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Newborn Nursing. The Newborn. 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.

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nursing assessment of the normal newborn
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


Cry – strong and lusty

nursing assessment of the normal newborn1
Nursing Assessment of the Normal Newborn

Initial assessment (continued)

  • 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
newborn s immediate needs
Newborn’s Immediate Needs
  • Airway
  • Breathing
  • Circulation
  • Warmth
initial newborn assessment
Initial newborn assessment
  • Stimulate & dry infant
  • Assess ABCs
  • Encourage skin-to-skincontact
  • Assign APGAR scores
  • Give eye prophylaxis &vitamin K
  • Keep newborn, mother, &partner together wheneverpossible
newborn period neonatal transition
  • Newborn period: birth to 28 days
  • Neonatal transition: first 6-8 hoursafter birth
  • Establishment of respiratory gasexchange & circulatory system
  • Nurse must be aware of normalphysiologic & behavioral adaptations,as well as deviations from the normto ensure safety of the newborn
the newborn1
The Newborn
  • 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.
dry the baby
Dry the Baby
  • Hypothermia is common
  • Wet newborns rapidly lose heat
  • Use a warm, dry, soft towel
  • Any absorbent material:
    • Shirt
    • T-shirt
    • Socks
    • Battle dressings
replace the wet towels
Replace the Wet Towels
  • Then let the mother hold the baby
  • Her body heat will help keep the baby warm
  • Cover the head to prevent heat loss
position the baby
Position the Baby
  • 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.
suction the airway
Suction the Airway
  • 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.
ventilate if necessary
Ventilate if Necessary
  • If not breathing following brief stimulation, ventilate
  • Ideally, bag/mask, 100% oxygen, pressure gauge, flow control valve
  • May need to use mouth-to-mouth
  • Cover nose and mouth
  • Use shallow puffs to ventilate
evaluate the baby
Evaluate the Baby
  • Breathing
  • Color
  • Heart Rate
  • Tactile stimulation (rubbing) with a towel. may effectively stimulate a mildly depressed baby
keep the baby warm
Keep the Baby Warm
  • 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

At birth-warmth, keep the baby in skin to skin contact with the mother

Teaching Aids: ENC



apgar score
Apgar Score
  • 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.
apgar score1
Apgar Score
  • 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
nursing assessment of the normal newborn2
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

vital signs
Vital Signs
  • 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

    • 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.
nursing assessment of the normal newborn3
Nursing Assessment of the Normal Newborn
  • 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
gestational age relationship to intrauterine growth
Gestational Age Relationship to Intrauterine Growth
  • 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
nursing assessment of the normal newborn4
Nursing Assessment of the Normal Newborn

Skin characteristics





Erythema toxicum – “Newborn rash”


Skin turgor

nursing assessment of the normal newborn5
Nursing Assessment of the Normal Newborn

Skin Characteristics (continued)

Vernix caseosa

Ruddy color

Cracked and peeling skin


Forceps or vacuum marks



  • Expected findings
  • Skin reddish in color, smooth and puffy at birthAt 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
common normal variations
Common Normal Variations
  • 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 African-American 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.


  • Most newborns have acrocyanosis (body is centrally pink, but hands and feet are blue
  • Cyanosis requires treatment:
    • Oxygen
    • Airway
    • Ventilation



color of the baby
Color of the baby
  • Normal vs. Abnormal

Teaching Aids: ENC



  • Cheesy-white
  • Normal
  • Antibacterial properties
  • Protects the newborn skin
  • 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.
nursing assessment of the normal newborn6
Nursing Assessment of the Normal Newborn

General appearance of the head

  • Cephalhematoma – bleeding between the periosteum and the cranial bone
  • Caput succedaneum – localized edema from pressure
  • Molding – movement of the cranial bones during birth
  • Fontanels
the head and chest
The Head and Chest
  • 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
anterior and posterior fontanelles
Anterior and Posterior Fontanelles
  • Anterior diamond shaped 2-3 - 3-4 cms
  • Posterior triangular 0.5 - 1 cm
  • Fontanels soft, firm and flat
  • Molding is shaping of fetal head to adapt to the mothers pelvis during labor.
caput succedaneum
Caput succedaneum
  • 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
  • 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
caput succedaneum vs cephalohematoma
Caput succedaneum vs. cephalohematoma
  • Normal vs. Abnormal

Teaching Aids: ENC



abnormal position of arm and hand
ABNORMAL position of arm and hand

Teaching Aids: ENC



nursing assessment of the normal newborn7
Nursing Assessment of the Normal Newborn


  • Symmetry
  • Eyes
  • Nose
  • Mouth
  • Ears
nursing assessment of the normal newborn8
Nursing Assessment of the Normal Newborn
  • Neck
  • Chest
  • Cardiac
  • Peripheral vascular
  • Abdomen
check the heartbeat
Check the Heartbeat
  • Normal newborn rate is >100
  • Palpate umbilical cord or brachial artery
  • If pulse <100, ventilate the baby, using whatever skills and equipment you have
cardiovascular changes at birth
  • Onset of respirations stimulates changesin cardiovascular system of newborn
  • Closure of fetal shunts
  • Foramen ovale
  • Ductus venosus
  • Ductus arteriosus: functionally closes within24 hours of birth, but may take several weeksto permanently close
nursing assessment of the normal newborn9
Nursing Assessment of the Normal Newborn
  • Umbilical cord
    • Examined for 2 arteries, 1 vein.
    • Will dry up and detach in 10 to 14 days
    • Cord Care: alcohol, soap & water
umbilical cord care
Umbilical Cord Care
  • Clean & dry
  • Alcohol wipe once a day
  • Topical antiseptic only in contaminated areas
the umbilicus which one is normal
The umbilicus: Which one is normal?
  • Normal vs. Abnormal

Teaching Aids: ENC



nursing assessment of the normal newborn10
Nursing Assessment of the Normal Newborn
  • Genitals
    • Female may have thick white mucousy vaginal discharge
    • Male evaluate for the position of the urinary meatus, scrotum, testicles
nursing assessment of the normal newborn11
Nursing Assessment of the Normal Newborn
  • 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
nursing assessment of the normal newborn12
Nursing Assessment of the Normal Newborn
  • Neurologic Status
    • Alertness
    • Resting posture
    • Cry
    • Muscle tone and activity



Palmar grasp

Plantar grasp

Tonic neck





Crossed extension reflex


Nursing Assessment -Normal Newborn

Reflexes: indicate neurological integrity

rooting reflex
Rooting Reflex
  • 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
sucking reflex
Sucking Reflex
  • 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.
extrusion reflex
  • 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.
palmer grasping reflex
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!
tonic neck reflex fencing
Tonic Neck Reflex (FENCING)
  • 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

startle moro reflex
Startle/Moro Reflex
  • 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.
galant reflex
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.
stepping reflex
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.
babinski reflex
Babinski Reflex
  • 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.
placing reflex
Placing reflex
  • 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.
neural tube defects
Neural Tube Defects
  • 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

Spina bifida occulta


Spina bifida Occulta


nursing care of the normal newborn
Nursing Care of the Normal Newborn
  • Identification
  • Medications
    • Vitamin K
    • Erythromycin
  • Thermoregulation
  • Feedings
prophylactic care
Prophylactic Care
  • 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
newborn intramuscular injection
Newborn: Intramuscular injection
  • aquaMEPHYTON (Vit.K)
  • 1 mg/0.5 ml IM lateral thigh
  • Vastus lateralis
nursing care of the normal newborn1
Nursing Care of the Normal Newborn
  • Infant protection
  • Parent teaching
    • Positioning
    • Cord care
    • Circumcision
    • Car seat safety
  • Screening tests, immunizations and other procedures
  • Assessing and supporting bonding
bathing the newborn
Bathing the Newborn
  • No tub bath until after the cord has fallen off and healing is complete.
  • Newborn’s first bath- the nurse needs to wear gloves to prevent infection.
  • What is wrong with this nursing action?
  • 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.
  • 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
infant formula
Infant Formula
  • 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.
respiratory distress
Respiratory Distress
  • 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.
infants of dm mothers idm complications
Infants of DM mothers (IDM) Complications
  • 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.

 Newborn infants need:

      •  easy access to the mother
      •  appropriate feeding
      •  adequate environmentaltemperature
      •  a safe environment



Newborn infants need: 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



 Newborn infants need: Cont’d…

    • nurturing, cuddling, stimulation
    •  protection from
      • disease
      • harmful practices
      • abuse/violence



Newborn infants need: Cont’d…

  • Acceptance of
        • sex
        • appearance
        • size



 Newborn infants need: Cont’d…

    • recognition by the state
    • (vital registration system).