N106
Nursing Care of
the Newborn
Immediate Baby Care
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Airway - Clean mouth and nose
Thermoregulation - Warmth
APGAR
Gross assessment
Identification
Bonding – safety against infection
Medications
Fetus to Newborn:
Respiratory Changes
• Initiation of respirations
• Chemical
surfactant reduces surface tension 34-36wks
decrease in oxygen concentration
• Thermal
sudden chilling of moist infant
• Mechanical
compression of fetal chest during delivery
normal handling
Nursing Process for Respirations
• Assess for respiratory distress
• Plan: Maintain patent airway
• Interventions
- Positioning infant – head lower
- Suction secretions – bulb, keep near
head, mouth first, avoid trauma to
membranes
• Evaluation – rate 30-60, no distress
Fetus to Newborn:
Neurological adaptation:
Thermoregulation
Methods of heat loss
Evaporation – wet surface exposed to air
Conduction – direct contact with cool objects
Convection- surrounding cool air - drafts
Radiation – transfer of heat to cooler objects
not in direct contact with infant
Convection
Radiation
Evaporation
Conduction
Nonshivering thermogenesis
The distribution of brown adipose tissue (brown fat)
Nursing Care – Cold Stress
• Preventing heat loss – radiant warmer
• Providing immediate care - dry quickly,
cover head with cap, replace wet blankets
• Providing on going prevention - safety
• Restoring thermoregulation – if becoming
chilled - intervene
Effects of Cold Stress
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Increased oxygen need
Decreased surfactant production
Respiratory distress
Hypoglycemia
Metabolic acidosis
Jaundice
APGAR
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Heart rate – above 100
Respiratory Effort – spontaneous with cry
Muscle tone – flexed with movement
Reflex response – active, prompt cry
Color – pink or acrocyanosis
• 0-3 infant needs resuscitation
• 4-7 Gentle stimulation – Narcan
• 8-10 – no action needed
Early Assessments
• Assess for anomalies
• Head – anterior fontanelle closes 12-18 mo
posterior fontanelle closes 2-3 months
• Neck and clavicles
fracture of clavicle – large infant, lump, tenderness,
crepitus, decreased movement
• Cord
• Extremities
flexed and resist extension
assess fractures, clubfeet
hips
vertebral column
Not crossing
suture line
Cephalhematoma is a collection of blood between the
surface of a cranial bone and the periosteal membrane.
Crossing
suture line
Caput succedaneum is a collection of fluid (serum)
under the scalp.
A, Congenitally dislocated right hip
B, Barlow’s (dislocation) maneuver.
C, Ortolani’s maneuver
Measurements
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Weight – loss of 10% normal
Length
Head and chest circumference
Normal VS
temp 97.7-99.5F axillary
apical pulse 120-160bpm
respirations 30-60/min
head larger
A, Measuring the head circumference of the newborn.
B, Measuring the chest circumference of the newborn.
Assessment of Cardio-respiratory
Status
• History
• Airway
• Assess
rate
q 30minX2hrs
symmetry
breath sounds - moisture for 1-2 hrs
Assessment of Thermoregulation
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Check soon after birth
Set warmer controls
Take temp q 30 min until stable
Rectal for first temp
Insert only 0.5 inch
Axillary route rest of time
Axillary temperature measurement. The thermometer
should remain in place for 3 minutes.
Assessment of Hepatic Function
• Blood Glucose
Signs of hypoglycemia
jitteriness
respiratory difficulties
drop in temp
poor sucking
Tx- feed infant if glucose below 40-45 mg/dl
• Bilirubin
physiologic jaundice peaks 2-4 days of life
early onset may be pathologic
Jaundice
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Hemolysis of excessive erythrocytes
Short red blood cell life
Liver immaturity
Lack of intestinal flora
Delayed feeding
Trauma resulting in bruising or
cephalhematoma
• Cold stress or asphyxia
Potential sites for heel sticks. Avoid shaded areas to
prevent injury to arteries and nerves in the foot.
Assessment of Neuro System
• Reflexes
• Babinski
Grasp
Moro
Rooting
Stepping
Sucking
Tonic neck reflex “fencing”
• Cry
• Infant response to soothing
Assessment of Gastrointestinal
System
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Mouth
Suck
Abdomen
Initial feeding
Stools
meconium – within 12-48 hours of birth
dark greenish black
breastfed – soft, seedy, mustard yellow
formula-fed – solid, pale yellow
Assessment of Genitourinary
System
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Umbilical cord vessels
Urine – within 24 hours of birth
Voiding – 6 to 10 times a day after 2 days
Genitalia
female – edema normal, majora covers
minora, pseudomenstruation
male – pendulous scrotum, descended
testes by 36 wks gest., placement of meatus
Assessment of Integumentary System
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Vernix – white covering
Lanugo – fine hair
Milia
Erythema toxicum – red blotchy with white
Birthmarks
Mongolian spots – sacral area
Telangiectatic nevus “stork Bite” - blanches
Nevus flammeus “port wine stain”
- no blanching
Nevus vasculosus “strawberry hemangioma”
usually on head, disappears by school age
Port Wine Stain
Erythema toxicum
Fetus to Newborn:
Psychosocial adaptation
• Periods of Reactivity
active – 30-60 min
sleep – 2-4 hours
alert – 4-6 hours
• Behavioral States
quiet sleep
active sleep
drowsy state
quiet alert – best for bonding
active alert
crying state
Gestational Age Assessment
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Assessment tool – Dubowitz, Ballard
Weeks from conception to birth
Used to identify high risk infants
Neuromuscular characteristics
Posture – more flexion
Square window – more pliable
Arm recoil - active
Popliteal angle - less
Scarf Sign – less crossing
Heel to ear – most resistance
Newborn maturity rating and classification
Gestational Age Assessment
• Physical characteristics
Skin- deep cracking, no vessels seen, post-leathery
Lanugo – less as age
Plantar creases – more with age
Breasts – larger areola
Eyes and Ears – stiff with instant recoil
Genitals – deep rugae, pendulous, covers minora
• Gestational Age & Size – may not correspond
small SGA <10% for weight
large LGA >90% for weight
appropriate AGA between 10-90%
Classification of newborns based on maturity and
intrauterine growth.
Classification of newborns by birth weight and
gestational age.
Ongoing Assessment and Care
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Bathing
Cord care
Cleansing diaper area
Assisting with feedings
Protecting infant
identifying infant
preventing infant abduction – alert to unusual
preventing infection
• Review beige cue cards in center of book for teach
One method of swaddling a baby.
Common Breastfeeding Positions
Infant in good breastfeeding position : tummy-to-tummy,
with ear, shoulder, and hip aligned.
LATCH was created to provide a systematic method for
breastfeeding assessment and charting.
Infant teaching checklist is completed by the time of
discharge.
Circumcision
• Most common neonatal surgical procedure
• Reasons for choosing
• Reasons for rejecting – hypospadias,
epispadias
• Pain relief
• Methods
• Nursing care
Circumcision using a circumcision clamp.
Circumcision using the Plastibell.
Other Concerns
• Immunizations
Hepatitis B – begin vaccine at birth
• Screening tests
Hearing
Phenylketonuria – by law
Further Assessments
• Complications r/t poorly functioning placenta
hypoglycemia
hypothermia
respiratory problems
• Complications r/t LGA infant
hypoglycemia
birth injury due to size
Shoulder Dystocia
• Risk factors
diabetes; macrosomic infant
obesity
prolonged second stage
previous shoulder dystocia
• Morbidity- fracture of clavicle or humerus,
brachial plexus injury
• Management – generous episiotomy
Neonatal morbidity by birth weight and gestational age.
High Risk Infants
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Preterm – before 38 weeks gestation
IUGR – full term but failed to grow normally
SGA LGA
Infants of Diabetic mothers
Post mature babies
Drug exposed
Preterm infants
• Survive - Weight 1250 g -1500 g – 85-90%
500-600g at birth 20% survive
• Ethical questions
• Characteristics – frail, weak, limp, skin
translucent, abundant vernix & lanugo
• Behavior – easily exhausted, from noise
and routine activities, feeble cry
Nursing Care of Preterm Infants
• Inadequate respirations
• Inadequate thermoregulation
• Fluid and electrolyte imbalance – dehydration
sunken fontanels <1ml/kg/hr or over hydration
bulging, edema and urine output >3ml/kg/hr
• Signs of pain – high-pitched cry, >VS
• Signs of over stimulation - >P, >RR, stiff
extended extremities, turning face away
• Nutrition – signs of readiness to nipple
resp <60/m, rooting, sucking, gag reflex
Measuring gavage tube length.
Auscultation for placement of gavage tube.
Complications of Preterm Infants
• Respiratory Distress Syndrome -RDS
• Bronchopulmonary dysplasia – chronic lung
disease
• Periventricular-Intraventricular Hemorrhage
30% infants <32 wk gest or <1500 g
• Retrolenthal fibroplasia – visual impairment
or blindness from O2 & ventilator
• Necrotizing Enterocolitis (NEC) – distention,
increased residual, Tx - rest bowel
Respiratory Distress Syndrome
• RDS also know as “hyaline membrane disease”
• Cause – besides preemie, C/S, diabetic mothers,
birth asphyxia – interfere with surfactant
• S&S
tachypnea - over 60/min
retractions- sternal or intercostal
nasal flaring
cyanosis- central
grunting- expiratory
seesaw respirations
asymmetry
Evaluation of respiratory status using the
Silverman-Andersen index.
Therapeutic Management of RDS
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Surfactant replacement therapy
Installed into the infant’s trachea
Improvement in breathing occurs in minutes
Doses repeated prn
Other treatment
mechanical ventilation
correction of acidosis
IV fluids
Post Term Infants
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Born after 42 weeks
Increase risk of meconium aspiration
Hypoglycemia
Loss of subcutaneous fat
Skin –peeling, vernix sparse, lanugo
absent, fingernails long
• Focus on prevention – “due date”
• Attention to thermoregulation & feeding
Meconium Aspiration Syndrome
• Occurs most often post term infants,
decreased amniotic fluid /cord compression
• Meconium enters lung – obstruction
• S & S vary from mild to severe respiratory
distress: tachypnea, cyanosis, retractions,
nasal flaring, grunting
• Tx – suction at birth, may need warmed,
humidified oxygen, or ventilators
Hyperbilirubinemia
• Pathologic jaundice – occurs within first 24
hours
• Bilirubin levels >12 in term or 10-14 preterm
• May lead to kernicterus – brain damage
• Most common cause – blood incompatibility of
mother and fetus, Rh or ABO – only occurs with
mother negative Rh or O blood
• Treatment focus on prevention, assess
coombs, monitor bilirubin levels, most common
treatment is phototherapy, blood transfusions
Conjugation of bilirubin in the newborn.
Phototherapy for Hyperbilirubinemia
• Phototherapy – bilirubin on skin changes
into water-soluble excreted in bile & urine
• “Bili” lights placed inside warmer, need
patches over eyes, infant wearing only
diaper or fiberoptic phototherapy blanket
against skin
• Side effects of phototherapy: freq, loose,
green stools, skin changes
• Can use at home
Other interventions for
hyperbilirubinemia
• Exchange transfusions – if lights not working
• Maintain neutral thermal environment – not
too hot or too cold
• Provide optimal nutrition – hydrate
• Protecting the eyes from retinal damage
• Enhance therapy by expose as much skin
as possible to light, remove all clothing
except diaper, turn frequently
Infant of a Diabetic Mother
• Macrosomia – face round, red, body obese,
poor muscle tone, irritable, tremors
• High risk for – trauma during birth, congenital
anomalies, RDS, hypocalcemia
• Hypoglycemia occurs 15-50% of time
<40-45 mg/dl, test right after birth, q 2hX4,
then q 4 hrX6 until stable
• Most frequent symptom: jitteriness or tremors
• Tx – fed, gavage or IV if needed
Hypoglycemia
• Serum glucose is below 40 mg/dL
• Tx: feed infant formula or breast milk and
retest until glucose stable
• S & S: jitteriness, lethargy, poor feeding,
high-pitched cry, irregular respirations,
cyanosis, seizures
• Risk factors: DM, PIH, preterm, post term,
LGA, cold stress, maternal intake of ritodrine
or terbutaline
Large for Gestational Age
• Infants weight is in the 90th % for neonates
same gestational age, may be pre, post, or
full term infants
• LGA does not mean post term
• Most common cause – maternal diabetes
• Infant at risk: birth injuries, hypoglycemia,
and polycythemia - macrosomia
Small for Gestational Age
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Infant whose wt is at or below the 10th %
Results from failure to thrive
Is a high risk condition
SGA does not mean “premature.”
Causes: anything restricting uteroplacental
blood flow, smoking, DM, PIH, infections
• Complications: hypoglycemia, meconium
aspiration, hypothermia, polycythemia
Mother with Substance Abuse
• Use of alcohol or illicit drugs
• Tobacco and alcohol are most frequent
• Prenatal alcohol exposure is the most
commons preventable cause of mental
retardation
• Signs of maternal addition: wt loss, mood
swings, constricted pupils, poor hygiene,
anorexia, no prenatal care
Drug Withdrawal in Infants
• Signs of drug exposure
opiates – 48-72 hours
cocaine – 2-3 days
alcohol – within 3-12 hours
• Symptoms: irritable, hyperactive muscle
tone, high-pitched cry
• High risk for SGA, preterm, RDS, jaundice
• Obtain infant mec and urine sample for test
Nursing Care of Drug-Exposed Infant
• Feeding – more difficult may need to
gavage
• Rest – keep stimulation to minimum,
reduce noise and lights, calm, slow
approach
• Promote bonding
• Teach measures for frantic crying: rock,
coo, dark room, avoid stimulation
Phenylketonuria - PKU
• Genetic disorder causes CNS damage from
toxic levels of amino acid phenylalanine
• caused by deficiency of the enzyme
phenylalanine hydroxylase
• Signs- digestive problems, vomiting, seizures,
musty odor to urine, mental retardation
• Tx – low phenylalanine diet – start within 2
months
• Screening before 24-48 hours needs to be
repeated for accuracy
Signs Bonding Delayed
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Using negative terms describing infant
Discussing infant in impersonal terms
Failing to give name – check culture
Visiting or calling infrequently
Decreasing length of visit
Refusing to hold infant
Lack of eye contact with infant