The Normal Newborn

ASSESSMENT AND CARE

 Three transition phases

Phase One: the first hour

Phase Two: from one to three hours
Phase Three: from two to 12 hours
 Priorities in first hour

Cardiovascular assessment and support

Thermoregulation
Assessment and support of blood glucose
Identification
Observing urinary/meconium passage
Observing for major anomalies and for apparent
gestational age concerns
 APGAR ASSESSMENT

One and five minutes

Meant to identify the need for neonatal resucitation
APGAR SCORE
 APGAR SCORE

Criteria 0 1 2

Color Blue or pale Acro-cyanotic CompletelyPink

Heart Rate Absent Slow  >100/min

   (< 100/min)

Reflex irritability No response Grimace Cough, sneeze,

cry

Muscle tone Limp Some flexion Active motion

Respirations Absent Slow, irregular Good, crying

 Additional signs of respiratory distress

Persistant cyanosis
Grunting respirations
Flaring of the nostrils
Retractions
Respiratory rate >60
Heart rate >160 or <110
 Maintaining thermoregulation

Referred to as maintaining a neutral thermal

environment
 Heat loss is minimal
 Oxygen consumption needs are at their lowest
Hypothermia can cause
 Hypoglycemia
 Increased oxygen needs
 Four mechanisms of heat loss
and corresponding interventions

Evaporation
 Dry infant immediately

Conduction
 Place on mothers body skin to skin

Convection
 Cover with a blanket, wear a cap

Radiation
 Keep away from cold windows and cold objects
Mechanisms of heat loss
 Vital Sign Normals

97.7-98.6 F (36.5-37 C)
110-160
 A soundly sleeping baby can go to 80 bpm
 A crying baby may be as high as 180
30-60
 Voids and Stools

Document from the moment of birth

Urination sometimes missed in early minutes
Generally expect both within the first 24 hours
One really wet diaper per day of age until milk is
fully in.
 Observation for Gestational Age

Thorough assessment with Ballard Scale done later

A quick assessment is done in the delivery room
This enables infants earlier admission to the nursery
and anticipatory intervention to the problems of pre
and post term infants
 Quick Assessment of Gestational Age

Skin
Vernix
Hair
Ears
Breast tissue
Genitalia
Sole Creases
Resting Posture
Cracked Skin
Abundant Lanugo
Ear of a preterm infant
Areola and increased lanugo
Sole creases
Female genitalia, very preterm
Preterm and Term Genitalia
Male Genitalia
Comparison of resting posture
Preterm and Term Male Genitalia
 Hypoglycemia

Criteria vary from source to source

LPN book says <40
RN book says <36 but a threapuetic objective of 45
mg/dl or greater
The brain is dependent on a steady supply of glucose
for its metabolism
 Infants at Increased Risk for Hypoglycemia

Preterm/postterm
Infants of diabetic mothers
Large for gestational age
Small for gestational age
Infants with Intrauterine growth retardation
Asphyxiated infants
Infants who are cold stressed
Infants whose Moms took ritodrine or tgerbutaline
to stop preterm labor
 Symptoms of Hypoglycemia
Jitteriness Poor suck
Poor muscle tone Feeding difficulties
Sweating High pitched cry
Respiratory difficulty Weak cry
Apnea Lethargy
Low temperature Seizures
 Hypoglycemia protocol

Low risk infants have a serum glucose drawn only if

symptomatic
High risk infants will have one per a hospital
protocol
Protocol typically at birth and q 1 hour x 3
 Routine Medications

Erythromycin Eye
Ointment
Aquamephyton
(vitamin K)
First Hepatitis B
vaccine
HBIG if Mother is
Hep B surface
antigen positive
Physical Characteristics

DURING PHASES TWO AND THREE

 Nervous System: Reflexes
Head lag Rooting reflex
Moro reflex Suck
Rooting Hand and foot grasp
Tonic Neck reflex Babinski
Dancing reflex Trunk incurvation
Magnet reflex Observe for symmetry
Head Lag
Moro Reflex
Tonic Neck Reflex
Dancing Reflex
Suck Reflex
Hand Grasp
Foot Grasp
 Head

Head circumference
Molding
Caput succedaneum
Cephalohematoma
Fontanelles
 Anterior closes between 12-18 months
 Posterior closes by the end of the 2nd month
Molding
Cehpalhematoma
Caput Succedaneum and Cephalhematoma
 Eyes

Eye placement
Epicanthal folds
Blink reflex
Discharge
Pupil reaction
Follows to midline
 Hearing

Check overall response to sudden sound

 Moro reflex
Check for placement of ears
 Low set ears may indicate a congenital anomaly
Most infants receive hearing screening within the
first week of life
 Respiratory and Cardiovascular

Ongoing assessment of cardio respiratory status that

has occurred since birth
More thorough heart assessment
Murmur may be present until fetal openings have
completely closed however they must be carefully
verified by pediatrician
Femoral and brachial pulses
Abdominal breathing; nose breathers
Femoral Pulses
Brachial Pulses
Assessment of Respiratory Status
 Musculoskeletal

Symmetry!!
Five finger and five toes!!!
Clavicles
Movement of arms
Hips for developmental hip dysplasia
Lower legs/feet for “club foot”
Back: curvatures, cysts or dimples
Hip Check
Hip Check Skin Folds
 GenitoUrinary

Male or female
Male
 Testes descended
 Proper placement of meatus
Female
 Teach parents about pseudomenstruation
Always watch for and record voids!!!
 Gastrointestinal

Passage of meconium
Placement and patency of anus
Abdomen should be soft and non tender
Round but not distended
Bowel sounds are present after first hour of birth
Umbilical cord inspection
 Skin, many normal findings

Acrocyanosis
Desquamation
Epstein’s Pearls
Erythema toxicum
Harlequin Color
Milia
Mongolian Spots
Port Wine Stains *
The Normal Newborn

CARE MEASURES FOR THE

NORMAL NEWBORN PLUS A
LITTLE MORE.
 Jaundice
Yellow coloring of an infants skin
Common and is caused by the natural breakdown of
RBCs in the infant after birth
Is never considered normal in the first 24 hours.
 Physiologic Jaundice
Most jaundice in newborns is physiologic
It peaks between 48-72 hours
Usually disappears within a week
Usually benign
Can become elevated to a point of concern for the
baby
 Significance of Jaundice
 Bilirubin is toxic to the brain.  
 Bilirubin is prevented from entering the brain by
blood brain barrier under normal circumstances.
 However the blood brain barrier isn’t well developed
in the newborn. Unconjugated bilirubin (lipid
soluble) could cross to the newborn and would cause
encephalopathy. (Kernicterus)
 Physiologic Jaundice
Infants have extra RBCs due to fetal life
They need to be broken down by the body
Bilirubin is a component of the degradation of the
RBCs.
The liver is immature and does not conjugate and get
rid of the bilirubin fast enough.
 More data on Physiologic Jaundice

RBC/Hgb level is higher than required

 Neonatal RBC: 4.8-7.1 Infant: 4.2-5.2
 Neonatal Hbg 14-24 Infant 11-17
Cells containing fetal hemoglobin have a shorter life
span
Bilirubin Nomogram
Phototherapy Nomogram
 Other factors that will exacerbate physiologic
jaundice
Drugs Hypoglycemia
Bruises Hypothermia
Caput Poor feeding
Cephalohematoma Delayed passage
Fetal hypoxia meconium
Polycythemia Trisomy 21
 Care to prevent hyperbilirubinemia

Early feeding
Frequent feeding
Neutral thermal environment
Prevention of hypoglycemia
Prevention of hypoxia
 Causes of Pathologic Jaundice

Excessive hemolysis
 Rh incompatibility
 ABO incompatibility
 G6PD defficiency

Infection
Metabolic/endocrine abnormalities
Delayed defecation/intestinal obstruction
Liver/biliary disease
Spleen pathology
Polycythemia
PHOTOTHERAPY
 Care of Infant on Phototherapy
Risk of injury to eyes
Risk of injury to gonads
Risk of impaired skin integrity
Risk for fluid volume deficiency
Risk for hyperthermai or hypothermia
Risk of neurological injury
Imbalance nutrition
Parental anxiety
Exchange Transfusion
Isn’t he lovely?
 Other Newborn Care issues

Bulb suctioning: RN 731 LPN 286

Umb cord care: RN 733 LPN 219
Heel Sticks: RN 741-43 LPN219
Circumcision: RN 755 See patient teaching page 757
LPN 290