1. Chapter 12
The Term Newborn

2. Objectives
Briefly describe three normal reflexes of the neonate, including the approximate age of their disappearance.
Demonstrate the steps in the physical assessment of the newborn.
State four methods of maintaining the body temperature of a newborn.
State the cause and appearance of physiological jaundice in the newborn.
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3. Objectives (cont.)
Define the following skin manifestations in the newborn: lanugo, vernix caseosa, Mongolian spots, milia, acrocyanosis, desquamation.
State the methods of preventing infection in newborns.
Interpret discharge teaching for the mother and her newborn.
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4. Adjustment to Life Outside the Uterus
Adjustment is dependent upon
Genetic background
Health of the recent uterine environment
A safe delivery
Care during the first month of life
Discuss how genetic background affects the newborn’s adjustment to life.
Discuss the effects of prenatal care, labor, and delivery on the newborn.
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5. Adjustment to Life Outside the Uterus (cont.)
Respirations stimulated due to chilling and chemical changes in the blood
Sensory and physical stimuli
First breath opens alveoli
Independent air exchange begins
Initiates cardiopulmonary interdependence
What is the nurse’s role in providing sensory and physical stimuli to assist the newborn in breathing?
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6. Adjustment to Life Outside the Uterus (cont.)
Ability to metabolize food hampered by immaturity of digestive system (deficient in enzymes from pancreas and liver)
Kidney’s ability to concentrate urine and maintain fluid balance is limited due to decreased rate of glomerular flow and limited renal tubular reabsorption
Neurological functions are primitive
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7. Physical Characteristics
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8. Nervous System: Reflexes
Moves arms and legs vigorously but cannot control them
Full-term infants are born with the following reflexes (which help keep them alive)
Blinking
Sneezing
Gagging
Sucking
Grasping
They can also cry, swallow, and lift their head (slightly) when lying on their abdomen
Describe each of the reflexes listed.
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9. Reflexes Moro Rooting Tonic neck Dancing Describe each reflex.
What is the nurse’s role in assessing the newborn’s reflexes?
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10. Head Molding from delivery process
May have swelling of the soft tissues of the scalp, called caput succedaneum
May see a cephalhematoma—a collection of blood beneath the periosteum of the cranial bone
Does not cross the suture line
Fontanels (soft spots) protect the head during delivery and allow further brain growth
Refer to Figure 12-5 on page 284 and discuss caput succedaneum and cephalhematoma.
Why is the newborn’s head circumference measured?
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11. Visual Stimuli and Sensory Overload
Can see and fixate on points of contrast
Toys with contrasting colors or those that make noise attract the newborn’s attention
Tears are absent until 1 to 3 months of age
Sensory overload can occur if there is too much detrimental stimulation
Important for the nurse to keep surrounding environment as calm and quiet as possible, no bright lighting or loud alarms
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12. Hearing Ears well-developed, but small
Hearing ability present at birth (sick or premature newborn may not respond to sounds)
Normal drainage and sneezing occurs after birth to rid ear canals of amniotic fluid
May react to sudden sounds by increased pulse or respiratory rate or startle reflex
Responds to voices by decreasing motor activity, sucking activity, and turning head toward the sound
Hearing screening performed before discharge
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13. Sleep 15 to 20 hours per day Phases of sleep-wake cycle
First reactive
Sleep
Second reactive
Stability
Specific pattern of reactivity that can influence the response to stimuli and bonding
Quiet sleep
Rapid eye movement (REM) sleep
Active alert
Quiet alert
Crying
Transitional
Describe each phase of the sleep-wake cycle.
Discuss each of the patterns of reactivity listed.
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14. Pain Produces catecholamines and cortisol
Heart and respiratory rates change
Blood pressure increases as does blood glucose levels
Untreated pain can have long-term effects
Pain pathways and structures required for long-term memory are well developed by 24 weeks gestation
Unrelieved pain can cause exhaustion, irritability, and delay the healing process
What is the nurse’s role in assessing pain in the newborn?
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15. Pain Assessment Tools COMFORT CRIES FLACC PIPP NIPS NPASS
Discuss the CRIES 10-point scale, the PIPP profile, the NIPS scale, and the NPASS scale.
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16. Conditioned Responses
A response of reflex that is learned over time
Example is a hungry infant stops crying when it hears its mother’s voice, even though food is not available
Emotions particularly subject to this type of conditioning
What are some examples of conditioned responses?
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17. Neonatal Behavioral Assessment Scale
Measures inherent neurological capacities and response to selected stimuli
Areas tested include
Alertness
Response to visual and auditory stimuli
Motor coordination
Level of excitement
Organizational process in response to stress
How can this scale help new parents?
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18. Respiratory System
Once umbilical cord is clamped and cut, the lungs take on the function of breathing oxygen and removing carbon dioxide
First breath helps to expand the collapsed lungs
Full expansion does not occur for several days
Most critical period is the first hour of life
Newborn should be position on the back or side to help maintain a patent airway
What is the nurse’s role in maintaining a patent airway in the newborn?
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19. Bulb Suctioning
Nurse ensures patent airway is maintained through correct positioning of neonate (on its back or side) and removing any mucus from the mouth and nose with a bulb syringe
Describe proper suctioning with a bulb syringe.
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20. Apgar Score
Standardized method of evaluating newborn’s condition immediately after delivery
Five objective signs measured
Heart rate
Respiration
Muscle tone
Reflexes
Color
Score is obtained at 1 and 5 minutes after birth
Nurse monitors for respiratory distress as evidenced by
Rate and character of respirations
Color (cyanosis)
General behavior
Sternal retractions must be reported immediately to the health care provider
Give an example of how to measure the Apgar score.
What are the implications of sternal retractions and the nurse’s role in managing this urgent situation?
Audience Response Question #1
An Apgar score of 5 at 5 minutes indicates the neonate is in:
1. Good condition
2. Fair condition
3. Poor condition
4. Critical condition
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21. Circulatory System
If the ducts fail to close when they are supposed to, the neonate may become cyanotic because the blood bypasses the lungs and does not pick up any oxygen
Has approximately 300 mL of circulating blood volume
Neonatal circulation differs from fetal circulation
Dependent upon ducts within the heart to close at certain points in time, such as
Foramen ovale
Ductus arteriosus
Discuss the difference between neonatal circulation from that of a fetus.
Describe the location and pathophysiology of the foramen ovale and ductus arteriosus.
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22. Providing Warmth Unstable heat-regulating system
Acrocyanosis is evident because of sluggish peripheral circulation
Cannot adapt to change in temperatures easily
Sweat glands do not function during neonatal period, so infant is at risk for developing elevated temperature if overdressed or placed in overheated environment
How can you ensure the newborn is kept warm?
Hands and feet are not used as a guide to determine warmth because the extremities tend to be cooler than the rest of the body.
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23. Obtaining Temperature, Pulse Rate, and Respirations
Temperature: can be taken rectally or in the axilla
Pulse and respiratory rates: count before taking temperature as infant may cry when disturbed
The nurse should report
Temperature elevations >99.8° F or <97.1° F
Pulse rates >160 or <110 beats/min
Respirations >60 or <30 breaths/min
Noisy respirations
Nasal flaring or chest retraction
Discuss proper methods to count respiratory and pulse rates.
How would you describe noisy respirations, nasal flaring, and chest retractions?
Audience Response Question #2
A neonate's vital signs are assessed as follows: axillary temperature 96.5° F, pulse 125 bpm, respirations 44. The nurse is aware that:
1. these are within normal limits.
2. pulse is elevated.
3. respirations and temperature are normal.
4. temperature is decreased.
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24. Maintaining Body Temperature of the Newborn
What is another reason for swaddling a newborn besides temperature control?
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25. Musculoskeletal System
Skeleton is flexible
Movements are random and uncoordinated
Development of muscle control proceeds from head to foot and from the center of the body to the periphery
Head and neck muscles are the first ones under control
Audience Response Question #3
Average newborn length is inches. What is the average newborn weight?
1. 6 lb lb.
2. 6 lb. - 9 lb
lb lb
4. 7 lb -10 lb
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26. Length and Weight Average length Average weight
19 to 21.5 inches (46-56 cm)
Average weight
6 to 9 pounds (2722 to 4082 g)
In the first 3 to 4 days after birth, the infant loses about 5% to 10% of its birth weight
May be a result of withdrawal from maternal hormones, fluid shifts, and the loss of feces and urine
Why is it important to weigh the newborn daily?
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27. Genitourinary System Kidneys not fully developed at birth
Glomeruli are small
Renal blood flow is about a third of an adult
Ability to handle a water load is reduced
Renal tubules are short and have limited capacity for reabsorbing important substances
Decreased ability to concentrate urine and cope with fluid imbalances
Important for nurse to note first void
Newborn has about 6 wet diapers per day
Discuss the rationale regarding the importance of the first void.
Why should the nurse monitor the frequency of urination?
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28. Male Genitalia Testes descend into scrotum before birth
Location of the urethral opening should be on the tip of the penis
A white cheesy substance (smegma) is found under the foreskin
Some parents may choose to have their child circumcised while others may not
Whatever their decision, proper care of the male genitalia must be taught to the parents
What instructions should be given to the parents regarding care of the genitalia?
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29. Female Genitalia May be slightly swollen
Thin white or blood-tinged mucus may be discharged from the vagina (pseudomenstruation) caused by hormonal withdrawal from the mother
Cleanse the vulva from the urethra to the anus to prevent fecal matter from entering the urinary meatus, leading to UTI
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30. Integumentary System Assess turgor and overall skin condition
Usually covered with fine hair called lanugo (disappears within a week of birth)
Covered in vernix caseosa—made of cells and glandular secretions; thought to protect skin from irritation and effects of a watery environment
Physiological jaundice (icterus neonatorum) seen as a yellow tinge to the skin; caused by the rapid destruction of excess red blood cells
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31. Safety Alert
Jaundice that appears in the first day of life is not normal and should be recorded and reported
What causes jaundice?
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32. Gastrointestinal System
Normal functions begin shortly after birth
Meconium, the first stool, is a mixture of amniotic fluid and intestinal gland secretions
Sticky, greenish black, thick, and passed 8 to 24 hours after birth
Stool color and consistency change over time
Color, amount, and consistency are somewhat dependent upon what the infant is fed (breast milk versus formula)
Give an example of typical documentation for a newborn’s stools.
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33. Normal Infant Stool Cycle
Discuss Figure on page 298.
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34. Gastrointestinal System Upsets
Constipation
Hiccoughs
Digestion
Discuss methods to manage constipation and hiccoughs.
What is the gastrocolic reflex?
What vitamins are necessary for the newborn?
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35. Preventing Infections
Newborn’s response to inflammation and infection is slow because of the immaturity of the immune system
Umbilical cord stump primary site of infection if not kept clean
Hand hygiene is the primary means of preventing infection and/or its spread
What is considered proper umbilical cord care?
Discuss the importance of hand hygiene.
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36. Immunoglobulin G (IgG)
Crosses the placenta and provides newborn with passive immunity
Rarely lasts longer than 3 months
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37. Immunoglobulin M (IgM)
Produced by the newborn
Elevated level suggests serious infection
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38. Immunoglobulin A (IgA)
Produced after neonatal period (about 1 month) ends
Contained in breast milk
Provides some resistance to respiratory and gastrointestinal infection
Before age 1 month, infants are at risk for such infections
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39. Discharge Planning Begins upon admission of the laboring mother
Areas may include
Basic infant care
Safety measures
Immunizations
Return appointments
Proper use of a car seat
Signs and symptoms of problems and who to contact
What information should be provided to parents in each of the areas listed?
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40. Home Care Feeding Furnishings Clothing Skin care
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41. Question for Review
When is the Apgar score assessed and what does it mean?
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42. Review Objectives Key Terms Key Points Online Resources
Critical Thinking Question
Review Question
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