Physiologic & Behavioral Transition to
Extrauterine Life
The Normal Newborn
Assessments @ 1 min. and 5
 A = appearance
 P = pulse
 G = grimace
 A = activity
 R = respirations
APGAR Scores
Physiologic Transitions of
Major Systems
Pulmonary system transition
Cardiac system transition
Metabolic transition
Gastrointestinal system transition
Assessing for Congenital
 Observe general appearance.
Gross external anomalies.
 Observe breathing pattern & auscultate
Cardiorespiratory problems, diaphragmatic
 Observe breathing with infant’s mouth
Choanal atresia.
Congenital Anomalies (cont.)
 Pass gastric tube or aspirate stomach
Esophageal atresia.
 Observe appearance of abdomen.
Intestinal atresia (distended), diaphragmatic
hernia (scaphoid), omphalocele,
 Confirm passage of meconium & observe
appearance of anus including wink reflex;
perform rectal temperature.
Imperforate anus.
 Count umbilical vessels.
<3 associated with genitourinary or cardiac
 Measure head circumference & palpate
Microcephaly, hydrocephalus.
 Inspect and palpate palate.
Cleft palate.
 Evaluate hips.
Congenital hip dysplasia.
 Axillary temp: 97.1-97.8 F (36-36.5 C).
 Heart rate: 120-160 bpm apical (assess for 1
full minute).
 Respirations: 30-60 per min. not crying
(assess for 1 full minute).
 Infants are considered AGA if weight, length,
& head circumference are btw.10th & 90th
percentiles, on standardized growth chart.
 Average weight: 7.5 lbs. (3.5 kg).
 Average length: 20 in. (51 cm).
 Head circumference: 13-14 in. (3335.5 cm).
 Chest circumference: 12-13 in. (30.533 cm).
 Head circumference: 0.8 in. larger
than chest circumference (2 cm).
Assessment of the Normal Newborn
 Color.
 Observe general tone, activity, & posture
(initially & throughout exam).
 Observe & palpate skin.
 Measure & record weight & length, and plot
on growth curve.
 Measure & record temperature.
Head, Face and Neck:
 Measure & record head circumference,
& plot on growth curve.
 Inspect & palpate head.
 Palpate sutures.
 Palpate & measure fontanelles.
 Observe face, nose, & lips.
 Observe eyes & measure position.
 Observe and palpate ears, measure
 Inspect & palpate mouth.
 Inspect & palpate neck, clavicle, &
shoulders; assess mobility.
Chest, Abdomen, and Back:
Observe thorax.
Measure chest circumference at nipple line.
Observe breathing movements.
Count respiratory rate.
Auscultate lungs.
Auscultate heart sounds.
Count heart rate.
Auscultate bowel sounds (all 4 quadrants,
before palpation).
Observe & palpate abdomen.
Inspect umbilical cord & umbilicus.
Palpate femoral lymph nodes & pulses.
Record passage & character of stools.
Determine patency of anus (rectal
 Palpate & inspect spinal column.
 Observe back & buttocks.
Genitals & Urinary System:
 Confirm urination; observe stream of
urine in male infant.
 Note appearance of external genitalia.
 Observe genitalia & palpate testes of
male infant.
 Observe genitalia of female infant.
 Observe arms & legs for symmetric
appearance, size, length, & movement.
 Observe hands & feet.
 Evaluate rotation of hips: Ortolani &
Barlow maneuvers.
 Palpate peripheral pulses.
 Rooting (assess bilaterally).
 Swallow.
 Sucking.
 Moro (startle reflex).
 Palmar and planter grasp (assess
 Tonic neck reflex or fencing (assess
 Stepping or walking.
 Pull to sit (traction).
 Blink (glabellar).
Nutritional Needs of the Newborn
 Growth in the neonatal period
 Needs of the newborn and infants up to 2
months and after 2 months
 Actual caloric requirement...depends on the
infant activity level and growth rate
 Necessary for the formation of the new
 The newborn and infant need amino acids
 Unaltered cow’s milk not recommended
 Casein Vs. Lactalbumin
 Linoleic acid
 ......Necessary for growth and skin integrity
in infants
 Lactose found in human milk and
commercial formulas
 ........Improves calcium absorption and assist
in nitrogen retention.
 ........Allows protein to be used for building
new cells rather than calories
 ........Decrease the possibility of
gastrointestinal illness
 Aid in bone growth
 Decrease level lead to tetany
 Term infant will not need iron supplement
for the first 3 months
 Until they begin to produce adult
 Aid in building teeth and preventing tooth
 Given to child at 6 months of age
 ......If the child not receiving adequate
amount from breast feeding
 Fluid requirements for a newborn is 150200 ml/kg (2.5-3.0 oz) over 24 hrs
 Fruit juice is not recommended.
Physical examination of the newborn
Vital signs
Growth measurements
Head and neck
Respiratory System
Cardiovascular system
Musculoskeletal system
Central nervous system
Positions for Breastfeeding
Advantages of Breastfeeding
For Mother:
 Helps the uterus to shrink back to prepregnancy size more quickly
 Serves as a protective function in preventing
breast cancer
 Convenience – breast milk is always ready to
use, clean & is always at the right temperature
for the baby and can be refrigerated for later
 Strengthens mother-baby bonding
 Cost
Advantages of Breastfeeding
For Baby:
Breast milk is individualized for the baby
Better digestion
Lessens susceptibility to allergies
Better mouth development
A DISADVANTAGE of breastfeeding is that
the breast milk may carry microorganisms
(i.e.: Hep B, Cytomegalovirus, HIV)
 Burping is important during and after
feedings to bring up any excess air that was
taken in during feeding
 Baby should be burped every couple of
ounces or between breast change
Three common ways of burping baby:
1. Over the shoulder
2. Face baby down on your lap while sitting
3. Sitting Up
Myths about Breastfeeding
Myth: “You can’t breast feed if you have small breasts”.
Reality: Breasts of all shapes and sizes can satisfy the hungry baby.
Myth: “Breast feeding is a lot of trouble”.
Reality: Breasts, as opposed to bottles, are ready when the baby is
Myth: “Breast feeding ties you down”.
Reality: Breast milk can be stored if mother decides she wants to go out.
When the mother goes out she always has the food supply for the baby
no matter how long she plans to stay out.
Myth: “Breast feeding ruins your breasts”.
Reality: Breast-feeding does not change the shape or size of the breasts.
There are other factors (i.e. – age, not wearing a bra, or excess weight)
that can change the shape & size of breasts.
Myth: “The father is excluded during breast feeding”.
Reality: An involved father will take advantage of opportunity such as
bathing, diapering, holding, & playing with the baby.
Nursing Outcomes – Mom is able to
demonstrate following:
 Comfortable position to breastfeed
 Determines whether or not the breast is
full prior to feeding
 No nipple tenderness
 Recognizes hunger signs
Is satisfied with breastfeeding
Milk Production
First stage of milk
milk ejection or let down reflex
Milk production can be influenced by
Emotional stress
Ambivalence to breastfeeding
Physical well being of infant and mother
 extra calories (250 - 500)
 6-8 glasses of water or liquid
 Selection from each of the four main food
 Maternal use of iron or iron supplements
 Advance of alcohol, tobacco and drugs
Nutritional Management at home
 Nurse baby every 1-3 hours
 both breast at each feeding
 expect 6-8 wet diapers every 24 hours (after
first week
 bowel movement (consistency + appearance)
 most babies have periods of irritable crying
 growth spurts
 community resources - LaLeche League, WIC,
community Lactation Consultants, hospital
programs + support groups
Common Problems Encountered
in Breast Feeding
Cracked or Sore Nipples
check for correct latch
frequent feedings
rotation during breastfeeding
air drying
warm soaks
Flat or Retracted Nipples
 use of milk cups
 electric pumps
 ice wrapped
Infant’s Position
Encourage rooting reflex
areola into mouth
avoid having infant press nose
removal of infant from the breast
last first, first last
Care of the Breast and Nipples
air dry
support bra
Advantages of Bottle Feeding
 Baby is satisfied longer
 Monitoring intake
 More freedom for mother (i.e.: if she wishes to
go out for the evening)
 Father is able to participate in feeding the baby
 Increased opportunity for sibling as to
participate in feeding
 Birth control methods are less restrictive
 Less stress for feeding the baby in public
Infant Formula
 What is formula? All formula is designed to
similate nutritional content of breast milk
 What does formula contain?
Protein,fat,iron,carbs &vit A,D,E,K linoleic
 Caloric: 20 cal. per oz.
 Allergies
 Soy for sensitivity to milk protein,lactose free
for possible lactose , and alimentum for severe
for severe food allergies/colic r/t protein
Types Of Formula
 Powdered, Prepared,Concentrate
 Cost $$$- Which is best?
 Preparation-boil H2O approx 1 min.
 Initial feedings are only ¼-1 oz.
 Most newborns approx. 2-3 oz per feeding q 2-3
hrs. Add 2 or 3 to infants age. Ex. A 3 month
old would require 5-6 oz.
 Ample feedings will produce 6-8 wet diapers
per day
 Discard unused bottle formula after, discard
formula after baby is done, bacteria from
baby’s mouth has passed into milk. Bacteria.
 Can be stored in fridge up to 24 h
Nursing Process
 Nutritional status prior to and during mother’s
 Assess the newborn for adequate nutrition
 Identify mother’s skills and knowledge about
breastfeeding vs. formula usage.
 Mother’s ability to recognize signs of hunger in a
newborn (e.g., restlessness, tense body posture,
smacking lips, or tongue thrusting)
 Check mom’s knowledge whether newborn is receiving
enough feeding by voiding, growing, and alert
Nursing Dx:
 Imbalanced nutrition, less than body requirements r/t
poor newborn sucking response.
 Health seeking behavior r/t lack of knowledge about
lactation and breast feeding technique
 Effective breast feeding r/t well prepared mother and
healthy newborn
 Ineffective breast feeding r/t anxiety and inexperience
 Pain r/t breast engorgement or sore nipples
 Deficit knowledge r/t potential harm to baby of drugs
taken by breast feeding mother
 Health seeking behaviors r/t techniques of bottle
 Begins while the newborn is pregnant
 Focus on providing information on breast feeding or
bottle feeding
 Provide information to woman who expects to formula
feed to purchase supplies in advance
 Advise client to drink at least 4 to 6 8oz. Glasses of fluid
per day
 Give information on how / where to allocate community
resources base on financial needs
Outcomes For Breastfeeding
The client will be able to verbalize
knowledge in the following:
 Hunger signs of the baby & signs of proper
 Proper positioning & techniques of
The client will be able to verbalize
knowledge in the following:
 Latch on properly, proper sucking & tongue
 Swallowing should be audible at a minimum of
5-10 minutes per breast at 8 feedings per day
 2 or more loose, yellow, seedy stools per day (at
least 6 voidings per day)
Nursing Outcomes – Mom is able to
demonstrate following:
 Comfortable position to breastfeed
 Determines whether or not the breast is full
prior to feeding
 No nipple tenderness
 Recognizes hunger signs
Is satisfied with breastfeeding

Positions For Breastfeeding