Newborn Nursing
1
The Newborn
2
Nursing Assessment of the Normal
Newborn
Assessment of the newborn is imperative immediately after
birth followed by an assessment within 1 to 4 hours and
continued assessment procedures during the first 24 hours
of life.
Initial Assessment immediately following birth
 Need for resuscitation
 APGAR scoring
 Heart rate
 Respiratory effort
 Muscle tone
 Reflex response
 Color
 Cry – strong and lusty
3
Nursing Assessment of the
Normal Newborn
Initial assessment (continued)
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Newborn responses to birth
Assessment and care of the newborn
Check for congenital anomalies especially
cardiovascular, pulmonary and neurologic
If stable, place with parents for initial bonding
and early breastfeeding
4
Newborn’s Immediate Needs
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Airway
Breathing
Circulation
Warmth
5
Initial newborn assessment
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Stimulate & dry infant
Assess ABCs
Encourage skin-to-skin contact
Assign APGAR scores
Give eye prophylaxis & vitamin K
Keep newborn, mother, & partner together
whenever possible
6
NEWBORN PERIOD & NEONATAL
TRANSITION
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Newborn period: birth to 28 days
Neonatal transition: first 6-8 hours after birth
Establishment of respiratory gas exchange &
circulatory system
Nurse must be aware of normal physiologic &
behavioral adaptations, as well as deviations
from the norm to ensure safety of the newborn
7
The Newborn
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Neonatal transition: 1st few hours after
birth newborn stabilizes respiratory and
circulatory functions.
When the cord is clamped, placental gas
exchange ceases.
These changes stimulate carotid and aortic
chemoreceptors which send impulses to
the respiratory center in the medulla.
A brief period of asphyxia stimulates
respirations.
8
Dry the Baby
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Hypothermia is common
Wet newborns rapidly lose
heat
Use a warm, dry, soft towel
Any absorbent material:
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Shirt
T-shirt
Socks
Battle dressings
9
Replace the Wet Towels
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Then let the
mother hold the
baby
Her body heat will
help keep the baby
warm
Cover the head to
prevent heat loss
10
Position the Baby
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Keep the baby on its’ back or side,
not on its’ stomach
Neither extend nor flex the head.
Either may obstruct the airway.
Newborn babies normally make this
adjustment themselves. If
depressed, however, you may need
to position the head to get a good
airway.
11
Suction the Airway
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May need to help them clear mucous
and amniotic fluid from the airway
Use a bulb syringe
Use it gently
If bulb syringe is not available, use
any suction device, including a small
hypodermic syringe without the
needle.
12
Ventilate if Necessary
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If not breathing following
brief stimulation, ventilate
Ideally, bag/mask, 100%
oxygen, pressure gauge,
flow control valve
May need to use mouthto-mouth
Cover nose and mouth
Use shallow puffs to
ventilate
13
Evaluate the Baby
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Breathing
Color
Heart Rate
Tactile stimulation
(rubbing) with a
towel. may
effectively stimulate
a mildly depressed
baby
14
Keep the Baby Warm
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Keep the airway open
Keep the head covered
Use any available cloth or
heat-retaining material
Check temp several times:
97.7-99.3F axillary
15
Temperature

At birth-warmth, keep the baby in skin to
skin contact with the mother
Teaching Aids: ENC
EN- 16
16
Apgar Score
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Assesses the infants
cardiopulmonary
adaptations to
extrauterine life
Provides a quick
evaluation on how the
heart and lungs are
adapting
5 items to be assessed
1 and 5 minutes after
birth.
17
Apgar Score
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Heart rate, respiratory rate, muscle tone, reflex irritability and color
Score of 0 – 2 for each item, then totaled.
Apgar Score 8 or higher no intervention
Apgar Score 4 – 8 gentle rubbing, oxygen
Apgar Score 0 – 4 resuscitation
Points Given
0
1
2
A Activity/muscle Limp/flaccid
tone
Some
Active motion/well
motion/flexion flexed
P Pulse Rate
<100 bts/min
>100 bts/min
G Grimace/Reflex No Response
Irritability
Grimace
Cry, cough,
sneeze
A Appearance/
Skin Color
Blue, Pale
Body pink,
extremities
blue
Pink all over
Absence of
cyanosis
R Respiration
Absent
Slow weak cry Good Cry
Absent
18
Nursing Assessment of the Normal
Newborn
Second physical assessment – within first 4 hours
of life
General appearance
 Measurements: weight, length, head & chest
circumference
 Temperature (axillary not rectal)
 Respiration: Normal 30 – 60 (average 40s)
Heart: Normal 120 – 160. Temporary murmur from
open ductus arteriosus common. Brachial and
femoral pulses strong and equal.
 Blood Pressure not routinely assessed
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
19
Vital Signs
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Temperature - range 36.5 to 37 axillary (97.7-98.6)
Axillary vs Rectal about 0.2 to 0.5 difference
Common variations
 Crying may elevate temperature
 Stabilizes in 8 to 10 hours after delivery
Heart rate - range 120 to 160 beats per minute

Apical pulse for one minute
Common variations
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Heart rate range to 100 when sleeping to 180 when crying
Color pink with acrocyanosis
Heart rate may be irregular with crying
Respiration - range 30 to 60 breaths per minute
Blood pressure - not done routinely

Ranges between 60-80 mm systolic and 40-45 mm diastolic.
20
21
Nursing Assessment of the
Normal Newborn
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Estimation of gestational age through
physical assessment
Physical maturity characteristics – skin,
lanugo, plantar creases, breasts, ear/eye,
genitals characteristics
Neuromuscular characteristics: resting
posture, arm recoil, popliteal angle, scarf
sign, heel to ear and square window signs
22
Gestational Age Relationship to Intrauterine Growth
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Normal range of birth weight for each week
of gestation.
Birth weight is classified as follows:
Large for gestational age (LGA): weight falls
above the 90th percentile for gestational age
Appropriate for gestational age (AGA):
weight falls between the 90th and 10th
percentile for gestational age
Small for gestational age (SGA): weight falls
below the 10th percentile for gestational age
23
Intrauterine Growth Grid
24
Nursing Assessment of the Normal
Newborn
Skin characteristics
Acrocyanosis
Mottling
Harlequin
Jaundice
Erythema toxicum – “Newborn rash”
Milia
Skin turgor

25
Nursing Assessment of the Normal
Newborn
Skin Characteristics (continued)
Vernix caseosa
Ruddy color
Cracked and peeling skin
Lanugo
Forceps or vacuum marks
Birthmarks
Café-au-lait
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26
Skin
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Expected findings
Skin reddish in color, smooth and puffy at
birth
At 24 - 36 hours of age, skin flaky, dry and
pink in color
Edema around eyes, feet, and genitals
Vernix caceosa
Lanugo (baby hair)
Turgor good with quick recoil
Hair silky and soft with individual strands
27
Common Normal Variations
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Acrocyanosis - result of sluggish peripheral
circulation.
Mongolian Spots: Patch of purple-black or
blue-black color distributed over coccygeal
and sacral regions of infants of AfricanAmerican or Asian descent.
Milia: Tiny white bumps papules (plugged
sebaceous glands) located over nose, cheek,
and chin.
Erythema toxicum: Most common newborn rash.
Variable, irregular macular patches. Lasts a few
days.
28
Color
Pink
Acrocyanosis
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Most newborns have
acrocyanosis (body is
centrally pink, but hands
and feet are blue
Cyanosis requires
treatment:
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Cyanosis
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Oxygen
Airway
Ventilation
29
Color of the baby
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Teaching Aids: ENC
Normal vs. Abnormal
EN- 30
30
Erythema toxicum, acrocyanosis, milia and
mongolian spots
31
Vernix
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Cheesy-white
Normal
Antibacterial
properties
Protects the
newborn skin
32
Hyperbilirubinemia
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Physiologic Jaundice =Appears 24 hours after
birth peaks at 72 hrs.
Bilirubin may reach 6 to 10 mg/dl and resolve in 5
to 7 days.
Due to Unconjugated bilirubin circulating in the
blood stream that is deposited in the skin.
Immature liver unable to conjugate bilirubin
released by destroyed RBC.
Pathologic Jaundice =Not appear until after 24
hrs leads to Kernicterus (deposits of bili in brain).
Bilirubin >20mg/dl
The most common cause is Rh incompatibility.
33
Nursing Assessment of the
Normal Newborn
General appearance of the head
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Cephalhematoma – bleeding between the
periosteum and the cranial bone
Caput succedaneum – localized edema
from pressure
Molding – movement of the cranial bones
during birth
Fontanels
34
The Head and Chest
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The Head: Anterior
fontanel diamond shaped
2-3 - 3-4 cms
Posterior fontanel
triangular 0.5 - 1 cm
Fontanels soft, firm and flat
head circumference is 33 –
35 cm
The head is a few
centimeters larger than the
chest!!!!
The Chest: circumference
is 30.5 – 33 cm
35
Anterior and Posterior
Fontanelles
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Anterior diamond shaped 2-3 3-4 cms
Posterior triangular 0.5 - 1 cm
Fontanels soft, firm and flat
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Molding is shaping of
fetal head to adapt to
the mothers pelvis
during labor.
36
Caput succedaneum
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Swelling of the soft tissue
of the scalp caused by
pressure of the fetal head
on a cervix that is not
fully dilated.
Swelling is generalized.
may cross suture line and
decreases rapidly in a few
days after birth. Requires
no treatment
2 – 3 days disappears
37
Cephalohematoma
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Collection of blood
between the periosteum
and skull of newborn.
Does not cross suture
lines
Caused by rupturing of
the periosteal bridging
veins due to friction and
pressure during labor.
Lasts 3 – 6 weeks
38
39
Caput succedaneum vs.
cephalohematoma

Teaching Aids: ENC
Normal vs. Abnormal
EN- 40
40
The normal resting posture of
a baby born breech
Teaching Aids: ENC
EN- 41
41
ABNORMAL position of arm
and hand
Teaching Aids: ENC
EN- 42
42
Nursing Assessment of the
Normal Newborn
Face
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Symmetry
Eyes
Nose
Mouth
Ears
43
44
Nursing Assessment of the
Normal Newborn
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Neck
Chest
Cardiac
Peripheral vascular
Abdomen
45
Check the Heartbeat
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Normal newborn rate is
>100
Palpate umbilical cord or
brachial artery
If pulse <100, ventilate the
baby, using whatever skills
and equipment you have
46
CARDIOVASCULAR CHANGES AT
BIRTH
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Onset of respirations stimulates changes in
cardiovascular system of newborn
Closure of fetal shunts
Foramen ovale
Ductus venosus
Ductus arteriosus: functionally closes within 24
hours of birth, but may take several weeks to
permanently close
47
Nursing Assessment of the
Normal Newborn
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Umbilical cord
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Examined for 2 arteries, 1 vein.
Will dry up and detach in 10 to 14 days
Cord Care: alcohol, soap & water
48
Umbilical Cord Care
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Clean & dry
Alcohol wipe once a
day
Topical antiseptic only
in contaminated areas
49
The umbilicus: Which one is
normal?

Teaching Aids: ENC
Normal vs. Abnormal
EN- 50
50
Nursing Assessment of the
Normal Newborn
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Genitals
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Female may have thick white mucousy vaginal
discharge
Male evaluate for the position of the urinary
meatus, scrotum, testicles
51
Nursing Assessment of the
Normal Newborn
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Anus – verify patency
Arms and hands- count fingers, evaluate
palmar creases and position of the arms
Legs and feet – count toes, legs of equal
length and check for hip dislocation (hip
click)
Back – Spine straight, no spina bifida
52
Nursing Assessment of the
Normal Newborn
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Neurologic Status
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Alertness
Resting posture
Cry
Muscle tone and activity
53
Nursing Assessment -Normal
Newborn
Reflexes: indicate neurological integrity
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Rooting
Sucking
Extrusion
Palmar grasp
Plantar grasp
Tonic neck
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Moro
Gallant
Stepping
Babinski’s
Crossed extension
reflex
Placing
54
Rooting Reflex
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Birth to 3-4months
Rooting reflex: A reflex
seen in newborn babies,
who automatically turn
their face toward the
stimulus and make
sucking (rooting) motions
with the mouth when the
cheek or lip is touched.
The rooting reflex helps
to ensure breastfeeding
55
Sucking Reflex
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Birth to 10 months
The sucking reflex is initiated
when something touches the
roof of an infants mouth.
Infants have a strong sucking
reflex which helps to ensure
they can latch onto a bottle or
breast. The sucking reflex is
very strong in some infants
and they may need to suck on
a pacifier for comfort.
56
Extrusion reflex
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Extrusion Reflex or Tongue-Thrust Reflex
A newborn baby is not developmentally ready to
eat solid foods. Her throat muscles will not be
developed enough to swallow solid foods until
she is at least four months old. It is roughly
around this time that she will be able to use her
tongue to transfer food from the front to the
back of the mouth to swallow safely. To see this
in action, touch her tongue -- she should react
by pushing her tongue outward or forward to
resist.
57
Palmer Grasping Reflex

Birth to 4 months. This
is always a fun one to
see. If you place your
finger into the palm of
your baby's hand, his
fingers will grasp your
finger and hold on
tightly. It's as if he
were born knowing
that he wanted to hold
your hand!
58
Tonic Neck Reflex (FENCING)
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EXTENDS arm & leg on the side
that the face points.
Flexes opposite arm & leg
6-8 wks to 6 months
The tonic neck reflex is
demonstrated in infants
who are placed on their
abdomens. Whichever
side the child’s head is
facing, the limbs on that
side will straighten,
while the opposite limbs
will curl
59
Startle/Moro Reflex
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Moro Reflex
Birth to 4-6 months
Infants will respond to
sudden sounds or
movements by throwing
their arms and legs out,
and throwing their heads
back. Most infants will
usually cry when startled
and proceed to pull their
limbs back into their
bodies.
60
Galant Reflex

You can see this reflex by placing your
baby face down across your lap. If you run
your finger down the left side of his spine,
you will see him seem to curl in sideways
to the left. The same should happen on
the right side as well.
61
Stepping Reflex

If you hold your baby upright and place
her feet on a flat surface, she will place
one foot in front of the other and appear
to "walk." Of course without strength,
coordination, and balance, she could
never really walk at this point. This reflex
should disappear after around three
months.
62
Babinski Reflex
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Babinski Reflex is (+)
This is Normal
Birth to after walking
12-18 months age
You can see this newborn reflex in action by
running your finger down the center of the bottom
of your baby's foot. His toes will spread apart and
the foot will turn slightly inward. If you do the
same thing to an adult's foot, you will see the
opposite happen. The toes should clench together
tightly.
63
Placing reflex
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
When:This occurs from birth until about 6
weeks of age of normal baby milestones.
What:When the baby is held upright and
the top (dorsum) of the foot is brushed
against the edge of a table, the baby will
lift the foot and place it on the table.
64
Neural Tube Defects
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3 types:
Spina Bifida Occult: failure of the vertebral arch
to close. Has dimple on the back with a tuft of hair.
No treatment required.
Meningocele: saclike protrusion along the
vertebral column filled with cerebrospinal fluid and
meninges. Surgery required.
Myelomeningocele: saclike protrusion along the
vertebral column filled with spinal fluid meninges,
nerve roots, and spinal cord = paralysis. Surgical
repair required.
Sterile saline dressing.
hydrocepalus
65

Spina bifida occulta

Spina bifida Occulta

meningocele

myelomeningocele
66
Nursing Care of the Normal
Newborn
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Identification
Medications
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Vitamin K
Erythromycin
Thermoregulation
Feedings
67
Prophylactic Care

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Vitamin K –to prevent hemorrhagic
disorders – vit k (clotting process) is
synthesized in intestine requires food for
this process. Newborn’s stomach is sterile
has no food. aquaMEPHYTON
Hepatitis B vaccination –within the first 12
hours
Eye prophylaxis –(Erythromycin Ointment)
to prevent ophthalmia neonatorum –
gonorrhea/chlamydia
68
Newborn: Intramuscular injection



aquaMEPHYTON (Vit.K)
1 mg/0.5 ml IM lateral thigh
Vastus lateralis
69
Nursing Care of the Normal
Newborn
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Infant protection
Parent teaching
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Positioning
Cord care
Circumcision
Car seat safety
Screening tests, immunizations and other
procedures
Assessing and supporting bonding
70
Bathing the Newborn
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No tub bath until after
the cord has fallen off
and healing is
complete.
Newborn’s first baththe nurse needs to
wear gloves to
prevent infection.
What is wrong with
this nursing action?
71
Circumcision
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Circumcision is considered an elective procedure
Anesthesia should be provided.
Parents must give written consent
Full term health infants
Aftercare: Check hourly for 12 hours
Check for bleeding and voiding
Before discharge:
Newborn goes home within the first 12 hours
after procedure
Bleeding should be minimal and infant must void
Ensure that parents know how to care for the
circumcision.
72
Breastfeeding
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Colostrum is rich in immunoglobulins to protect
newborn GI tract from infection; laxative effect.
Breast milk in 2 weeks sufficient nutrients 20
kcal/oz (infant’s nutritional needs)
To support Breastfeeding: Mother needs to
consume extra 500 calories per day.
Feeding length: should be long enough to
remove all the foremilk (watery 1st milk from
breast high in lactose - skim milk & effective in
quenching thirst)
Hindmilk: higher in fat content leads to weight
gain and more satisfying.
Breastfeeding time approximately 30 minutes
73
Infant Formula

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
Formula 7.5 ml to 15 ml at feeding
gradually increase to 90 ml to 120 ml at
each feeding in 2 weeks.
Formula preparation: mixing must be
accurate to provide the 20 kcal/oz.
(newborn nutritional need)
Burping: is needed to expel air swallowed
when infant sucks.
Should be done about ½ way through
feeding for bottle feeders and when
changing breasts for breast feeders.
74
75
Respiratory Distress

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2 types: Respiratory Distress Syndrome (RDS) and
Transient Tachypnea of the Newborn (TTN)
RDS: preterm infants/surfactant deficiency
Hypoxia, respiratory acidosis and metabolic acidosis
Surfactant is produced by alveoli - lung maturity
L/S ratio 2:1 is a test done before birth to determine
fetal lung maturity
TTN: AGA, near term infants
Intrauterine or intrapartum asphyxia
Newborn unable to clear airway of lung fluid, mucous or
amniotic fluid aspiration.
Expiratory grunting nasal flaring, tachypnea with
respirations as high as 100 to 140 breaths/minute.
76
Infants of DM mothers (IDM) Complications

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Hypoglycemia: maternal glucose declines at
birth. Infant has high level of insulin
production= decreases infant’s blood glucose
within hours after birth.
Respiratory Distress: less mature lungs due
to insulin
Hyperbilirubinemia: hepatic immaturity,
increased hematocrit, bruising due to difficult
delivery.
Birth trauma: large size of infant
Congenital birth defects: birth defects –
Patent Ductus Arteriosus, Ventricular Septal
Defect and more.
77
 Newborn infants need:

easy access to the mother

appropriate feeding
adequate environmental
temperature


prgilbert/mc-99
a safe environment
78
 Newborn infants need:




prgilbert/mc-99
Cont’d…
parental care
cleanliness
observation of body signs by
somebody who cares and can
take action if necessary
access to health care for
suspected or manifest complications
79
 Newborn infants need:


Cont’d…
nurturing, cuddling, stimulation
protection from
• disease
• harmful practices
• abuse/violence
prgilbert/mc-99
80
 Newborn infants need:
Cont’d…
 Acceptance of
• sex
• appearance
• size
prgilbert/mc-99
81
 Newborn infants need:

prgilbert/mc-99
Cont’d…
recognition by the state
(vital registration system).
82