GEORGIA BAPTIST COLLEGE OF NURSING
OF MERCER UNIVERSITY
NUR 330 Nursing Care of the Childbearing Family
Unit 5: Holistic Care of the Neonatal Client
Class Notes
Neonatal Adaptation to Extrauterine Life
1.1
Respiratory Adaptation:
To establish respiratory function the following must occur:
1. Initiation of extrauterine respiratory movements
2. Air entry must overcome opposing forces so that the lungs expand.
3. Some air must remain in the alveoli (functional residual capacity)
during expiration to prevent lung collapse.
4. Pulmonary blood flow must increase and cardiac output must be
redistributed
Factors opposing the first breath include:
(1)
(2)
(3)
Stimuli that initiate respirations:
Mechanical – compression of thorax during birth increases
intrathoracic pressure and expels fetal lung fluid. At birth the
chest wall recoilssmall passive inspiration.
Chemical – Transitory asphyxia during birth  pCO2 ,
pO2stimulate aortic and carotid chemoreceptors  impulses
medullary respiratory center which in stimulates respirations
Sensory–thermal -  in environmental temperature (cooling) 
skin nerve endings stimulated  impulses to medullary
respiratory center.
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With the onset of respiration, the functions of the
cardiovascular and respiratory systems become
interrelated.
 As air enters the lungs, p02 rises in the alveoli which stimulates the
relaxation of the pulmonary arteries and triggers a decrease in the
pulmonary vascular resistance and lowering of pulmonary artery
blood pressure.
 Reduced pulmonary vascular resistance results in increased blood
flow into the lungs.
 Removal of placental circulation (clamping of cord) increases the
newborn's peripheral vascular resistance, which increases systemic
blood pressure.
 The reversal of the relationship between pulmonary artery blood
pressure and systemic blood pressure results in the closure of the
right-to-left shunts found in fetal circulation
Fetal Circulation: Pulmonary Artery BP higher than Systemic BP
(Right side pressure higher than left side pressure thus blood
shunted from pulmonary artery to descending aorta circulation
through the ductus arteriosus)
Neonatal Circulation: Systemic BP higher than Pulmonary BP (Left
side pressure higher than right side pressure thus direction of
shunting is reverse of fetal circulation)
Characteristics of Neonatal Respiration:
Normal rate =
Initial respirations may be diaphragmatic with shallow and irregular
depth and rhythm. They then become abdominal and diaphragmatic.
Short periods of apnea (5-15 sec) are common. Periodic breathing may
occur.
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Signs of neonatal respiratory distress:
(1)
(2)
(3)
(4)
(5)
1.2 Cardiovascular Adaptation:
Expansion of the lungs with the first breath decreases the pulmonary
vascular resistance and increases left atrial pressure. Clamping of the
cord raises systemic vascular resistance. This physiologic mechanism
marks the beginning of transition from fetal to neonatal circulation.
Several cardiovascular changes occur:
1. Dilation of pulmonary blood vessels and  blood flow
2. Increased peripheral vascular resistance results in systemic blood
pressure
3. Ductus arteriosus constricts due to  O2 saturation of blood and
blood is no longer shunted from pulmonary artery to aorta due to
reversal of the pressure relationship between pulmonary systemic
circulation. Ductus arteriosus functionally closes by 24 hours of
age.
4.  pressure in left atrium and pressure in right atrium closes
foramen ovale within minutes. Some right to left shunting may
normally continue for a few months.
5. Ductus venosus (shunts blood from umbilical vein to inferior vena
cava in fetus) closes 3-7 days after birth. Closure mechanism
unknown.
Characteristics of the neonatal cardiovascular system:
Heart rate:
Resting rate as low as:
A rate while crying may be as high as:
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Average B/P is 65-95
30-60
1.3 Hematologic Adaptation
Normal newborn hemoglobin range:
Normal newborn hematocrit range:
Normal Newborn WBC ranges:
1.4 Temperature Regulation
Temperature regulation requires the newborn to balance loss of heat to
the environment and the production of heat. Humans are
homeotherms (warm blooded) because they can maintain a constant
core body temperature in a wide range of environmental temperatures.
Newborns, however, have a greatly reduced range of environmental
temperatures to which they can adapt without being severely stressed.
Normal newborn temperature is 97.7 to 99.5FAx or 99.7R.
Newborn Factors that limit newborns thermal regulatory ability:
1.
2
3.
Thermal Neutral Zone - range of environmental temperatures in which
the individual can maintain a normal internal temperature with minimal
metabolism and oxygen consumption for heat production.
(Environmental range for normal newborn: 89.6oF to 93.2oF; Size and
age also affect the TNZ) Below this range (Critical temperature),
there is increased metabolism and oxygen consumption for heat
production.
Heat loss from the body surface to the environment takes place by four
mechanisms:
(1) Convection
(2) Radiation
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(3) Evaporation
(4) Conduction
Newborn Heat Production (Thermogenesis)
Several sources of heat production (thermogenesis) are available
muscular activity, positional changes, vasomotor control, and chemical
thermogenesis (same as nonshivering thermogenesis)
Nonshivering thermogenesis
Unique to the newborn and uses the newborn’s stores of brown adipose
tissue (BAT) also called brown fat. BAT is the primary source of heat in
the cold stressed newborn. BAT is found in the midscapular area
around the neck, in the trachea, esophagus, abdominal aorta, kidneys,
and adrenal glands.
Brown fat metabolism is activated when skin receptors perceive
environmental temperature changes and transmit sensations to the
central nervous system that stimulates the sympathetic nervous system.
Cold Stress - excessive body heat loss resulting in compensatory
mechanisms such as nonshivering neogenesis to maintain core body
temperature In the cold stressed infant, oxygen consumption and
energy are diverted from maintaining normal brain and cardiac function
and growth to thermogenesis for survival!
Neonatal Risks from Cold Stress
Hypoglycemia:
 glucose consumption due to  BMR  hypoglycemia
Respiratory acidosis:
 respiratory rate  O2 consumption   arterial O2 & p CO2  
pH  respiratory acidosis
Metabolic acidosis:
 BMR anaerobic glycolysis  production of acids  metabolic
acidosis
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Increased risk of jaundice:
Excessive fatty acids displace the bilirubin from the albumin binding
sites   risk of jaundice and kernicterus
1.5 Hepatic Adaptation
Iron Storage:
Carbohydrate Metabolism:
Conjugation of Bilirubin:
Bilirubin:
Bilirubin conjugation - conversion of bilirubin from a fat soluble form
(unconjugated bilirubin also called indirect bilirubin to a water soluble
form (conjugated bilirubin also called direct bilirubin.
Physiologic Jaundice – (Icterus Neonatorum or Physiologic
Hyperbilirubinemia):
A normal occurrence in 50% of full-term newborns because:
1. Newborn has a higher rate of bilirubin production due to large
numbers of RBC’s and shorter survival time of fetal RBC’s.
2. The newborn’s small intestine reabsorbs a large amount of bilirubin.
Criteria for Physiologic Jaundice:
1. The infant is otherwise well.
2. In full-term infants jaundice first appears after 24 hours and
disappears by the end of the 7th day.
3. Serum unconjugated bilirubin concentration does not exceed
12 mg/dL
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4. Hyperbilirubinemia is almost exclusively of the unconjugated
(indirect) variety and conjugated bilirubin (direct) should not
exceed 1.5 mg/dL.
5. Daily increments of bililrubin concentration should not exceed 5
mg/dl per day
The appearance of jaundice during the first 24 hours of life or
persisting beyond 7 days usually indicates a pathologic process.
Kernicterus, a neurological syndrome that results from deposition of
unconjugated bilirubin in the brain, is the most severe complication
of neonatal hyperbilirubinemia. Survivors can have cerebral palsy,
epilepsy, and mental retardation. Kernicterus usually does not occur in
a term neonate until serum bilirubin levels  25 mg/dL are reached...
Coagulation:
.
1.6 Gastrointestinal Adaptation:
Stools: The lower ileum empties rapidly so stools are frequent. The
cardiac and pyloric sphincters are immature; therefore, frequent
regurgitation (spitting) may occur.
Initial stools:
Breastfeed Infant Stools:
Formula Fed Infant’s Stools:
1.7 Renal Adaptation:
1.8 Immunologic Adaptation:
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 Of the three major types of antibodies are IgG, IgA, and IgM, only
IgG crosses the placenta.
 Maternal immunoglobulin is transferred primary during the 3rd
trimester.
 Immunity acquired from the mother is passive acquired immunity
and lasts an average of 3 months.
 IgM is produced by the fetus. Elevated levels at birth may indicate
placental leaks or exposure to TORCH viruses.
 IgA appears to provide protection mainly on secreting surfaces such
as the respiratory tract, GI tract, and eyes. Colostrum is very high in
secretory IgA.
1.9 Neurologic and Sensory/Physical Adaptation
 Newborn’s brain is about 1/4 the size of an adult’s and myelination of
nerve fibers is incomplete.
 Brain requires glucose and a relatively large supply of O2 for
adequate metabolism.
 Partially flexed extremities, with the legs near the abdomen, is the
usual position of the normal newborn.
 When awake, the newborn may exhibit purposeless, uncoordinated
bilateral movements of the extremities.
 Cry of a newborn should be lusty and vigorous.
Neonatal Reflexes:
The normal infant has many primitive reflexes. The times at which
these reflexes appear and disappear reflect maturity and intactness of
the developing nervous system. Absences of reflexes may indicate
central nervous system damage
Moro reflex
Palmer and plantar grasp
Tonic neck
Sucking and rooting
Swallowing
Babinski’s
Stepping and walking
Trunk incurvation (Galant's reflex)
Traction /Head Lag
Arm recoil
Crawling (Bauer’s)
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Sensory Capabilities:
Habituation – the newborn’s ability to process and respond to
complex visual and auditory stimulation.
Orientation – the newborn’s ability to be alert, follow and fixate on
complex visual stimuli that have a particular appeal and attraction.
Self-quieting ability – the newborn’s ability to use resources to
quiet and comfort himself/herself.
Alertness States:
Deep /Quiet Sleep:
Light/Active Sleep:
Drowsy:
Quiet Alert:
Active Alert:
Crying:
Newborn Physical and Gestational Age Assessment
Factors that influence newborn assessment include maternal conditions
such as PIH and diabetes, maternal analgesia and anesthesia during labor,
length and response of newborn to labor, method of delivery, and
complications of delivery.
Initial Assessment and Care of the Newborn in the LDR/Delivery
Room
(1) First priority - maintain respiration. Suction initially with a bulb
syringe.
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APGAR SCORING:
 performed to rapidly assess the newborn's physiological status at
birth and determines the support or resuscitation approaches that
need to be implemented.
 based on 5 signs that indicate the physiological status
 Heart rate - based on auscultation or palpation at junction cord
and skin.
 Respiratory rate - based on observed movement of chest wall
 Muscle tone - based on degree of flexion and resistance to
straightening of the extremities and observation of activity level
 Reflex irritability- based on response to gentle flicking the soles
of the feet or rubbing the back
 Skin color- based on observation. Assess for cyanosis and pallor.
Expect most newborns to have acrocyanosis.
 Scoring is done:
Apgar Scoring System
SCORE
1
Slow (<100)
Slow, weak cry
SIGN
Heart Rate
Respiratory
Rate
Muscle Tone
0
Absent
Absent
Reflex
Irritability
Color
No
Cry
Response
Blue, pale Body pink, extremities Completely
blue
Pink
Flaccid
Some flexion of
arms&legs
Grimace
2
Over 100
Good cry
Well flexed
 Give a score of 0 to 2 on each sign. Total score range is 0-10.
 Scores of 7-10 indicates an uncompromised newborn. Suction
prn, provide and maintain warmth to support transitioning to
extrauterine life.
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 Scores of 3-6 moderately depressed neonate who will need some
resuscitation (blow by oxygen, stimulation, and close observation)
 Scores of 0, 1 or 2 indicate a severely compromised newborn who
needs resuscitation (probably ventilatory assistance and intensive
observation & care)
(2)
Second priority - provide and maintain warmth.
3. Brief physical assessment to determine if there are any gross
physical abnormalities present.
4. Newborn identification:
5. Initiation of parent-infant attachment-
Nursery Admission Assessment
In some institutions all of the assessments described are completed in
the LDR unit during the mother’s recovery period and the infant is
transferred directly to the mother-baby unit with the mother. There is no
separation of mother and infant and no required time in an admission
nursery for uncompromised newborns.
1. Significant data to be collected upon admission to the nursery:
 Condition of the newborn-
 Labor and birth record (copy required for newborn’s chart).
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 Antepartal history-
 Parent-infant interaction-
 Parent desires
2 Admission Nursing Care
 Identification: Read aloud info on each ID bands as Nursery RN
checks the ID form for accuracy.
 Vital signs- Initial temp usually rectal, then all others axillary. 97.698.6 is preferred range. Apical pulse and respiratory rate per protocol
until stable. HR: 120-160, RR: 30-60. BP assessed in some
institutions- use Doppler or Dinemapp. Average BP: 65-95/30-60.
 Weight - unclothed in both grams and pounds. Cover scales to
prevent cross infection and heat loss from conduction. Avg. Wt.: 7
1/2 pounds; Normal Range: 5lbs-9lbs.
 Measure length, head, and chest in centimeters or inches per
agency protocols.
Length - Average: 50cm (20 in), Normal Range: 45 -55 cm (18-20
in)
Head Circumference- Average: 33-35 cm (13-14 in)
Chest Circumference - should be no greater than head
circumference and is typically 1-2 cm less than head circumference.
 H & H and blood glucose according to agency protocol. Glucose
usually done for SGA, LGA, infants of diabetic mothers, and for
infants who appear jittery or who are hypothermic. Normal Hgb: 1424 g/dl Normal Hct: 48% - 69% Glucose: 40-60mg/dl
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 Vitamin K (Aquamephyton) injection and erythromycin ophthalmic
ointment may be administered at this time or within a few hours of
birth.
3. Physical and Gestational Age Assessment
A complete physical assessment should be completed within two hours
of birth. Some institutions complete a gestational age assessment on
newborns. The nursing plan of care is based on these assessments.
The newborn physical assessment and gestational age assessment
videos will be shown during OB labs prior to beginning OB clinical.
They are also on library reserve for student use in preparing for clinical
and exams.
Normal physical variations - not considered abnormalities:
caput succedaneum- edematous swelling of the scalp and soft
tissues; crosses suture lines.
cephalohematoma- subperiosteal hemorrhage; confined to one bone,
doesn’t cross suture lines.
milia-small, white sebaceous cysts, usually on nose, chin or forehead.
Mongolian spots-dark blue or purplish area usually over sacrum of
darker skinned infants.
telangiectatic nevi- “stork bites”, usually on forehead, back of head
and neck.
molding- asymmetry of skull bones due to birth process.
nevus vasculosis - “strawberry mark”
Epstein’s pearls - white, shiny cysts on gums or palate.
overriding sutures- due to birth process.
4. Behavioral Assessment-
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5 Periods of Reactivity
The newborn shows a predictable pattern of behavior during the first
several hours after birth
 First period of reactivity-
Physiological behavior:
 rapid, shallow respirations and maybe transient chest retractions,
flaring, and grunting.
 Heart rate - rapid and irregular.
 Bowel sounds usually absent.
 Sleep phase- Activity decreases.
 Second period of reactivity-
Common Newborn Nursing Diagnoses and Interventions during the
Immediate Newborn Period
1. Nursing Diagnosis: Ineffective Airway Clearance; Ineffective Breathing
Pattern.
Interventions:
2 Nursing Diagnosis: Ineffective Thermoregulation; Hypothermia;
Impaired gas exchange r/t hypothermia; Alteration in peripheral tissue
perfusion r/t hypothermia
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Interventions:
3. Nursing Diagnosis: Potential for fluid volume deficit; Potential for
alteration in tissue perfusion.
Interventions:
4. Nursing Diagnosis: Risk for infection r/t colonization of eyes by
neisseria gonorrhea or chlamydia trachomatis; Risk for infection r/t
colonization of the umbilical cord with pathological microorganisms.
Intervention:
5. Nursing Diagnosis: Nutrition, less than body requirements r/t
hypoglycemia
Interventions:
6. Nursing Diagnosis: Risk for fluid volume deficit r/t hemorrhage from
umbilical cord
Intervention:
7. Nursing Diagnosis: Potential for fluid volume deficit r/t inadequate fluid
intake. Potential for nutrition, less than body requirements r/t
inadequate intake
Interventions:
Ongoing Newborn Assessments
however the following should be assessed at least daily while the baby is in
the facility:
1. Vital signs15
2. Daily Weight-
3. Skin color-
4. I&O
5. Umbilical cord care-
6. Circumcision-
Post Circumcision Care:
7. Pain-
8. Nutrition-
9. Parent Education-
10. Attachment-
Daily Newborn Care
1. Common newborn nursing diagnoses:
Ineffective airway clearance
Hypothermia
Impaired skin integrity
Altered patterns of urinary elimination
Constipation
Risk for infection
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Altered nutrition: less than body requirements
Risk for pain
Knowledge deficit (parents)
Altered health maintenance
Family coping: potential for growth
Altered family process
Altered parenting
2. Interventions:
 Maintenance of cardiopulmonary function- Always place infant on
back when not being directly observed. Bulb syringe must always
be within easy reach. If a newborn is found not breathing, the first
action is to suction with a bulb syringe. If suctioning does not
work, stimulate the infant by vigorous stroking of the spine.
 Maintenance of neutral thermal environment- Prevent heat loss
by evaporation, conduction, radiation, and convection.
 Prevention of infection-cord care per protocol; keep diaper below
the level of the cord. Remove clamp when cord is dry, usually after
24 hours.
Note: No infected babies should be with well babies in the nursery.
They must be isolated. Research does not support the need for cover
gowns-hand washing is the most effective method to prevent
infections in the nursery.
Infection is difficult to diagnose in newborns: Symptoms include
hypothermia; inactivity; poor feeding; jaundice; mottled skin; abdominal
distention; full, bulging fontanel, high-pitched cry; and irritability
 Monitor nutritional intake:
 Newborns require 115cal/kg/day. Breastfeeding is the best
nutrition for newborns and infants.
 Bottle-feeding- Numerous commercially prepared formulas
available. All have the necessary 20 cal/oz. and come iron
fortified, but none exactly replicate breast milk.
 Bottle-fed infants usually gain weight faster than breastfed infants
and are more likely to have infant obesity. Allergic reactions to
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formula are common due to the foreign proteins. Many infants
must be placed on soy formula.
 Regurgitation is common after feeding- place infant on right side
to aid drainage and facilitate gastric emptying.
 The nurse has a responsibility to support the feeding method
decisions and help the family achieve a positive result. Positive
bonds in parent-child relationships may be developed with either
method.
 Circumcision care as described above.
 Bathing-
Teach parents:
 Therapy for hyperbilirubinemia
 Prevention is best. Early and frequent feedings stimulate the GI tract
and passage of meconium.
 Jaundice is usually treated when it reaches a level or 12 mg./100 ml
 Phototherapy (bili-lights) - Infant placed unclothed, except for diaper,
in open crib under lights. Must wear eye patches to prevent
damage to the retina. Turn infant every 2 hours to expose evenly
to light. Monitor temperature carefully. Monitor light intensity with
photometer. Infant will probably need extra fluid due to increased
excretion and insensible water loss used.
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 Bililight alternative: Fiber-optic bili blanket-attached to a halogen
light source and wrapped around baby’s trunk or placed under
baby. Fluid and weight loss are not complications; often used for
home therapy.
 Newborn screening programs
 Sensory enrichment
 Parent education- Topics to be included are:
Bathing
Symptoms of illness
Cord care
Normal elimination
Circumcision care
Safety-car seats
Feeding
Immunizations and follow-up care
Position on back- “Back to Sleep”
Normal Newborn Activity
How to take temperature
"NeoAssess&Care"
Revised: 2/08 KH
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