Developed by D. Ann Currie, RN MSN
Assessment Data:
Condition of the Infant
 Apgar scores at 1 and 5 minutes
 Resuscitative measures
 Physical examination
 Vital signs
 Voidings
 Passing of meconium
Apgar Score
Care of the Newborn
immediately after birth
 Maintain respirations
 Provide and maintain warmth
 Apgar score
 Physical assessment
 Newborn identification
 Facilitate attachment
Signs of Newborn Transition
Neonatal Distress
Newborn Care
 Positioning
 Feeding
 Elimination
 Safety Issues
Newborn identification
 Newborn abduction
 Bonding
 Cord Care
 Circumcision Care/Uncircumcision Care
When to Call for Help
Assessment Data:
Infant Complications
 Excessive mucus
 Delayed spontaneous respirations or responsiveness
 Abnormal number of cord vessels
 Obvious physical abnormalities
Assessment Data:
Labor and Birth
 Duration and course
 Status of mother and fetus
 Analgesia or anesthesia
 Prolonged rupture of membranes
 Meconium-stained amniotic fluid
 Nuchal cord
 Precipitous birth
 Use of forceps or vacuum extraction assisted device
 Fetal distress
Assessment Data: Maternal
Complications
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Preeclampsia
Spotting
Illness
Recent infections
Rubella status
Serology results
Hepatitis B screen results
Exposure to group B streptococci
History of maternal substance
Human immunodeficiency virus (HIV) test result
Assessment Data: Family
 Parents’ interactions with their newborn
 Their desires regarding infant care
 Information about other children in the home
 Available support systems
 Patterns of interaction within each family unit
Physiologic Alterations
 Respiratory distress
 Pallor
 Hypothermia
 Alterations in feeding and elimination
Nursing Care: Assessment
 Airway clearance
 Vital signs
 Body temperature
 Neurologic status
 Ability to feed
 Evidence of complications
Nursing Care: Assessment
 Review of prenatal and birth information
 Gestational age
 Newborn’s adaptation to extrauterine life
 Weight and measurement
 Vital signs every 30 minutes
 Assessment of Hct or blood glucose if warranted
Daily Assessments
 Vital signs
 Weight
 Overall color
 Intake and output
 Umbilical cord
 Circumcision
 Newborn feeding
 Attachment
Daily Newborn Care
 Assist with feedings
 Thermoregulation
 Skin care
 Cord care
 Prevention of infection
 Security
Cord Care
Common Concerns
 How to pick up a newborn
 Holding and feeding the infant
 Changing the diaper
 Interpreting newborn cues
 Bathing the newborn
 Cord and circumcision care
 Normal voiding and stooling pattern
Parent Education
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Periods of reactivity and expected newborn responses
Normal physical characteristics of the newborn
The bonding process
The infant’s capabilities for interaction
The role of touch in facilitating parent-infant
interaction
 Comforting techniques
 Progression of infant behaviors
 Information about available educational materials and
support
Discharge Education
 Safety measures
 Voiding and stool characteristics
 Circumcision care
 Cord care
 Waking and quieting the newborn
 Car safety
 Immunizations
 Signs of illness
Wrapping Newborn
Infant car restraint for use from
birth to about 12 months of age
Signs of Illness
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Temperature above 38oC or below 36.6oC axillary
Continual rise in temperature
Forceful or frequent vomiting
Refusal of two feedings in a row
Difficulty in awakening baby
Cyanosis with or without a feeding
 Absence of breathing longer than 20 seconds
 Inconsolable infant or continuous high-pitched cry
 Discharge or bleeding from umbilical cord, circumcision, or any
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opening
Two consecutive green watery or black stools, or increased frequency of
stools
No wet diapers for 18 to 24 hours
Fewer than 6 to 8 wet diapers per day after 4 days of age
Development of eye drainage
Documentation of Discharge
 Teaching
 How
 Checking of ID Bands
 With whom
 Condition at discharge
 Where
The End of Part III