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‡ The nurse is in a unique position to aid the newborn infant in the stressful transition from a warm, dark, fluid-filled environment to an outside world filled with light, sound, and novel tactile stimuli. ‡ During this period of the newborn adjusting from intrauterine to extrauterine life, the nurse must be knowledgeable about a newborn's normal biopsychosocial adaptations to recognize any deviations.

‡ To begin life as an independent being, the baby must immediately establish pulmonary ventilation in conjunction with marked circulatory changes. ‡ These radical and rapid changes are crucial to the maintenance of life. ‡ All other neonatal body systems change their functions or establish themselves over a longer period of time. ‡ The nurse performs an initial assessment to evaluate the neonate, its immediate post birth adaptations, and the need for further support

120-140/mt Resp.30-50/mt Bp 80/40 +/-20 .5kg Length-47-53cm US:LS -1.NORAML NEWBORN ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Born after 37wks of gestation Born by normal vaginal delivery Weighing 3-3.7:1 Pulse.

CHARACTERISTICS OF THE NEWBORN ‡ a. . ‡ His internal organs are poorly insulated and his skin is very thin and does not contain much subcutaneous fat. Temperature Regulation. The infant's body temperature drops immediately after birth in response to the extrauterine environment. ‡ The flexed position that the infant assumes is a safeguard against heat loss because it substantially diminishes the amount of body surface exposed. ‡ His temperature rapidly reflects that of his environment. ‡ The infant's heat regulating mechanism has not fully developed.

The normal pulse range for an infant is 120 to 140 beats per minute (bpm). This greatly improves accuracy. The average blood pressure (BP) of an infant at birth is 72/42. . ‡ The newborn's BP may be taken with a Doppler blood pressure device. A drop in systolic BP of about 15 mm Hg the first hour after birth is common.CHARACTERISTICS OF THE NEWBORN ‡ Pulse. ‡ The apical pulse is considered the most accurate. The rate may rise to 160 bpm when the infant is crying or drop to 100 bpm when the infant is sleeping. ‡ Blood Pressure.

and rhythm and vary from 30 to 60 beats per minute. rapid. ‡ No sound should be audible on inspiration or expiration . The respirations of a newborn infant are irregular in depth. ‡ They are most easily observed by watching abdominal movement because the infant's respirations are accomplished mainly by the diaphragm and abdominal muscles . crying). respirations are gentle. rate. ‡ Normally. and shallow.CHARACTERISTICS OF THE NEWBORN ‡ Respirations. quiet. ‡ Respirations are affected by the infant's activity (that is.

Such molding reduces the diameter of the skull temporarily. During delivery. This elongated look usually disappears a few hours after birth as the bones assume their normal relationships . The average size is 13" to 14" (33-35 cm).HEAD The newborn infant's head represents one-fourth of his total body length. Its circumference is equal to that of his abdomen or chest. the skull bones may actually overlap in a process referred to as molding. Molding. for the large head to pass through the small birth canal. The head is shaped or molded as it is forced through the birth canal in vertex presentations.

Where more than two bones come together. It is diamond-shaped and strongly pulsatile. and less pulsatile. the space is called a fontanel. The posterior fontanel is located at the junction of the sutures of the 2 parietal bones and 1 occipital bone. triangular shaped. It normally closes at 1 1/2 to 3 months of age. The infant's pulse is sometimes visible there. The anterior fontanel is located at the intersection of the sutures of the two parietal bones and the frontal bones. The infant's skull is separated into six bones one from another along the suture lines . The anterior fontanel is the larger of the two. It is small.CHARACTERISTICS OF THE NEWBORN Fontanels. . It normally closes at 9 to 18 months of age. This is the unossified space or soft spot between the cranial bones of the skull in an infant.

‡ Color. This will cause concern if it extends beyond six months. the iris color is usually grayish-blue in Caucasians and grayish brown or brown in darkcomplexioned races. At birth.CHARACTERISTICS OF THE NEWBORN ‡ Eyes. . A gradual deposition of pigment produces the final eye color of the baby at the age of three to six months and sometimes it may take a year. The infant's eyes may not track properly and may cross (strabismus) or twitch (nystagmus). The infant's eyes may be folded and creased and may seem out of shape because they contain little hardened cartilage.

‡ (3) Lacrimal apparatus. ‡ Subconjuctival haemorrhage may be seen . The infant's blinking is a natural protection reflex.CHARACTERISTICS OF THE NEWBORN ‡ (2) Pupils. The lacrimal apparatus is small and nonfunctioning at birth and tears are not usually produced with crying until one to three months of age. The pupils do react to light and the infant can focus on objects about eight inches away.

Ears ‡ The infant's ears tend to be folded and creased. The infant usually responds to sound at birth .A line drawn through the inner and outer canthi of the eye should come to the top notch of the ear where it joins the scalp. Pinna soft.

AP and transverse diameter is same. ‡ Thorax is circular.bell shaped.‡ Nose : narrow nostrils. nose breathing ‡ Neck: short and creased ‡ Chest. chest and abdominal circumference same. ‡ Breast engorgement may be present .

. This redness can be seen through heavily pigmented skin and becomes even more flushed when the baby cries.The infant has delicate skin at birth that appears dark red because it is thin and layers of subcutaneous fat have not yet covered the capillary beds.CHARACTERISTICS OF THE NEWBORN ‡ SKIN.

is absorbed in the skin after birth. white. cheesy. it should be meticulously removed as it is thought to be a good culture medium for bacteria. . This is a soft. ‡ If there is a large amount of vernix caseosa present. ‡ It is caused by the secretions of the sebaceous glands of the skin. Vernix Caseosa. yellowish cream on the infant's skin at birth. and serves as a natural moisturizer. ‡ It offers protection from the watery environment of the uterus.SKIN«. ‡ a.

It disappears early in postnatal life. back. ‡ Mongolian Spots. These spots occur less frequently in Caucasian babies. Indian.SKIN«. ‡ b. The spots are not bruises nor are they associated with mental retardation. and forehead. This is a long. They disappear in early childhood . buttocks. soft growth of fine hair on the infant's shoulders. These are blue-black colorations on the infant's lower back. They are often seen in infants of Black. or Mediterranean ancestry. Lanugo. and anterior trunk. Mongolian..

. blue-red dots on the infant's body caused by breakage of tiny capillaries. ‡ e.SKIN«. They appear as small white or yellow dots and are common on the nose. They are of pin head size and opalescent. and cheeks of the infant. They disappear spontaneously within a few weeks.. ‡ d. Petechiae. ‡ f. Milia. This is a yellow discoloration that may be seen in the infant's skin or in the scera of the eye. These are small. These are tiny sebaceous retention cysts. forehead. Milia is due to blocked sweat and oil glands that have not begun to function properly. Jaundice. True petechiae does not blanch on pressure. Jaundice is caused by excessive amounts of free bilirubin in the blood and tissue. They may be seen on the face as a result of pressure exerted on the head during birth.

Birthmarks. is extremely warm. mid-forehead. or becomes excited.SKIN«« ‡ . They may be the result of local dilatation of skin capillaries and abnormal thinness of the skin. They may be noticeable when the infant blushes. and nape of the neck. reddened areas sometimes present on the infant's eyelids. . They are sometimes called stork bites or telangiectasia. These marks usually fade and disappear altogether. ‡ (1) These are small.

rough surface. . Surgical removal is not recommended. They may regress spontaneously or may even increase in size.SKIN««. There is a "wait-and-see" attitude advocated before surgical removal. They do not develop for several days. ‡ 2) A Hemangioma or strawberry mark is a type of birthmark that is characterized by a dark or bright red raised.

‡ Abdomen. peristalsis may be visible. gelatinous contain 2 artery and 1 vein. bowel sounds audible ‡ Liver palpable 1´ ‡ Umbilical cord-bluish white.rounded and slightly protruberant. Falls off by 7-10days .

‡ The connective tissue attached to the underside of the tongue should not restrict the mobility of the tip of the tongue.CHARACTERISTICS OF THE NEWBORN ‡ Mouth. . ‡ The gums may have tooth ridges along them. and the uvula should be present. A common site for them is at the junction of the hard and soft palates. The roof of the mouth should be closed. and rarely a tooth or two may have erupted before birth. ‡ Sometimes there are glistening spots (firm white or grayish-white nodules. ‡ The tongue should not extend or protrude between the lips. usually multiple) on the palate that are referred to as Epstein's pearls. The infant's lips should be pink and the tongue smooth and symmetrical.

but has a limited ability to digests fats . The capacity of the infant's stomach is about one to two ounces (30 to 60 ml) at birth. but increases rapidly.CHARACTERISTICS OF THE NEWBORN ‡ Stomach. The infant is capable of digesting simple carbohydrates and proteins. Milk passes through the infant's stomach almost immediately.

a gradual transition occurs. Peristaltic increases in the lower ileum. The first stools after birth and for three to four days afterwards are called meconium. . tenacious. There may be few greenish stools and the stools will gradually become more yellow. Pass in first 24hrs ‡ Meconium is stringy. and black and has a tarry texture. soft. ‡ Formula stools are lemon yellow and curdy. Intestines. and more frequent. ‡ Breast milk stools are yellow-orange. Irregularity in peristaltic motility slows stomach emptying.CHARACTERISTICS OF THE NEWBORN ‡ c. which results in one to six stools a day. With the ingestion of colostrum or formula.


girls may have a white. testes descended. ‡ In boys. Exposure to maternal hormones may also cause swelling in the baby's genitals. blood-tinged. especially the labia in girls. as this may hurt your baby.In the first few weeks. dark coloured and deeply rugated. mucous discharge from the vagina due to withdrawal from those hormones. Labia minora and clitoris appear large. scrotum may be edematous. . urethral opening at the tip of penis. Don't try to force it back. the foreskin that covers the penis is not easily retractable.CHARACTERISTICS OF THE NEWBORN ‡ Genitals.

CHARACTERISTICS OF THE NEWBORN ‡ Back. sacral and lumbar curve develop later ‡ Buttocks.plump and firm ‡ Arms and Legs. Legs are small. ‡ Extending her arms and legs makes her feel insecure. The legs often flop open at the hips. giving her a froglegged look. When she frets. Arms are short. short. She prefers to keep them flexed and close to her body. Their exact position may resemble her posture during the last few weeks in the uterus. . ‡ baby can move all four extremities quite well.straight and flat. you may be able to make her more comfortable by wrapping her snugly in a blanket and holding her close to you. bowed outward with feet turned inward.

sudden pressure differences occur within the circulatory system. .Circulatory system ‡ Blood Flow. ‡ Peripheral circulation refers to residual cyanosis in hands and feet. When the umbilical blood stops flowing at birth. ‡ This may be apparent for one to two hours after birth and is due to sluggish circulation. ‡ These differences cause the blood flowing to the lungs and liver to increase and the blood flowing through the bypass channels to decrease. ‡ Blood is shunted to vital organs immediately after birth.

‡ This process is most acute between the second and fifth postnatal days. and maturation of the liver. vitamin K is manufactured by the baby and clotting time stabilizes within a week to ten days. During the first few days of life. . the prothrombin level decreases and clotting time in all infants is prolonged.Circulatory system ‡ b. establishment of digestion. ‡ With the ingestion of food. ‡ It can be prevented to a large extent by giving vitamin K to the infant after birth. Blood Coagulation.

the fluid/liquid that flows in the lungs during normal delivery is squeezed or drained from the infant lungs. the alveoli (air sacs) in the lungs are in an almost complete state of collapsed. However.Respiratory system ‡ Until the infant's first breath of air is taken. . ‡ The major portion of the fluid is absorbed after delivery by the avcolar membranes into the blood capillaries. ‡ The lungs should be in this state because the lung must not fill with amniotic fluid or other liquids.

does not have to interrupt feedings to breathe. ‡ Periods of apnea less than 15 seconds is normal. ‡ Irregular rate. ‡ Easily altered by external stimuli. ‡ Usually abdominal or diaphragmatic in character. ‡ Nose breathers. ‡ Acrocyanosis may occur during periods of crying . ‡ Breathing is quiet and shallow.‡ Common characteristics of newborn respirations. Sleeps with mouth closed.

analgesics.Respiratory system ‡ b. tranquilizers. These drugs make the baby sleepy and disinclined to take the first breath . and anesthetics that affect not only the mother. but pass over the placenta to the infant. The most frequent cause of respiratory difficulty in the first few hours of birth has been due to the too liberal use of sedatives.

Endocrine system ‡ The endocrine glands are considered better organized than other systems. There are usually only a few blood spots seen on the diapers. The entire process terminates in one to two days. and prolactin) that may cause the following conditions: ‡ a. Bleeding may occur as a result of withdrawal from maternal hormones at the time of birth. Vaginal discharge and/or bleeding may occur in female infants. luteal. Disturbances are most often related to maternally provided hormones (estrogen. This discharge is white mucoid in color. .

it only increases the chances of infection and injuries to the tender tissue. Swelling usually subsides in two to three weeks. . Breast secretion may also occur. The breast should not be squeezed. Enlargement of the mammary glands may occur in both sexes. This is particularly noticeable about the third day of life.Endocrine system ‡ b.

Absence of reflex activity often indicates some form of brain damage. He has the ability to contract when stimulated. followed by finer motor development. . He wiggles and stretches. but lacks the ability to control them. The infant's muscles are firm and resilient. Reflex actions present at birth serve the infant until neuromuscular development is improved. but movements are uncoordinated.Neuromuscular system ‡ The newborn infant exhibits remarkable sensory development and an amazing ability for selforganization in social interactions. ‡ Cephalo-Caudal (Head to Toe) in Development. Gross motor development occurs first.

he automatically sucks and swallows in a coordinated fashion. his head turns toward it. his mouth opens. When you stimulate his cheek. . a baby automatically knows how to respond to attempts to feed him. mouth. and his tongue moves forward. Just as a mother's breasts are programmed to provide milk to nourish her newborn. occurs when you stroke your baby's cheek or the palm of his hand. This movement of his head and mouth is called the rooting reflex and helps him find a source of nourishment. This reflex helps babies suck and swallow any mucus that might have been clogging their upper airways (nose and mouth) after birth. His mouth roots and his arm flexes. As soon as the inside of his sensitive mouth is stimulated. the hand-to-mouth reflex.Reflexes ‡ Rooting reflex. he may suck his fist energetically for several minutes. or lips with the nipple of a breast or a bottle. After his hand and mouth find each other. ‡ Hand-to-mouth reflex. A similar reaction.

the arm on the same side straightens and the opposite arm bends. For the first few weeks. As his head turns to one side. your baby lies with one cheek down when on his back. Because it is difficult to turn over on an outstretched arm. ‡ Tonic neck reflex. his head wobbles back and forth. You will quickly learn to support his head when you pick him up. he makes a gallant attempt to keep his head upright. this reflex must fade before your baby can roll over.Reflexes ‡ Righting reflex. Because his head is heavy and his muscles are not yet strong enough to hold it steady. When you slowly pull your baby to a sitting position from his back. Lying in this position gives your baby an opportunity to discover his own hand in the weeks to come. This response is called the righting reflex. This posture resembles a fencing position and is called the tonic neck reflex. .


He moves as though to escape from a harmful stimulus. He alternately bends each leg as though walking. Stroking the side of his soles causes his toes to spread and the big toe to extend upward. A newborn baby has a very strong grasping reflex. Gentle pressure against the sole of his foot causes his toes to curl downward. . When you place your finger in his palm.Reflexes ‡ Grasping and Babinski reflexes. The automatic grasp reflex fades over the first two to three months to enable your baby to grasp objects voluntarily. This Babinski reflex is the opposite of the normal adult response. Holding your baby upright and pressing the sole of one foot at a time to a firm surface elicits the stepping reflex. ‡ Stroking one leg causes the other to bend. This remarkable reflex fades rapidly but reappears months later as learned voluntary behavior in preparation for true walking. and push away the offending object. his fingers curl tightly around it. in which the big toe turns downward. ‡ Stepping reflex. cross the first leg.

Then he brings his arms together in an embrace and flexes his legs. When placed on his belly. flat surface. His own furious crying only serves to startle him again. and never place your baby on a mattress that is excessively soft. your baby lifts his head and turns it from side to side. pillows. His responses make it virtually impossible for him to smother when he is lying on his stomach on a firm. you need not worry that your baby will have trouble breathing while prone. or simply holding him securely against your own body. ‡ Moro reflex.Reflexes ‡ Lifting the head. be sure to keep excess bedclothes. He may even attempt to crawl. response. Unfortunately. your baby's response disturbs him further. extend his neck. The most dramatic reflex is the Moro. and stuffed animals out of the way. this reflex disappears. A loud noise or rough handling causes your baby to throw back his arms and legs. You can help break this cycle by calmly bringing his flailing extremities close to his body. You should. however. and cry out. gentle pressure with your hand against his chest and abdomen. toys. applying steady. For this reason. . By three months of age. or startle.

strong till 2 months .3-4 months when awake. by 7-8 months in sleep ‡ Extrusion. gagging.disappear by 4 months ‡ Dolls¶eye-disappear when fixation develops ‡ Palmar grasp-disappear by 3months ‡ Plantar -disappear by 8-9months ‡ Babinski-disappear by 3months ‡ Tonic neck-disappear by 5months ‡ Moro. sneezing and coughing reflexes do not disappear ‡ Sucking-diminish by 6 months ‡ Rooting.Reflexes ‡ Swallowing .

While inside the womb. that same swaying motion comforts him. A fretful infant often becomes quiet if you gather him close to body and gently rock him. . ‡ After birth.The Newborn's Five Senses ‡ Touch-One of the most important means you have for communicating with your baby is touch. Babies enjoy gentle handling and rhythmic motion. baby became accustomed to being rocked by your movements.

It is no coincidence that breast milk is very sweet. baby can tell sweet from sour and much prefers the former. ‡ Although his taste buds aren't completely mature at birth. especially care givers scent. .SENSES ‡ Smell and Taste. At birth. babies demonstrate that they discriminate odors by turning away from unpleasant smells. baby quickly learns to recognize familiar smells.

but he can accurately determine the location of a sound source. a baby listens to his mother's muffled voice as well as to the sounds of her heartbeat.SENSES ‡ Hearing. ‡ Loud. During the last trimester of pregnancy. Even men unconsciously raise the pitch of their voices when speaking to babies ‡ baby gains more control over his head movements. ‡ Baby selectively listens to higher-pitched voices. breathing. Soft. ‡ When baby's head is pressed against mother¶s chest. sharp noises often upset babies. rhythmic sounds calm them . he no doubt finds those familiar sounds comforting. and many a baby falls asleep in this position. it becomes clear that not only can he hear. and digestion.

. This response is called the blinking reflex. Soon the monologue turns into a delightful dialogue as he starts replying with his own babbling sounds. Upon emergence from their dim intrauterine environment. ‡ Vision. babies exhibit a protective reflex of tightly shutting their eyes against bright light.SENSES ‡ He enjoys listening to you sing and talk to him.

to focus the eyes with changing object distance ‡ The muscles that move the eyes to help them both focus on an object to produce a single image are immature at birth. one eye or the other occasionally wanders ‡ Color vision is probably immature at birth . He quickly learns to accommodate -.SENSES ‡ newborn infant has fixed focus: He is not able to adjust his eyes to clearly see images closer than 8 inches or farther away than 12 inches.

The infant is extremely vulnerable to heat loss because his body surface area is great in relation to his weight and he has relatively little subcutaneous weight. Heat loss after delivery is increased by the cool delivery room and the infant's wet skin. ‡ Place the infant in a radiant heat warmer. ‡ Place the infant closely to the mother's skin. ‡ Receive baby in prewarmed towel ‡ Dry the infant thoroughly immediately after delivery. Skin-to-skin contact with the mother will help prevent heat loss . ‡ Place a stockinette cap on the infant's head to prevent heat loss through the head. ‡ Wrap the infant snugly in a warm blanket.Immediate care in LR ‡ Maintaining Body Temperature.

and/or rubbing his back gently. ‡ Once the infant is delivered.‡ Establishing and Maintaining the Newborn's Airway. ‡ The infant is then positioned with his head slightly down when placed in the radiant warmer. his head is held slightly downward to promote drainage of mucus and fluid. ‡ The infant's mouth is suctioned first and then his nose. ‡ Suctions the infant before it is completely born with a bulb syringe or a DeLee trap. If the infant doesn't breathe spontaneously. ‡ The bulb syringe is used to remove mucus from his mouth and nose . ‡ The infant's face is wiped thoroughly clean. lightly tapping the buttocks. he should be stimulated to cry by slapping his heels.

An identical band matching the infant's band is placed on the mother's wrist. Each facility has its own instant identification method. An identification (ID) band is placed on the infant's wrist and leg. ‡ The infant's footprints or palm prints placed next to the mother's thumb print is rarely done in most facilities.‡ Identify the Infant After Delivery. ‡ The infant must be properly identified before leaving the delivery room. .

. and to identify neonates at risk for morbidity and mortality ‡ Evaluations at each of the five categories are initially done at one minute after birth. with a maximum score of ten. ‡ The final APGAR score is the sum total of the five items. determine the need for resuscitation. the better condition of the infant.The APGAR scoring chart ‡ The APGAR scoring chart is used to evaluate the conditions of the baby at birth. The higher the final APGAR score. ‡ Evaluations at one minute quickly indicate the neonate's initial adaptation to extrauterine life and whether or not resuscitation is necessary. ‡ Each item has a maximum score of two and a minimum score of zero. evaluate the effectiveness of resuscitative efforts. ‡ The five-minute score gives a more accurate picture of the neonate's overall status. including obvious neurologic impairment or impending death.


It is administered intramuscular (IM) in the vastus lateralis muscle .‡ ADMINISTRATION OF VITAMIN K ‡ Vitamin K is given as a prophylaxis for hemorrhagic disease.

GOALS OF NEWBORN NURSING CARE ‡ 1) Observe and record the infant's vital signs. ‡ (3) Monitor bowel and bladder function. ‡ (5) Monitor interactions and bonding with parents. ‡ (2) Monitor weight loss or gain (daily by some local policy). ‡ To provide safeguards against infection (that is. ‡ To provide guidance and health instruction to parents. ‡ To initiate feedings. . handwashing). ‡ (4) Monitor activity and sleep patterns.


‡ Weight recording should be done daily ‡ 5-10%weight loss in till 5-6 days, regain back 1 week ‡ To ensure adequacy of feeding ‡ Vital signs monitoring for hypothermia, respiratory problems and infections

‡ Clean the eyes daily with sterile water and sterile cotton ‡ Observe for signs of infection ‡ Apply prophylatic medication if prescribed-

Skin care
‡ ‡ ‡ ‡ ‡ Initial cleaning to remove vernix and blood Sponge bath daily Special care to body folding and creases Full bath as per hospital policy Preferably after the temperature stabilization and cord falls off and stabilization of body temperature

Otherwise. Some may not come off during the first bath because it is so "sticky. Allow the parent to participate if possible. If the infant's temperature is greater than 98ºF rectally. the bath may be done after all admission procedures are done. wait until the infant's temperature has stabilized above 98ºF. Remove as much of the vernix as possible.INITIAL BATH ‡ The amount of time required for the initial bath is determined by local policy." . ‡ The procedure for actually completing the bath is also determined by local policy.

The signs of infection are purulent drainage. . The cord dries faster when left uncovered. Have the parents roll the infant's diaper down some in front initially so the cord is not covered. The cord detaches in ten to fourteen days. The dye prevents infection and helps the cord to dry. and possible swelling (more than usual). ‡ Observe for signs of infection and report findings immediately. ‡ Observe for cord detachment.CORD CARE FOR THE NEWBORN INFANT ‡ Inspect the cord frequently for signs of bleeding immediately after it has been cut. redness. ‡ Swab the cord with alcohol at least three times per day (refer to local policy). ‡ Apply triple dye (refer to local policy) to the cord after the infant has had his bath and has been determined to be stable. The alcohol aids in drying.

the infant returns to a sleep state or less alert state . ‡ The significant other should be allowed to participate in as much of the care as possible during the admission process to develop the bond between him and the infant. ‡ It is an excellent time to establish breast-feeding while the infant is awake. ‡ This is considered a critical time for both individuals to interact and get to know one another.BONDING PROCESS ‡ Bonding should be initiated in the delivery room. ‡ Transport the infant back to the mother as soon as local policy allows to take advantage of the alert state newborns have during those first few hours after birth. ‡ Approximately the first four hours after delivery.

‡ (3) Tape measure. ‡ Assemble necessary equipment. .COMPLETE INSPECTION OF THE NEWBORN ‡ A complete inspection of the newborn infant is performed within 24 hours after delivery. ‡ (2) Penlight. The goal is to compile a complete record of the newborn that will act as a database for subsequent assessment and care. ‡ (4) Rectal/oral thermometer. ‡ (5) Infant scale. ‡ (1) Pediatric stethoscope.

‡ Wash hands for a full three minutes. Subsequent temperatures are to be taken by the axillary method. The infant's temperature is taken rectally only on admission. draft-free area. . Auscultate the infant's lungs. Count for a full minute. ‡ Determine the infant's apical heart rate. keeping the infant undressed for as short a time as possible. ‡ Balance the scale. ‡ Approach and identify the infant. ‡ Provide for a warm. Count for a full minute. ‡ Determine the infant's respiratory rate. Note any signs of respiratory distress (retractions. grunting. well-lighted. or periods of apnea. ‡ Take the infant's temperature. ‡ Place the infant on a flat. nasal flaring) rate over 60 bpm. protected surface.

Cranial molding from a vaginal delivery may affect this measurement. ‡ Measure the infant's length from top of the head to the heel with the leg fully extended and record measurements. ‡ Measure the infant's head circumference and record measurements.700 and 4. ‡ Measure the infant's chest circumference at the nipple line and record the measurement . The measurement should be repeated on the second and third day after delivery.000 grams). as well as in grams. Record the weight in pounds and ounces. Most newborns weigh between six to nine pounds (2.‡ Weigh the naked infant. The normal head circumference is 13 to 14 inches (33 to 35 cm).

thick. The infant should be able to move his neck from side to side. from flexion to extension. . The anterior fontanelle is approximately two inches long and is gem/diamond shaped.‡ Observe the general contour of the infant's head. and covered with folds of tissue. Gently palpate the sutures and fontanelles. The posterior fontanelle is smaller than the anterior fontanelle. the fontanelle feels soft and is either flat or slightly indented. The anterior fontanelle usually bulges when the infant cries. coughs. or vomits. ‡ Observe the general appearance of the infant's neck. Normally. The infant's neck is usually short. and can hold his head in the midline position.

. Note the infant's eye movements. The ears should be firm with weeformed cartilage. An infant older than ten days should look in the direction in which you turn. Tops of the auricles should be parallel to the outer canthus of the eye (refer to figure 7-5). shape. Strabismus caused by poor neuromuscular control is normal. ‡ Inspect the infant's nose for patency. Note the color of the infant's eyes. and position. ‡ Inspect the infant's ears for structure.‡ Observe the infant's eyes for symmetry of size and shape.

Normally. . Observe the infant's hands and feet for normal creases. Acrocyanosis may be present up to 24 degrees. and lanugo. milia. ‡ Palpate the infant's peripheral pulses (femoral. ‡ Inspect the infant's skin and nails. ‡ Inspect the size. especially when the infant is crying. birthmarks. and radial). Observe for jaundice.‡ Inspect the infant's mouth for cleft palate by gently depressing his tongue when he cries. Make sure they are in tact. petechiae. The breast tissue of both male and female infants may be slightly engorged during the first few days of life. Check the mucous membranes. shape. Observe the color of the infant's nail beds. brachial. Observe the soft and hard palate. they should be pink. an infant's chest is circular or barrelshaped. and symmetry of the infant's chest.

‡ Auscultate the infant's abdomen for bowel sounds. gagging. or cyanosis during feeding. ‡ Observe for excessive drooling. The abdomen should be cylindrical in shape.‡ Inspect the size and shape of the infant's abdomen. Bowel sounds should be present within one to two hours after birth. coughing. Check the umbilical cord for the number of vessels. Sunken or distended abdomen should be reported. .

Release it and observe whether it returns to its normal position. ‡ Observe the infant's spontaneous or involuntary movements for symmetry. Gently straighten his arm or leg. or abnormal openings. The labia majora may appear edematous and cover the clitoris and the labia minora. ‡ Dress the infant carefully and return him to his bassinet.‡ Place the infant on his abdomen and observe his spine for curves. . The scrotum may appear edematous and proportionately large. The penis should be checked for location of the urinary meatus. If the extremity is difficult to straighten and rapidly flexes when released. he may be hypertonic. the infant may be hypotonic. ‡ Inspect the male infant's genitalia. ‡ Inspect the female infant's genitalia. If the extremity remains limp. masses. or rigidity. spasticity.

‡ Record all significant nursing observations in the infants' health record. This test must be done. if the infant is discharged prior to his third or fourth day of life. Four days are preferred. ‡ Ensure that the infant has been on milk or formula feeding for three full days. Report your observations to the Charge Nurse. ‡ Label and transport the specimen to the laboratory. ‡ Notify the parents of follow-up care of the infant. . ‡ Explain to the parents the purpose of the test ‡ Perform a heel stick to obtain needed specimen ‡ Place one drop of blood on each of the three circles on the filter paper or in accordance with local policy.