Physiologic & Behavioral Transition to Extrauterine Life

The Normal Newborn

Assessments @ 1 min. and 5 min.

A = appearanceP = pulseG = grimaceA = activityR = respirationsAPGAR Scores

Physiologic Transitions of Major Systems

Pulmonary system transition Cardiac system transition Thermoregulation Metabolic transition Gastrointestinal system transition

Assessing for Congenital Anomalies:

Observe general appearance. Gross external anomalies.

Observe breathing pattern & auscultate chest. Cardiorespiratory problems, diaphragmatic

hernia.Observe breathing with infant’s mouth

closed. Choanal atresia.

Congenital Anomalies (cont.)Pass gastric tube or aspirate stomach

contents. Esophageal atresia.

Observe appearance of abdomen. Intestinal atresia (distended), diaphragmatic

hernia (scaphoid), omphalocele, gastroschisis.

Confirm passage of meconium & observe appearance of anus including wink reflex; perform rectal temperature. Imperforate anus.

Count umbilical vessels. <3 associated with genitourinary or cardiac

anomalies.Measure head circumference & palpate

fontanelles. Microcephaly, hydrocephalus.

Inspect and palpate palate. Cleft palate.

Evaluate hips. Congenital hip dysplasia.

IMPORTANT NORMAL VALUES:

Axillary temp: 97.1-97.8 F (36-36.5 C).Heart rate: 120-160 bpm apical (assess for 1

full minute).Respirations: 30-60 per min. not crying

(assess for 1 full minute). Infants are considered AGA if weight, length,

& head circumference are btw.10th & 90th percentiles, on standardized growth chart.

Average weight: 7.5 lbs. (3.5 kg).Average length: 20 in. (51 cm).Head circumference: 13-14 in. (33-

35.5 cm).Chest circumference: 12-13 in. (30.5-

33 cm).Head circumference: 0.8 in. larger

than chest circumference (2 cm).

Assessment of the Normal Newborn

NEONATAL PHYSICAL ASSESSMENT:

GENERAL APPEARANCE:Color.Observe general tone, activity, & posture

(initially & throughout exam).Observe & palpate skin.Measure & record weight & length, and

plot on growth curve.Measure & record temperature.

Head, Face and Neck:Measure & record head circumference,

& plot on growth curve.Inspect & palpate head.Palpate sutures.Palpate & measure fontanelles.Observe face, nose, & lips.Observe eyes & measure position.

Observe and palpate ears, measure position.

Inspect & palpate mouth.Inspect & palpate neck, clavicle, &

shoulders; assess mobility.

Chest, Abdomen, and Back:

Observe thorax.Measure chest circumference at nipple line.Observe breathing movements.Count respiratory rate.Auscultate lungs.Auscultate heart sounds.Count heart rate.Auscultate bowel sounds (all 4 quadrants,

before palpation).

Observe & palpate abdomen.Inspect umbilical cord & umbilicus.Palpate femoral lymph nodes & pulses.Record passage & character of stools.Determine patency of anus (rectal

temperature).Palpate & inspect spinal column.Observe back & buttocks.

Genitals & Urinary System:

Confirm urination; observe stream of urine in male infant.

Note appearance of external genitalia.Observe genitalia & palpate testes of

male infant.Observe genitalia of female infant.

Extremities:

Observe arms & legs for symmetric appearance, size, length, & movement.

Observe hands & feet.Evaluate rotation of hips: Ortolani &

Barlow maneuvers.Palpate peripheral pulses.

Reflexes:Rooting (assess bilaterally).Swallow.Sucking.Moro (startle reflex).Palmar and planter grasp (assess

bilaterally).Tonic neck reflex or fencing (assess

bilaterally).

Stepping or walking.Pull to sit (traction).Blink (glabellar).

Nutritional Needs of the Newborn

THE NORMAL

NEWBORN

NUTRITIONAL ALLOWANCES FOR THE NEWBORN

Calories

Growth in the neonatal periodNeeds of the newborn and infants up to 2

months and after 2 monthsActual caloric requirement...depends on the

infant activity level and growth rate

Protein

Necessary for the formation of the new

cellsThe newborn and infant need amino acidsUnaltered cow’s milk not recommendedCasein Vs. Lactalbumin

Fat

Linoleic acid......Necessary for growth and skin integrity

in infants

Carbohydrate

Lactose found in human milk and commercial formulas

........Improves calcium absorption and assist in nitrogen retention.

........Allows protein to be used for building new cells rather than calories

........Decrease the possibility of gastrointestinal illness

Calcium

Aid in bone growth Decrease level lead to tetany

Iron

Term infant will not need iron supplement for the first 3 months

Until they begin to produce adult hemoglobin

Fluoride

Aid in building teeth and preventing tooth decay

Given to child at 6 months of age ......If the child not receiving adequate

amount from breast feeding

Fluid

Fluid requirements for a newborn is 150-200 ml/kg (2.5-3.0 oz) over 24 hrs

Fruit juice is not recommended.

Physical examination of the newborn Vital signs Growth measurements Skin Head and neck Respiratory System Cardiovascular system Abdomen Genitalia Musculoskeletal system Central nervous system

Positions for Breastfeeding

Advantages of BreastfeedingFor Mother:

Helps the uterus to shrink back to pre-pregnancy size more quickly

Serves as a protective function in preventing breast cancer

Convenience – breast milk is always ready to use, clean & is always at the right temperature for the baby and can be refrigerated for later use

Strengthens mother-baby bondingCost

Advantages of BreastfeedingFor Baby:

Breast milk is individualized for the babyBetter digestionLessens susceptibility to allergiesBetter mouth developmentA DISADVANTAGE of breastfeeding is that

the breast milk may carry microorganisms (i.e.: Hep B, Cytomegalovirus, HIV)

Burping

Burping is important during and after feedings to bring up any excess air that was taken in during feeding

Baby should be burped every couple of ounces or between breast change

Three common ways of burping baby: 1. Over the shoulder 2. Face baby down on your lap while sitting 3. Sitting Up

Myths about BreastfeedingMyth: “You can’t breast feed if you have small breasts”.

Reality: Breasts of all shapes and sizes can satisfy the hungry baby.

Myth: “Breast feeding is a lot of trouble”.

Reality: Breasts, as opposed to bottles, are ready when the baby is ready.

Myth: “Breast feeding ties you down”.

Reality: Breast milk can be stored if mother decides she wants to go out. When the mother goes out she always has the food supply for the baby no matter how long she plans to stay out.

Myth: “Breast feeding ruins your breasts”.

Reality: Breast-feeding does not change the shape or size of the breasts. There are other factors (i.e. – age, not wearing a bra, or excess weight) that can change the shape & size of breasts.

Myth: “The father is excluded during breast feeding”.

Reality: An involved father will take advantage of opportunity such as bathing, diapering,

holding, & playing with the baby.

Nursing Outcomes – Mom is able to demonstrate following:

Comfortable position to breastfeedDetermines whether or not the breast is

full prior to feedingNo nipple tendernessRecognizes hunger signs

Is satisfied with breastfeeding

Teaching

Milk Production

First stage of milk Colostrum milk ejection or let down reflex Milk production can be influenced by

1. Emotional stress

2. Ambivalence to breastfeeding

3. Physical well being of infant and mother

Nutritionextra calories (250 - 500)6-8 glasses of water or liquidSelection from each of the four main food

groupMaternal use of iron or iron supplementsAdvance of alcohol, tobacco and drugs

Nutritional Management at home

Nurse baby every 1-3 hoursboth breast at each feedingexpect 6-8 wet diapers every 24 hours (after

first weekbowel movement (consistency + appearance) most babies have periods of irritable cryinggrowth spurtscommunity resources - LaLeche League, WIC,

community Lactation Consultants, hospital programs + support groups

Common Problems Encountered in Breast Feeding

Cracked or Sore Nipples

check for correct latch frequent feedingsrotation during breastfeedingair dryingwarm soaks

Flat or Retracted Nipples

use of milk cupselectric pumps ice wrapped

Infant’s Position

Encourage rooting reflexareola into mouthavoid having infant press noseremoval of infant from the breast last first, first lastburp

Care of the Breast and Nipples

air drypads support bracramp

Advantages of Bottle Feeding

Baby is satisfied longerMonitoring intakeMore freedom for mother (i.e.: if she wishes to

go out for the evening)Father is able to participate in feeding the baby Increased opportunity for sibling as to

participate in feedingBirth control methods are less restrictiveLess stress for feeding the baby in public

Infant Formula

What is formula? All formula is designed to similate nutritional content of breast milk What does formula contain? Protein,fat,iron,carbs &vit A,D,E,K linoleic acid Caloric: 20 cal. per oz. Allergies Soy for sensitivity to milk protein,lactose free for possible lactose , and alimentum for

severe

for severe food allergies/colic r/t protein sensitivity

Types Of Formula

Powdered, Prepared,ConcentrateCost $$$- Which is best?Preparation-boil H2O approx 1 min.

Feeding

Initial feedings are only ¼-1 oz.Most newborns approx. 2-3 oz per feeding q 2-3

hrs. Add 2 or 3 to infants age. Ex. A 3 month old would require 5-6 oz.

Ample feedings will produce 6-8 wet diapers per day

Discard unused bottle formula after, discard formula after baby is done, bacteria from baby’s mouth has passed into milk. Bacteria.

Can be stored in fridge up to 24 h

Nursing Process

Assessment

Nutritional status prior to and during mother’s pregnancy

Assess the newborn for adequate nutrition Identify mother’s skills and knowledge about

breastfeeding vs. formula usage. Mother’s ability to recognize signs of hunger in a

newborn (e.g., restlessness, tense body posture, smacking lips, or tongue thrusting)

Check mom’s knowledge whether newborn is receiving enough feeding by voiding, growing, and alert

Nursing Dx: Imbalanced nutrition, less than body requirements r/t poor

newborn sucking response. Health seeking behavior r/t lack of knowledge about

lactation and breast feeding technique Effective breast feeding r/t well prepared mother and healthy

newborn Ineffective breast feeding r/t anxiety and inexperience Pain r/t breast engorgement or sore nipples Deficit knowledge r/t potential harm to baby of drugs taken

by breast feeding mother Health seeking behaviors r/t techniques of bottle feeding

Planning/Interventions

Begins while the newborn is pregnant Focus on providing information on breast feeding or

bottle feeding Provide information to woman who expects to formula

feed to purchase supplies in advance Advise client to drink at least 4 to 6 8oz. Glasses of

fluid per day Give information on how / where to allocate

community resources base on financial needs

Outcomes For BreastfeedingThe client will be able to verbalize

knowledge in the following:

Hunger signs of the baby & signs of proper nourishment

Proper positioning & techniques of breastfeeding

The client will be able to verbalize knowledge in the following:

Latch on properly, proper sucking & tongue placement

Swallowing should be audible at a minimum of 5-10 minutes per breast at 8 feedings per day

2 or more loose, yellow, seedy stools per day (at least 6 voidings per day)

Nursing Outcomes – Mom is able to demonstrate following:

Comfortable position to breastfeedDetermines whether or not the breast is full

prior to feedingNo nipple tendernessRecognizes hunger signs

Is satisfied with breastfeeding