a horse’s foot)
o “Varus” means deviated towards
midline
 Talipes VARUS - most common form of clubfoot, the foot
generally turns inward so that the leg and foot look
somewhat like the letter J.
 Talipes VALGUS - foot rotates outward like the letter L
 Talipes EQUINUS - foot points downward, similar to that
of a toe dancer.
 Talipes CALCANEUS - foot points upward, with the heel
pointing down.
 TERM newborn’s foot has many crisscrossed lines on
the sole, covering approximately two thirds of the foot.
PRETERM newborn’s foot has creases cover less than
two thirds of the foot or are absent.
 To test if the FEMUR is situated comfortably in the hip
socket, with a newborn in a supine position, flex both
hips and abduct the legs as far as they will go (typically
180 degrees or the knees touch or nearly touch the
surface of the bed)
 If the hip joint seems to lock short of this distance (160
to 170 degrees), it suggests hip subluxation. If
subluxation is present, a “clunk” of the femur head
striking the shallow acetabulum can be heard (Ortolani
sign). If the femur can be felt to actually slip in and out of
the socket, this is a Barlow sign.
N. LABORATORY STUDIES
 After the first hour of undisturbed rest, depending on
health agency policy, newborns may have a heel-stick
test for hematocrit, hemoglobin, and hypoglycemia
determinations.
 Hemoglobin is assessed to detect newborn anemia that
could have been caused by hypovolemia because of
bleeding from placenta previa or abruptio placentae or
by a cesarean birth that involved incision into the
placenta.
 Another condition as dangerous as anemia is the
presence of excess red blood cells (polycythemia),
probably caused by excessive flow of blood into an infant
from the umbilical cord.
 A heel-stick hematocrit reveals both hypovolemia and
hypervolemia if they are present. A normal hematocrit at
1 hour of life is about 50% to 55%.
 Hypoglycemia, like anemia, produces few symptoms in
newborns, so glucose is also tested with the heel
capillary blood sample.
 A serum glucose reading that is less than 40 mg/100 ml
of blood (30 mg/100 ml in the first 3 days of life) indicates
hypoglycemia
MJ - CH. 18
 To correct this condition, the infant is prescribed oral
glucose or is breastfed immediately because either will
elevate the infant’s blood sugar to a safe level. It is
important to treat hypoglycemia quickly because if brain
cells become completely depleted of glucose, brain
damage can result. Newborn symptoms of
hypoglycemia include jitteriness, lethargy, seizures, and
intravenous glucose may be prescribed.
 A continuous intravenous infusion of glucose may be
necessary if the newborn is unable to maintain glucose
levels higher than 40 mg/100 ml. Heel sticks require a
minimum of blood and are minimally traumatic.

ASSESSING FAMILY READINESS TO CARE FOR NEWBORN

AT HOME
 Daily home care
 Sleep patterns
 Crying
 Parenteral concerns r/t to breathing
 Health maintenance
 Car safety

NURSING DIAGNOSES: NEWBORN PERIOD

 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

OUTCOMES: NEWBORN PERIOD

 Infant establishes respirations of 30-60 cpm
 Infant maintains temp at 97.8 degrees – 98.6 degrees
Fahrenheit (36.5 °C-37 °C)
 Infant breastfeeds well with a strong sucking reflex.

NURSING CARE OF A NEWBORN AT BIRTH

 IDENTIFICATION AND REGISTRATION
o Identification band
o Birth registration
o Birth record documentation
 INEFFECTIBE THERMOREGULATION
o Keep infant warm and dry
o Skin-to-skin contact
 INEFFECTIVE AIRWAY CLEARANCE
o Promote adequate breathing pattern
o Prevent respiration
o Record first cry
 RISK FOR INFECTION
o Inspect, care of umbilical cord
o Administer eye care
o Infection precautions

NURSING CARE OF A NEWBORN AND FAMILY IN THE

POSTPARTAL PERIOD
 Initial feeding
 Bathing
 Sleeping position
 Diaper area care
 Metabolic screening tests
 Hepatitis B Vaccination
 Vitamin K administration
 Circumcision