Palpate PMI, auscultate rate and quality of heart tones, murmurs, character of respirations, equality of breath sounds on each side of chest
Rounded abdomen, absenceof anomalies, number of vessels in cord
Muscle tone, reflex reaction, Moro reflex, palpate anterior fontanel for fullness or bulge, presence of size of fontanels and sutures
If excess mucus is present, moth and nose may be suctioned with bulb syringe
Percussion over the chest wall using soft circular mark or percussion cup to aid in loosening secretions
If coughing and choking support with head to side
Cold stress is detrimental, increases need for oxygen and upset acid and base balance
Place infant on mother abdomen with warm blanket, drying and wrapping the newborn in warmed blankets right after birth, keeping head well covered,keep in nursery at 24 degrees Celsius
Baby warmer 36-37 degrees Celsius
Axillary temp every hour until stable
8. Therapeutic Interventions 9. Nursing Diagnoses
Ineffective airway clearance related to airway obstruction with mucus
Impaired gas exchange related to hypothermia
Ineffective thermoregulation related to heat loss to the environment
Risk for infection related to umbilical cord stump/fetal scalp electrode sites
Assessing a newborn's weight:
The average weight for term babies (born between 37 and 41 weeks gestation) is about 7 lbs (3.2 kg).
In general, small babies and very large babies are more likely to have problems.
In most cases the metric system is used for weighing babies.
Converting grams to pounds and ounces:
1 lb. = 453.59237 grams
1 oz. = 28.349523 grams
1000 grams = 1 kg
Head circumference - the distance around the baby's head (head circumference is normally about 1/2 the baby's body length plus 10 cm).
abdominal circumference - the distance around the abdomen.
length - the measurement from crown of head to the heel.
12. Gestational Age
Head: normal measurements32-37 cm (12.5-14.5 in); should be 2cm larger than chest circumference
Length: normal measurements48-52 cm (18-22 in)
Weight: normal measurements2500-4000 g (5lbs 8oz-8lbs 13oz)
The Dubowitz/Ballard Examination
Points are given for each area of assessment:
Skin textures (sticky, smooth, peeling)
Lanugo (the soft downy hair on a baby's body) - is absent in immature babies
Plantar creases - range from absent to covering the entire foot
Breast - the thickness and size of breast tissue and areola
Eyes and ears - eyes fused or open and amount of cartilage and stiffness of the ear tissue.
Genitals, male - presence of testes and appearance of scrotum, from smooth to wrinkled.
Genitals, female - appearance and size of the clitoris and the labia.
13. Physical Examination
Temperature normal axillary temperature 36.5- 37.2C in normal room environment; stabilized by 8-10 hours of age.
Pulse - normally 120 to160 beats per minute; listen for 1 FULL minute.
Blood pressure 80-90/40-50 mm Hg; use 2.5 cm wide cuff.
Respiration rate - normally 30 to 60 breaths per minute
14. Physical Assessment
Skin: generally pink (varying with ethnic origin), no skin edema with vernix caseosa and lanugo, check for jaundice.
Face: characteristics normal & symmetrical, patency in orifices, imaginary line drawn through eyes reaching to top notch of ears.No tears.Responds to hearing voices & other sounds.Epsteins pearls. Has rooting, sucking and extrusion reflexes.
Head: of body length, molding.Check for abnormalities with the fonatels, sutures and hair.
15. Physical Examination
Head and Neck:
Appearance, shape, presence of molding (shaping of the head from passage through the birth canal)
Fontanels (the open "soft spots" between the bones of the baby's skull)
Clavicles (bones across the upper chest)
16. Physical Examination
Level of consciousness
Presence of rashes
17. Physical Examination
Face - eyes, ears, nose, cheeks
Mouth - palate, tongue, throat
Lungs - breath sounds, breathing pattern
Heart sounds and femoral (in the groin) pulses
Abdomen - presence of masses or hernias
Genitals and anus - for open passage of urine and stool
Arms and legs - movement and development
18. Physical Examination
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