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

• Chemicalsurfactant reduces surface tension 34-36wksdecrease in oxygen concentration

• Thermalsudden chilling of moist infant

• Mechanicalcompression 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

Cephalhematoma is a collection of blood between the

surface of a cranial bone and the periosteal membrane.

Not crossing

suture line

Caput succedaneum is a collection of fluid (serum)

under the scalp.

Crossing

suture line

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

A, Measuring the head circumference of the newborn.

B, Measuring the chest circumference of the newborn.

head larger

Assessment of Cardio-respiratory

Status

• History

• Airway

• Assessrateq 30minX2hrssymmetrybreath 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

Grasp

Moro

Rooting

Stepping

Sucking

Tonic neck reflex “fencing”

• Cry

• Infant response to soothing

Assessment of Gastrointestinal

System

• Mouth

• Suck

• Abdomen

• Initial feeding

• Stoolsmeconium – within 12-48 hours of birth

dark greenish blackbreastfed – soft, seedy, mustard yellowformula-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

Erythema toxicum

Port Wine Stain

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 characteristicsPosture – more flexionSquare window – more pliableArm recoil - activePopliteal angle - lessScarf 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.

Infant teaching checklist is completed by the time of

discharge.

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

Neonatal morbidity by birth weight and gestational age.

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 nippleresp <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 Hemorrhage30% 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- centralgrunting- expiratoryseesaw respirationsasymmetry

Evaluation of respiratory status using the

Silverman-Andersen index.

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