Unit 1 Objectives
Quick book references & learning assignments: (Don't fill these out)
Ricci, S. (2021) Essentials of maternity, newborn, and women’s health nursing (5th
Ed): Philadelphia: Wolters Kluwer.
● Neonatal Assessment: Chapter 18, pp 582-620
● Newborn Medications: Chapter 18 pp 588-590
o Completion of Newborn Medications Templates PRIOR to class
● Postpartum Adaptations: Chapter 15, pp 498-513
● Nursing Assessment in the Postpartum Client: Chapter 16, pp 520-534
● Assisting with screening tests: Chapter 18 pp 615-617
● CCHD Screening: current recommendations
● Laboratory Tests in Pregnancy: Chapter 12, pp 376-377 and Table 12.1
● Rh Status: Chapter 16, p 547-548
● Blood Incompatibility: Chapter 19, pp 674-675
● Resulting jaundice in the newborn with blood incompatibility: Chapter 24, pp 890895
● Rubella: Chapter 20, pp 717-718
● Hepatitis B Virus: Chapter 20 pp 719-720
● Group B Beta Strep: Chapter 20, pp 721-722
● Providing Immunizations: Chapter 16. P 547
Lesson 1: Nursing Assessment of the Well Newborn
1. Describe the sequence to follow in the assessment of the newborn.
https://youtu.be/cracmPo3iYo
https://youtu.be/pXrGIZOLz4k (registered nurse RN)
Skin: general appearance, color, transient cutaneous lesions, birthmarks
Cardiopulmonary: rate(110-160bpm, ALWAYS count 1 full minute at the apex),
murmurs? Asses brachial and femoral pulses, assess cap refill
Respiratory: rate(30-60 breaths/min. ALWAYS count 1 full min,
shape(round+symmetric), movement(chest+abd move in synchrony), breathing patterns
(periodic; irregular and varying depths along with the newborn having 5-10seconds w/o
breathing IS NORMAL)
Head assessment: 33-37 cm (13-14 in)
-General appearance(size, shape, symmetry)
-Sutures(sutures should be flat and FLEXIBLE)
-Fontanelles: Shape is same on ALL, size may vary, bulging/tense are assoc. w/ illness,
depressed= late sign of dehydration
-Observe for abrasions, lacerations, bruising: typically related to labor procedure, rapid
second stage, presentation, or birth trauma… facial+scalp bruising increase risk for
hyperbilirubinemia due to RBC breakdown from bruise and immaturity of the liver,
building up and creating a jaundice(yellow) look to the baby
Face assessment:
EYES: edema in eyelids is common, WHITE sclera, absent drainage, blink reflex
EARS: where do the ears set?.. preauricular skin tags and dimples are common(may
suggest renal malformations though).. hairy ears common in infants of diabetic mothers
NOSE: patency(unlabored breathing, do not occluded nare) and sneeze reflex
MOUTH/LIPS: lips are sense touch, baby should demonstrate "ROOT" reflex, lips+buccal
mucosa are PINK, gloved finger to assess hard and soft palates for cleft palate AND to
asses suck/swallow reflex… tongue(freely mobile).. cry (LOUD, LUSTY & moderate
pitch)
NECK: ROM (by stroking infants cheek), gently palpate masses, assess for webbing,
clavicle intactness and straightness, assess nape of the neck for "stork bite"
Chest assessment: breast enlargement is secondary to effects of maternal estrogen,
may secrete "witches milk" and has no clinical significance
inspect : Flat, concave? (Pectus excavatum) Convex? Pectus carinatum more common
in some connective tissue and cardiac disorders cardiac
Apical 110-160 newborn
Circumference 30-33 cm (12-13 in newborn)
Abdomen assessment: inspect(mildly protuberance and softly rounded), consistency is
SOFT, bowel sounds present 30-60minutes after birth
-umbilical assessment; assess for discharge, redness, odor, edema around the base of
the cord for omphalitis (infection).. cord clamp is present or removed
Genitalia:
-female: fully enclosed within labia majors.. 2 types of discharge
common(pseudomenstruation; slightly bloody r/t increased estrogen levels in intrauterine
environment…. Smegma; white mucus discharge that is the result of leukocytosis of
pregnancy)
-male: glans completely covered by foreskin.. scrotum(length+rugae).. palpate for testes
Anus: assess for imperforate anus.. definitive assessment of anal latency is the first stool
Extremities:
ARMS: ROM(full +uncoordinated), color (pink), muscle tone("strong" is infant resists
abduction of arms), position: flexed
HANDS: position(clenched), # of digits (abnormal: polydactyly, syndactyly), # of creases
(3 distinct creases), color (PINK, however may have acrocyanosis), reflexes(palmer
grasp), nail length(at or past fingertips)
LEGS: ROM(full, uncoordinated), color(pink), muscle tone( "strong" if infant resists
abduction), position (flexed)
FEET: # of toes, creases, color(pink, however, may have acrocyanosis), reflexes(plantar
grasp, babinski)
Back: observe for abnormal spine curvature, gross defects, evidence of spina bifida…
assess the pilonidal sinus (dermal sinus) for complete closure.. assess gluteal folds for
symmetry.. NURSES DO NOT PERFORM BARLOW MANEUVER OR ORTOLANI
MANEUVER
Neonatal neurological exam: behavioral state assessment (deep sleep, light sleep,
drowsy, quiet alert, active alert, crying…. Normal term newborns move from one state to
the next with a smooth transition in response to appropriate stimuli)
2. Perform the assessments needed during the immediate newborn period.
APGAR- https://youtu.be/cQKaTCMFjwc
Perform 1minute immediately after birth, then again at 5 minutes and may require a
recheck at 10 minutes(if 5 min score is less than 7) to determine which infant
resuscitation intervention is needed depending on score of assessment
Score of 8-10 normal no intervention
4-7 moderate difficulty
3 below distress
APGAR
1 &5 min
0 - poor response
1-
2- normal response
Appearance - color
cyanotic /pale
Acrocyanosis (blue
extremities)
Pink all over
Pulse heart rate
most impt
absent
Less 100
Higher 100
Grimace - reflex
irritability
No response
Grimace or frown
when irritated
Sneeze, cough,
vigorous cry
Activity (muscle
tone)
Limp flaccid
Some flexion
Limited resistance
to extension
Tight flexion, good
resistance to extension;
good return to flexed
position
Respiratory(effort)
apneci
Slow irregular
shallow
Regular 30-60 breath
per min
Strong / good cry
3. Describe the normal physical and behavioral characteristics of the newborn.
Normal Physical:
● skin: soft, smooth, opaque and warm color consistent with genetic background … normal
variants
○ vernix caseosa - thick white film that protects skin of fetus, found first 2-3 days,
leave
○ petechiae of head and neck,
○ dry/peeling skin transient cutaneous lesions:
○ benign variants;
■ Milia - white heads, unopened sebaceous gland dissapear in 2-4 weeks
■ Epstein pearls - milia in mouth and gums
■ hyperplasia,
■ erythema toxicumnewborn rash resembling flea bites
late gray, macular hemangioma, petechiae
● skin color: all newborns are PINK with some variations of plethora, jaundice,
pallor,cyanosis, bruising
● common birthmarks: Port wine stain(does not disappear), Hemangioma (2 types:
cavernous and strawberry…. Many regress on own, others require laser therapy)
Birthmarks are not common/expected on the face.
● Face
○ Full cheeks, features symmetrical
● Eyes
○ Same as adult (symmetrical, PERRL, tract objects to midline)
■ Birth may cause eyelid edema, subconjunctival hemorrhages
● Ears
●
●
●
●
●
○ Soft, pliable, quick recoil when folded & released, patent.
Nose
○ Small & narrow, Midline, patent, intact septum
Mouth
○ Symmetrical, midline, intact hard and soft palate
Neck
○ Short, creased, moves freely, baby holds head midline.
Chest
○ Round “barrel chest”, symmetrical, smaller than head.
Extremities & spine
○ Symmetric, free movement, spine midline.
Newborn Vitals: (This list assumes baby is full term)
Temp 97.7 - 99.5 F (37 c +/- 0.5) axillary (rectal not used now due to perforation risk)
Heart rate (pulse) 110-160bpm up to 180 while crying
Respirations : 30-60 breaths per min at rest
Blood pressure (Not normally performed, only done if clinical indication or low apgar score)
● 50-75 mm Hg systolic/ 30-45 mmHg diastolic crying, moving, delayed clamping will
increase systolic pressure
● Full term newborn measurements: Usual findings
○ Head circumference - 33-37cm
○ Chest circumference - 30-33 cm
○ Weight - 2,500-4,000 g (5.5-8.5 lb)
○ Length - 45-55 cm (19-21 in)
Head variants: molding, caput succedaneum, cephalhematoma, craniosynostosis
●
Normal behavioral characteristics:
○ The newborn (initially) should be alert and not persistently lethargic.
■ Deep sleep, light sleep, drowsy, quiet alert, active alert, crying, self
comforting skills (hand to mouth)… an infant should be able to
demonstrate all 7 behavioral states in the hospital stay
4. Recognize deviations from normal physiologic and behavioral findings during the
examination of the newborn.
●
Abnormal physiological:
○ Skin:
■ Jaundice, acrocyanosis, milia, mongolian spots, stork bites, port wine
stains, erythema toxicum, harlequin sign
Cardiopulmonary:
Respiratory:
- "see-saw" breathing patterns indicate newborn is using intercostal muscles to breathe and is
experiencing respiratory distress
- Apnea: >20seconds w/o breathing infant goes cyanotic
-Respiratory distress: Tachypnea, substernal or intercostal retraction, grunting on expiration,
nostril flaring, cyanosis
●
Head:
○ Microcephaly - head circumference below average/expected gestational age.
■ More serious/clinically significant than macrocephaly
○ Macrocephaly - Head circumference above average/expected gestational age
■ Often benign
●
●
○
Face:
○
Enlarged fontanelles
Facial nerve paralysis, nevus flammeus (“Port wine stain” on face), nevus
vasculosus (“strawberry” on face)
Abdomen:
○ Infection signs in umbilicus, distended, only two vessels in umbilical cord
(three is normal)
●
Genitalia:
○ -males: hypospadias(incomplete formation of anterior urethra resulting in
urethral meatus forming on ventral shaft of penis.. ¹/³⁰⁰ male infants)... Chordee
(prescience of fibrotic tissue that causes ventral curvature of the erect penis…
Cryptorchidism (undescended testicles, usually resulting in infertility... descent
normally occurs 7th and 9th month of gestation). Impalpable testes. Any bulging,
discoloration, edema.
○ Females - Discharge or pseudomenstruation (though its common)
●
Anus:
○ Anal fissures/fistulas, no meconium passed within 24 hours of birth.
ARMS:
○ Non-symmetrical, ROM issues
HANDS:
○ polydactyly (6+), syndactyly(4 or less), simian crease (singular crease) is seen in
infants w/ chromosomal + congenital abnormalities (three creases is considered
normal)
○
LEGS & HIPS
○ Non-symmetrical, ROM issues
○ developmental dysplasia of the hip (use Ortolani and Barlow maneuvers to
assess)
FEET:
○ Club footing, unequal length or non-symmetrical skinfolds.
Back:
○ Tuft or dimple on spine (tethered cord)
●
●
●
●
●
5. Discuss/describe the neurologic and neuromuscular characteristics of the
newborn and describe normal newborn reflexes.
https://youtu.be/rHYk1sYsge0 (reflexes Registered nurse RN)
Newborn Reflexes
Reflex
Appearance
Disappearance
Stepping
Birth
1-2 mo
grasp
nb
3-4 mo
Tonic Neck (fencing)
NB
3-4 Mo
Moro (startle)
NB
3-6 mo
Rooting
Birth
4-6 mo
Babinski Sign
NB
12 mo
*Blinking
NB
persists
*Sneeze
NB
persists
*Gag Reflex
nb
persists
*Cough
Nb
persists
*protective reflexes
6. Describe the behavioral adaptations of the newborn, including periods of
reactivity and sleep-wake states.
Lesson 2: Postpartum Physical Assessment
https://youtu.be/DzVhumIrqd0
1. Describe the sequence to follow in the assessment of the postpartum patient.
BUBBLE-HE
Breasts: Texture and consistency.. Redness/pain.. Nipple assessment
Uterus: Fundus Location(midline or deviated to the right).. Fundus height(measured in
fingerbreadths above/below umbilicus)..Fundus consistency(firm or boggy)
Bowel: Rate..4 quad assessment..Provide pt. teaching to prevent/minimize constipation
Bladder: is the pt. voiding adequately? Is there s/s of UTI? (pain/burning w/ voiding or
normal/steady stream?)
Lochia: Amount (scant,light,mod., heavy).. Color(Rubra, serosa, alba)// Odor?.. clots?..
Documentation of lochia
Episiotomy: Evidence of infection?(REEDA).. Hemorrhoids?.. Pt. teaching regarding peri care
Homan’s sign:
● Reflexes
● Edema
● Homan’s
● Clonus
● Capillary refill
● Pedal pulses
Emotional:
● Mother’s general attitude, feelings of competence, supportive systems, and caregiving
skill
● Evaluates fatigue and ability to accomplish developmental task
● Describe level of attachment to infant
● Determine mothers phase of adjustment to parenting
Epidural: Assess epidural/spinal site for hematoma formation and S/S of infection and drainage
Lesson 3: Newborn Screening
1. Explain the purposes for newborn metabolic screening.
● To identify NB who appears healthy but could be at risk of developing conditions
with severe complications if left untreated.
● Most common screened below:
●
●
●
●
PKU - inherited deficiency in enzyme necessary for metabolism of phenylalanine
to tyrosine (amino acid found in most food) done 24-48 hours after protein
feeding - Heel stick
Congenital hypothyroidism - deficiency of thyroid hormone necessary for brain
growth, calorie metabolism, done between 4-6 days, if untreated irreversible
brain damage and intellectual disability before age 1
Galactosemia - absence of enzyme needed for the conversion of hte milk sugar
galactose to glucose - done on discharge with followup test at 1 month
Sickle cell anemia - recessively inherited abnormality in hemoglobin structure,
most commonly found in African American newborns. Bloodspot obtained at
same time of other nb screening tests or prior to 3 months of age.
2. Explain the purposes for a newborn hearing screening. (614-15)
● Most common birth disorder in US
● Delays in identifying hearing loss may affect language development, academic
performance, and cognitive development
● Detection before 3 months greatly improves outcomes- can prevent severe
psychosocial, educational, and language development delays
● 50% of infants with hearing loss have no known factors
3. Explain procedure and purposes for Critical Congenital Heart Disease Screening
(CCHD).
● CCHD is a group of the 7 most severe congenital heart diseases
● Pulse oximetry screening will most likely detect the 7 critical CCHD
● Purpose of the screening is if an anomaly is identified prenatally, the parents can
decide whether or not to continue the pregnancy. If after birth parents can be
nformed promptly and given a realistic appraisal of the severity of the condition,
the prognosis, and treatment options
4. Review procedures for performing a heel stick.
● Newborn Screening Blood Specimen Collection
●
5. Review procedures for atraumatic care of the newborn during invasive
procedures.
a.
Lesson 4: Laboratory Values in the Pregnant/Postpartum Client
1. Explain the purposes for drawing critical lab values in the pregnant and
postpartum client.
a. Tests are generally ordered during the initial visit so that baseline data can
be obtained, allowing for early detection and prompt intervention if any
problems occur. Additional tests may be needed or suggested based on
health status, exam findings, risk factors such as genetic diseases.
Ultimately it is the choice of the patient.
b. Ongoing/followup lab tests help achieve positive outcomes and identify
potential issues such as gestational diabetes, anemia
(hemoglobin/hematocrit) Rh-negative antibody titers in the mother
(rhogam is given if indicated)
c. Late pregnancy (37-40 weeks) group b streptococcus, gonorreia, chlamydia
tests are performed due to infantile risks including newborn blindness.
2. Explain the variations of acceptable lab values for the pregnant and postpartum
client.
(**)CBC VALUES TO KNOW!!!.... (--)Other important labs to know
Non pregnant
Pregnant
**Hemoglobin (Hgb)
12-16g/dl
11.5-14g/dl
**Hematocrit (Htc)
37-47%
32-42%
**WBC
4500-10,000 mm3
5000-15,000 (Postpartum
WBC can be 25,000-30,000
and be normal)
**Platelets
150,000-350,000 mm3
150,000-350,000 mm3
STAYS THE SAME
(Increases 3-5 days after
delivery before gradually
dropping.)
**Plasma volume
Increases in pregnancy
12-13 U
4-32 U
-- ALT(SGPT)
7-41
2-25
-- 24hr Urine protein/creatinine
<300 g of protein
<0.3
-- Serum creatinine
0.5-0.9
0.4-0.9
Aspartate Aminotransferase
aka (-- AST(SGOT)
(Liver enzyme)
3. Explain the ABO blood group in determining ABO incompatibility and the impact on the
neonate.
ABO incompatibility increases the risk of hyperbilirubinemia in the newborn.. It is less
severe than Rh incompatibility
Usually occurs with an incompatibility, mother is type O with an anti-A and Anti-B
antibodies in her blood, infant will be blood type A, B or AB
4. Explain the Rh sensitization process and the impact on the neonate.
a. Simple explanation: Mom is Rh - and has a Rh + baby and there is an
incompatibility issue with the blood between the mom and baby.. Mom
typically has to take a medication so she does not miscarry.
i. The risk is significantly higher in the second pregnancy.
5. Explain the purpose of determining rubella immunity in the prenatal period and the
implications of the newborn with rubella exposure in non-immune mothers. Determine
prevention strategies for future pregnancies.
Risk of congenital rubella syndrome in pregnancy, greatest risk in the first trimester which can lead
to hearing loss, eye defects, CNS abnormalities such as microcephaly, heart defects such as PDA
and pulmonary artery stenosis.
-Women who are rubella non immune should receive the vaccine after delivery and before DC from hospital
Newborn Medicaitons:
Phytonadione (Vitamin K) ((Aqua-Mephyton, Konakion, Mephyton)) ● Action: Provides NB with Vitamin K (necessary for production of adequate clotting factor II, VII, IX, X by liver)
during the first week of birth until NB can manufacture it. - deficiency might lead to delayed clotting and
hemmorhage
● Action Prevents Vitamin K deficiency bleeding (VKDB) of NB
● Nursing Implications:
○ Aminister within 1-2 hr of birth
○ Admin im injection outer middle third vastus lateralis
○ 25 guage , 5/8 in needle
○ Hold firmly inject slowly - std precautions- assess for bleeding after
Erythromycin opthalmic ointment 0.5%
● Action : provides bactericidal and bateriostatic actions to prevent Neisseria gonorrhoeae and chlamydia
trachomatis conjunctivitis, prevents ophthalmia neonatorum (which can cause neonatal blindness)
● Nursing implications
○ Administer ASAP
○ Be alert for chemical conjunctivitis for 1-2 days
○ Wear gloves, and open eyes by placing tumb and finger above and below eye
○ Gently squeeze the tube or ampule to apply medication into conjunctival sac from the inner canthus
to outer
○ Do not touch tip of eye
○ Close eye to make sure med permeates
○ Wipe off excess ointment after 1 min
Vitamin D
● 400 IU of vit D starting within the first few days of life to prevent rickets and Vitamin D difficiency
●