Nursing Care for the Newborn & Family
Nursing Care of the Newborn
 Newborns undergo many profound physiologic and psychological changes.
 They are released from a warm, close, dark, liquid filled environment that met
all needs, into a chilly, unbound, brightly lit, gravity based, outside world.
 Within minutes respirations are initiated and circulatory accommodation are
made.
 Within 24 hours neurologic, renal, endocrine, GI, and metabolic functions must
operate.
 Newborn or neonatal period is the first 28 days of life.
 2/3 of deaths occur in the 1st year
 ½ occur in the 1st 24 hours
 Assessment
 Mother’s pregnancy history
 Physical exam of the newborn
 Lab reports
 Bonding
Profile of the Newborn
 All newborns are different.
 Vital Statistics
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Weight:
Plot on neonatal graph (Appendix E)
Average weight R/T gestational age
 White female 7.5 lbs.– 3.4 kg.
 White male 7.7 lbs.-3.5 kg.
Other races-0.5 lbs less
Limits-5.5 lbs to10 lbs (17 lbs largest)
Newborn loses 5 to 10 % of birth weight ( 6 to 10 oz. during first few days.
Loss due to salt and fluid retaining maternal hormones. Voiding and stool, and
diuresis.
After wt. loss then 1 day of stable wt. then recaptures birth weight within:
 Breastfed 10 days
 Formula fed 7 days
Will gain 2 lb/month (6 to 8 oz/week) for first 6 months.
Length:
Female-53 cm.- 20.9 in.
Male-54 cm. –21.3 in.
Limits 18 in. to 23 in.
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Head Circumference:
34 to 35 cm. (13.5 to 14 in.)
Limits-less than 33 cm. or greater than 37 cm.
Measure with tape drawn across center of forehead and around the most
prominent portion of the posterior head.
Chest Circumference:
About 2 cm. less than head circumference (0.75 to 1 in.).
Measure at level of the nipples.
Viral Signs:
Temp 99 F at birth
Newborns lose heat by:
 Convection
 Conduction
 Radiation
 Evaporation
They have little subcutaneous fat for insulation. Shivering is rare.
They have brown fat – helps to conserve or produce body heat by increasing
metabolism.
Quickly dry and wrap newborns and place under radiant heat source or place
directly against mothers skin.
Newborn with a bacterial infection will have a subnormal temperature.
Pulse:
Immediately after birth 180 bpm.
Within 1 hour- 120 to 140 bpm.
Irregular and transient murmurs due to immaturity of the cardiac regulatory
center in the medulla and closure of the shunts.
Sleeping – 90 to110 bpm.
Always check apical for 1 full minute
Check femoral pulse for coarctation.
Respiration:
30 to 60 breaths / min.
Rate, depth, and rhythm may be irregular with short periods of apnea (without
cyanosis) called periodic respirations.
Observe movement of the abdomen.
Coughing and sneezing clear the airway.
Newborns are nose breathers
Short periods of crying are beneficial.
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Blood Pressure:
80/46 mm Hg at birth
10th day 100/50 mm Hg
Cuff 2/3 the length of upper arm or thigh.
Physiologic Function
Cardiovascular System:
Peripheral circulation is sluggish for 1st 24 hours.
Common to see cyanosis of the feet and hands (acrocyanosis) cold to touch.
Blood values:
Blood volume-300 mL
Increased erythrocyte count-will decrease after 3 days. Breakdown of these
cells cause an increase bilirubin >4 mg/100mL
At 7 mg/ml tissue is jaundice. Physiological jaundice R/T brusing,
cephalhematoma, dehydration, or intestinal obstruction.
Treat at 10-12 phototherapy, fluids, >20 neuro kernicterus (permanent cell
damage)
Hgb 17-18
Hct 45-50% (use warm cloth on heel to increase sluggish circulation to get a
more accurate value).
WBC increased due to stress of birth.
Blood Coagulation:
Prolonged coagulation or prothrombin time for 24 hours because of low
vitamin K level.
Infant intestine is sterile at birth.
Administer Vitamin K (AquaMephyton) 1 hour after birth in lateral anterior
thigh.
Respiratory:
First breath initiated by
 Cold receptors
 Lowered PO2 (15 mm Hg)
 Increased PCO2 (70 mm Hg)
Surfactant allows the alveoli to inflate more easily.
1/3 of fluid is forced out of the lungs with the pressure of delivery.
Within 10 min. a good residual volume is established.
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Gastrointestinal System:
Sterile tract for 1st 24 hours
Stomach holds 60 to 90 mL
Decreased ability to digest fat and starch
Regurgitation due to immature cardiac sphincter between stomach and
esophagus.
Lower glucose and protein serum levels due to immature liver.
Stools – meconium 1st 24 hours. Sticky, tarlike, blackish green, odorless.
If no meconium in 24-48 hours possibility of ileus, imperforate anus, or bowel
obstruction.
Transitional stool- day 2-3 becomes green and loose.
Day 4 breastfed will pass 3-4 light yellow stools per day.
Bright green is due to increased bilirubin.
Watery and loose or mucus may be a milk allergy.
Gray clay stool – bile duct obstruction.
Urinary System
Voids within 24 hours
Light color and odorless; kidneys do not concentrate urine well and no
reabsorption.
6 voids /day 15 to 50 mL
By 1st week total daily volume is 300 mL
Immune System:
Unable to form antibodies the 1st 2 months.
Has passive immunity from the mother
Hepatitis B vaccine during 1st 12 hours.
Neuromuscular System:
Reflex Maneuvers:
Blink reflex
Rooting
Sucking
Swallowing
Extrusion
Palmar Grasp
Step-Walk in Place
Placing
Plantar Grasp
Tonic Neck
Moro
Babinski
Magnet
Crossed Extension
Trunk Incurvation
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Landau
Deep Tendon
Senses:
Hearing in utero
Vision see immediately, blink, follow objects
Touch well developed
Taste likes glucose and avoids salt
Smell breast milk
Adjustment to Extrauterine Life
Skin
Color:
Ruddy due to increased concentration of RBC in blood vessels and decreased
fat. Fades slightly over the 1st month.
Cyanosis-lips, hands, feet
 Central cyanosis is a great concern
 Suction mouth before the nose because suctioning the nose may trigger a
reflex gasp, possibly leading to aspiration.
Appearance of the Newborn
 Hyperbilirubinemia leads to jaundice or yellowing of the skin.
 Occurs on day 2 or 3 in 50% of all newborns due to breakdown of fetal RBC.
 Indirect bilirubin > 7mg/100 mL
 Early feeding promotes intestinal movement and helps prevent bilirubin build
up.
 Pallor due to anemia.
 Excessive blood loss when cord was cut.
 Inadequate flow of blood from cord into infant at birth.
 Fetal maternal transfusion
 Low iron stores
 Blood incompatibility
 Internal bleed in the baby
 CNS damage
 Harliquin Sign-newborn lying on side and it will appear red on the dependent
side of the body and pale on the upper side, changing positions will make it
fade.
 Birthmarks
 Hemangiomas-vascular tumors of the skin.
 Nevus flammeus-port-wine stain
 Macular purple or dark red lesion
 Appears on face or thigh
Those above the bridge of the nose fade
 Can be covered by cosmetics, remover surgically, or by laser therapy.
Stork’s beak marks – at nape of neck, lighter pink patches. More frequent in
females. Do not fade.
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Strawberry Hemangiomas:
 Elevated areas formed by immature capillaries and endothelial cells.
 Appear at birth or 2 week later.
 Due to high estrogen levels
 50 to 75% may disappear by age 7
 Mark may grow in size.
 Surgery not recommended due to scarring
Cavernous Hemangiomas:
Dilated vascular spaces
Raised and resemble a strawberry hemangioma but does not disappear.
Surgically removed.
Mongolian Spots:
Collection of pigment cells (melanocytes) that appear slate-gray patches on
sacrum or buttocks S/T arms and legs.
Asian, Southern European, or African
Disappear by school age.
Vernix Caseosa:
White, cream cheese-like substance that serves as a skin lubricant.
Lanugo:
Fine hair, covers newborn’s shoulders, back, and upper arms. Forehead and
ears.
By age 2 weeks it has disappeared.
Desquamation:
Dry skin on palms of hands and soles of feet.
Milia:
Pinpoint white papule found on cheek or across bridge of nose.
Disappear by 2 to 4 week as sebaceous glands mature.
Erythema Toxicum (flea-bite rash):
Rash, appears 1st to 4th day up to 2 weeks of age.
Lacks pattern and will last only hours.
Due to eosinophils reacting to environment.
Forceps Marks:
May have a circular or linear contusion matching the rim of the blade on
infants cheek.
Disappears in 1 to 2 days
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Assess facial nerve while at rest and crying.
Skin Turgor:
Feels elastic, smooth if well hydrated.
Head:
Appears large, 1/4th total length, forehead large and prominent.
Chin receding, quivers easily.
Full-body of hair if well nourished
Pinpoint ulcer where monitor was attached.
Fontanelles:
Openings where skull bones join
Anterior fontanelle
 Junction of parietal and frontal bones.
Diamond shaped-2 to 3 cm. width and 3 to 4 cm. length.
Closes at 12 to 18 months
Posterior fontanelle
Triangle shaped-1 cm. length.
Closed at 2 months.
Sutures:
May override at birth.
Molding:
Infant’s head (vertex) engages the cervix.
After birth, appears prominent and asymmetric.
Will restore to normal shape in a few days.
Caput Succedaneum:
Edema of the scalp at the presenting part of the head.
Crosses the suture line, will be absorbed and disappear by the 3rd day.
Cephalhematoma:
Collection of blood between periosteum of the skull bone and bone itself
caused by rupture of periosteum capillary at birth.
Occurs 24 hours after birth, severe swelling, black and blue, egg shape.
Swelling stops at suture line.
Takes weeks to be absorbed.
Craniotabes:
Localized softening of the cranial bones.
Indents easily with touch of the finger.
Corrects after a few months.
Eyes:
Usually tearless, lacrimal ducts mature at 3 months.
Irises-gray or blue
Sclera-blue due to thinness.
Permanent eye color between 3 to 12 mo.
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Erythromycin ointment EES-for chlamydia and gonorrhea
Subconjunctival hemorrhage-red spot on sclera or red ring around cornea.
Absorbed in 2 to 3 weeks.
Edema around orbit or on eyelid. Will remain for 2-3 day until kidneys remove
the fluid.
Ears:
External not completely formed.
Top part in line with inner canthus of eye.
Test hearing by ringing a bell 6 in. from ear.
Nose:
Appears large.
Assess by closing mouth and compress one naris.
Mouth:
Open evenly, tongue appears large.
Palate intact, check for cysts.
No teeth (1-2 natal teeth sometimes).
Neck:
Short, chubby, skin folds, rotates freely.
May try to raise head but lacks control.
Chest:
Breast appear engorged, may secrete a thin, watery fluid (witch’s milk). 1 wk
to subside
2 in. less than head.
Lungs have rhonchi due to mucus for first 24 to 48 hours. Alveoli open slowly.
Abdomen:
Slightly protuberant
Bowel sounds within 1 hour.
Liver palpable 1 to 2 cm below right costal margin.
Umbilical cord-white, gelatinous structure with red and blue streaks. Count
veins and arteries.
Inspect cord clamp, within 1 hour cord begins to dry and shrink and turns
brown. Day 2 to 3 will turn black.
Day 6 to 10 breaks free and new granulating area will heal in next week.
Assess abdomen by stroking each quadrant and observe umbilicus to move or
wink in that direction.
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Anogenital Area:
Check for patency.
Male Genitalia:
Scrotum edematous and has rugae.
Penis 2 cm., check prepuce (foreskin).
Circumcision
Female Genitalia:
Vulva swollen due to effect of maternal hormones.
Mucus vaginal secretion, sometimes blood tinged.
Back:
 Flat in lumbar and sacral areas.
 Back rounded, arms and legs flexed on abdomen and chest.
 Extremities:
 Appear short, hands plump,clinched and palmar crease.
 Fingernails soft, smooth and long.
 Muscle tone- unflex arm and immediately returns flexed.
 Fingertips cover proximal thigh.
 Legs bowed and short, feet turn inward.
 ROM
 Ortolani’s sign-clunk of femur head striking the shallow acetabulum.
 Barlow’s sign-hip slips in socket.
 Lying on abdomen newborns bring arms and legs underneath them and rise
their stomach off the bed.
Assessment of the Newborn
 Apgar Scoring:
 1 minute and 5 minutes after birth Rated 0,1,or 2 then added together.
 Score of 4-6 = guarded, 7-10 = good.
 Heart rate-auscultate with stethoscope.
 Respiratory effort-cries spontaneously at 30 seconds after birth.
 Muscle tone-extremities tightly flexed.
 Reflex irritability-suctioning or sole of feet slapped.
 Color-cyanotic at birth, pink shortly after first breath.
 Respiratory Evaluation
 Highest priority in newborn care.
 Physical Examination
 Given immediately after birth, very quickly
 Height and Weight
 Nude, also head, chest and abdominal circumferences.
 Weight daily at same time.
 Laboratory Studies
 Heel stick for H&H and hypoglycemia (< 40mg/100 mL)
 Gestational Age
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Ballard’s assessment
Behavior Capacity
Physically active and emotionally prepared to interact with people.
Brazelton Neonatal Behavioral Assessment Scale
 Evaluates newborn’s behavioral capacity or ability to respond to stimuli.
Care of the Newborn at Birth
Equipment-radiant heat table, warm soft blankets, O2, resuscitation, suction,
eye care, identification, scales.
Handle gently
Newborn ID and Registration
ID
Kidnapper profile- recently lost a pregnancy
or had an infant stillborn and who desires an infant very much.
Familiar with hospital, pretends to be a volunteer or unlicensed health care
worker and says she needs to take the baby out of the nursery.
ID Band (one arm and one leg)
Plastic bracelet, number corresponds to the mother’s hospital number,
mother’s full name, sex,date and time of infant’s birth.
Has built in sensor unit that alarms if baby is transported beyond set
boundaries.
Foot prints are taken and placed on chart.
Registration filed with the Bureau of Vital Statistics of the state of birth.
 Infant’s name, mother’s name, father’s name if mother chooses, birth date
and place.
 Important because it provides eligibility for school, voting, social security
benefits, passports.
Birth Record Documentation:
Time of birth
Time the infant breathed
Whether respirations were spontaneous or aided
Apgar at 1 and 5 minutes of life
Whether eye prophylaxis was given
Whether vitamin K was administered
General condition of the infant
Number of vessels in umbilical cord
Whether cultures were taken
Whether infant(1)voided and (2) passed stool.
Nursing Interventions
Keep Newborn Warm:
Reassess temp in 1 hour then q 4-8 hours.
Promote Adequate Breathing Pattern and Prevent Aspiration:
Suction with bulb syringe
Record First Cry:
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Aided or unaided
Inspect and Care for Umbilical Cord
Hazeltine or Kane clamp
Count vessels
Apply triple dye
Coed falls off 7 to 10th day. Do sponge bath.
Apply alcohol to cord site.
Administer Eye Care
Erythromycin ointment
General Infection Precautions
Wash up to elbows between babies, gown
Personnel with infections excluded until clear.
Isolate with contagious illness.
Postpartal Period
Initial Feeding:
May breastfed immediately
Formula fed in 2-4 hours
On demand schedule may be q 2 hours
First bath within 1 hour
Supervise parents with 1st bath, cleanest to most soiled. No soap on face.
Football hold
Sleeping Position
On back due to SIDS
Diaper Area Care
Wash with clear water and dry.
A&D may be applied to buttocks
Metabolic Screening Tests
PKU-phenylketonuria-disease of defective protein metabolism
Hypothyroidism
3 drops from heel stick on special filter paper.
Hepatitis B Vaccination
Within 12 hours after birth, second dose due in 1 month and 3rd due at 6
months.
Care of the Newborn in Postpartal
 Vitamin K Administration
 Newborn’s are at risk for bleeding disorders
 Single dose 0.5 to 1.0 mg IM of vitamin K is administered within 1 hour after
birth.
 Circumcision
 Surgical removal of penis foreskin
 1st or 2nd day of life
 Check q 15 min for 1 hour for bleeding, document voiding after the procedure.
 Petrolatum for 3 days.
Readiness To Care For Newborn
 Assess how prepared each family is to care for the newborn.
 Infants wake up during the night for 1 or more feedings for about the 1st 4
months.
 Numerous questions to ask to assess for an adequate and safe home.
 Daily care:
 Some consistency
 Satisfy the infant
 Sense of well-being and contentment
 Sleep Patterns
 Sleeps 16 of 24 hours in 1st week at 4 hour intervals
 By 4 months 15 hours of 24 and through the night.
 Crying
 2 hours of every 24 for 1st 7 weeks. Peaks at 6 to 7 weeks then tapers off.
 Most typical wakeful time is between 6pm to 11 pm.
 Pacifier is up to parents.
 Cleanliness is a concern
 Parental Concerns Related to Breathing
 Stuffy nose or making snorting noises in sleep, have mucus for 2 weeks
 Breath irregularly
 Continued Heath Maintenance for Newborn
 Appointment with PCP in 2 to 6 weeks
 Parents need to judge the infants state of health, appearance, eating, activity,
disposition.
 Car Safety
 Meets federal guidelines
 Health Dept or Red Cross has info.
 Place in back seat may use a blanket to support the head. Facing the back.