NURSING CARE OF THE NEWBORN

THE NEONATE

Immediate Care of the Newborn in the Delivery Room

Principle No. 1: Establish and maintain patent airway. Important: Never stimulate the baby to cry unless the secretions have been drained out.

1. Place the newborn in Trendelenburg’s position to drain

out secretions. Except if there are signs of increased intracranial pressure (ICP) such as shrill, high-pitched cry, vomiting, bulging anterior fontanel and large head. If these are present, place the baby in reverse T-position.

2. Suction the newborn properly.- suction gently and quickly. Prolonged suctioning may

stimulate the vagus nerve and cause bradycardia.- suction the mouth first before the nose because when

suctioning the nose, there is reflex inhalation of the pharyngeal materials into the trachea and bronchi.Principle No. 2: Maintain appropriatebody temperature. Chilling increases the body need foroxygen. Dry the baby immediately, wrapwarmly, and place under a drop light.

Four Mechanisms of Heat Loss:Convection – flow of heat from the

body surface to cooler surrounding air.

Conduction – transfer of body heat to a

cooler solid object in contact with the

baby.

Radiation – transfer of body heat to a cooler solid object not in contact with the baby. Evaporation – loss of heat

through conversion of a liquid to a

vapor.

Other reasons why newborns lose heat easily: Newborns have difficulty conserving heat.

Insulation is not effective because they have little subcutaneous fat to provide insulation.

Shivering is rarely seen in newborns. Immaturity of the hypothalamus. Inadequate adipose tissue and brown fats. The baby is born wet.

Principle No. 3: Immediate Assessment of the Newborn. i. Apgar Scoring – standardized evaluation of the newborn. Done at one minute after birth to determine the general condition at birth, and then at 5 minutes to determine how well the newborn is adjusting the extrauterine life. Interpretation:

0 – 3 the baby is in serious danger and needs immediate resuscitation

4 – 6 the baby’s condition is guarded and needs more extensive clearing of the airway

7 – 10 the baby is in the best possible health

Apgar Scoring Chart

SIGNS O 1 2

Heart Rate absent < 100/min > 100/min

Respiratory Effort

absent weak cry good, strong cry

Muscle Tone limp, flaccid some flexion of the extremities

well-flexed extremities

Reflex Irritability

no response grimace, weak cry

sneeze, good strong cry

Color blue, pale body pink, extremities blue

pink all over

Example: Baby Lara is assessed by Nurse Lon one

minute after birth. Nurse Lon noted that the arms and legs are blue, and body pink. The legs are flaccid, and arms are flexed. When the sole of the foot was slapped, the baby responded with a weak cry. Auscultation of the apical heart showed 98 beats per minute. What is Baby Lara’s Apgar score? How should Nurse Lon interpret the result?

5. The baby’s condition is guarded, and needs more extensive clearing

of the airway.

ii. Silverman-Andersen Index – this can be used to estimate degrees of respiratory distress in newborns. The features observed are chest movement, intercostal retraction, xiphoid retraction, nares dilatation, and expiratory grunt.

Interpretation: 0 no respiratory distress 4 – 6 moderate respiratory distress 7 – 10 severe distress

Silverman-Andersen Index

iv. Ballard’s Scoring – this assessment consists of two portions: physical maturity and neuromuscular maturity.Physical maturity assesses: - skin texture - color - lanugo - foot creases - genitalia - ear - breast maturity

Neuromuscular maturity assesses: - posture - square window (wrist) - arm recoil - popliteal angle - scarf sign - heel to ear

iii. Gestational Age Assessment – five criteria are used to evaluate gestational maturity. These include sole creases, breast nodule diameter (mm), scalp hair, ear lobe, and testes and scrotum.

Physical Maturity

Neuromuscular Maturity

Principle No. 4: Identification of the Newborn Identification of the newborn should be done in the DR before bringing to the nursery. Footprints are said to be the best form, although identical ID bands for both mother and baby may suffice.

Physical Assessment of the NewbornUsual Findings Common

Variations/ Minor Abnormalities

Potential Signs of Distress/ Major Abnormalities

General MeasurementsHC – 34 to 35 cmCC – 32 to 33 cmAC – 32 to 33 cmBL – 46 to 54 cm

BW – 2.5 to 3.4 kg

Vital SignsTemp – 36.5-37.6

Molding after birth may alter HC.HC and CC may be equal for first 1-2 days after birth.Loss of 10% of BW in first week; regained in 10-14 days.

Crying may increase body temp slightly.Radiant warmer will falsely increase axillary temp.

Head circumference <10th or >90th percentile.

BW <10th or >90th percentile.

Hypothermia

Hyperthermia

Apical HR – 120-140 bpm

Respirations – 30-60 breaths/min

Blood Pressure – 65/41 mmHg in arm and calf.

General AppearancePosture – flexion of head and extremities, which rests on chest and abdomen.

Crying will increase HR; sleep will decrease HR.During 1st period of reac- tivity (6-8 hrs), rate can reach 180 bpm.Crying will increase RR; sleep will decrease RR.During 1st period of reac- tivity, rate can reach 80 breaths /min.Crying and activity will increase BP

Frank breech – extended legs, abducted and fully rotated thighs, flattened occiput, extended neck.

Bradycardia (<80 bpm)

Tachycardia (>160 bpm)

Tachypnea (>60 breaths /min)Apnea of 20 seconds or more

Oscillometric SBP in calf 6-9 mmHg less than in upper extremity (sign of coarctation of the aorta).

Limp posture, extension of extremities

SkinAt birt - bright red, puffy, smooth2nd to 3rd day – pink, flaky, dryVernix caseosaLanugoEdema around eyes, face, legs, dorsa of hands, feet, and scrotum or labia.AcrocyanosisCutis marmorata – tran- sient mottling when infant is exposed to decreased temp.

Neonatal jaundice after first 24 hrs.Milia – distended seba- ceous glands that ap- pear as tiny white papules on cheeks, chin, and noseMiliaria or sudamina – distended sweat (ecri- ne) glands that appear as minute vesicles, especially on faceErythema toxicum – pink papular rash with vesi- cles superimposed on thorax, back, buttocks, and abdomen; may ap- pear in 24-48 hrs and resolve after several days

Progressive jaundice, especially in first 24 hrsGeneralized cynosisPallorMottlingGraynessPlethora – excess of blood in a part of the body, especially in the face, causing a ruddy complexionHemorrhage, ecchymo- ses, or petechia that persistSclerema – hard and stiff skin Poor skin turgorRashes, pustules, or blisters

Skin – cont’d

HeadFontanels should be flat, soft, and firm

Harlequin color change – clearly outlined color change as infant lies on side; lower half of body becomes pink, and upper half is paleMongolian spots – irreg- ular areas of deep blue pigmentation, usually in sacral and gluteal regionsTelangiectatic nevi (stork bites) – flat, deep pink localized areas usually seen in back of neck

Molding following vaginal deliveryBulging fontanel due to crying or coughing

Café-au-lait spots – light brow spotsNevus flammeus – port- wine stain

Fused suturesBulging or depressed fontanels when quietWidened sutures and fontanels

Head – cont’d Caput succedaneum – edema of soft scalp tissueCephalhematoma (unco- mplicated) – hemato- ma between perios- teum and skull bone

Craniotabes – snapping sensation along lamboid suture that resembles indentation of Ping-Pong ball

EyesLids usually edematousColor – slate gray, dark blue, brownAbsence of tearsPresence of red reflexCorneal reflex in respon- se to touchPupillary reflex in respon- se to lightBlink reflex in response to light and touchRudimentary fixation on objects and ability to follow to midline

EarsPosition – top of pinna on horizontal line with outer cantus of eyeStartle reflexPinna flexible, cartilage

Searching nystagmus or strabismus

Subconjunctival (scleral) hemorrhages – ruptu- red capillaries, usually at limbus

Inability to visualize tympanic membrane because of filled aural canals

Pink color of irisPurulent dischargeHypertelorism (3cm or >)HypotelorismCongenital cataractsConstricted or dilated fixed pupilAbsence of red reflexAbsence of pupillary or corneal reflexInability to follow object or bright light to midlineYellow sclera

Low placement of earsAbsence of startle reflex in response to loud noise

Ears – cont’d

NoseNasal patencyNasal discharge – thin white mucusSneezing

Mouth and ThroatIntact, high-arched palateUvula in midlineFrenulum of tongueFrenum of upper lipSucking reflex – strong and coordinatedRooting reflex

Pinna flat against headIrregular shape or sizePits or skin tags

Flattened and bruised

Natal teeth

Minor abnormalities may be signs of various syndromes, especially renal

Nonpatent canalsThick, bloody nasal dischargeFlaring of nares (alae nasi)Copious nasal secretions of stuffiness (maybe minor)

Cleft lipCleft palateLarge, protruding tongue or posterior displace- ment of tongueProfuse salivation or drooling

Mouth and Throat – cont’dGag reflexExtrusion reflexAbsent or minimal salivationVigorous cry

NeckShort, thick, usually surrounded by skin foldsTonic neck reflex

Epstein pearls – small, white epithelial cysts along midline of hard palate

Torticollis (wry neck) – head held to one side with chin pointing to opposite side

Candidiasis (thrush) – white, adherent pat- ches on tongue, palate, and buccal surfaces

Inability to pass NGTHoarse, high-pitched, weak, absent, or other abnormal cry

Excessive skinfoldsResistance to flexionAbsence of tonic neck reflexFractured clavicle

ChestAnteroposterior and late- ral diameters equalSlight sternal retractions evident during inspira- tionXiphoid process evidentBreast enlargement

Funnel chest (pectus excavatum)

Pigeon chest (pectus carinatum)

Supernumerary nipplesSecretion of milky subs- tance from breasts (“witch’s milk”)

Depressed sternumMarked retractions of chest and intercostal spaces during respirationAsymmetric chest expansionRedness and firmness around nipplesWide—spaced nipples

LungsRespirations chiefly abdominalCough reflex absent at birth, present by 1-2 daysBilateral equal bronchial breath sounds

Rate and depth of respirations may be irregular, periodic breathing Crackles shortly after birth

Inspiratory stridorExpiratory gruntRetractionsPersistent irregular breathingPeriodic breathing with repeated apneic spellsSeesaw respirations (paradoxical)Unequal breath soundsPersistent fine cracklesWheezingDiminished breath soundsPeristaltic bowel sounds on one side, with diminished breath sounds on same side

HeartApex – 4th to 5th ICS, lateral to left sternal borderS2 slightly sharper and higher in pitch than S1

Sinus arrhythmia – heart rate increases with inspiration and decrea- ses with expirationTransient cyanosis on crying or straining

Dextrocardia – heart on right side

Displacement of apex, muffledCardiomegalyAbdominal shuntsMurmursThrillsPersistent cyanosisHyperactive precordium

AbdomenCylindric in shapeLiver – palpable 2-3 cm below right costal marginSpleen – tip palpable at end of first week of ageKidneys – palpable 1-2 cm above umbilicus Umbilical cord – bluish white at birth

Femoral pulses – equal bilaterally

Umbilical herniaDiastasis recti – midline gap between recti muscles

Wharton’s jelly – unusu- ally thick umbilical cord

Abdominal distentionLocalized bulgingDistended veinsAbsent bowel soundsEnlarged liver and spleenAscitesVisible peristaltic wavesScaphoid or concave abdomenGreen umbilical cordPresence of only one artery in cordUrine or stool leaking from cordPalpable bladder distention following scanty voidingAbsent femoral pulsesCord bleeding or hematoma

Female GenitaliaLabia and clitoris usually edematousUrethral meatus behind clitorisVernix caseosa between labiaUrination within 24 hrs

Pseudomenstruation – blood-tinged or mucoid dischargeHymenal tag

Enlarged clitoris with urethral meatus at tipFused labiaAbsence of vaginal openingMeconium from vaginal openingNo urination within 24 hrsMasses in labiaAmbiguous genitalia

Male GenitaliaUrethral opening at tip of glans penisTestes palpable in each scrotumScrotum usually large, edematous, pendulous, and covered with rugaeSmegmaUrination within 24 hrs

Urethral opening covered by prepuceInability to retract foreskin

Epithelial pearls – small, firm, white lesions at tip of prepuceErection or priapismTestes palpable in inguinal canalScrotum small

Hypospadias – urethral opening on ventral surface of penis

Epispadias – urethral opening on dorsal surface of penis

Male Genitalia – cont’d

Chordae – ventral curvature of penisTestes not palpable in scrotum or inguinal canalNo urination within 24 hrsInguinal herniaHypoplastic scrotumHydrocele – fluid in scrotum

Masses in scrotumMeconium from scrotumDiscoloration of testesAmbiguous genitalia

Back and RectumSpine intact, no ope- nings, masses, or prominent curvesTrunk incurvation reflexAnal reflexPatent anal openingPassage of meconium within 48 hrs

Green liquid stools in infant under photo- therapyDelayed passages of meconium in very-low- birth-weight neonates

Anal fissures or fistulasAbsence of anal reflexNo meconium within 36- 48 hrsPilonidal cyst or sinusTuft of hair along spineSpina bifida (any degree)

Imperforate anus

ExtremitiesTen fingers and toesFull ROMNail beds pink, with transient cyanosis immediately after birthCreases on anterior two thirds of soleSole usually flatSymmetry of extremitiesEqual bilateral brachial pulses

Partial syndactyly bet- ween 2nd and 3rd toesSecond toe overlapping into 3rd toeWide gap between 1st (hallux) and 2nd toesDeep crease on plantar surface of foot bet- ween 1st and 2nd toesAsymmetric length of toes

Polydactyly – extra digits

Syndactyly – fused or webbed digits

Phocomelia – hands or feet attached close to trunk

Extremities – cont’dEqual muscle tone bilaterally, especially resistance to opposing flexion

Dorsiflexion and shortness of hallux

Hemimelia – absence of distal part of extremity

Hyperflexibility of jointsPersistent cyanosis of nail bedsYellowing of nail bedsSole covered with creasesTransverse palmar (simian) creaseFracturesDecreased or absent ROM

Extremities – cont’d Dislocated or

subluxated hipLimitation in hip abductionUnequal gluteal or leg foldsUnequal knee height (Allis or Galeazzi sign)

Audible clunk on abduc- tion (Ortolani sign)Asymmetry of extremitiesUnequal muscle tone or ROM

Neuromuscular SystemExtremities usually maintain some degree of flexionExtension of an extremity followed by previous position of flexionHead lag while sitting, but momentary ability to hold head erectAble to turn head from side to side when proneAble to hold head in horizontal line with back when held prone

Quivering or momentary tremors

Hypotonia – floppy, poor head controlHypertonia – jittery, arms and hands tightly flexed, legs stiffly extended, startles easilyAsymmetric posturing (except tonic neck reflex)Opisthotonic posturing – arched backSigns of paralysisTremors, twitches, and myoclonic jerksMarked head lag in all positions

Systemic Evaluation of the NewbornCardiovascular and Hematologic System

Dying or clamping of the cord and stimulation of cold receptors

Increased PCO2, decreased PO2, and increasing acidosis

First breath

Decreased pulmonary artery pressure

Increased PO2

Closure of ductus arteriosus

Closure of foramen ovale (pressure in left side of heart

greater than in right side)

Closure of ductus venosus and

umbilical arteries and vein due to decreased blood

flow

Peripheral circulation remains sluggish for at least the first 24 hours.

Capillary heel sticks may reveal a false high hema- tocrit or hemoglobin value because of sluggish peripheral circulation. > Before obtaining the specimen, warm the extremity by wrapping it in a warm cloth to increase circulation, thus improving the accu- racy of this value.

Once proper lung oxygenation is established, the need for the high erythrocyte diminishes.

A newborn has an equally high WBC count at birth.

Most newborns are born with a prolonged coagulation or prothrombin time.

Respiratory System

A first breath of a newborn is initiated by a combination of cold receptors, a lowered PO2, and an increased PCO2.

The presence of lung fluid eases the surface tension on alveolar walls and makes a first breath easier.

Newborns who are immature and whose alveoli collapse each time they exhale have trouble establishing effective respirations.

Gastrointestinal System

Although GIT is usually sterile at birth, bacteria may be cultured from the intestinal tract in most babies within 5 hrs after birth and from all babies at 24 hrs of life.

Newborns have limited ability to digest fat and starch because the pancreatic enzymes, lipase and amylase are deficient for the first few months of life.

Newborns regurgitates easily because of an immature cardiac sphincter.

The first stool of the newborn, usually passed within 24 hrs after birth, consists of meconium (a sticky, tarlike, blackish-green, odorless mate- rial formed from mucus, vernix, lanugo, hormo- nes, and carbohydrates that accumulated during intrauterine life).

Transitional stool (green and loose) is obsereved on the 2nd or 3rd day of life, which may resemble diarrhea to the untrained eye.

By the 4th day of life, breastfed babies pass three or four light yellow stools per day. These are sweet smelling because breast milk is high in lactic acid.

A newborn who receives formula usually passes two or three yellow stools a day. These have slightly more noticeable odor.

Variations in color and consistency of stools: bright green – a newborn placed under phototherapy lights; this is because of increased bilirubin extretion. stool with mucus or watery and loose – milk allergy, lactose intolerance, or some other irritant should be suspected. clay-colored (gray) stools – bile duct obstruction blood-flecked – anal fissure tarry stool in 2 or more days – because of some maternal blood swallowed during birth. (Maternal blood may be differentiated from fetal blood by a dipstick Apt test). If the stools remain black or tarry, intestinal bleeding should be suspected.

Urinary System

Average newborns void within 24 hrs after birth. Newborns who do not void within this time should be examined for the possibility of urethral stenosis or absent kidneys or ureters.

The possibility of urinary tract obstruction can be assessed by observing the force of the urinary stream.

The kidneys of newborns do not concentrate urine well, thus the urine is usually light colored and odorless.

The first voiding may be pink or dusky because of uric acid crystals that were formed in the bladder in utero. This is an innocent finding.

Immune System

Newborns are prone to infection due to the difficulty forming antibodies until they are about 2 months of age.

The infant at birth, however, has passive antibodies (IgG) from the mother that have crossed the placenta. In most instances, these include antibodies against poliomyelitis, measles, diphtheria, pertussis, chickenpox, rubella, and tetanus.

There is little natural immunity against herpes simplex.

At birth, newborns should receive BCG and Hepatitis B vaccine.

Neuromuscular System

Mature newborns demonstrate general neuromuscular function by moving their extremities, attempting to control head movement, and exhibiting a strong cry.

Limpness or total absence of a muscular response to manipulation is never normal and suggests narcosis, shock, or cerebral injury.

A newborn occasionally makes twitching or flailing movements of extremities in the absence of a stimulus because of the immaturity of the nervous system.

Reflexes Expected Behavioral Responses

LocalizedEyesBlinking or cor- neal reflex

Pupillary

Doll’s eye

NoseSneeze

Glablella

Infant blinks at sudden appearance of a bright light or at approach of an object toward cornea; persists throughout life.

Pupil constricts when a bright light shines toward it; persists throughout life.

As head is moved slowly to right or left, eyes lag behind and do not immediately adjust to new position of head; disappears as fixation develops; if persists, indicates neurologic damage.

Spontaneous response of nasal passages to irritation or obstruction; persists throughout life

Tapping briskly on glabella causes eyes to close tightly.

Assessment of Reflexes in the Newborn

Mouth and ThroatSucking

Gag

Rooting

Extrusion

Yawn

Cough

Infant begins strong sucking movements of circumoral area in response to stimulation; persists throughout infancy, even without stimulation, such as during sleep.

Stimulation of posterior pharynx by food, suction, or passage of a tube causes infant to gag; persists throughout life

Touching or stroking the cheek along side of mouth causes infant to turn head toward that side and begin to suck; should disappear at about age 3-4 months, but may persist for up to 12 months.

When tongue is touched or depressed, infant responds by forcing it outward; disappears by age 4 months.

Spontaneous response to decreased oxygen by increasing amount of inspired air; persists throughout life.

Irritation of mucous membranes of larynx or tracheobronchial tree causes coughing; persists throughout life; usually present after first day of birth.

ExtremitiesGrasp

Babinski

Ankle clonus

MassMoro

Touching palms of hands or soles of feet near base of digits causes flexion of hands and toes; palmar grasp lessens after age 3 months, to be replaced by voluntary movement; plantar lessens by 8 months of age.

Stroking outer sole of foot upward from heel and across ball of foot causes toes to hyperextend and hallux to dorsiflex; disappears by age 1 year.

Briskly dorsiflexing foot while supporting knee in partially flexed position results in one to two oscillating movements (“beats”); eventually no beast should be felt.

Sudden jarring or change in equilibrium causes sudden extension and abduction of extremities and fanning of fingers, with index finger and thumb forming a C shape, followed by flexion and adduction of extremities; legs may weakly flex; infant may cry; disappears after age 3-4 months, usually strongest during first 2 months.

Startle

Perez

Asymmetric tonic neck

Trunk incur-vation (Gal-ant) reflex

Dance or step

A sudden loud noise causes abduction of the arms with flexion of elbows; hands remain clenched; disappears by age 4 months.

While infant is prone on a firm surface, thumb is pressed along spine from sacrum to neck; infant responds by crying, flexing extremities, and elevating pelvis and head; lordosis of the spine, as well as defecation and urination, may occur; disappears by age 4-6 months.

When infant’s head is turned to one side, arm and leg extend on that side, and opposite arm and leg flex; disappears by age 3-4 months, to be replaced by symmetric positioning of both sides of body.

Stroking infant’s back alongside spine causes hips to move toward stimulated side; disappears by age 4 weeks.

If infant is held so that sole of foot touches a hard surface, there is reciprocal flexion and extension of the leg, simulating walking; disappears by age 3-4 weeks, to be replaced by deliberate movement.

Crawl

Placing

When placed on abdomen, infant makes crawling movements with arms and legs; disappears at about age 6 weeks.

When infant is held upright under arms and dorsal side of foot is briskly placed against hard object, such as table, left leg lifts as if foot is stepping on table; age of disappearance varies.

Routine Care of the NewbornCare of the Newborn in the Nursery Room

1. Initial oil bath – done first to remove vernix caseosa

2. Initial infant bath – should be done as quickly as possible to prevent hypothermia.

3. Inspect and Care for umbilical cord > Until the cord falls off, at about the

seventh to tenth day of life, the infant should receive a sponge bath, rather than be immersed in a tub of water.

> After the cord falls off, a small, pink, granulating area about a quarter of an inch in diameter may remain.

4. Taking anthropometric measurements, including vital signs.

5. Crede’s prophylaxis – prophylactic eye treatment against gonorrheal conjunc-tivitis.

6. Vitamin K administration – newborns are at risk of bleeding during the first week of life because their GIT is sterile at birth and unable to produce vitamin K, necessary for blood coagulation.

Care of the Newborn in the Postpartal Period

Initial Feeding A term newborn who is to be breast- fed may be fed immediately after birth. A baby who is to be formula fed may receive a first feeding at about 2 to 4 hours of age.

Bathing Bathing should be done before, not after, a feeding.

Sleeping Position SIDS is the sudden, unexplained death of an infant under 1 year of age.

Diaper Area Care Diaper dermatitis should be prevented. A mild ointment, such as petroleum jelly, may be applied to the buttocks.

The High Risk Infant

Premature Infant- live-born infant born before the end of week 37 of gestation- another criterion used is a weight of less than 2500 g at birth- a lack of lung surfactant makes them extremely vulnerable to RDS- appears small and underdeveloped; head is disproportionately large; skin is usually ruddy because of little sub- cutaneous fat beneath it; veins are easily noticeable; high degree of acro- cyanosis may be present

Postmature Infant- born after the 42nd week of a pregnancy- an infant who stays in utero past week 42 of pregnancy is at special risk because a placenta appears to function effectively for only 40 weeks- characteristics: dry, cracked, almost leather-like skin from lack of fluid, and absence of vernix caseosa; they may be lightweight from the a recent weight loss that occurred because of the poor placental function- amniotic fluid may be meconium stained