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N106 Nursing Care of the Newborn. Immediate Baby Care. Airway - Clean mouth and nose Thermoregulation - Warmth APGAR Gross assessment Identification Bonding – safety against infection Medications. Fetus to Newborn: Respiratory Changes. Initiation of respirations

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immediate baby care
Immediate Baby Care
  • Airway - Clean mouth and nose
  • Thermoregulation - Warmth
  • Gross assessment
  • Identification
  • Bonding – safety against infection
  • Medications
fetus to newborn respiratory changes
Fetus to Newborn: Respiratory Changes
  • Initiation of respirations
  • Chemicalsurfactant reduces surface tension 34-36wksdecrease in oxygen concentration
  • Thermalsudden chilling of moist infant
  • Mechanicalcompression of fetal chest during delivery normal handling
nursing process for respirations
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
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






nursing care cold stress
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
Effects of Cold Stress
  • Increased oxygen need
  • Decreased surfactant production
  • Respiratory distress
  • Hypoglycemia
  • Metabolic acidosis
  • Jaundice
  • 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
Early Assessments
  • Assess for anomalies
  • Head – anterior fontanelle closes 12-18 mo posterior fontanelle closes 2-3 months
  • Neck and claviclesfracture of clavicle – large infant, lump, tenderness, crepitus, decreased movement
  • Cord
  • Extremitiesflexed and resist extensionassess fractures, clubfeethipsvertebral 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

  • Weight – loss of 10% normal
  • Length
  • Head and chest circumference
  • Normal VStemp 97.7-99.5F axillaryapical 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
Assessment of Cardio-respiratory Status
  • History
  • Airway
  • Assessrateq 30minX2hrssymmetrybreath sounds - moisture for 1-2 hrs
assessment of thermoregulation
Assessment of Thermoregulation
  • 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
assessment of hepatic function
Assessment of Hepatic Function
  • Blood GlucoseSigns of hypoglycemia jitteriness respiratory difficulties drop in temp poor suckingTx- feed infant if glucose below 40-45 mg/dl
  • Bilirubinphysiologic jaundice peaks 2-4 days of lifeearly onset may be pathologic
  • 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
Assessment of Neuro System
  • Reflexes
  • BabinskiGraspMoroRootingSteppingSuckingTonic neck reflex “fencing”
  • Cry
  • Infant response to soothing
assessment of gastrointestinal system
Assessment of Gastrointestinal System
  • Mouth
  • Suck
  • Abdomen
  • Initial feeding
  • Stoolsmeconium – within 12-48 hours of birth dark greenish blackbreastfed – soft, seedy, mustard yellowformula-fed – solid, pale yellow
assessment of genitourinary system
Assessment of Genitourinary System
  • Umbilical cord vessels
  • Urine – within 24 hours of birth
  • Voiding – 6 to 10 times a day after 2 days
  • Genitaliafemale – edema normal, majora covers minora, pseudomenstruationmale – pendulous scrotum, descended testes by 36 wks gest., placement of meatus
assessment of integumentary system
Assessment of Integumentary System
  • Vernix – white covering
  • Lanugo – fine hair
  • Milia
  • Erythema toxicum – red blotchy with white
  • BirthmarksMongolian spots – sacral areaTelangiectatic nevus “stork Bite” - blanches

Nevus flammeus “port wine stain” - no blanchingNevus vasculosus “strawberry hemangioma” usually on head, disappears by school age


Port Wine Stain

Erythema toxicum

fetus to newborn psychosocial adaptation
Fetus to Newborn: Psychosocial adaptation
  • Periods of Reactivityactive – 30-60 minsleep – 2-4 hoursalert – 4-6 hours
  • Behavioral Statesquiet sleepactive sleepdrowsy statequiet alert – best for bondingactive alertcrying state
gestational age assessment
Gestational Age Assessment
  • Assessment tool – Dubowitz, Ballard
  • Weeks from conception to birth
  • Used to identify high risk infants
  • Neuromuscular characteristicsPosture – more flexionSquare window – more pliableArm recoil - activePopliteal angle - lessScarf Sign – less crossing Heel to ear – most resistance
gestational age assessment31
Gestational Age Assessment
  • Physical characteristicsSkin- deep cracking, no vessels seen, post-leatheryLanugo – less as agePlantar creases – more with ageBreasts – larger areola Eyes and Ears – stiff with instant recoilGenitals – deep rugae, pendulous, covers minora
  • Gestational Age & Size – may not correspondsmall SGA <10% for weight large LGA >90% for weightappropriate AGA between 10-90%
ongoing assessment and care
Ongoing Assessment and Care
  • Bathing
  • Cord care
  • Cleansing diaper area
  • Assisting with feedings
  • Protecting infantidentifying infantpreventing infant abduction – alert to unusualpreventing infection
  • Review beige cue cards in center of book for teach

LATCH was created to provide a systematic method for breastfeeding assessment and charting.

  • Most common neonatal surgical procedure
  • Reasons for choosing
  • Reasons for rejecting – hypospadias, epispadias
  • Pain relief
  • Methods
  • Nursing care
other concerns
Other Concerns
  • ImmunizationsHepatitis B – begin vaccine at birth
  • Screening testsHearingPhenylketonuria – by law
further assessments
Further Assessments
  • Complications r/t poorly functioning placentahypoglycemiahypothermiarespiratory problems
  • Complications r/t LGA infanthypoglycemiabirth injury due to size
shoulder dystocia
Shoulder Dystocia
  • Risk factorsdiabetes; macrosomic infantobesityprolonged second stageprevious shoulder dystocia
  • Morbidity- fracture of clavicle or humerus,brachial plexus injury
  • Management – generous episiotomy
high risk infants
High Risk Infants
  • 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
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
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 nippleresp <60/m, rooting, sucking, gag reflex
complications of preterm infants
Complications of Preterm Infants
  • Respiratory Distress Syndrome -RDS
  • Bronchopulmonary dysplasia – chronic lung disease
  • Periventricular-Intraventricular Hemorrhage30% 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
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- centralgrunting- expiratoryseesaw respirationsasymmetry

therapeutic management of rds
Therapeutic Management of RDS
  • Surfactant replacement therapy
  • Installed into the infant’s trachea
  • Improvement in breathing occurs in minutes
  • Doses repeated prn
  • Other treatmentmechanical ventilationcorrection of acidosisIV fluids
post term infants
Post Term Infants
  • 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
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
  • 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
phototherapy for hyperbilirubinemia
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
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
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
  • 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
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
Small for Gestational Age
  • 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
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
Drug Withdrawal in Infants
  • Signs of drug exposureopiates – 48-72 hourscocaine – 2-3 daysalcohol – 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
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
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
Signs Bonding Delayed
  • 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