CHAPTER 58- NEWBORN CARE
INTRODUCTION:
Neonatal transition period:
1. First few hours after birth
2. Changes in respiratory and circulatory systems need to occur
3. Critical to maintain extrauterine life
IMMEDIATE NEEDS OF NEWBORN:
1. Airway
a. Must be clear
b. Needed for adequate gas exchange
2. Breathing:
a. In utero- gas exchange is accomplished by placenta and mother
b. By the 11th week fetal breathing occurs
c. By 35 weeks, surfactant adequate at 2:1 L/S ratio (prevents alveoli from
collapsing when infant starts to breath on own at birth)
d. 2 changes need to occur for lungs to function:
i. Pulmonary ventilation needs to be established at first breath and the
lungs are expanded
ii. Pulmonary circulation needs to increase
e. Breathing affected by 4 factors
i. Physical or mechanical factors:
1. Fetal chest is squeezed as it travels down the birth canal so
fluid is expelled from the lungs (this is why C/S babies are
more prone to respiratory failure)
2. Air displaces fluid in the lungs
ii. Chemical factors:
1. CO2 increases, O2 and PH decreases thus stimulating the
breathing center in the brain leading to respiratory effort.
iii. Thermal factors:
1. Change in temperature stimulates baby to breath
iv. Sensory factors:
1. Auditory, visual, tactile stimulation all assist in initiation of
respirations.
3. Circulation:
a. Pulmonary blood vessels:
i. dilate with first breath and blood freely circulates thru the lungs to
be oxygenated
ii. Ductus arteriosus:
1. Closes in 24 hours
2. Permanent closure occurs in 3-4 weeks
iii. Foramen ovale:
1. Closes within minutes after birth
2. Closure is permanent within about 3 months
iv. Ductus venosus:
1. When cord clamped blood stops flowing thru umbilical cord
2. Now flows thru liver and is filtered as in adult circulation
4. Warmth:
a. At birth, infant must begin thermoregulation or maintenance or body
temperature
b. When received in nursery, 1st concern is warmth.
c. 3 factors involved in thermoregulation:
i. Heat production:
1. Occurs thru general metabolism, muscular activity and
metabolism of brown fat
2. Brown fat is a special fat found only in newborns located at
back of neck, between the scapula, around the kidneys and
adrenals, in axilla and around heart and abdominal aorta
ii. Heat retention:
1. Flexed position helps to reduce the area of skin exposed to
environment so less heat loss
iii. Heat loss:
1. If excessive, is called cold stress (sxs: increased respiratory
rate and periods of apnea- can lead to acidosis)
2. Loses heat by:
a. Conduction- direct contact with a cooler object (cold
hands, cold stethoscope, cold scale) so warm objects
that touch NB- wrap in blanket, place skin to skin on
mother
b. Convection- loss of heat by the movement of air (open
door, window, people walking by) use radiant heater
c. Evaporation- loss of heat when H2O is changed to a
vapor – so immediately dry NB at birth (NB has wet
skin at birth), after receiving a bath and change wet
diapers and clothes promptly
d. Radiation- loss of heat by transfer to cooler objects
nearby but not thru direct contact (placed near cold
window, incubator walls cold)- keep cribs and
incubators away from cold windows
IMMEDIATE CARE OF THE NEWBORN:
1. Apgar score:
a. Assesses 5 entities:
i. Respiratory rate
ii.
2.
3.
4.
5.
b. If less tan 4- do resuscitation
c. If between 4 and 8- suction baby, gently rub infants back for stimulation and
give O2.
d. Suction mouth first then nose to prevent aspiration
Neutral thermal environment:
a. The environment in which NB can maintain internal body temperature
b. First hour or so (until warms up) goes into radiant heater
Identification:
a. ID bands placed on mother, infant, and father or s/o
b. Check ID bands each time baby is brought into mother’s room
Parent/infant bonding:
a. Promote interaction between parents and infant
Prophylactic care:
a. Administer Vitamin K
i. reason- baby’s intestines do not have sufficient flora to produce
Vitamin K
ii. given 1st hour after birth to prevent hemmorhagic disorder
iii. given in mid thigh (vastus lateralis) as muscle development is most
adequate at this site
iv. Can produce own Vitamin K by 8th day
b. Administer hepatitis B vaccination
i. needs mother’s signed permission
ii. 1st dose given within 12 hours of birth
iii. Given in same place as Vitamin K
c. Eye prophylaxis:
i. Instill an antibiotic ophthalmic ointment
ii. Needed to prevent opthalmia neonaturum and blindness
iii. Can get opthalmia neonaturum from mother’s vaginal canal infection
of gonorrhea or Chlamydia
iv. Usually erythromycin ointment
v. Mandatory to be given in US
d. Umbilical cord care
i. paint with triple dye
ii. Assess for redness, edema, purulent drainage each time diaper
changed.
PHYSICAL CHARACTERISTICS OF THE NEWBORN:
1. Weight and height:
a. Between 5 lb 8 oz to 8lb 3 oz (2,500 to 4,000 g)
b. NBs lose 5% to 10% of their body weight in first 3-4 days; regain by about 10
days of age.
c. Weight loss is caused by 1st BM (meconium), urination and small fluid intake.
d. Head to heel length- 19-21” (48 to 53 cm)
e. Crown to rump length- 12-14” (31 to 35 cm)
2. Vital signs:
a. Axillary temp- 36.5 to 37.2 C (97.6 to 98.9F)
b. Pulse (heart rate)- 120 to 160 beats/min.; if sleeping P decreases; if crying P
increases
c. Respirations- 30-60 breaths/min.; if sleeping R decrease; if crying R increase
d. BP- 60–80 systolic and 40-45 diastolic; by 10 days of age 100/50; activity and
crying increase BP
3. General appearance:
a. Flexed posture
i. Head flexed on chest, arms flexed on chest and legs flexed on
abdomen
b. Skin
i. At birth: red, puffy and smooth
ii. Vernix caseosa (white creamy substance) thinly covers skin
iii. Lanugo ( fine downy hair)
iv. Acrocyanosis (blue hands and feet lasting several hours after birth)
v. Edema may be present around eyes, face, hands, legs, feet, labia or
scrotum
c. Head
i. Measure just below eyebrows and over most prominent part of the
head- 33to35 cm (13-14”)
ii. 2 fontanelles- soft spots
iii. Anterior fontanelle
1. Largest, diamond shaped open and flat
2. Closes by 18 months of age
iv. Posterior fontanelle
1. Triangular in shape
2. Closes about 2 months after birth
d. Eyes
i. Color varies- may be slate gray, blue or brown
ii. Permanent eye color usually established by 3 months
iii. No tears
iv. Eyelids edematous
e. Ears
i. Soft, pliable and recoil swiftly when bent and released
ii. Top of ear should be in line with the outer canthus of eye
f. Neck
i. Short, thick, usually has several skin folds
g. Chest
i. Circumference is 30.5 to 33 cm (12-13”)
ii. Measure directly over the nipple line and lower edge of scapulas
iii. Usually 2 to 3 cm smaller than head
h. Abdomen
i. Cylindrical in shape
ii. Bluish-white umbilical cord protrudes from center
iii. Assess for bleeding from umbilical cord first few hours after birth
i. Genitalia
i. Female
1. Labia usually edematous
2. Vernix caseosa between labia
3. May have some bloody vaginal drainage that is caused by
female hormones absorbed from mother
ii. Male
1. If testes descended, scotum is large, pendulous and
edematous
2. If not, scotum is small
3. Scotum covered with rugae
4. If dark skinned, scrotum is deeply pigmented
iii. Voiding
1. Should void within 24 hours
2. Call dr. if infant does not void in 8 hours (after the first 24
hours)
iv. Bowel function
1. Meconium
a. black tarry substance expelled from rectum
b. first BM
j. Back
i. Spine intact with no openings, masses or prominent curves
ii. If any tufts of hair noted on spinal area, report for further evaluation
k. Extremities
i. Usually flexed
ii. Have a full ROM
iii. Are symmetrical
iv. Should have 10 fingers and toes with creases on anterior 2/3rds of
sole of foot
l. Sleep
i. About 15-20 hours/day in first several months of life
m. Voice
i. Neonates recognize mother’s voice within 1st few days of life
COMMON VARIATION IN THE NEWBORN:
1.Skin:
a. Jaundice
i.
Occurs AFTER 1st 24 hours
ii.
Is related to normal destruction of the excess RBCs in NB
iii.
Peaks at 72 hours
iv.
Disappears in a couple of weeks
v.
Blood work is done daily to check bilirubin levels
vi.
May need to be put under bililights
vii.
If occurs DURING 1st 24 hours is abnormal
b. Ecchymosis
i. Bruising and/or petechiae due to difficult delivery
c. Milia
i. White, pinhead-size distended sebaceous glands on cheeks, nose,
chin and trunk.
ii. Disappears in a few weeks
iii. NEVER squeeze milia- not whiteheads
d. Erythema Toxicum Neonatorum
i. Pink rash with firm yellow-white papules or pustules
iii. Found on chest, abdomen, back and buttocks
iv. Appears in 24-48 hours after birth
v. Disappears in a few days
vi. No treatment needed
e. Telangiectactic Nevi
i. Stork bites
ii. Birthmarks of dilated capillaries
iii. Blanch with pressure
iv. Found on eyelids, nose, occipital area, nape of neck
v. Fades between 1-2 years of age
f. Nevus Flammeus
i. Strawberry mark
ii. Birthmark of enlarged superficial blood vessels
iii. Are elevated, red and vary in size and shape
iv. Found on head, neck, arm
v. Disappear by school age
g. Mongolian spots
i. Deep blue areas of discoloration
ii. Usually found in sacral area at birth
iii. Seen in infants of African, Asian, American Indian, Hispanic and
southern European descent
2.Head:
a. Molding
i. shaping of fetal head to adapt to the mother’s pelvis during labor
ii. goes away in 2-3days
b. Caput Succedaneum
i. edema of NB’s scalp
ii. present at birth
iii.may cross suture line
iv. Caused by head compression against the cervix
v. Disappears in 2-3 days
vi. No treatment needed
c.Cephalhematoma
i.
collection of blood between periosteum and the skull of NB
ii. can appear several hours to a day after birth
iv. Does NOT cross suture line
v. Caused by rupturing of veins during L&D
vi. Largest on 2nd or 3rd day
vii. Spontaneously reabsorbs in 3-6 weeks
3.Eyes
a. Strabismus
i. caused by poor neuromuscular control
ii. disappears in 3-4 months
b. subconjuncival hemorrhages
i.
caused by vascular tension/ocular pressure
ii. occurs in about 10% of all NB
iv. Lasts for few months
v. Does not impair vision
4.Ears
a. maybe in irregular in shape and size
b. pinna may be flat against head
5. Mouth
a.
b.
c.
may have precocious teeth in middle of lower gum
should be removed to prevent aspiration especially if loose
Epstein’s pearls
i. small, whitish-yellow epithelial cysts on hard palate
ii. disappear in few weeks
a.
engorged breasts
i.
both sexes
ii.
occurs by 3rd day
iii.
lasts 2 weeks
iv.
may secrete witch’s milk- a whitish fluid
6.Chest
7.Genitalia
a.
Female
i. pseudo menustration
a. blood tinged mucous discharge from vagina
b. seen in 1st week of birth
c. cause: withdrawal of maternal hormones
d. vaginal tag or hymenal tag may be present
e. will disappear in a few weeks
f. is normal
b.
Male
i.
hypospadias- placement of urinary meatus in underside of
penis
ii. phimosis- opening in foreskin is so small, foreskin cannot be
pulled back, may cause problems with urination
iii. cryptorchidism- failure of one or both testes to descend
iv. hydrocele- fluid around testes in scotum; usually disappears
without any treatment
v.epispadias- placement of urinary meatus on top of penis
8.
Extremities
a.
b.
REFLEXES:
1.
2.
3.
4.
partial syndactyly
i.
fusion of (2 or more fingers or toes-webbing) 2nd and 3rd
Toes
halux varus
i.
placement of great toe farther from other toes
Some reflexes are present for life; others disappear 1st or 2nd year of life
Neonatal reflexes must be lost before motor development can proceed
Presence of reflexes means neurological system intact
Rooting reflex:
a. Stroke skin at one corner of mouth and the infant turns head toward the side
stroked
b. Lasts 3-4 months of age
c. If absent- may indicate frontal lobe lesion
5. Sucking reflex;
a. If touch lips, infant starts sucking
b. Lasts till 10 months old
c. If preterm or an infant being breastfed by mother taking barbiturates won’t
have it due to CNS depression
6. Extrusion reflex:
a. When tip of tongue depressed or touched, infant will force tongue outward
b. Disappears at 4 months old
7. Palmar grasp reflex
a. When examiner’s finger placed across palm, infant’s fingers flex and grasp
the examiner’s finger
b. If present after 4 months, frontal lobe lesion is suspected
8. Plantar grasp reflex:
a. When infant’s leg is held in one hand and with the other hand the sole of the
foot is touched below the toes, the infant’s toes curl downward
b. Lasts about 8 months
c. If not present in one foot- may have an obstructive lesion
d. If both feet- could be neurological problem
9. Tonic neck reflex:
a. Called the “fencing” reflex
b. Done by placing the infant on their back and rotate the infant’s head to one
side. The arm and leg on the side to which jaw is turned will extend while
the opposite arm and leg will flex
c. Sometimes not seen till 6-8 weeks of life
d. If present after 6 months- cerebral damage
10. Moro reflex:
a. “startle” reflex
b. Infant lies on back, hit the surface to startle the infant
c. Infant less than 4 months old will quickly extend and abduct the arms with
fingers fanning out, thumb and forefinger forms a C followed by abduction of
the arms in an embracing motion.
d. Slight tremor may be noted
e. Legs may extend the flex
f. Present at birth
g. Disappears between 4-6 months of age
h. If present after 6 months of age-possible brain damage
i. If assymetrical response- injury to clavicle, humerus, brachial plexus
11. Gallant reflex:
a. Infant lies on abdomen with hands under abdomen, infant’s skin is stroked
along one end of the spine, infant’s shoulders and pelvis turn outwards
toward stimulated side
b. If no response from infant younger than 2 months of age, a spinal cord lesion
is suspected
c. Present from birth to 2 months of age
12. Stepping reflex:
a. Hold infant under arms with the feet placed on a firm surface, infant will lift
alternate feet as if walking
b. Disappears approximately at 3 months of age
13. Babinski’s reflex:
a. The sole of the foot is stroked from the heel upward and across under the
toes, great toe should dorsiflex and the other toes fan out.
b. If present after baby has mastered walking (12-18 months) abnormal
14. Crossed extension reflex:
a. Infant lying on back and hold one leg extended with the knee pressed down
and stimulate the bottom of that foot, other leg should flex, abduct the
extend as if trying to push away the stimulus
b. Present 1st 4 weeks of life
15. Placing reflex:
a. Hold infant under arms from behind then brought to a standing position,
touching the top of the foot on the edge of the table. Tested leg will flex and
lift onto the table
b. If no response, abnormal
BEHAVIORIAL CHARACTERISTICS:
1. Periods of reactivity
a. 2 periods of reactivity occur during the 1st few hours of life, separated by a
period of sleep
b. First period of reactivity
i. 1st 30 minutes after birth
ii. Awake, alert and active
iii. Prime time for parent-infant interaction
iv. Ideal time to start breastfeeding
c. Sleep period
i. Lasts 2-4 hours
ii. Deep sleep
d. 2nd period of reactivity
i. Lasts 4-6 hours
ii. Awake, alert
iii. Respirations increase, may be period sof apnea, mottled or slightly
cyanotic
iv. May gag, spit up, choke on gastric and respiratory mucous increase
v. Close observation needed to prevent complications
vi. 1st BM- meconium
vii. 1st voiding
viii. Ready for feeding
BEHAVIORAL STATES:
1. Sleep states:
a. Quiet sleep state
i. Eyes closed
ii. No eye movement
iii. Respirations quiet and slower
iv. Heart rate 100-120
v. Startle or jerky movements at regular intervals
b. Active sleep state
i. Respirations rapid and irregular
ii. Sucking movements may be observed
iii. Infant stretches
iv. Moves extremeties
v. Makes faces
vi. May fuss briefly
vii. REM occurs
2. Alert states:
a. Drowsy state
i. Transition between sleep and awake
ii. Eyes open and then slowly close
iii. When open, eyes glazed and unfocused
b. Quiet, alert state
i. Focuses on people, objects
ii. Responds with intense gazing
iii. Seems very interested in immediate environment
iv. Body movements minimal
v. Good time to enhance bonding
vi. Good time to test for reflexes
c. Active, alert state
i. Fussy
ii. Restless
iii. Rapid and irregular respirations
iv. Frequent movements
d. Crying state
i. Cries with jerky movements
ii. Cries as a distraction from stimuli that disturb him/her
iii. Allows a discharge of energy
iv. Is a method of communication
v. If cries with a high pitched weak cry- means a nervous system
disorder
GESTATIONAL AGE:
1. Should be determined in 1st 4 hours of life
2. Ballard score tool
a. Used most often to determine gestational age
b. Has 2 elements
i. External physical characteristics
ii. Neuromuscular maturity
3. Assessment of external physical characteristics
a. Resting posture
i. Assess first
ii. Assess posture of NB when lying undisturbed
iii. Preterm has no flexion of extremities
iv. Full-term infant is fully flexed
b. Skin
i. Preterm-transparent and thin
ii. Vernix caseosa disappears near term but may remai0n in creases
iii. Cracking and peeling of skin, especially around ankles and feet
c. Lanugo
i. Most abundant between 28-30 weeks gestation
ii. Disappears as gestational age increases
iii. Full term may remain on shoulders, ears and sides of forehead
d. Plantar creases
i. During 1st 12 hours of life, reliable sign of gestational age
ii. Sole creases develop from top beginning at 32 weeks of gestation
iii. Creases cover 2/3rds by 37 weeks
iv. Creases cover entire sole by 40 weeks
e. Breast
i. Bud should be 1cm in size
ii. Measure by placing forefinger and middle finger on each side of
breast tissue and measuring between fingers
f. Eye/ear
i. Eyelids fused until 25-28 weeks geatation
ii. Upper pinna begins to curve over at approximately 33-34 weeks
geatation and is complete by 39-40 weeks
iii. If infant < 32 weeks- no ear cartilage- when folded, ear remains
iv. By 36 weeks- ear slowly returns to its original state when folded
v. By 40 weeks, ear springs back quickly when folded
g. Male genitalia
i. Determined by descent of testes, presence of rugae on scrotum and
scrotal size
ii. Testes in inguinal canal by 30 weeks, upper scrotum by 37 weeks and
fully descended by full term
iii. Before 36 weeks, few rugae on scrotum, by 38 weeks rugae on outer
part of scrotum and cover scrotum by 40 weeks
iv. Scrotum large and pendulous at 40 weeks
h. Female genitalia
i. Labia majora are small at 30-32 weeks and do not v=-cover labia
minora and clitoris
ii. At 36-38 weeks, clitoris is mostly covered by labia majora,
iii. By 40 weeks , labia majora covers labia minora and clitoris
NEUROMUSCULAR MATURITY:
1. Square window
a. Bend wrist so palm is flat against arm as possible
b. If angle between palm and arm is 90 degrees then gestational age is 32
weeks or less
c. If > 90 degrees more mature. Full term palm can fold flat against the arm
2. Arm recoil
a. Infant’s arms are held with elbows fully flexed for 5 seconds, then arms are
pulled straight down at infant’s sides and quickly released
b. Full term elbows rapidly recoil and have an angle of < 90 degrees;
c. If preterm, no recoil noted
3. Popliteal angle
a. Thigh is flexed on abdomen, hips remain flat on table, the lower leg is
straightened just until met by resistance, then angle behind knee is scored
4. Scarf sign
a. NBs arm is drawn across the body toward the opposite shoulder until
resistance is felt, the shoulder of the arm being tested should remain on the
table.
b. The relation of the elbow to the infant’s midline is noted for scoring
c. If elbow does not reach the midline, the infant is full term
d. If elbow goes across and beyond the infant’s body, the infant is preterm
5. Heel to ear
a. With hips remaining on flat surface of table, the NB’s foot is moved toward
the ear on the same side.
b. When resistance felt, foot position and degree of knee extension is notedc. Preterm infant’s leg will remain straight and foot will be near ear
d. The more mature infant the more resistance is felt and more flexion will be
noted
GESTATIONAL AGE RELATIONSHIP TO INTRAUTERINE GROWTH:
1. LGA- infant’s weight falls above the 90th percentile for gestational age
2. AGA- infant’s weight falls between 90th and 10th percentile
3. SGA- infant’s weight falls below the 10th percentile
4. Length of infant and head circumference is also used to document the infant’s level
of maturity
5. Classification of infants at birth is based on gestational age and birth weight
CARE OF THE INFANT:
1. Sleeping
a. Back position to decrease incidence of SIDS
2. First bath and cord care:
a. Sponge bath
i. 1st bath and type of bath to be given for the next 10 days to 2 weeks
(until cord falls off)
ii. Nurses giving 1st bath should wear gloves
iii. Can bathe infant at one hour after birth if stable
iv. Each eye should be wiped with separate cottomn ball or separate
area on washcloth
v. Wipe from inner canthus to outer canthus, wash entire face and
creases of ears. NO q-tips
vi. Head- wash with soap and water and comb if a lot of hair to remove
all substances, dry well.
vii. Soap ued on rest of body. Cleanse creases well to remove all traces of
blood, rinse well, dry and wrap in dry, warm blanket
viii. Cord is cleansed with bacteriostatic agent per agency protocol- triple
dye.
ix. Cord is to be cleansed daily with alcohol
x. Keep diaper off cord.
3. Circumcision
a. Decision to be circumcised may be due to preference of parents, physical
condition of infant or religious customs.
b. Surgical removal of prepuce (foreskin) which covers the glans penis
c. Need written permission from parents
d. Only full term, healthy NBs should be circumcised
e. Procedure:
i. Infant placed on a circumcision board and restrained
ii. Analkgesia given:
1. Penile nerve root block
2. Local Emla ointment applied to penis 1 hour before procedure
3. Pacifier with 20% sucrose
iii. Prepuce slit is made
iv. Either a Gomco (yellow) clamp or plastibell is used
v. After applying either, excess skin is cut off
vi. If Gomco clamp is used, A&D ointment or Vaseline jelly is put on penis
to prevent diaper from sticking to site
vii. At each diaper change, new ointment is applied for 1st 24-48 hours
viii. Some controversy regarding circumcision- see professional tip
f. Nursing management:
i. Ensure permit was signed
ii. Get equipment/supplies ready
iii. Infant placed on circumcision board with diaper removed
iv. Kept NPO for 2-4 hours before procedure
v. Keep a bulb syringe handy in case of need for suctioning
vi.
vii.
viii.
ix.
x.
xi.
xii.
Talk to and comfort infant during procedure
Keep infant warm with use of heat lamp
Afterwards hold the infant
Check hourly for 12 hours for bleeding and that infant is voiding
Cannot go home until bleeding is minimal and is voiding
Instruct on how to care for circumcision at home
Instruct parents in signs and symptoms of infection
4. Nutrition:
a. Americam Academy of Pediatrics recommends breast milk for at least 2
months
b. Nutritional needs of newborn
i. 100-120kcal/kg (50-55kcal/lb.) each day is needed to meet energy
and growth requirements
ii. Should be adequate carbohydrates and fats for energy so proteins
can be used for growth
iii. 20 oz. of breast milk or formula/day= kcal needed
iv. NBs lose 5 to 10% body weight 1st few days of life
v. Stomach capacity of a NB is 20 ml (1 oz. is 30 ml); by 7 days stomach
can hold 2 to 3 ozs. at each feeding
vi. Regains birth weight by age 10 days
BREAST MILK AND INFANT FORMULA COMPOSITION:
1.Breast milk:
a. Easily digested
b. Colostrums 1st few days is produced and contains sufficient nutrients to meet
needs- has 10kcal/g
c. Breastfeeding leads to more breast milk being produced
d. Mother’s diet affects fat And vitamin content of breast milk
e. Mother needs extra 500 calories /day needed to support breast feeding
2.Infant formula:
a. most modified cow’s milk to match components of breast milk as much as
possible
b.protein decreased, saturated fat removed and replaced with vegetable fat,
decreased vitamins and some minerals are added
c.if allergies, use soy formulas
d. preterm formulas 24kcal/oz.
e. phenylalanine free or low formulas
3. Feeding method:
a. breastfeeding or bottle feeding
b. whatever mother chooses, nurse should support decision and make it a
meaningful experience
c.disadvantages/advantagesof both - see table
d. other factors that influence decision of which one to do:
i. support offered by the infant’s father
ii. support by other family members
iii.the need to work outside of home
iv. Income level of parents
4. Breast feeding:
a. Positions for feeding
i. Hold infant with head slightly higher than body
ii. Cradle hold common
iii. Other positions are football hold, side-lying and across the lap
positions
iv. Mom’s free hand should be in a “C” position, supporting the
underside of breast with fingers
v. Change positions to vary pressure points on nipple
b. Latching on
i. Use rooting reflex to allow positioning of nipple in baby’s mouth
ii. Brush nipple across baby’s lower lip- this causes baby to open mouth
iii. When mouth open and tongue is down, bring infant closer to breast
iv. Place tongue on top of lower gum and under the breast
v. If properly latched on, suction is strong
vi. To remove infant from breast
a.place a finger into the corner of the infant’s mouth
between the gums to break the suction
b.never pull nipple out of mouth-will cause damage to
nipple
c. Length of feeding
i. Varies, is individualized
ii. Long enough to receive foremilk (watery 1st milk from breast, high in
lactose, helps with thirst) and hind milk (higher in fat content, leads
to weight gain and is more satisfying)
d. Timing of feedings
i. Given when infant hungry (demand feeding)
ii. Is ready to eat if wide awake, sucking on hands, rooting and slighty
fussy
iii. Average time is 30 minutes; when infant satisfied the breast will be
softer, baby will suck and swallow more slowly
iv. Start with one breast, completely empty it and then go to other
breast
v. At next feeding, the breast used last at previous feeding is used 1 st
vi. Always burp when changing breasts
vii. Stool soft and yellow- if water ring around stool this is ABNORMAL
viii. To maintain milk production, infant has to suckle
ix. Breast milk less alllergenic then cow’s milk
x. If infant sleeps after eating and gains weight, milk is adequate
xi. If infant preterm, may need gavage (tube) feedings as does not have a
good suck or swallow reflex. Can pump breasts and freeze milk for
later use
5. Bottle feeding
a. bottles are washed with hot soapy water and rinse well. No need to boil
b. need to hold close and cuddle while feeding
c.formula preparation:
i. available in 3 forms: ready to feed, concentrated and powdered
ii. formula choice up to parents
iii. great difference in price
iv. provides 20k/cal per ounce
d.amount of feeding
i. most infants eat 1/4th to ½ oz.at each feeding initially, by end of 2 weeks up to
3-4 oz/feeding
ii. growth spurts occur at 2 weeks, 6 to 9 weeks and 3-6 months so amount of
formula should be increased by 1 oz/bottle
iii.stool- formed and yellow brown
f. Burping
i. All babies need to be burped
ii. Prevents aspiration and regurgitation
iii. Positions to facilitate burping
1. held upright on feeder’s shoulder
2. in a sitting position on feeder’s lap with head and chest
supported by one hand
3. prone across feeder’s lap
iv. gently pat or rub the baby’s back
v. do when halfway through bottle feeding
PROBLEMS OF NEWBORNS:
1.HYPERBILIRUBINEMA:
a. physiological -excess of bilirubin in blood due to breakdown of RBCs which
release the excess bilirubin
b. can be physiological (appears after 24 hours of life) or pathological (appears
1st 24 hours of life)
c. pathological can lead to kernicterus (deposits of bilirubin in the brain causing
yellow staining, severe mental retardation and brain damage
d. blood level is uaually 20ml/dL full term and lower in preterm
e. cause is often Rh incompatibility
f. physiological often occurs once baby goes home
g. treatment: phototherapy- “bili” lights- special florescent lamps in blue light
spectrum
g. depending on which type used, infant may or may not need eyes covered
h. only a diaper is used for clothing
i. depending on which kind, parents may keep baby and hold baby or must
be kept under lights except for changing or feeding
j. frequent, green loose stools are noted
k. if bilirubin level cannot be reduced quickly or maintained below 12 with
bililights then an exchange transfusion may be needed. Blood type O Rh –
blood is used. 5-10 ml of baby’s blood is removed and exchanged with donor
blood at a time; very slow process, complications can be hypo or hyper
volemia, infection, cardiac arrhythmias and air embolism
l. diet consists of increased fluids to assist in elimination of the bilirubin
through the urinary system
m.assess jaundice:
i. in light skinned infants, blanch skin by pressing firmly with thumb over
bony prominence (forehead, nose, sternum); when thumb removed, area has
yellowish appearance before normal color returns
ii. in darker skinned infants, oral mucosa, posterior aspect of hard palate
and conjunctivial sacs are yellowed
n.the higher the bilirubin, the greater chance of brain damage
2. RESPIRATORY DISTRESS:
a.2 types:
i. respiratory distress syndrome (RDS)
ii. transient tachypnea of NB (TTN)
b. RDS:
i. caused by alterations in surfactant quality, composition, function or
production; if not enough surfactant, alveoli collapse
ii. usually preterm
iii. S/S: hypoxia, respiratory acidosis, and metabolic acidosis
iv. goals:
1. maintain respirations with adequate O2 and ventilation
2. correct respiratory and metabolic acidosis
3. if mild, use increased humidified O2; i8f moderate, may need
CPAP; if severe ventilator
c. TTN:
i. found in AGA and near-term infants
ii.NB has trouble clearing airway of lung fluid and mucous or aspiration of
amniotic fluid
iii.at birth, no problem with respirations
iv. shortly after birth- flaring of nostrils and expiratory grunting
v.by 6 hours of age tachypnea noted. Respirations can be as high as 100140
vi.goal: ambient O2 of 30-50% initially then this need decreases over 1st
48 hours.
vi. Treatment – 4 days
vii. C/S baby more at risk for respiratory problem because C/S babies
don’t have the traveling down the birth canal to remove excess fluid
from lungs.
d.nursing management:
i. check heart rate and pulse ox 1x/hr.
ii.Silverman-Anderson Index
1. Rates respiratory effort
2. O2 as ordered- monitor O2 concentration
3. Strict aseptic technique
e. S/S: cyanosis, pallor or mottling of skin, tachypnea, grunting respirations,
retraction, nasal flaring
f. May need L/S ration before birth to determine fetal lung maturity
3. CLEFT LIP/ PALATE:
a. Problem: feeding the infant - depends on how much is involved is how
difficult it will be
b. Special nipples needed
c. Infant needs to be held in upright position when feeding
d. Burp frequently as swallows a lot of air
e. Keep in side-lying position when sleeping
f. Parents will grieve over loss of normal infant
g. Nurse needs to be a positive role model when interacting with the baby
h. NO NG tube
i. Surgery by 2 months of age
4. HYDROCEPHALOUS:
a. Excess cerebrospinal fluid in the cerebral ventricle of the brain
b. Enlarged head
c. Need to measure head circumference daily
d. Need to check fontanelles for bulging/flatness
e. Need to change infant’s position frequently as infant cannot move own head
(to prevent pressure sores)
f. Surgery- ventricular-peritoneal shunt
5. SPINA BIFIDA (NEURAL TUBE DEFECTS):
a. 3 types:
i. Spins bifida occulta- failure of vertebral arch to close; dimple on back
that may have a tuft of hair in it; no treatment needed
ii. Meningocele- saclike protrusions along vertebrae filled with CSF and
meninges; needs surgery to correct; no long-term effects
iii. Myelomeningocele- same as meningocele but sacs also filled with
nerve roots and spinal cord; surgical repair needed; some paralysis
occurs
b. Treatment:
i. Keep saclike protrusions covered with wet NSS dressings till repair is
done
ii. Handle infantr carefully
iii. Keep sac infection free
iv. Measure head circumference each shift
v. Check fontanelles for bulging at same time
6. DOWN SYNDROME:
a. Chromosomal abnormality- Trisomy 21
b. Routine care given
7. Talipes Equinovarus:
a. Also called clubfoot
b. Is a congenital deformity in which ankle and foot are twisted inward and
cannot be moved to a midline position
c. May need range of motion exercises and / or cast
8. INFANT OF A DIABETIC MOTHER:
a. Requires close observation the 1st few hours to several days after birth
b. Most babies of diabetic mothers are LGA especially if DM has not been well
controlled- large size fat deposits and increased overall size for all organs
except for brain
c. If mother has a vascular problem in addition to diabetes the baby may be
SGA
d. Complications seen in babies of diabetic mothers:
i. Hypoglycemia- due to loss of maternal glucose and increased
production of insulin by baby
ii. Respiratory distress
iii. hyperbilirubenemia – due to liver immaturity, increased HCT,
decreased extracellular fluid volume or bruises from birth
iv. birth trauma- large size predisposes them to trauma during labor and
delivery
v. congenital birth defects- often go hand in hand with diabetes
especially patent ductus arteriosus.
e. Medical management:
i. blood glucose monitoring by heel stick done hourly x 4-6hours and
then every 4 hours x 24 hours
f. Pharmacological:
i. IV of glucose may be needed if early feeding does not keep blood
glucose @ 45mg/dL or above
g. Diet:
i. A feeding of 5% glucose may be given soon after birth, followed in an
hour by a breast/formula feeding theat is continued okn a regular
basis
h. Nursing management:
i. Blood sugars done as ordered
ii. Ensure timely feedings
iii. Oral or IV glucose as ordered
iv. Prevent cold stress
v. Hold and comfort after a heel stick
i. Significant S/S:
i. Blood sugar <45
ii. Jittery/tremors
iii. If hypoglycemia may have diaphoresis (babies don’t sweat!)
iv. Poor muscle tone
v. Decreased temperature
vi. Rapid respirations
9. INFANT OF AN HIV + MOTHER:
a. Transmission rate of HIV infection is 28-35% mother to infant
b. Can be transmitted 3 ways:
i. Through the placenta
ii. Maternal blood and secretions during L&D
iii. Breast milk
c. If born to a seropositive mom, the infant will have HIV antibodies; by age 8 to
15 months of age, uninfected infants have lost the maternal antibodies and
will test negative; infected infants will develop klown antibodies and are HIV
seropositive
d. At birth- no s/s
e. Appearance of opportunistic disease may occur at 3-6 months
f. Lymphoid interstitial pneumonitis is considered a criteria for diagnosis
g. breastfeeding not recommended
h. All infants of HIV + moms should be condidered HIV+ until proven otherwise
10. INFANT OF SUBSTANCE ABUSING MOTHER:
a. Is a substance abuser at birth
b. Experiences withdrawal- severity depends on:
i. Substance(s) abused
ii. Time and amount of last dose
c. S/S can occur as early as 24-48 hours after birth opr as late as 4-5 days of age
d. Complications:
i. Withdrawal
ii. Respiratory distress
iii. Jaundice
iv. Behavior problems
v. Congenital anomalies
vi. Growth retardation
vii. May also have Fetal Alcohol Syndrome (FAS)
e. Medical management:
i. Treat complications
f. Pharmacological:
i. Phenobarbital or tincture of opium may help to control withdrawal
S/S
ii. Phenobarbital or valium may be used to control seizy=ures in an
alcohol dependent infant
g. Diet:
i. 24Kcal/oz.
h. Nursing management:
i. Monitor weight, T, skin turgor, fontanelles
ii. Strict I&O
iii. Provide small frequent feedings
iv. Have a quiet environment
v. Keep stimulation to a minimum
vi. Give meds as ordered
vii. Role model interacting with the infant-encourage mom to interact
with infant
viii. Refer to social service agencies and infant development programs
i. S/S:
i. Hyperactivity
ii. Persistent high-pitched, shrill cry
iii. Tremors
iv. Seizurestachypnea
v. Disorganized sucking and swallowing
vi. Fever
vii. Vomiting/diarrhea
viii. stuffy nose
ix. Yawning
x. Sneezing
xi. Sweating
xii. Cry inconsolably
xiii. Abdominal distention
xiv. Great activity
xv. Exaggerated rooting and sucking
xvi.
xvii.
xviii.
xix.
xx.
xxi.
May or may not have FAS
Mental retardation
Hyperactivity
Growth deficiency
Distinctive facial abnormalities if FAS
Congenital anomalies
11. PHENYLKETONURIA:
a. inborn error of metabolism in which infant has a deficiency of enzyme
needed to digest amino acid phenylalanine
b. test done at least 24 hours after initial breast or formula feeding
c. baby placed on diet low in phenylalanine, preferably by 1 month of age
d. if not done, severe mental retardation results
e. US requires PKU testing be done on all babies born before going home from
the hospital
12. Miscellaneous:
a. C/S babies have greater risk for respiratory complications because of not
having the compression of the birth canal on the chest which forces fluid
from the lungs
b.congenital hip dysplasia- assess gluteal/popliteal folds of hips
c. suction mouth before nose to reduce possibility of aspiratioin
d. shopulder dystocia- asymmetrical clavicles abnormal- means broken clavicle