NCM 101: CARE OF THE MOTHER, CHILD AND

FAMILY (Pedia Part )

Maricris B. Florendo
Clinical Faculty
UNP – College of Nursing
THE NEWBORN

Physiologic Function
and
Appearance
 1. Temperature

 Range from 36.5 to 37 axillary

 Crying may elevate temperature
 Stabilizes in 8-10 hours after delivery

Signs of Potential Distress:

1. Temperature is no a reliable indicator
of infection
2. A temp of less than 36.5
 2. Heart Rate

 Range from 120 to 160 beats

per minute
 Range to 100 when sleeping
and 180 when crying
 Color pink wih acrocyanosis
 Maybe irregular when crying

SIGNS OF POTENTIAL DISTRESS:

1. Murmurs
2. Deviation from range
3. Faint heart sounds
 3. Respiration
 30 – 60 breaths per minute
 Bilateral bronchial breath sounds
 Moist breath sounds may be present shortly after birth
SIGNS OF POTENTIAL DISTRESS:
1. asymmetrical chest movements
2. apnea for more than 15 seconds
3. diminished breath sounds
4. seesaw respirations
5. grunting
6. nasal flaring
7. retractions
8. deep sighing
9. tachypnea
10. persistent irregular breathing
11. excessive mucus
12. excessive fine crackles, stridor
 4. Blood Pressure

 Varies with change in activity level

 Appropriate cuff size
 65/41 mmHg 1 to 3 days in both upper and
lower extremities
SIGNS OF POTENTIAL DISTRESS:
1. Calf systolic pressure of 6-9 mmHg
less than systolic pressure in upper
extremities may be indicative of
coarctation of the aorta
 5. Head Circumference

• 33 – 35 cm
• Should be 2 – 3 cm larger than the chest
• Molding may result in a lower head
circumference measurement
 6. Chest circumference

• 30.5 to 33 cm
• Head and chest circumference
maybe equal for the first 24 –
48 hrs of life
 7. Weight

2500 – 4000 gms

 8. Length

• 48 – 53 cms
 9. Skin

 Reddish, smooth and puffy at birth  May have acrocyanosis

 At 24-36 hrs skin is flaky, dry and  Mongolian spots
pink color  Mottling
 Edema around eyes, feet and  Physiologic jaundice
genitals
 Good skin turgor with good recoil
 Cord with 1 vein,2 arteries
 Hair silky and soft with individual  Milia
strands  Erythema toxicum
 Nipples present in expected  Petechia or bruises over
locations presenting part
 Nails to end of fingers and often  Skin tags
extend slightly beyond  Harlequin coloring
 Presence of vernix caseosa
 Presence of lanugo
 SIGNS OF POTENTIAL DISTRESS:
 Jaundice within 24 hours
 Forceps mark
 General cyanosis
 Circumoral cyanosis between feedings
 Petechiae or ecchymoses other than on presenting
part
 All rashes with exeption of erythema toxicum
 Pigmented nevi
 Yellow vernix
 Hemangioma
 pallor
 10. Head

 Anterior fontanel diamond shaped

 Posterior fontanel triangularly shaped
 Fontanels: soft firm, and flat
 Sutures palpable with small separation in between
 There may be caput succedaneum
 molding

SIGNS OF POTENTIAL DISTRESS:

1. Cephalhematoma
2. Hydrocephalus
3. macrocephaly
 11. Eyes

 Slate gray or blue eye color

 No tears
 Fixation at times
 Red reflex
 Blink reflex
 Distinct eyebrows
 Cornea: bright and shiny
 Pupils equal and reactive to light
 Edematous eyelids
 May focus for a few seconds
 Uncoordinated movements
SIGNS OF POTENTIAL DISTRESS:
1. Discharges
2. Opaque lenses
3. Absence of red reflex
4. Epicanthal folds in newborns not
of oriented descent
5. Reflexes absent
6. Chemical conjunctivitis
7. Subconjunctival hemorrhage
 12. Ears

 Loud noise elicits startle

reflex
 Flexible pinna with
cartilage present
 Pinna top on horizontal
line with outer canthus of
the eye
 Skin tags on or around the
ears
 SIGNS OF POTENTIAL DISTRESS

1. Low ear placement

2. Clefts present
3. Malformations
4. Cartilage absent
5. Preauricular sinus
 13. Nose

• Nostrils patent bilaterally

• Obligate nose breathers
• No nasal discharge
• Sneezes to clear nostrils
• Bridge appears absent
• Thin white nasal mucus discharge

SIGNS OF POTENTIAL DISTRESS:

1. Cloanal atresia and discharge
2. Malformation
3. Nasal flaring beyond first few
moments after birth
 14. Mouth and Throat

• Uvula midline
• Minimal or absent salivation
• Tongue moves freely and does
not protrude
• Well developed fats pads on
bilateral cheeks
• Sucking reflex
SIGNS OF POTENTIAL DISTRESS: • Rooting reflex
1. Cleft lip palate • Gag reflex
2. Circumoral pallor • Extrusion reflex
3. Asymmetrical lip movement • Moist mucosa
4. Absent or incomplete reflexes
• High arched palate
5. Protruding tongue
6. Diminished tongue movement
• Epstein’s pearls on ridges of the
7. Candida albicans gums
8. Percocious teeth
 15. Neck

• Short and thick

• Turns easily on sides
• Clavicles intact
• Tonic neck reflex present
• Neck-righting reflex present
• Some head control

SIGNS OF POTENTIAL DISTRESS:

1. Torticollis stiff neck drawing head to one side
2. Resistance to flexion
3. Webbing of neck
4. Large fat pad on back of the neck
5. Palpable crepitus, movement with palpation of the clavicle
 16. Chest

 Evident xiphoid process

 Bilateral synchronous chest movement
 Symmetrical nipples
 Equal anteroposterior and lateral diameter
 Witch’s milk
 Enlarge breasts
 Accessory nipples
 SIGNS OF POTENTIAL DISTRESS

1.Asymmetrical chest movements

2.Depressed sternum
3.Marked retractions
4.Absent breast tissue
5.Flattened chest
6.Supernumerary nipples
7.Nipples widely spaced
8.Bowel sounds auscultated
 17. Abdomen
• Dome-shaped abdomen
• Abdominal respirations
• Soft to palpation
• Well-formed umbilical cord
• Three vessels in cord
• Cord dry at the base
• Liver palpable 2-3 cm below the right costal
margin
• Bilaterally equal femoral pulses
• Bowel sounds auscultated within two hours
of birth
• Voiding within 24-48 hours of birth
• Small umbilical hernia
 SIGNS OF POTENTIAL DISTRESS
• absent bowel sounds
• visible peristaltic waves
• abdominal distention
• palpable masses
• scaphoid shaped abdomen
• omphalocele
• base of cord with redness or
drainage
• cord with two vessels only
 18. Female Genitalia
• Edematous labia and clitoris
• Labia majora are larger and
surrounding labia minora
• Vernix between labia
• Hymental tag
• Pseudomenstruation
• Smegma-sebaceous secretion
• Increased pigmentation
• Ecchymosis and edema after breech
birth
• Red, brick pink-stained urine
SIGNS OF POTENTIAL DISTRESS

 Labia fused
 Fecal discharge from vaginal opening
 Inperforate hymen
 Ambiguous genitalia
 Widely separated labia
 19. Male Genitalia

• Urinary meatus at the tip of the glans penis

• Palpable testes in scrotum
• Large, edematous, pendulous scrotum, with
rugae-(fold)
• Smegma beneath the prepuce
• Stream adequate on voiding
• Prepuce covering urinary meatus
• Erections
• Increased pigmentation
• Edema and ecchymosis after breech delivery
SIGNS OF POTENTIAL DISTRESS:

1. Non palpable testes

2. Hypospadias
3. Epispadias
4. Scrotum smooth
5. Ambiguous genitalia
20. Back and Rectum

• Intact spine without

masses or openings
• Trunk incurvature
reflex
• Potential anal opening
• Wink reflex present
SIGNS OF POTENTIAL DISTRESS:

1. Limitation of movement
2. Fusion of vertebrae
3. Spina bifida
4. Tuft of hair
5. Imperforate anus
6. Anal fissures
7. Pilonidal cyst
 21. Neuromuscular System
• Maintains position of flexion
• When prone, turns head side to side
• Holds head and back in horizontal plane when held prone
• Ability to hold head momentarily erect
NORMAL NEWBORN REFLEXES:
 Blink reflex  Tonic-neck reflex
 Rooting reflex  Moro reflex
 Sucking reflex  Babinski reflex
 Swallowing reflex  Magnet reflex
 Extrusion reflex  Crossed extension reflex
 Palmar grasp reflex  Trunk incurvation reflex
 Step-in-place reflex  Landau reflex
 Placing reflex  Deep tendon reflex
 Plantar grasp reflex
1. Hypotonia- low muscle tone
2. Quivering
3. Limp extremities or strainghtening of extremities
4. Clonic jerling
5. paralyis

SIGNS OF POTENTIAL DISTRESS

22. Cardiovascular System

• Functional closure of the

ductus arteriosus, foramen
ovale , ductus venosus and
umbilical artery
• Blood volume is 80-
100ml/kgBW or total of
300 ml
• High ESR, hgb and WBC
count
• Prolonged coagulation or
prothrombin time
 23. Respiratory System

Onset of breathing occurs as

air replaces that fluid that
filled the lungs during the
intrauterine life
 24. Gastrointestinal System

 Sterile at birth
 Limited ability to digest fats
 Immature cardiac sphincter between the
stomach and the esophagus
 Immature liver functions
 Meconium to transitional stool
• Voids within 24 hours after birth
• System does not fully mature until after the first
year of life

25. Urinary System/Renal

 26. Immune System

• Difficulty of antibody formation