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
• 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
• Increased oxygen need
• Decreased surfactant production
• Respiratory distress
• Hypoglycemia
• Metabolic acidosis
• Jaundice
 APGAR
• 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
• 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
• 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
• 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 - The Babinski sign is obtained by stimulating the external portion (the outside) of the sole.
The examiner begins the stimulation back at the heel and goes forward to the base of the toes.

Grasp
Moro - He’ll tighten his body, fling his arms up and out and open up his usually tightly clenched fists,
draw up his knees and then bring his arms and re-clenched fists close to his body — almost as if he’s giving
himself a hug.

Rooting
Stepping
Sucking
Tonic neck reflex “fencing”
• Cry
• Infant response to soothing
 Assessment of Gastrointestinal
System
• 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
• 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
• 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
• 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
• 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.
 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
 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
• 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.
Silverman-Andersen Index
• Evaluation of respiratory status using the Silverman-Andersen index. The
baby’s respiratory status is assessed. A grade of 0, 1, or 2 is determined for
each area, and a total score is charted in the baby’s record or on a copy of
this tool and placed in the chart.
• 4.Cyanosis
• a. Central cyanosis indicates true hypoxia
• b. Peripheral cyanosis normal immediately after birth (Figure 20-7)
• c. May be present at birth or appear later
• d. May occur during feeding
• 5.Grunting
• a. Noise on expiration as pressure is increased to keep alveoli open
• b. Common sign of respiratory distress syndrome
• c. Indicates need for continued assessment and treatment
• 6.Seesaw respirations
• a. Chest falls when abdomen rises
• b. Chest rises when abdomen falls
• c. Sign of severe respiratory difficulty
• 7.Asymmetry of chest expansion
 Therapeutic Management of RDS
• 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
• 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
• 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
• 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