GOOD SHEPHERD MEDICAL CENTER
PROTOCOL
Division Nursing
Department: Nursery
EFFECTIVE DATE:
9/15/2012
Date/Historical File:
5/2/2011
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Committee Approval /Dates
OB/GYN/PEDI Executive
Committee: 9/13/2012
SUBJECT: Newborn Infant
PURPOSE: Care of infant while hospitalized and preparation for discharge. Infant will have stooled, voided
and retained oral feedings by discharge; caretaker will demonstrate appropriate response to infant as evidenced
by smiling at baby, holding, cuddling, feeding the baby; family will be instructed on newborn care and
demonstrate ability to provide basic newborn care prior to discharge.
KEY WORD
Assessment
NURSING MANAGEMENT
1. Assess within 2 hours after birth by a RN, then every 30 minutes until
the newborns condition has remained stable for 2 hours, then
every shift, or as patient condition warrants to detect any
unusual signs/symptoms. Those infants admitted to
Admission/Regular nursery will continue using this Protocol.
2. Take Temperature, Pulse, Respirations on admit, then with assessments as
outlined above, at the beginning of each shift and at mid shift (q6h) until
discharge or as patient condition warrants. No rectal temperatures unless
specifically ordered per MD.
Identification of
Less than 38 wks
3. Identification of newborns less than 38 weeks gestation will be identified by
placing a yellow “Great Expectation” card in crib and placement of yellow
stocking hat on infant as a means of easy identification/communication for all
nursing staff.
4. Make rounds on infants a minimum of every 2-3 hours, or as patient condition
warrants, when infant staying in room with mother.
Notification of MD
5. Notify attending physician of newborns admission.
ID of Newborn
6. Footprint all infants at delivery (or ASAP depending on infant’s
condition) on Newborn Identification Record.
7. Photographs are to be made ASAP after delivery.
Security
8. Apply security transmitter and band to infant’s ankle at delivery.
Positioning of Infant
9. Position infant on their back when in their bassinets unless ordered otherwise
by their MD. Positioning infants on their backs is recommended by the
American Academy of Pediatrics for the reduction of Sudden Infant Death
Syndrome.
Newborn Infant
Thermo-regulation
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10. Preferably place skin to skin with mother or apply cap and double blankets.
Keep mother and baby together as much as possible. If infant temperature is
below 97.5 stress the importance of keeping baby warm and skin to skin
contact with mother/family.
11. Monitor temperature as needed.
Respiratory assessment
12. Observe for character and rate, skin color, temperature,
frequency and type of cry.
13. Change infant's position and stimulate to cry if lethargic.
14. Use bulb suction, or # 8-10 Fr Delee if necessary on infant if
gagging, choking, and/or vomiting.
15. Assess for mucus obstruction and remove by bulb syringe.
Notify physician if no significant improvements noted.
Circulatory Assessment
16. Assess for peripheral cyanosis, apical pulse, strength of
femoral and brachial pulses and obvious bleeding.
GI/GU Systems Assessment 17. Record weight every day in grams and pounds and ounces.
18. Assess ability to take and retain feedings.
19. Record intake, and all stools and voids.
20. Initiate dietary consult or lactation consult as needed for poor intake or
inadequate weight gain.
Dietary Consult

Birth weight < 2000g

Difficulty swallowing or nippling feeds

Inadequate (20-30g) weight gain per day or significant decrease in an
individual usual growth percentile

TPN or Gavage feeds

Multidisciplinary/Professional referral for high Nutritional Risk




Lactation Consult Refer breast-feeding infants
Poor latch-on
Inadequate, weak suck
Inadequate weight gain
and Maternal discomfort
Newborn Infant
Hemolytic Assessment
Page -321. Observe skin color and level of activity. Assess infant for risk for
development of hyperbilirubinemia. (See Hyperbilirubinemia
Protocol)Notify MD of identified risks.
22. Note mother's blood type and Coombs, Rh test results. Report
abnormal cord blood studies to physician.
Teaching
23. Assess mother and family knowledge level of infant care.
24. Instruct mother in the following areas on first visit and as
needed.
a. Do not leave infant unattended.
b. Make sure of identification of person transporting your infant. Check
for "Hot Pink photo Identification Badge and if the picture matches
face of person to pick up the infant.
c. Make sure the staff member gives you the code prior to removing the
infant from the room
d. Wash hands before handling infant and have visitors wash hands if
they will be handling infant.
e. Instruct and provide information packets on Hepatitis B vaccine and
encourage reading information.
f. Assist breast-feeding mother as needed per mother’s request.
g. Instruct mother on signs of infant distress and how to contact nurse.
h. Instruct mom to restrict contact to her infant only, and not to carry
infant around in her arms, but may push infant in the crib around the
mother/baby floor.
25. Instruct mother and family according to assessed needs.
26. Allow mother to verbalize feelings and concerns, and answer
question or provide reassurance as needed.
Bonding
27. Allow infant to remain with parents when possible, encourage
family to hold, touch, and talk to infant.
28. Assist mother with feedings, so mother has a positive feeding experience.
29. Consult Social Service as needed for bonding concerns, ability to care for
baby (financial as well as physical), inappropriate behavior.
Discharge Planning
30. Reassess mother's knowledge level in infant care and reinforce
instruction given as needed. Use NB Teaching protocol and
discharge as guideline for needed instructions to the family. Have
mother sign documented discharge summary.
31. Check for completion of Hearing Screen before allowing discharge. Generate
and distribute letters for Primary Care Practitioner and Parent.
Newborn Infant
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32. Check for completion of Newborn Screening prior to allowing discharge.
Infant should be 24 hours of age or greater for collection of Newborn
Screening.
33. Administer Hepatitis B Vaccine with parental consent.
34. Instruct and schedule appointments as needed in physician office visit,
newborn follow-up, Lactation Clinic and return visits.
35. Make sure that parents have physician's phone number.
36. Give mom Immunization Schedule with explanation on how to use.
37. Ensure mom has her copy of Infant Hearing Screen letter.
38. Give breast-feeding mothers Lactation number 315-5595.
39. Remove security transmitter from infant’s ankle at time of discharge to mom.
40. Provide mother with instructions on observation and prevention of newborn
jaundice
Documentation
40. Document notification of attending physician.
41. Document any unusual findings, treatments, transmitter #, teaching, referrals
and any needed follow-up.
42. Document infant’s response to treatments.
43. Document parent’s response and understanding of teaching given.
44. Document administration of Hepatitis B Vaccine on Hepatitis B consent form.
45. Document Newborn Screening.
References:
Guidelines for Perinatal Care / American Academy of Pediatrics and the American College of Obstetricians and
Gynecologists. 6th Ed., Washington DC.
Revised: S.Capt RNC, 9/2012