1. Nursing Care of the Newborn
Newborns undergo many profound physiologic and psychological changes.
They are released from a warm, close, dark, liquid filled environment that met all needs, into a chilly, unbound, brightly lit, gravity based, outside world.
Within minutes respirations are initiated and circulatory accommodation are made.
Within 24 hours neurologic, renal, endocrine, GI, and metabolic functions must operate.

2. Nursing Care of the Newborn
Newborn or neonatal period is the first 28 days of life.
2/3 of deaths occur in the 1st year
½ occur in the 1st 24 hours
Assessment
Mother’s pregnancy history
Physical exam of the newborn
Lab reports
Bonding

3. Profile of the Newborn All newborns are different. Vital Statistics
Weight:
Plot on neonatal graph (Appendix E)
Average weight R/T gestational age
White female 7.5 lbs.– 3.4 kg.
White male 7.7 lbs.-3.5 kg.
Other races-0.5 lbs less
Limits-5.5 lbs to10 lbs (17 lbs largest)
Newborn loses 5 to 10 % of birth weight ( 6 to 10 oz. during first few days.

4. Profile of the Newborn
Loss due to salt and fluid retaining maternal hormones. Voiding and stool, and diuresis.
After wt. loss then 1 day of stable wt. then recaptures birth weight within:
Breastfed 10 days
Formula fed 7 days
Will gain 2 lb/month (6 to 8 oz/week) for first 6 months.
Length:
Female-53 cm in.
Male-54 cm. –21.3 in.

5. Profile of the Newborn Limits 18 in. to 23 in. Head Circumference:
34 to 35 cm. (13.5 to 14 in.)
Limits-less than 33 cm. or greater than 37 cm.
Measure with tape drawn across center of forehead and around the most prominent portion of the posterior head.

6. Profile of the Newborn Chest Circumference:
About 2 cm. less than head circumference (0.75 to 1 in.).
Measure at level of the nipples.
Viral Signs:
Temp 99 F at birth
Newborns lose heat by:
Convection
Conduction
Radiation
Evaporation

7. Profile of the Newborn
They have little subcutaneous fat for insulation. Shivering is rare.
They have brown fat – helps to conserve or produce body heat by increasing metabolism.
Quickly dry and wrap newborns and place under radiant heat source or place directly against mothers skin.
Newborn with a bacterial infection will have a subnormal temperature.

8. Profile of the Newborn Pulse: Immediately after birth 180 bpm.
Within 1 hour- 120 to 140 bpm.
Irregular and transient murmurs due to immaturity of the cardiac regulatory center in the medulla and closure of the shunts.
Sleeping – 90 to110 bpm.
Always check apical for 1 full minute
Check femoral pulse for coarctation.

9. Profile of the Newborn Respiration: 30 to 60 breaths / min.
Rate, depth, and rhythm may be irregular with short periods of apnea (without cyanosis) called periodic respirations.
Observe movement of the abdomen.
Coughing and sneezing clear the airway.
Newborns are nose breathers
Short periods of crying are beneficial.

10. Profile of the Newborn Blood Pressure: 80/46 mm Hg at birth
10th day 100/50 mm Hg
Cuff 2/3 the length of upper arm or thigh.
Physiologic Function
Cardiovascular System:
Figure 23.3 p. 634
Peripheral circulation is sluggish for 1st 24 hours.
Common to see cyanosis of the feet and hands (acrocyanosis) cold to touch.

11. Profile of the Newborn Blood values: Blood volume-300 mL
Increased erythrocyte count-will decrease after 3 days. Breakdown of these cells cause an increase bilirubin >4 mg/100mL
At 7 mg/ml tissue is jaundice. Physiological jaundice R/T brusing, cephalhematoma, dehydration, or intestinal obstruction.
Treat at phototherapy, fluids, >20 neuro kernicterus (permanent cell damage)
Hgb 17-18

12. Profile of the Newborn
Hct 45-50% (use warm cloth on heel to increase sluggish circulation to get a more accurate value).
WBC increased due to stress of birth.
Blood Coagulation:
Prolonged coagulation or prothrombin time for 24 hours because of low vitamin K level.
Infant intestine is sterile at birth.
Administer Vitamin K (AquaMephyton) 1 hour after birth in lateral anterior thigh.

13. Profile of the Newborn Respiratory: First breath initiated by
Cold receptors
Lowered PO2 (15 mm Hg)
Increased PCO2 (70 mm Hg)
Surfactant allows the alveoli to inflate more easily.
1/3 of fluid is forced out of the lungs with the pressure of delivery.
Within 10 min. a good residual volume is established.

14. Profile of the Newborn Gastrointestinal System:
Sterile tract for 1st 24 hours
Stomach holds 60 to 90 mL
Decreased ability to digest fat and starch
Regurgitation due to immature cardiac sphincter between stomach and esophagus.
Lower glucose and protein serum levels due to immature liver.
Stools – meconium 1st 24 hours. Sticky, tarlike, blackish green, odorless.

15. Profile of the Newborn
If no meconium in hours possibility of ileus, imperforate anus, or bowel obstruction.
Transitional stool- day 2-3 becomes green and loose.
Day 4 breastfed will pass 3-4 light yellow stools per day.
Bright green is due to increased bilirubin.
Watery and loose or mucus may be a milk allergy.
Gray clay stool – bile duct obstruction.

16. Profile of the Newborn Urinary System Voids within 24 hours
Light color and odorless; kidneys do not concentrate urine well and no reabsorption.
6 voids /day 15 to 50 mL
By 1st week total daily volume is 300 mL
Immune System:
Unable to form antibodies the 1st 2 months.
Has passive immunity from the mother
Hepatitis B vaccine during 1st 12 hours.

17. Profile of the Newborn Neuromuscular System: Reflex Maneuvers:
Blink reflex
Rooting
Sucking
Swallowing
Extrusion
Palmar Grasp
Step-Walk in Place
Placing

18. Profile of the Newborn Plantar Grasp Tonic Neck Moro Babinski Magnet
Crossed Extension
Trunk Incurvation
Landau
Deep Tendon

19. Profile of the Newborn Senses: Hearing in utero
Vision see immediately, blink, follow objects
Touch well developed
Taste likes glucose and avoids salt
Smell breast milk
Adjustment to Extrauterine Life
Table 23.1 p. 639

20. Appearance of the Newborn
Skin
Color:
Ruddy due to increased concentration of RBC in blood vessels and decreased fat. Fades slightly over the 1st month.
Cyanosis-lips, hands, feet
Central cyanosis is a great concern
Suction mouth before the nose because suctioning the nose may trigger a reflex gasp, possibly leading to aspiration.

21. Appearance of the Newborn
Hyperbilirubinemia leads to jaundice or yellowing of the skin.
Occurs on day 2 or 3 in 50% of all newborns due to breakdown of fetal RBC.
Indirect bilirubin > 7mg/100 mL
Early feeding promotes intestinal movement and helps prevent bilirubin build up.
Pallor due to anemia.
Excessive blood loss when cord was cut.
Inadequate flow of blood from cord into infant at birth.

22. Appearance of the Newborn
Fetal maternal transfusion
Low iron stores
Blood incompatibility
Internal bleed in the baby
CNS damage
Harliquin Sign-newborn lying on side and it will appear red on the dependent side of the body and pale on the upper side, changing positions will make it fade.

23. Appearance of the Newborn
Birthmarks
Hemangiomas-vascular tumors of the skin.
Nevus flammeus-port-wine stain
Macular purple or dark red lesion
Appears on face or thigh
Those above the bridge of the nose fade
Can be covered by cosmetics, remover surgically, or by laser therapy.
Stork’s beak marks – at nape of neck, lighter pink patches. More frequent in females. Do not fade.

24. Appearance of the Newborn
Strawberry Hemangiomas:
Elevated areas formed by immature capillaries and endothelial cells.
Appear at birth or 2 week later.
Due to high estrogen levels
50 to 75% may disappear by age 7
Mark may grow in size.
Surgery not recommended due to scarring

25. Appearance of the Newborn
Cavernous Hemangiomas:
Dilated vascular spaces
Raised and resemble a strawberry hemangioma but does not disappear.
Surgically removed.
Mongolian Spots:
Collection of pigment cells (melanocytes) that appear slate-gray patches on sacrum or buttocks S/T arms and legs.
Asian, Southern European, or African
Disappear by school age.

26. Appearance of the Newborn
Vernix Caseosa:
White, cream cheese-like substance that serves as a skin lubricant.
Lanugo:
Fine hair, covers newborn’s shoulders, back, and upper arms. Forehead and ears.
By age 2 weeks it has disappeared.
Desquamation:
Dry skin on palms of hands and soles of feet.

27. Appearance of the Newborn
Milia:
Pinpoint white papule found on cheek or across bridge of nose.
Disappear by 2 to 4 week as sebaceous glands mature.
Erythema Toxicum (flea-bite rash):
Rash, appears 1st to 4th day up to 2 weeks of age.
Lacks pattern and will last only hours.
Due to eosinophils reacting to environment.

28. Appearance of the Newborn
Forceps Marks:
May have a circular or linear contusion matching the rim of the blade on infants cheek.
Disappears in 1 to 2 days
Assess facial nerve while at rest and crying.
Skin Turgor:
Feels elastic, smooth if well hydrated.

29. Appearance of the Newborn
Head:
Appears large, 1/4th total length, forehead large and prominent.
Chin receding, quivers easily.
Full-body of hair if well nourished
Pinpoint ulcer where monitor was attached.
Fontanelles:
Openings where skull bones join
Anterior fontanelle
Junction of parietal and frontal bones.

30. Appearance of the Newborn
Diamond shaped-2 to 3 cm. width and 3 to 4 cm. length.
Closes at 12 to 18 months
Posterior fontanelle
Triangle shaped-1 cm. length.
Closed at 2 months.
Sutures:
May override at birth.
Molding:
Infant’s head (vertex) engages the cervix.

31. Appearance of the Newborn
After birth, appears prominent and asymmetric.
Will restore to normal shape in a few days.
Caput Succedaneum:
Edema of the scalp at the presenting part of the head.
Crosses the suture line, will be absorbed and disappear by the 3rd day.
Cephalhematoma:
Collection of blood between periosteum of

32. Appearance of the Newborn
the skull bone and bone itself caused by rupture of periosteum capillary at birth.
Occurs 24 hours after birth, severe swelling, black and blue, egg shape.
Swelling stops at suture line.
Takes weeks to be absorbed.
Craniotabes:
Localized softening of the cranial bones.
Indents easily with touch of the finger.
Corrects after a few months.

33. Appearance of the Newborn
Eyes:
Usually tearless, lacrimal ducts mature at 3 months.
Irises-gray or blue
Sclera-blue due to thinness.
Permanent eye color between 3 to 12 mo.
Erythromycin ointment EES-for chlamydia and gonorrhea
Subconjunctival hemorrhage-red spot on sclera or red ring around cornea. Absorbed in 2 to 3 weeks.

34. Appearance of the Newborn
Edema around orbit or on eyelid. Will remain for 2-3 day until kidneys remove the fluid.
Ears:
External not completely formed.
Top part in line with inner canthus of eye.
Test hearing by ringing a bell 6 in. from ear.
Nose:
Appears large.
Assess by closing mouth and compress one naris.

35. Appearance of the Newborn
Mouth:
Open evenly, tongue appears large.
Palate intact, check for cysts.
No teeth (1-2 natal teeth sometimes).
Neck:
Short, chubby, skin folds, rotates freely.
May try to raise head but lacks control.
Chest:
Breast appear engorged, may secrete a thin, watery fluid (witch’s milk). 1 wk to subside

36. Appearance of the Newborn
2 in. less than head.
Lungs have rhonchi due to mucus for first 24 to 48 hours. Alveoli open slowly.
Abdomen:
Slightly protuberant
Bowel sounds within 1 hour.
Liver palpable 1 to 2 cm below right costal margin.
Umbilical cord-white, gelatinous structure with red and blue streaks. Count veins and arteries.

37. Appearance of the Newborn
Inspect cord clamp, within 1 hour cord begins to dry and shrink and turns brown. Day 2 to 3 will turn black.
Day 6 to 10 breaks free and new granulating area will heal in next week.
Assess abdomen by stroking each quadrant and observe umbilicus to move or wink in that direction.
Anogenital Area:
Check for patency.

38. Appearance of the Newborn
Male Genitalia:
Scrotum edematous and has rugae.
Penis 2 cm., check prepuce (foreskin).
Circumcision
Female Genitalia:
Vulva swollen due to effect of maternal hormones.
Mucus vaginal secretion, sometimes blood tinged.

39. Appearance of the Newborn
Back:
Flat in lumbar and sacral areas.
Back rounded, arms and legs flexed on abdomen and chest.
Extremities:
Appear short, hands plump,clinched and palmar crease.
Fingernails soft, smooth and long.
Muscle tone- unflex arm and immediately returns flexed.
Fingertips cover proximal thigh.

40. Appearance of the Newborn
Legs bowed and short, feet turn inward.
ROM
Ortolani’s sign-clunk of femur head striking the shallow acetabulum.
Barlow’s sign-hip slips in socket.
Lying on abdomen newborns bring arms and legs underneath them and rise their stomach off the bed.

41. Assessment of the Newborn
Apgar Scoring:
1 minute and 5 minutes after birth (Table 23.2 p. 650) Rated 0,1,or 2 then added together.
Score of 4-6 = guarded, 7-10 = good.
Heart rate-auscultate with stethoscope.
Respiratory effort-cries spontaneously at 30 seconds after birth.
Muscle tone-extremities tightly flexed.
Reflex irritability-suctioning or sole of feet slapped.

42. Assessment of the Newborn
Color-cyanotic at birth, pink shortly after first breath.
Respiratory Evaluation
Highest priority in newborn care.
Physical Examination
Given immediately after birth, very quickly
Height and Weight
Nude, also head, chest and abdominal circumferences.
Weight daily at same time.

43. Assessment of the Newborn
Laboratory Studies
Heel stick for H&H and hypoglycemia (< 40mg/100 mL)
Gestational Age
Table 23-4 p. 654
Ballard’s assessment (figure p. 655)
Behavior Capacity
Physically active and emotionally prepared to interact with people.
Brazelton Neonatal Behavioral Assessment Scale

44. Assessment of the Newborn
Evaluates newborn’s behavioral capacity or ability to respond to stimuli.
Care of the Newborn at Birth
Equipment-radiant heat table, warm soft blankets, O2, resuscitation, suction, eye care, identification, scales.
Handle gently
Newborn ID and Registration ID
Kidnapper profile- recently lost a pregnancy

45. Care of the Newborn at Birth
or had an infant stillborn and who desires an infant very much.
Familiar with hospital, pretends to be a volunteer or unlicensed health care worker and says she needs to take the baby out of the nursery.
ID Band (one arm and one leg)
Plastic bracelet, number corresponds to the mother’s hospital number, mother’s full name, sex,date and time of infant’s birth.

46. Care of the Newborn at Birth
Has built in sensor unit that alarms if baby is transported beyond set boundaries.
Foot prints are taken and placed on chart.
Registration filed with the Bureau of Vital Statistics of the state of birth.
Infant’s name, mother’s name, father’s name if mother chooses, birth date and place.
Important because it provides eligibility for school, voting, social security benefits, passports.

47. Care of the Newborn at Birth
Birth Record Documentation:
Time of birth
Time the infant breathed
Whether respirations were spontaneous or aided
Apgar at 1 and 5 minutes of life
Whether eye prophylaxis was given
Whether vitamin K was administered
General condition of the infant
Number of vessels in umbilical cord

48. Care of the Newborn at Birth
Whether cultures were taken
Whether infant(1)voided and (2) passed stool.
Nursing Interventions
Keep Newborn Warm:
Reassess temp in 1 hour then q 4-8 hours.
Promote Adequate Breathing Pattern and Prevent Aspiration:
Suction with bulb syringe
Record First Cry:
Aided or unaided

49. Care of the Newborn at Birth
Inspect and Care for Umbilical Cord
Hazeltine or Kane clamp
Count vessels
Apply triple dye
Coed falls off 7 to 10th day. Do sponge bath.
Apply alcohol to cord site.
Administer Eye Care
Erythromycin ointment
General Infection Precautions
Wash up to elbows between babies, gown

50. Care of the Newborn at Birth
Personnel with infections excluded until clear.
Isolate with contagious illness.
Postpartal Period
Initial Feeding:
May breastfed immediately
Formula fed in 2-4 hours
On demand schedule may be q 2 hours

51. Care of the Newborn in Postpartal
First bath within 1 hour
Supervise parents with 1st bath, cleanest to most soiled. No soap on face.
Football hold
Sleeping Position
On back due to SIDS
Diaper Area Care
Wash with clear water and dry.
A&D may be applied to buttocks

52. Care of the Newborn in Postpartal
Metabolic Screening Tests
PKU-phenylketonuria-disease of defective protein metabolism
Hypothyroidism
3 drops from heel stick on special filter paper.
Hepatitis B Vaccination
Within 12 hours after birth, second dose due in 1 month and 3rd due at 6 months.

53. Care of the Newborn in Postpartal
Vitamin K Administration
Newborn’s are at risk for bleeding disorders
Single dose 0.5 to 1.0 mg IM of vitamin K is administered within 1 hour after birth.
Circumcision
Surgical removal of penis foreskin
1st or 2nd day of life
Check q 15 min for 1 hour for bleeding, document voiding after the procedure.
Petrolatum for 3 days.

54. Readiness To Care For Newborn
Assess how prepared each family is to care for the newborn.
Infants wake up during the night for 1 or more feedings for about the 1st 4 months.
Numerous questions to ask to assess for an adequate and safe home.
Daily care:
Some consistency
Satisfy the infant
Sense of well-being and contentment

55. Readiness To Care For Newborn
Sleep Patterns
Sleeps 16 of 24 hours in 1st week at 4 hour intervals
By 4 months 15 hours of 24 and through the night.
Crying
2 hours of every 24 for 1st 7 weeks. Peaks at 6 to 7 weeks then tapers off.
Most typical wakeful time is between 6pm to 11 pm.
Pacifier is up to parents.

56. Readiness To Care For Newborn
Cleanliness is a concern
Parental Concerns Related to Breathing
Stuffy nose or making snorting noises in sleep, have mucus for 2 weeks
Breath irregularly
Continued Heath Maintenance for Newborn
Appointment with PCP in 2 to 6 weeks
Parents need to judge the infants state of health, appearance, eating, activity, disposition.

57. Readiness To Care For Newborn
Car Safety
Meets federal guidelines
Health Dept or Red Cross has info.
Place in back seat may use a blanket to support the head. Facing the back.