Ch18 Nursing Care of A Family With A Newborn

CHAPTER 18
NURSING CARE OF A
FAMILY
WITH A NEWBORN
Copyright © 2018 Wolters Kluwer · All Rights Reserved
NAME: KATHLEEN T. ANG
YEAR AND SECTION: Date Created:
November 3, 2020
BSN-2B
PROFILE OF A NEWBORN #1

HEAT LOSS IN THE NEWBORN

Vital signs - begins to change from those present in intrauterine life at the moment
of birth.
 Pulse
• The heart rate of a fetus in utero averages 110 to 160 beats/min.
• After birth , the newborn struggles to initiate respirations, the heart rate may be as rapid
as 180 beats/min.
• One hour after birth, the newborn settles to sleep and the heart rate stabilizes to an
average of 120 to 140 beats/min.
• The heart rate of a new born often remains irregular because of immaturity of the
cardiac regulatory center in medulla and the transient murmurs can be result from
incomplete closure of fetal circulation shunts.
• During crying, the heart rate may rise to 180 beats/min.
• Heart rate can decrease during sleeping ranging from 90 to 110 beats/min.
• Should be able to palpate femoral pulses since radial and temporal pulses are hard to
locate.
• It is best to listen to a newborn’s heart rate in apical heartbeat for a full minute than
assessing in pulse in an extremity or over the carotid artery.

Vital signs—(cont.)
Respiration
• In the first few minutes of life may be as high as 90 breaths/min.
• Respiratory activity is established and maintained over the next hour, this will settle
to an average of 30-60 breaths/min.
• Respiratory depth, rate and rhythm are more likely to be irregular and short periods
of apnea (w/out cyanosis) and sometimes called periodic respirations.
• Period respirations are common and normal during this time.
• Can be observed most easily by watching the movement of newborn’s abdomen
because breathing primarily involves diaphragm and abdominal muscles.
• Coughing and sneezing reflexes are present at birth to clear airway.
• Newborns are obligate nose breathers and shows signs of distress if nose is
obstructed.
• Short period of crying: increase depth of respirations and aid in aerating deep
portions of the lungs (beneficial to the newborn).
• Long period of crying: exhaust the cardiovascular system becoming fatigue and no
purpose.

Vital signs—(cont.)
Blood pressure
• At birth, approximately 80/46 mmHg .
• 10th day, rises to 100/50 mmHg and remains the same during infant years.
• Measurement of bp in newborns are somewhat inaccurate due to the small
size of the arms, it is not routinely measured unless cardiac anomaly is
suspected.
• For accurate reading, the cuff width must be no more than two thirds the
length of the upper arm or thigh.
• Tends to increase with crying so doppler method may achieve better
results.
• Hemodynamic monitoring is used when continuous assessment is required.

Physiologic function
Cardiovascular system
Blood values
• A newborn’s blood volume is 80 to 110 ml/kg of body weight or about 300 ml total.
• A newborn has more red blood cells than average adult, hemoglobin level averages 17 to 18
g/200 ml of blood (adult is 11 to 12g/ml).
• A newborn’s hematocrit is bet. 45% to 50% (adult is 36% to 45%).
• A newborn’s red blood cell count is about 6million cells/mm3 (adult is 3.5-5.5 million
cells/mm3)
• Once proper lung oxygenation, the need for high red cell count diminishes so within a
matter of days, red cells begin to be destroyed.
• At birth, indirect bilirubin level is about 1 and 4 mg/100 ml.
• A newborn has a corresponding high white blood cell count about 15,000 to 30,000
cells/mm3 at birth.
• Seeing the count increased, is not an evidence of infection but reflects how stressful an
event birth is for a fetus.
• Although the high white blood cell count makes infection difficult to prove in a newborn,
infection must not be diminished as a possibility if other signs of infection such as pallor,
respiratory difficulty or cyanosis are present.

Physiologic function—(cont.)
Cardiovascular system—(cont.)
Blood coagulation
• Vitamin K, synthesized through 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 clotting sequence.
• Newborn’s intestine is sterile at birth unless membranes were ruptured more
than 24 hours it will take about 24 hours for flora to accumulate and for
ongoing Vitamin K to be synthesized.
• Causes most newborns to be born with a lower than usual level of Vitamin
K leading to a prolonged coagulation or prothrombin time.
• Because almost all newborns can be predicted to have this diminished
blood coagulation ability, Vitamin K is usually administered intramuscularly
into the lateral anterior thigh (prefer site for injections for newborns).
• Vitamin K can be taken orally.


Respiratory system
• First breath is a major undertaking because it requires a tremendous amount
of pressure (40 to 70cm of H2O) for a newborn to be able to inflate alveoli
for the first time.
• The reflex to breathe is initiated by a combination of cold receptors; a
lowered partial pressure of oxygen (PO2), which falls from 80 mmHg
before a first breath & an increased partial carbon dioxide pressure (PCO2)
which rises as high as 70 mmHg before a first breath.
• Some fluid present in the lungs from intrauterine life makes a newborn’s
first breath possible because fluid eases surface tension on alveolar walls
and allow alveoli to inflate more easily than if the lungs were dry.
• About 1/3 of this fluid is forced out of lungs by the pressure of vaginal birth.
• Rest of the fluid is quickly absorbed by lung blood vessels and lymphatics
after the first breath.

Respiratory system—(cont.)
• Once the alveoli have been inflated this first time, breathing becomes much
easier for a baby (6-8 cm H2O pressure).
• Within 10mins after birth, most newborns have established easy
respirations and good residual volume.
• By 10 to 12 hours of age, vital capacity is established at newborn
proportions.
• A baby born in cs does not have much lung fluid expelled at birth as one
born vaginally and has more difficulty establishing respiration because
excessive fluid blocks air exchange space.
• Any newborn who had difficulty in establishing respiration at birth needs
to be examined closely in the postpartal period for a cardiac murmur or any
other indication that he or she has the patent cardiac structures from fetal
life especially a patent ductus arteriosus.

Gastrointestinal system
• Usually sterile at birth, bacteria may be cultured from the tract in most babies
within 5 hours after birth and from all babies at 24 hours of life.
• Most of these bacteria enter the tract through the newborn’s mouth from airborne
sources. Others may come from vaginal secretions at birth, hospital bedding, and
from breast contact.
• Accumulation of bacteria is helpful because bacteria in the gastrointestinal tract are
necessary for digestion through probiotics and for synthesis of vitamin k.
• A newborn stomach holds 60-90 ml, a newborn has a limited ability to digest
everything taken especially in fat and starch because the pancreatic enzymes, lipase
and amylase, remain deficient for the first few months of life.
• Cardiac sphincter bet stomach and esophagus is immature, a newborn tends to
regurgitate easily.
• Immature liver function can lead to a tendency toward lowered glucose and protein
serum levels.

Gastrointestinal system—(cont.)
Stools
• The first stool of a newborn is usually passed within 24 hours after birth.
• It consists of meconium, a sticky, tar-like, blackish green, odorless material
formed from mucus, vernix, lanugo, hormones and carbohydrates that
accumulated in the bowel during intrauterine life.
• If a newborn does not passed a meconium stool by 24 to 48 hours after birth, the
possibility of some problem such as meconium ileus, imperforate anus or
volvulus should be suspected.
• About second or third day of life, newborn stool changes in color and consistency.
• Transitional stool, a bowel contents appear both loose and green and they may
resemble diarrhea to the untrained eye.
• 4th day of life, breastfeed babies pass three or four light yellow stools per day that
have a soft consistency. No foul smelling because breast milk is high in lactic acid
which reduces the amount of putrefactive organisms in the stool.

Gastrointestinal system—(cont.)
Stools—(cont.)
• Newborn who receives formula usually passes two or three bright yellow stools a day of
soft consistency. More noticeable odor compared with those of breastfed babies.
• 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 intestinal tract.
• Blood-flecked stools usually indicate an anal fissure.
• Occasionally, a newborn who 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 may be differentiated by a dipstick Apt-Downey test
and 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, milk allergy, lactose
intolerance or some other condition interfering with digestion or absorption is suspected.

Urinary system
• The average newborn voids within 24 hours after 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 newborn do not concentrate urine well, making newborn
urine usually light colored and odorless.
• The infant is about 6 weeks of age before much control over reabsorption
of fluid in tubules and concentration of urine becomes evident.
• 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 30-60 ml total.

Urinary system—(cont.)
• 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 (looks a lot like blood in urine but is an innocent finding).
• If tested for protein, a small amount may be normally present in voidings for
a first few days of life until kidney glomeruli are more mature.
• Diapers can weighed to determine the amount and timing of voiding which is
done when there is a concern.
• The possibility of obstruction in the urinary tract can also be assessed by
observing the force of the urinary stream in both male and female infants.
• Males should void with enough force to produce a small projected arc.
• Females should project a steady stream not just continuous dribbling.
• Projecting urine farther than normal may signal urethral obstruction because
it indicates urine is being forced through a narrow channel.

Immune system
• Newborns have limited immunologic protection at birth because they are
not able to produce antibodies until about 2 months of age.
• Born with passive antibodies (immunoglobulin g) passed to them from their
mother that crossed the placenta.
• In most instances, these include antibodies against poliomyelitis, measles,
diphtheria, pertussis, chickenpox, rubella and tetanus.
• Newborn are routinely administered hepatitis b vaccine before they leave
their birth setting to promote antibody formation against disease.
• Bec 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.
• Without any antibody protection, herpes simplex type 2 infections can
become systemic or create a rapidly fatal form of disease in a newborn.

Neuromuscular system
Blink reflex
• Serves the same purpose as it does in adult which is 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 flashlight into an eye.
• A sudden movement toward the eye can elicit the blink reflex but is not reliable.
Rooting reflex
• Newborn’s cheek is brushed or stroke near the corner of the mouth.
• The infant will turn the head in that direction.
• Serves to help the newborn find food, when a mother holds the child and allows
her breast to brush the newborn’s cheek, the reflex causes the baby to turn
around the breast.
• This reflex disappears at about 6th week of life, not coincidentally at the same
time a newborn’s eyes focus steadily so a food source can be seen.

Neuromuscular system—(cont.)
 Sucking reflex
• Newborn’s lips are touched, the baby makes a sucking motion.
• Like rooting reflex, this reflex also helps a newborn find food.
• Begins to diminish at about 6 months of age.
• Disappears immediately if it is never stimulated such as in a newborn with
tracheoesophageal fistula who cannot take in oral fluids.
• Can be maintained in such as an infant by offering a child a nonnutritive sucking
object such as pacifier.
 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 clean
airway.

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.
• If newborns are offered solid food before this reflex fades at 4 months, it will
look as if they are rejecting the food.
• Be certain that parents are aware of this reflex so they don’t offer solid food at
this early.
Palmar grasp reflex
• Newborns grasp an object placed in their palm by quickly closing their fingers
on it.
• Mature newborn grasp so strongly they can be raised from a supine position
and suspended momentarily from an examiner’s fingers.
• This disappears at about 6 weeks to 3 months of age.
• After it fades, a baby begins to grasp meaningfully.
 Step-in-place reflex
• Newborn who are held in a vertical position with their feet touching a hard
surface will take a few quick, alternating steps.
• Disappears by 3 months of age.
 Placing reflex
• Is elicited by touching anterior lower leg against a surface such as edge of
table.
• Newborn makes a few quick lifting leg motions as if to step onto the table.
 Plantar grasp reflex
• An object touches the sole of a newborn’s foot at the base of the toes, the toes
grasp in the same manner as the fingers.
• Disappears at about 8-9 months of age in preparation for walking.

PALMAR GRASP REFLEX

STEP-IN PLACE REFLEX

Tonic neck reflex
• When the arm and the leg on the side toward which the head is turned
extend, and the opposite arm and leg contract .
• This posture is most evident in the arms but should not be totally absent
in the legs.
• If you turn a newborn’s head to the opposite side, he or she may change
the extension and contraction of legs and arms accordingly.
• Also called “boxer” or “fencing reflex”.
• The purpose or function of this reflex is not known.
• Typically disappears between the second and third months of life.

Moro reflex
• Startle reflex.
• 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 inch.
• 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.
• Reflex stimulates 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 then fades by the end of the fourth of fifth
month.

Babinski reflex
• When the sole of a newborn’s foot is stroked in an inverted “j” curve from the heel
upward, a newborn fans the toes (positive Babinski sign).
• This is in contrast to the adult, who reflexes the toes if the foot is stroked this way.
• The reflex remains positive (toes fan) until at least 3 months of age, when it is
supplanted by the down-turning response.
Magnet reflex
• If pressure is applied to the soles of the feet of a newborn lying in a supine position,
he or she pushes back against the pressure.
• This and the two following reflexes are tests for spinal cord integrity.
Crossed extension reflex
• When a newborn is lying supine, if one leg is extended and the sole of the 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 the first leg.

TONIC NECK REFLEX

MORO REFLEX

BABINSKI REFLEX

Trunk incurvation reflex
• When a newborn lies in a prone position and is touched along the
paravertebral area on the back by a probing finger, the newborn flexes the
trunk and swings the pelvis toward the touch.
Landau reflex
• When a newborn is supported in a prone position by a 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 muscle tone which needs to
be investigated.
Deep tendon reflex
• Both a patellar and a biceps reflex are intact in a newborn.
TRUNK INCURVATION REFLEX

Senses - In newborns are important for survival and are already

fully developed at birth.
Hearing
• Newborns appear to recognize their mother’s voice almost immediately
and calm to the sound since they have been heard in the utero.
• By 25 to 27 weeks gestation, hearing is functional and the fetus can hear
the mother’s heartbeat and voice.
• Continues to develop so that the fetus hears a broader range of frequencies
throughout gestation and shortly after birth (Clark-Gambelunghe & Clark,
2015).
• As soon as amniotic fluid drains or is absorbed from the middle ear by way
of eustachian tube within hours after birth, hearing becomes acute.
• Newborns respond with generalized activity to a sound such as bell.
• Appear to have difficulty locating where a sound is coming from.

Senses—(cont.)
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
as soon as they are born.
• Be certain parents know their newborn cannot follow an object past the
midline or appears to lose track of objects easily.
• Teach also that newborns focus best on black and white objects at a
distance of 9 to 12 inches.

Senses—(cont.)
Touch
• Is also well developed at birth.
• Newborns quite down at a soothing touch, cry at painful stimuli and show
sucking and rooting reflexes that are elicited by touch.
Taste
• Newborn has ability to discriminate taste because taste buds are developed
and functioning even before birth.
• A fetus in utero, for example will swallow amniotic fluid more rapidly than
usual if glucose is added to sweeten taste.
• Swallowing decreases if a bitter flavor is added.
• After birth, a baby continues to show a preference for sweet over bitter
tastes.

Senses—(cont.)
Smell
• Present in newborns as soon as the nose is clear of lung and amniotic fluid.
• Probably turn toward their mothers’ breasts partly out of recognition of the
smell of breastmilk and partly as manifestation of the rooting reflex.


ASSESSING A NEWBORN #1

GRADING OF NEONATAL RESPIRATORY DISTRESS

Gestational age
• To be term if they are born between 37 and 42 weeks of gestation or
within 2 weeks of their due date.
• If born 5 days after the due date, it would be recorded as 40 + 5
• If born 3 days before the due date, it would be recorded as 40 – 3
Dubowitz maturity scale

• May be performed if the mother did not have a prenatal care or if there is
another question regarding maturity of the newborn.
• Use extensive criteria to assess gestational age.
• The process of rating the infant, completed shortly after birth includes
physical maturity and neuromuscular maturity.

Gestational age—(cont.)
Dubowitz maturity scale —(cont.)
• The newborn’s skin, lanugo, foot creases, breast maturity, eyes and ears, and
genitalia are observed and given a score of -1 to +5.
• Using this standard method to rate maturity helps detect infants who were thought
to be term instead are actually preterm because of miscalculated due date and who
need additional observation and perhaps high-risk care.
Brazelton neonatal behavioral assessment
• Term newborns are physically active and emotionally prepared to interact with the
people around them.
• They are people oriented from the beginning and how much so can be
demonstrated by the way they immediately attune to human voices or concentrate
on their mother’s face.
• A rating scale of six different categories of behavior: habituation, orientation,
motor maturity, variation, self-quieting ability and social behavior and was devised
by Brazelton in the early 1970s.

Gestational age—(cont.)
Brazelton neonatal behavioral assessment—(cont.)
• To evaluate a newborn’s behavioral capacity or ability to respond to set
stimuli.
• Total evaluation takes 20 to 30 minutes to be completed.
• To perform the test, it requires training to ensure it is used consistently.
• The infant is scored on best performance rather than on average
performance.
• Not used routinely, such as how infants alert to a voice (eyes widened,
head held as if listening) or how they naturally cuddle when held next to
their parent are excellent examples of newborn behavior to point out to
parents to help them interact with their newborn.

Gestational age —(cont.)

Health history
• The history of a newborn is obtained from examination of the mother’s pregnancy record
if this is available, her labor and birth record and an interview with the mother.
• Important information to gather includes:
• Any complications of pregnancy such as gestational diabetes, hypertension, premature
rupture of membranes, serious falls or other injuries.
• Length of pregnancy and length of labor.
• Type of birth (vaginal or cesarean) and whether an infant breathed spontaneously or
needed assistance at birth.
Physical exam
• Newborn is given preliminary physical examination as soon as parents have had an initial
time to spend with their new child in addition to height and weight determinations, to
establish gestational age and to detect any observable condition such as difficulty in
breathing, a congenital heart anomaly or any birthmarks.
• This assessment may be the responsibility of the primary care provider or a nurse
depending on the facility and circumstances of birth.



Skin - general inspection of a newborn’s skin includes color, any

birthmarks and general appearance.
Color
• Most term newborns have a ruddier complexion for their first month than
they will have later in life because of the increased concentration of red
blood cells in their blood vessels and a decrease 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.

Skin—(cont.)
Color—(cont.)
Cyanosis
• Generalized mottling of the skin is a common finding in newborns.
• Lips, hands and feet are likely to appear blue.
• Prominent in some newborns that the infant’s hands appear as if a
stricture at the wrist must be cutting off circulation because there is usual
skin color on one side and blue on the other.
• Acrocyanosis is a normal finding at birth through the first 24-48 hours
after birth.
• Central cyanosis or cyanosis of the trunk is always a cause for concern.
This indicates decreased oxygenation that could be occurring as a result
of a temporary respiration obstruction and could also reflect a serious
underlying respiratory or cardiac disease.

Skin—(cont.)
Color—(cont.)
Cyanosis—(cont.)
• Mucus obstructing a newborn’s respiratory tract causes sudden cyanosis and apnea
but can be relieved by suctioning the mucus from mouth and nose.
• Always suction from the mouth before the nose because suctioning the nose can
trigger reflex gasp possibly leading to aspiration if there is mucus in posterior throat.
• Follow mouth suctioning with suction to the nose because the nose is the chief
conduit for air in newborns.
Hyperbilirubinemia
• Is caused by the accumulation of excess bilirubin in the blood serum.
• Average in newborn , the skin and sclera of the eyes begin to appear noticeably
yellow on the second or third day of life as a result of a breakdown of fetal red blood
cells (physiologic jaundice).
• This occurs because as the high red blood cell count built up in utero is being
reduced, heme and globin are released.

Skin—(cont.)
Color—(cont.)
Hyperbilirubinemia—(cont.)
Kernicterus
• Acute bilirubin encephalopathy
• Above normal indirect bilirubin levels are potentially dangerous
because if enough indirect bilirubin (20mg/100ml) leaves the
bloodstream, it can interfere with the chemical synthesis of brain cells,
resulting in permanent cell damage.
• If this occurs, permanent neurologic damage including cognitive,
vision, and hearing problems may result.

Skin—(cont.)
Color—(cont.)
Pallor
• In newborns is potentially serious because it usually occurs as a result
of anemia which may caused by a no. Of circumstances such as:
• Low iron stores caused by poor maternal nutrition during pregnancy.
• Blood incompatibility in which a large number of red blood cells were
hemolyzed in utero.
• Fetal-maternal transfusion.
• Inadequate flow of blood from the cord into the infant before the cord
was cut.
• Excessive blood loss when the cord was cut.
• Internal bleeding. A baby who appears pale should be watched closely
for signs of blood in the stool or vomits.

Skin—(cont.)
Color—(cont.)
Harlequin sign
• Occasionally, because of immature blood circulation.
• A newborn who has been lying on his or her side appears red on the
dependent side of the body and pale on the upper side as if a line had
been drawn down the center of the body.
• This is the transient phenomenon and although startling, no clinical
significance.
• The odd coloring fades immediately if the infant’s position is changed or
the baby kicks or cries.

Skin—(cont.)
 Birthmarks - Several common types of birthmarks occurs in the
newborn baby.
Hemangiomas - Are vascular tumors of the skin and occur in three distinct
types:
1) Nervus flammeus - Two types: benign macular purple or dark-red lesion
(port-wine stain) & light pink patches: stork bites or telangiectasia.
2) Infantile hemangiomas (strawberry hemangiomas) - Elevated areas
formed by immature capillaries and endothelial cells. Appear at birth
within 2 weeks after birth. Size may enlarge up to 1 year of age. After 1
year, tend to be absorbed and shrink in size. By the time the child is 7
years old, 70% have involuted to a reasonable level (most involution is
completed in 10 years)
3) Cavernous hemangioma - Caused by dilated vascular spaces. Raised and
irregular space. Do not disappear in time. May have additional lesions on
internal organs such as spleen or liver.

Skin—(cont.)
Birthmarks—(cont.)
Mongolian spots
• Collections of pigment cells (melanocytes) that appear as slate-gray
patches across the sacrum or buttocks and possibly on the arms and legs
of newborns.
• Tend to occur most often in children of Asian, Southern European, or
African ethnicity and disappear at school age without treatment.


Skin—(cont.)
Vernix caseosa
• White, cream cheese-like substance that serve as a skin lubricant in utero.
• Typically noticeable on a term on newborn’s skin at least in the skin folds
at birth.
• Document the color of any vernix present because it takes on the color of
the amniotic fluid.
• Yellow vernix indicates amniotic fluid was stained from excessive
bilirubin or blood dyscrasia may be present.
• Green vernix suggests meconium was present in amniotic fluid.
• Always handle newborns with gloves to protect yourself from exposure to
vernix.

Skin—(cont.)
Lanugo
• Fine, downy hair that covers a term newborn’s shoulders, back, upper
arms and possibly the forehead and ears.
• Post term infants (born after 42 weeks) rarely have lanugo.
• Babies born at 37 to 39 weeks, have a generous lanugo hair.
• Following birth, lanugo is rubbed away by the friction of bedding and
clothes against the newborn’s skin.
• 2 weeks of age, has usually totally disappeared.

Skin—(cont.)
Desquamation
• Within 24 hrs. 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 the areas of peeling similar to those caused by sunburn.
• No treatment is needed.
• May apply mild lotion to prevent excessive dryness (if they wish).
• Newborns who are post term and have suffered intrauterine malnutrition may have
such extremely dry skin that it has a leathery appearance and actual cracks in the
skin folds.
Milia
• Sebaceous glands in a newborn are immature so at least one pinpoint white papule
(plugged or unopened sebaceous glands) usually found on cheek or across the
bridge of the nose of every newborn.
• Disappear by 3 to 4 weeks of age as the sebaceous glands mature and the plugged
ones drain.

Skin—(cont.)
Erythema toxicum
• Commonly presents on the skin of most term newborns.
• Rash usually appears in the first to fourth day of life but may appear as
late as 2 weeks of age.
• Begins with small papules, increases in severity to become erythematous
by the second day and then disappears by the third day.
• Sometimes called flea-bite rash because the lesions are minuscule.
• Chief characteristics of rash is the lack of pattern.
• Occurs sporadically and unpredictably and may last hours or days.
• Probably caused by newborn’s eosinophils reacting to rough environment
of sheets and clothing rather than a smooth liquid against the skin.
• Requires no treatment.

Skin—(cont.)
Forceps marks
• Are rarely used for birth today but if used, they may leave a circular or linear contusion
matching the rim of the forceps blade on the infant’s cheek.
• Mark occurs with normal forceps use and does not denote unskilled or overly vigorous
application of forceps.
• Mark disappears in 1 to 2 days along with the edema that accompanies with it.
Skin turgor
• Like adult skin, newborn skin should feel resilient if the underlying tissue is well
hydrated.
• 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
elevated ridge.
• Poor turgor is seen in newborns who have suffered from malnutrition in utero who have
difficulty in sucking at birth or who have certain metabolic disorders such as
adrenocortical insufficiency.
• Poor turgor means poor hydration.
MILIA

ERYTHEMA TOXICUM

FORCEPS MARKS

Head
• A newborn’s head appears disproportionately large because it is about ¼ of the
total body length compared with an adult. Whose head is 1/8 of total height.
• Forehead appears large and prominent. Chin appears to be receding and quivers
easily if infant is startled or cries.
• If newborn has hair, the hair should look full bodied.
• Both poorly nourished and preterm infants have thin and 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/openings where the skull bones join. The anterior is located at
the junction of the two parietal bones and two fused frontal bones.
• Diamond-shaped and measures 2 to 3 cm (0.8-1.2 in). In width is 3 to 4 cm
(0.4-0.7 in) in length.

Head—(cont.)
Fontanelles—(cont.)
• Anterior fontanelle can be felt as soft spot.
• Should not appear indented (sign of dehydration) or bulging (a sign of
increased intracranial pressure) when the infant is held upright.
• Should not appear indented (sign of dehydration) or bulging (a sign of
increased intracranial pressure) when the infant is held upright.
• May bulge if the newborn strains to pass a stool, cries vigorously, or lying
supine.
• The anterior fontanelle normally closes at 12 to 18 months of age.
• Some newborns, the posterior fontanelle is so small that it cannot be
palpated readily. It closes by the end of the second month.

Head—(cont.)
Sutures
• The separating lines of the skull.
• May override at birth because of extreme pressure exerted on the head
during passage through the birth canal.
• If the sagittal suture between the parietal bone overrides, the fontanelles are
less perceptible than usual.
• Overriding subsides in 24-48 hours.
• Should never appear widely separated in newborns.
• Suggests increased intracranial pressure because of abnormal brain
formation, abnormal accumulation of cerebrospinal fluid in the cranium
(hydrocephalus) or an accumulation of blood from a birth injury such as
subdural hemorrhage.
• Fused suture lines are abnormal.

Head—(cont.)
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.
• You can assure the parents that the head will evolve to more rounded
shape within a few days after birth.
Caput succedaneum
• Is edema of the scalp that forms on the presenting part of the head.
• 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.
• The edema which crosses the suture lines is gradually absorbed and
disappears within several days.
• No treatment is needed (Gooding & McCLead, 2015).

Head—(cont.)
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.
• Although the blood loss is negligible, edema which appears by 24hours after
birth, appears severe and is well outlined as an egg shape.
• It may be discolored (black and blue) because of the presence of coagulated
blood underneath the periosteum.
• Unlike caput, it is confined to an individual bone so the associated swelling
stops at the bone’s suture line.
• This will subside without treatment.
• May take weeks for the blood under the periosteum to be absorbed.
• As the blood breaks down, the infant needs to be observed for jaundice that can
occur from the large amount of indirect bilirubin that may be released
(Muchowski, 2014).

Head—(cont.)
Craniotabes
• Is localized softening of the cranial bones probably caused by the pressure
of the fetal skull against the mother’s pelvic bone in utero.
• More common in first-born infants than in infants born later 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 the examining finger can indent it.
• The bone then returns to its normal contour after the pressure is removed.
• The condition occurs itself without treatment after a few months as the
infant ingests calcium from milk.
• 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).

MOLDING

CAPUT SUCCEDANEUM AND
CEPHALOHEMATOMA

Eyes
• To inspect the eyes of the newborn, lay the infant in a supine position and lift the head.
• This maneuver usually causes the baby to open his/her eyes.
• Its rare to see tears in a newborn because their lacrimal ducts do not fully mature until
about 3 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 bet 3 to 12 months of age.
• The eyes should appear clear, without redness or purulent discharge.
• Occasionally, the administration of an antibiotic ointment such as erythromycin at birth,
to protect against chlamydia has caused the eyes to appear reddened with a slight
discharge.
• If this occurred, it lasts for about 24 hours of life then clears.
• Pressure during birth sometimes ruptures a conjunctival capillary of the eye resulting in
a small subconjunctival hemorrhage on the sclera.
• This appears as red spot, usually on the inner aspect of the eye or as a red ring around
the cornea.

Eyes —(cont.)
• The bleeding is slight and requires no treatment and is completely absorbed within 2-3
weeks.
• While it may appear as if the baby is bleeding from within the eye and that his/her
vision might be impaired, you can assure the mother that these hemorrhages occur
often and will soon resolve.
• Slight edema is often present around the orbit or on the eyelids and remains for the first
2-3 days until the newborn’s kidneys are capable of evacuating fluid more efficiently.
• Be certain the cornea of each eye appears round and proportionate in size to an adult
eye because a cornea that appears larger than usual may be a result of congenital
glaucoma.
• An irregularly shaped pupil or discolored iris may denote a congenital formation such
as coloboma.
• The pupil (adults) should appear dark.
• A white pupil suggests the presence of congenital cataract. Glaucoma, retinoblastoma
or other eye disorder and should be reported (Gomella, et. al, 2013)

Ears
• The newborn’s external ear is not as completely formed as it will eventually so the
pinna tends to bend forward easily.
• In a term newborn, 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, syndromes in which there are other
physical variations coupled with varying degrees of cognitive impairment.
• A small tag of skin is sometimes found just in front of an ear.
• Although these tags may be associated with chromosomal abnormalities or kidney
disease they usually are isolated findings of no consequence.
• They can be removed by ligation immediately or within the first week of life.
• Always inspect closely in front of the newborns’ ears for pinpoint-size openings
that may lead down to a hollow sinus because an open track under the skin lined
with squamous epithelium may also be present at these sites.

Ears —(cont.)
• The sinus itself is small and inconsequential but advise the parents that the closed
space can become infected.
• If this occurs, the site will appear red and swollen and the infant will need an
antibiotic ointment.
• Parents can have the tract removed surgically to prevent further infection.
• Amniotic fluid and flecks of vernix usually still fill the ear canal, obliterating the
tympanic membrane and its accompanying landmarks therefore visualization of
the membrane is usually not attempted.
• AAP recommends all newborns be screened for hearing before discharge from
their birth setting.
• Hearing screening is done with reliable standardized method such as the
optoacoustic emissions test or automated auditory brainstem response test.
• While waiting for hearing examiner, infants can be tested by ringing a bell held
about 6 in. From each ear.
• A hearing infant will blink, attend to the bell’s sound ad possibly startle.

Nose
• Usually has milia present and tends to appear large for the face.
• 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.
• Note any distress with breathing while one side of the nose is blocked this way.
Mouth
• Should open evenly when he/she cries.
• If one side of the mouth curves more than the other, facial nerve injury may have
occurred.
• The tongue may appear tongue tied because the frenulum membrane is attached close to
the tip.
• At one time it was almost routine to snip a newborn’s frenulum membrane to lengthen it.
• Inspect the palate of the newborn to be certain that 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 the utero.

Mouth —(cont.)
• The pearl-like cysts are insignificant and does not require any treatment and will disappear
spontaneously within a week.
• Epstein pearls must be distinguished from thrush, it’s a candida infection which appears on
the tongue and sides of the cheeks as white or gray patches and requires treatment like
antifungal drug (nystatin).
• Small, white epithelial pearls (benign inclusion cysts) may be noticed on the gum margins.
No treatment is needed.
• Highly unusual for a newborn to have teeth but sometimes one or two and are called natal
teeth.
• Any teeth that are detected must be evaluated for stability.
• If loose they are usually extracted. To remove possible aspiration during feeding.
• Most newborns have mucus in their mouth.
• Mucus born through cs usually have more mucus.
• If newborn is placed on the side, the mucus drains from the mouth and results in no distress.
• If mouth is filled with too much mucus that the neonate seems to be blowing bubbles,
suspect a tracheoesophageal fistula.

Neck
• Appears short with creased skin folds.
• The head should rotate or turn freely on it.
• If neck is rigid, congenital torticollis caused by injury to the sternocleidomastoid muscle
during birth might be present.
• Newborns whose membranes has been raptured more than 24 hours before birth, nuchal
rigidity may be an early sign of meningitis.
• The neck is not strong enough to support the total weight of the head but in a sitting
position a newborn should make a momentary effort at head control.
• When lying prone, newborns can raise the head slightly usually enough to lift the nose out
of mucus or spit-up the milk.
• If pulled up from sitting position the head will lag.
• Trachea usually appears prominent on the front of the neck.
• Thymus gland appears enlarged because of the rapid growth of glandular tissue early in
life.
• Even if thymus appears enlarged and bulging, it is rarely a cause of respiratory difficulty.
• Plays a crucial role in providing immunity so is not removed.


Chest
•Looks small because the head is so large in proportion to it.
•The chest averages 2cm (0.75 to 1 in) smaller in circumference than the
head and is wide in the anteroposterior diameter as it is across.
•Both right and left sides should appear symmetric.
•At around 2 years of age, the chest measurement typically exceeds that of
the head.
•The clavicles should appear straight and feel smooth.
•A crepitus (cracking) or actual separation of one or both clavicles suggests
a fracture occurred during birth (can happen to large infants).
•A supernumerary nipple (usually found below and in line with normal
nipples) may be present.
•Both male and female infants, the breasts may be engorged because of the
influence of maternal hormones during pregnancy.
•Breasts may secrete thin, watery fluid popularly called as witch’s milk.
•As soon as hormones are cleared from infant’s system about 1week, the
engorgement and fluid will subside.
Chest —(cont.)
• Fluid should never be expressed from infant’s breasts because the manipulation
could introduce bacteria and lead to mastitis (infection of the breasts).
• Respirations are normally rapid (30-60 breaths/min) but not distressed.
• Retraction (drawing in the chest wall with inspiration) should not be present.
• An infant who is breathing with retractions is using such a strong force to pull air
into the respiratory tract that he/she is pulling the anterior chest muscle as well.
• Breathing is not sustainable for a long period of time and immediate help such as
oxygen is needed.
• Because newborn’s lung alveoli is open slowly over the first 24-48 hours and
baby is invariably has mucus in the back of the throat, listening to lung sounds
often reveals rhonchi.
• Rhonchi is the sound of air passing over mucus.
• Abnormal sound such as grunting, suggests respiratory distress syndrome & a
high, crowning sound on inspiration suggests stridor or immature tracheal
development, both conditions that need immediate consultation.
Abdomen
• Looks slightly protuberant.
• Scaphoid or sunken appearance suggests missing abdominal contents or diaphragmatic
hernia (bowel or other abdominal organs positioned in the chest instead of the abdomen.)
• Bowel sounds show the bowel is beginning of peristalsis and should be present w/in
1hour after birth.
• On the right side, the edge of the liver is usually palpable 1-2 cm below the costal
margin.
• On the left side, the edge of the spleen may be palpable 1-2 cm below the left costal
margin.
• First hour after birth, the stump of umbilical cord appears as white, gelatinous structure
marked with the blue and red streaks of the one umbilical vein and two arteries.
• Any child with a single umbilical artery needs close needs and assessment for anomalies
that are frequently associated with the lack of an umbilical artery.
• Always inspect the cord lamp to be certain if it is secure.
• First hour of life, the cord will begin to dry, shrink and turn brown as if it were dead end
of a vine.

Abdomen—(cont.)
• Second or third day, it will turned into black.
• On day 6-10, it breaks free, leaving a granulating area a few cm wide that will heal
during the following week.
• There should be no bleeding at the base of the cord and it should not appear wet.
• Moist or odorous cord suggests infection requiring immediate antibiotic therapy to
prevent infectious organisms from entering the newborn’s bloodstream causing
septicemia.
• Moistness at the cord may also indicate a parent urachus (narrow opening that
connects the bladder and the umbilicus) which requires surgical repair.
• Inspect the base of the cord to be certain no abdominal wall defect such as an
umbilical hernia is present.
• If there is abdominal wall defect smaller than 2 cm in diameter, it will usually close
at school age.
• Larger defect may require surgical correction.
• Taping or putting buttons or coins on the cord are some of the home remedies.

Abdomen—(cont.)
• Heavy taping may worsen condition by preventing the development of abdominal
wall muscle and may also keep the cord moist increasing risk of infection.
• Newborn voids demonstrates that there is at least one kidney functioning (but not
necessarily two).
• Attempt to verify the presence of kidneys by deep palpation of the left and right
abdomen within the first few hours after birth before the intestines fill with air
making palpation more difficult.
• Small kidney suggests decreased function.
• Enlarged kidney suggests polycystic kidney/pooling of urine from a urethral
obstruction.
• To finish abdominal assessment, elicit abdominal reflex.
• Stroking each quadrant of the abdomen with a finger should cause the umbilicus
to move or wink in that direction.
• Superficial abdominal reflex, test for spinal nerves T8 and T10 is usually present
at birth but may not be observable until it is stronger at about 10 th day of life.

Anogenital area
• Examine the anus to ascertain its presence and patency.
• 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.
• Note the time after birth when the infant first passes meconium.
• If the newborn does not do so in the first 24 hrs, there may be an anatomical or
physiologic problem that needs to be assessed.
Male genitalia
• Scrotum is edematous and has rough rugae on the surface.
• May be deeply pigmented in the dark-skinned newborns.
• Both testes should be palpable in the scrotum.
• If one or both testicles are not present (cryptorchidism), referral is needed to further
investigate the problem.

Anogenital area—(cont.)
Male genitalia—(cont.)
• This condition can be caused by agenesis (absence of the testes), ectopic testes (the
testes are present in 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).
• Make a practice of pressing your nondominant hand against the inguinal ring
before palpating for testes so they do not slip upward and out of the scrotal sac as
you palpate.
• Newborns with agenesis of the testes are usually referred for investigation of
kidney anomalies because the testes arise from the same germ tissue as the kidneys.
• Always elicit a cremasteric reflex by stroking the internal side of the thigh while
inspecting the testes (as the skin on the thigh is stroked, the testis on the side moves
perceptibility upward).
• The response is indication that spinal nerves T8 through T10 are intact, although it
may be absent before 10 days of age when nerve stabilization is complete.

Anogenital area—(cont.)
Male genitalia —(cont.)
• The penis of newborns appears small, approx. 2 cm long. Shorter length requires
referral to an endocrinologist to investigate any other anomalies.
• 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 the ventral surface (hypospadias).
• In most newborns, the prepuce (foreskin) slides back very little from the meatal
opening so don’t try to retract it.
Female genitalia
• The vulva in female newborns may appear swollen because of the effect of
maternal hormones during intrauterine life.
• Some female newborns also have a mucus vaginal secretion, sometimes blood
tinged (pseudo menstruation), which is also caused by maternal hormones.
• The discharge does not indicate an infection of trauma and disappears in 1 or 2
days.

Back
• Normally assumes with 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 a face.
• The position of a baby with a face presentation sometimes stimulates
opisthotonos (backward arching of the spine) for the first week because the
curve of the back is concave.
• The spine of a newborn typically appears flat in the lumbar and sacral areas.
• These curves appear after a child is able to sit and walk.
• Inspect the base of a newborn’s spine carefully to be certain there is no
pinpoint opening, dimpling or sinus tract in the skin which suggests a
dermal sinus or spina bifida occulta.

Extremities
• The arms and legs of a newborn appear short in proportion to the trunk.
• The hands seem plump and are typically clenched.
• Newborn fingernails feel soft and smooth and extend over the fingertips.
• Test the upper extremities for muscle tone by unflexing the arms for approx.
5seconds 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 syndrome.
• When a newborn moves, the arms and legs should move symmetrically (unless the
infant is demonstrating a tonic neck reflex).
Extremities—(cont.)
• Asymmetry suggests birth injury, such as injury to a clavicle or to the brachial or
cervical plexus or fracture of long bone.
• Assess for webbing (syndactyly) bet. Fingers as well as missing or extra fingers
(polydactyly).
• Test to see whether the fingernails fill immediately after blanching from pressure
to test for adequate blood circulation.
• Newborn legs appear bowed and short. The sole of the foot is flat because of an
extra pad of fat in longitudinal arch.
• The foot of a term newborn has many crisscrossed lines on the sole, covering
approx. 2/3 of the foot or are absent, it suggests the infant is preterm.
• Move the ankle through a range of motion to evaluate that the heel cord is not
unusually tight.
• Check for ankle clonus by supporting the lower leg in one hand and dorsiflexing
the foot sharply two or three times by pressure on the sole of the foot with the
other hand.
• After dorsiflexion, one or two continued movements are normal.
• Rapid alternating contraction and relaxation (clonus) is not normal and suggests
neurologic or calcium insufficiency.
• The feet may turn in (varus deviation) because of their former intrauterine position.
• This is benign if the feet can be brought to the midline position by easy
manipulation.
• When the infant begins to bear weight, the feet will align themselves without
treatment.
• If a foot does not align readily or will not turn to a definite midline position, a
talipes deformity (clubfoot) may be present and warrants specialty referral.
• 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 (160-170 degrees), it suggests
hip subluxation.
• Confirm subluxation by holding the infant’s legs with the fingers on the greater and
lesser trochanters and then abduct the hips.
• If subluxation is present “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 socket, this is a Barlow sign.
• A subluxated hip may be bilateral or unilateral.
• Like talipes disorders, it is important that a hip subluxation be identified early
because correction is most successful if initiated early.
• Lastly, inspect the feet for missing or extra toes or unusual spacing of toes
particularly bet the big toe and the others.
• Although this finding can be a normal finding in some families.
• It is also present in certain chromosomal disorders.
• When placed on their abdomen, newborns should be capable of bringing their
arms and legs underneath them and raising their stomach slightly off bed.
• Preterm newborn is not able to do this.

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.
(Dependent on health agency policy)
Hematocrit
• Heel-stick hematocrit reveals both hypovolemia and hypervolemia if they are present.
• A normal hematocrit at 1 hour life is about 50% to 55%.
• Is the proportion by volume of the blood that consists of red blood cells.
Hemoglobin
• Is assessed to detect newborn anemia that could have been caused by hypovolemia
because of bleeding from placenta previa or abruption placentae or by cesarean birth
that involved incision into the placenta.
• Another condition as dangerous as anemia is the presence of red blood cells
(polycythemia) probably caused by excessive blood flow into an infant from the
umbilical cord.

Laboratory studies—(cont.)
Hypoglycemia —(cont.)
• 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.
• 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 quicky because if brain cells because
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

• Newborns thrive on a gentle rhythm of care and a sense of being able to anticipate what is
to come next.
• At the same time, there is no set of time which an infant should be bathed or put to sleep.
• If house is cold, the newborn doesn’t need to take a bath everyday.
• Aim is to help parents plan their schedule of care:
 Offers some consistency
 Appears to both satisfy the infant and offer the mother and her partner a sense of well-
being and contentment with the child.
Sleep patterns
• A newborn sleeps an average of 16 hours out of every 24 hours during first week home.
• Sleeping is about 4 hours at a time.
• Advise couples that their newborn needs fluid and nutrition so it is not recommended to
eliminate night feedings in the early weeks of life.
• Teach them not to put formula, glucose water or fruit juice because after their teeth erupt,
this can lead to early childhood caries and a syndrome popularly known as “baby-bottle-
caries”.

NEWBORN AT HOME
Crying
• Typically cry an average of 2 hours of every 24 during the first 7 weeks of
life.
• The freq. Seems to peak at age 6 or 7 weeks and then tapers off.
• Use pacifiers to reduce crying is a decision a parents should make,
depending on the infant’s feel about them and needs.
• Common for most newborns to cry and it doesn’t mean that they are ill.
Parental concerns related to breathing
• If newborns appears to have a great deal of mucus in the mouth following
birth, the primary care provider can suction mucus from infant’s mouth with
a bulb syringe.

NEWBORN AT HOME
Health maintenance
• Do not need to continue to weigh a newborn or take an infant’s temperature at home
because these practices can cause worry.
• Weight fluctuates day by day and infant activity and clothing can influence temperature.
• Teach parents to judge infant’s state of health by the child’s overall appearance,
eagerness to eat, general activity and disposition as well as weight gain assessed at
healthcare visits.
• Make and keep their healthcare appointment for a newborn assessment according to
their primary care provider’s schedule (2 to 6 weeks).
• To keep the child well.
Car safety
• Safety problem during childhood, beginning with the newborn period.
• Newborns should always be transported in rear facing car seats placed in the backseat.
• When purchasing a car seat, advise parents to ascertain that the seat meets current
federal guidelines.

NURSING DIAGNOSES: NEWBORN PERIOD
Ineffective airway clearance related to mucus in the airway

Ineffective thermoregulation related to heat loss from exposure in the
birthing room
Imbalanced nutrition, less than body requirements, related to poor
sucking reflex
Readiness for enhanced family coping related to birth of planned
infant
Health-seeking behaviors related to newborn needs

OUTCOMES: NEWBORN PERIOD
Infant establishes respirations of 30 to 60 breaths/min.

Infant maintains temperature at 97.8° to 98.6°F (36.5° to 37°C).
Infant breastfeeds well with a strong sucking reflex.

NURSING CARE OF A NEWBORN AT BIRTH #1
Identification and registration

Identification band
• One traditional form of identification used with newborns is a plastic bracelet
with a permanent lock that requires cutting to be removed.
• A number the corresponds to the mother’s hospital number, mother’s name,
sex, date and time of infant’s birth are printed on the band.
• If it is attached to a newborn’s leg or arm, two bands should be used because
bands can slide off easily.
• A newer form of identification band has a built-in sensor unit that sounds an
alarm similar to those attached to clothing in department stores to stop
shoplifting (if a baby is transported beyond set to hospital boundaries).
• After identification bands are attached, an infant’s foot-prints may be taken and
thereafter kept with the baby’s electronic record for permanent identification.
• Babies who are born elsewhere and then admitted to the hospital should have
bands applied and their footprints taken on admission.

Identification and registration—(cont.)

Birth registration
• The primary care provider who supervised a newborn’s birth has the
responsibility to be certain a birth registration is filed with the bureau of
vital statistics for the state in which the infant was born.
• The infant’s name, mother’s name, father’s name (if mother choses to
reveal this) and the birth date and place recorded.
• This official birth information is important for eligibility for school, voting,
passports, and social security benefits.

Identification and registration—(cont.)

Birth record documentation
• The infant’s chart is also a vital piece of documentation because it serves as a
baseline for the infant’s health. It should contain the following:
Time of birth
Time of infant breastfed
Whether respirations were spontaneous or aided
Apgar score at 1 min and 5 mins of life
Whether eye prophylaxis was given
Whether vitamin k was admitted
General condition of the infant
Number of vessels in the umbilical cord
Whether cultures were taken
Whether the infant voided and whether he/she passed a stool

Ineffective thermoregulation
• Keep infant warm and dry.
• Skin-to-skin contact.
Ineffective airway clearance
• Promote adequate breathing pattern.
• Prevent aspiration.
• Record first cry.
Risk for infection
• Inspect, care of umbilical cord.
• Administer eye care.
• Infection precautions.

NURSING CARE OF NEWBORN AND FAMILY IN
THE POSTPARTAL PERIOD
Initial feeding
• The baby-friendly hospital initiative (BFHI) is a global program sponsored by
the who and the united nations children’s fund (UNICEF) to encourage and
recognize hospitals and birthing centers that offer an optimal level of care for
infants that promotes breastfeeding.
• To qualify as a baby-friendly-designated facility, a setting must:
Maintain a written breastfeeding policy that is routinely communicated to all
healthcare itself.
Educate all healthcare staff in skills is necessary to implement written
policy.
Inform all pregnant women about the benefits and management of
breastfeeding.
Help mothers initiate breastfeeding within 1 hour of birth.
Show mothers how to breastfed and how to maintain their milk supply, even
if they are separated from their infants.

Initial feeding —(cont.)

Offer breastfed newborns no food or drink other than breast milk unless
medically indicated.
Practice “rooming in” or allow mothers and infants to remain together 24
hours a day.
Encouraged unrestricted or “on-demand” breastfeeding.
Give breastfeeding infants no pacifiers or artificial nipples.
Foster the establishment of breastfeeding support groups and refer mothers
to them on discharge from the birth setting (UNICEF, 2016).
• After the first feeding in the birthing room, both formula fed and breastfed
infants to do best with an “on-demand” schedule.
• Many needs to be fed as often as every 1.5 to 2 hours in the first few days and
weeks of life.

Bathing
• The association of women’s health, obstetric and neonatal nurses recommends
that most newborns receive a complete sponge bath in 2 to 4 hours after birth
when their temperature and vital signs are stable.
• There is no need to use antibiotic cleansers and no need to remove all vernix.
• All babies are sponge bathed once a day, although the procedure may be
limited to washing only the baby’s face, diaper area and skin folds.
• Wear gloves when handling newborns until the first bath to avoid exposing
your hands to body secretions such as vernix caseosa.
• Plan to help a mother give a first bath before (not after) a feeding to prevent
spitting up or vomiting and possible aspiration.
• As a rule bathing should proceed from the cleanest parts of the body to the
most soiled areas that is from the eyes and face to trunk and extremities then
lastly to the diaper area.
• Wipe newborn’s eyes with clear water from the inner canthus outward.

Bathing—(cont.)
• Use a clean portion of the washcloth for each eye to prevent spread of infection to
the other eye.
• Use a mild neutral soap for the sponging be sure to rinse well so no soap is left on
the skin because soap can be drying and newborns are susceptible to desquamation).
• Wash their infant’s hair daily during bath.
• Easiest way to do is to soap the hair with the baby lying in the bassinet.
• In male infants, the foreskin of the uncircumcised penis should not be forced back
while washing the penis or constriction of the penis.
• - Wash the vulva of the female infant, wipe from front to back to prevent
contamination of the vagina or urethra by rectal bacteria.
• Most agencies do not apply powder or lotion to newborns because some infants are
allergic to these products and breathing in powder can cause respiratory distress.
• If newborn’s skin is extremely dry and portals of infection are becoming apparent
because of cracking in the skin, lubricant such as nivea oil added to bath water or
applied directly to the skin should relieve the condition.

Sleeping position
• Sudden infant death syndrome (SIDS) is the sudden, unexplained death of
an infant younger than 1 year of age.
• Interventions: place infant on the back to sleep; use a firm sleep surface;
breastfeeding; room sharing without bed sharing; routine immunization;
consideration of using a pacifier; avoidance of soft bedding; overheating
and exposure to tobacco smoke, alcohol and illicit drugs.
Diaper area care

• Preventing diaper dermatitis or diaper rash is a practice parents need to
start from the very beginning with their newborns.
• Advise parents to change diapers frequently and with each diaper change,
wash the area with clear water and dry well.
• For yourself, wear gloves for diaper care as part of standard precautions.

Metabolic screening tests

• Newborn are routinely screened for more than 30 metabolic or inherited disorders
by a screening technique that requires a small blood sample obtained by a heel
stick and then dropped onto a special filter paper (Tluczek & De Luca, 2013)
• Ideally, a baby should received formula or breast milk for 24 hours before the
blood is obtained for best results.
• If blood testing is not done before discharge, alert parents that they need to
schedule screening tests at an ambulatory visit in 2-3 days’ time.
• Always assess at a newborn’s health supervision visit that screening was done.
Hepatitis B Vaccination
• All newborns in a hospital or a birthing center receive a first vaccination against
hepatitis b within 12 hours after birth.
• A second dose will then be administered at 1 month and a third one at 6 months.
• Infants whose mother are positive hep. B surface antigen (HBsAg) also receive
hep. B immune globulin (HBIG) at birth.

Vitamin K administration
• Newborns are at risk for bleeding disorders during the first week of life because their
gastrointestinal tract is sterile at birth and therefore unable to produce Vitamin K.
• Vitamin K is necessary for blood coagulation.
• A single dose of 0.5 to first hour of life helps prevent such problems.
Circumcision
• Is the surgical removal of the foreskin of the penis.
• Except for a baby who has constriction (phimosis) of the foreskin that obstructs the
urinary meatal opening (rare), there are a few medical indications to circumcise a
male newborn.
• Is performed as a religious rite among some groups such as Jewish and Muslim
communities.
• Contraindications: history of bleeding tendency in the family or hypospadias or
epispadias because the prepuce skin may be needed when a plastic surgeon repair
these defects.

Circumcision—(cont.)
• These procedure is best performed during first and second day of life after the
baby has been synthesized enough Vitamin K to reduce the chance of faulty blood
coagulation rather than immediately after birth.
• A specially designed plastic bell (Plastibell) is fitted over the end of penis then a
suture is then tied around the rim of the bell and a circle of the prepuce is cut
away allowing foreskin to be easily retracted and the glans to be fully exposed.
• Complications: hemorrhage, infection and urethral fistula formation.
• To keep the risk of these complications, check the infant for bleeding every 15
mins for the first hour and observe closely for the next 2 hours.
• Circumcision site is red but should not have a strong odor or discharge.
• A film of light yellow mucus often covers the glans by the second day after
surgery and should not be washed away because it serves as a protective function.
• Redness or tenderness or if baby is in constantly pain, report to primary healthcare
provider because this suggests infection.

Ch18 Nursing Care of A Family With A Newborn

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Ch18 Nursing Care of A Family With A Newborn

Uploaded by

Copyright:

Available Formats

CHAPTER 18

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Senses - In newborns are important for survival and are already

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Dubowitz maturity scale

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Gestational age —(cont.)

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Skin - general inspection of a newborn’s skin includes color, any

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved