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Assessment

Review of mother’s pregnancy history

Physical examination of the infant

Analysis of laboratory reports

Hematocrit

Bilirubin

Blood type

Assessment of parent-child interactions

To be certain bonding is beginning

Begins immediately after birth

Continued at every contact during:

newborn’s birthing center stay

early home visits

well-baby visits

sick baby visits

CRUCIAL: Teaching new mothers and their partners to make assessments concerning infant’s;

Temperature

Respiratory rate

Overall health

Why is it crucial?

> so they can continue to MONITOR AT HOME

Diagnosis

Nursing diagnoses associated with newborns center on the difficulty of establishing:

Respirations

Beginning nutrition

Assisting with parent–newborn bonding.

Outcome Identification and Planning

Nursing care planning; taken to account of the newborn’s needs

During this transition period

Mother’s need of adequate rest during postpartum period

Parents’ need to be acquainted with their new child

Adapt teaching schedules to the schedules of

Mother

Her partner

The newborn

The woman must go home from the healthcare setting with enough energy to practice what she has learned

Important planning measures for newborns

Help regulate their temperature

Help them grow accustomed to feeding

Refer parents to helpful websites and other resources when appropriate

Implementation

Effective way to help:

Role modeling by the nurse during the newborn period

New parents grow confident with their newborn

Parents will be observing you closely

Important consideration during all interventions

Conserving newborn warmth and energy

Help prevent hypoglycemia and respiratory distress

Outcome Evaluation

An evaluation of expected outcomes

A baby’s primary caregiver is able to give beginning newborn care with confidence

To ensure infant’s long-term health needs

Be certain a woman and her partner make arrangements for continued health supervision for their newborn

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Vital Statistics

Measured for a newborn usually consist:

Weight

Length

Head

Chest circumferences

All healthcare providers who care for newborns are aware of safety issues specific to newborn care when taking these measurements not leaving a newborn unattended on a bed or scale protecting against hypothermia.

Weight

Newborn breathing well:

Weighed nude and without a blanket soon after birth in the birthing room

Why the the vital statistics are obtained later

Performing these measurements while an infant is still damp exposes the newborn unnecessarily to chilling

Why taking the Newborn’s weight is important

Helps to determine maturity

Helps establish a baseline against which all other weights can be compared

What’s the reason why a newborn’s weight varies

Racial

Nutritional

Intrauterine

Genetic factors that were present during conception

Pregnancy

Plotting weight in conjunction with height and head circumference

Highlights disproportionate measurements

Measurements:

Length

Relation to weight is a second important determinant used to confirm that a newborn is healthy

Average birth length (50th percentile) of a mature female newborn: 49 cm(19.2 in.)

For mature males: 50 cm (19.6 in.)

The lower limit of expected birth length: arbitrarily set at 46 cm (18 in.)

FUN FACT: rare, babies as 57.5 cm (24 in.) have been reported.

Head circumference

Measured with a tape measure drawn across the center of the forehead and then around the most prominent portion of the posterior head (the occiput)

Mature newborn:  34 to 35 cm (13.5 to 14 in.)

A mature newborn with a head circumference greater than 37 cm (14.8 in.) or less than 33 cm (13.2 in.) should be carefully assessed for neurologic involvement, although some well newborns have these measurements.

Chest circumference

Measured at the level of the nipples

NOTE: If a large amount of breast tissue or edema of the breasts is present, this measurement will not be accurate until the edema has subsided.

chest circumference in a term newborn: 2 cm (0.75 to 1 in.) less than head circumference

Vital Signs

Measurements begin to change from those present in intrauterine life at the moment of birth.

> Temperature

At birth: 99°F (37.2°C)

Reason: confined in their mother’s warm and supportive uterus.

Baby will have lower temperature when born because of heat loss

Birthing room temperature

approximately 68° to 72°F [21° to 22°C]

Heat loss mechanisms

1. Convection

Flow of heat from the newborn’s body surface to cooler surrounding air

2. Radiation

Transfer of body heat to a cooler solid object not in contact with the baby, such as a cold window or air conditioner

3. Conduction

Transfer of body heat to a cooler solid object in contact with the baby

4. Evaporation

Loss of heat through conversion of liquid to vapor

> Pulse

In utero: 110 to 160 beats/min

Immediately after birth can be as rapid as 180 beats/min

Within 1 hour after birth (when sleeping): 120-140 beats/min

When crying: 180 beats/min

Can decrease during sleep: 90-110 beats/min

Should always palpate femoral pulses

Should always document

Absence: suggests possible coarctation (narrowing) of the aorta, which is a cardiovascular abnormality (Lissauer, 2015)

Difficult to palpate accurately: radial and temporal

Best to palpate: apical  heartbeat for a full minute THAN on an extremity or over the carotid artery

> Respiration

Few minutes of life: high as 90 breaths/min

About the next hour: 30-60 breaths per minute

> Blood pressure

At birth: 80/46 mmHg

By 10th day: 100/50 mmHg (remains for a year)

Reason:

Newborns is somewhat inaccurate due to the small size of their arms

It is not routinely measured unless a cardiac anomaly is suspected.

For an accurate reading, the cuff width used must be no more than two thirds the length

Increase when crying (use Doppler method - may achieve better results)

Psychological Functions

Just as changes occur in vital signs after birth, so do changes in all major body systems.

> Cardiovascular System

Now: lungs are responsible for oxygenating blood that was formerly oxygenated by the placenta.

Blood values

80-110 ml/kg of body weight or about 300 ml total

Blood Coagulation

a newborn’s intestine is sterile at birth unless membranes were ruptured more than 24 hours

it will take about 24 hours for flora to accumulate

for ongoing vitamin K to be synthesized

> Respiratory System

First breath: about 40 to 70 cm H2O

able to inflate alveoli for the first time

Reflex to breathe, combination of cold receptors

a. Lowered partial pressure of oxygen (PO2)

falls from 80 mmHg to as low as 15 mmHg before a first breath

b. An increased partial carbon dioxide pressure (PCO2)

rises as high as 70 mmHg before a first breath

> Gastrointestinal System

Usually sterile at birth

Bacteria may be cultured from the tract in most babies within 5 hours after birth and from all babies at 24 hours of life.

Stools

First stool: pass within first 24 hours

Consists of meconium (during intrauterine life)

If doesn’t pass first 24-48 hours could have:

Meconium ileus

Imperforate anus

Volvulus

Transitional stool

Comes on 2nd-3rd day of life

Changes color and consistency

Appears both loose green, may resemble diarrhea to the untrained eye

> Urinary System

Voids within 24 hours after birth

Doesn’t void a lot within 24 hours may void more but 24 hour-point is a general rule.

Doesn’t void in 24 hours:

Suspect urethral stenosis or

Absent kidneys or utereters

Kidneys of newborns do not concentrate urine well

usually light colored and odorless

The infant is about 6 weeks of age before much control over reabsorption of fluid in tubules and concentration of urine becomes evident.

Single voiding

Only about 15 ml

may be easily missed in an absorbent diaper

> Immune System

limited immunologic protection at birth

Not able to produce antibodies until about 2 months

Reason: most immunizations are not administered until 2 months of age

Now: lungs are responsible for oxygenating blood that was formerly oxygenated by the placenta.

Born with passive antibodies

Got from when they were in their mother’s placenta

> Neuromuscular System

Functions:

moving their extremities

attempting to control head movement

exhibiting a strong cry

demonstrating newborn reflexes

Maneuvers:

1. Blink Reflex; protect eye from any object coming near it by rapid eyelid closer

2. Rooting Reflex; moves head to direction where touched

3. Sucking Reflex; when lips are touched they start making a sucking motion

4. Swallowing Reflex; food that touches the posterior of the tongue is automatically swallowed

5. Extrusion Reflex; putting out inedible substances on the end of their tongue

6. Palmar Grasp Reflex; grapes object that’s placed in their palms and quickly wrapping their fingers around it

7. Step (Walk)-in-Place Reflex; held in a vertical position with their feet touching a hard surface will take a few quick, alternating steps

8. Placing Reflex; touching the anterior lower leg against a surface such as the edge of a table.

9. Plantar Grasp Reflex; if toes touches an object it will attempt to grasp the object like hands do

10. Tonic Neck Reflex; when the arm and leg on the side toward which the head is turned extend, and the opposite arm and leg contract (“boxer” or “fencing reflex”)

11. Moro Reflex; “startle reflex”

12. Babinski Reflex; foot is stroked in an inverted “J” curve from the heel upward, a newborn fans the toes (positive Babinski sign)

13. Magnet Reflex; If pressure is applied to the soles of the feet of a newborn lying in a supine position, he or she pushes back against the pressure.

14. Crossed Extension Reflex; When a newborn is lying supine, if one leg is extended and the sole of that foot is irritated by being rubbed with a sharp object, such as a thumbnail, the infant raises the other leg and extends it as if trying to push away the hand irritating the first leg.

15. Trunk Incurvation Reflex; lies in a prone position and is touched along the paravertebral area on the back by a probing finger, the newborn flexes the trunk and swings the pelvis toward the touch

16. Landau Reflex; supported in a prone position by a hand, the newborn should demonstrate some muscle tone.

17. Deep Tendon Reflexes; both a patellar and a biceps reflex are intact in a newborn

> The Senses

Hearing

Vision

Touch

Taste

Smell

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AGPAR Scoring

Apgar scoring is done at one and five minutes after birth.

The newborn is considered to be “vigorous” if the initial scores are 7 and above.

If the five-minute score is less than 7,scoring is done every five minutes thereafter until the score reaches 7.

Heart rate; use stethoscope  bserving and counting the pulsations of the umbilical cord at the abdomen if the cord is still uncut.

Respiratory effort; chest movements

Muscle tone

Reflex irritability

Response to a suction catheter in the nostrils

Response to having the soles of the feet slapped

Color; may appear cyanotic at moment of birth

Respiratory evaluation

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Skin

Color (ruddier for their first month than any other)

Cyanosis

Hyperbilirubinemia; caused by the accumulation of excess bilirubin in blood serum.

Pallor; occurs as the result of anemia

Harlequin Sign; lying on his or her side appears red on the dependent side of the body and pale on the upper side, as if a line had been drawn down the center of the body.

Birthmarks

Hemangiomas

Mongolian Spots

collections of pigment cells (melanocytes) that appear as slate-gray patches across the sacrum or buttocks and possibly on the arms and legs of newborns.

Vernix Caseosa

White, cream cheese–like substance that serves as a skin lubricant in utero.

Lanugo

Fine, downy hair that covers a term newborn’s shoulders, back, upper arms, and possibly also the forehead and ears.

Desquamation

Within 24 hours after birth, the skin of most newborns begins to dry

The dryness is particularly evident on the palms of the hands and soles of the feet and results in areas of peeling similar to those caused by sunburn.

Milia

Sebaceous glands in a newborn are immature, so at least one pinpoint white papule (a plugged or unopened sebaceous gland) is usually found on a cheek or across the bridge of the nose of every newborn.

(looks like whiteheads)

Erythema Toxicum

The rash usually appears in the first to fourth day of life but may appear as late as 2weeks of age.

It begins with small papules, increases in severity to become erythematous by the second day and then disappears by the third day.

“Flea-bite rash”: lesions are so minuscule.

Forceps Marks

Mark occurs with normal forceps use

Does not denote unskilled or overly vigorous application of forceps

The mark disappears in 1 to 2 days (along with the edema that accompanies it)

Skin Turgor

Poor turgor

suffered malnutrition in utero

difficulty sucking at birth

have certain metabolic disorders such as adrenocortical insufficiency

always needs to be reported as it suggests poor hydration

Fontanelles

The fontanelle may bulge if the newborn strains to pass a stool or cries vigorously or is lying supine

In some newborns, the posterior fontanelle is so small that it cannot be palpated readily

The posterior fontanelle closes by the end of the second month

Sutures

Suture lines should never appear widely separated in newborns

Wide separation suggests increased intracranial pressure because of abnormal brain formation

Molding

The part of the infant’s head that engaged the cervix (usually the vertex) molds to fit the cervix contours during labor

After birth, this area appears prominent and asymmetric

Caput Succedaneum

Edema of the scalp at the presenting part of the head.

It may involve wide areas of the head, or it may resemble a large egg

Cephalhematoma

A collection of blood between the periosteum of a skull bone and the bone itself

Caused by rupture of a periosteal capillary because of the pressure of birth

Craniotabes

A localized softening of the cranial bones that is probably caused by pressure of the fetal skull

More common in firstborn infants than in infants born later, because of the lower position of the fetal head in the pelvis

Eyes

Newborns usually cry tearlessly, because their lacrimal ducts do not fully mature until about 3 months of age

Pressure during birth sometimes ruptures a conjunctival capillary of the eye, resulting in a small subconjunctival hemorrhage

Ears

A newborn’s external ear is not as completely formed as it will be eventually

A good practice is to test a newborn’s hearing by ringing a bell held about 6 inches from each ear. A hearing infant who is crying will stop momentarily at the sound

Nose

A newborn’s nose tends to appear large for the face.

As the infant grows, the rest of the face grows more than the nose does, and this discrepancy disappears

Mouth

A newborn’s mouth should open evenly when he or she cries

All newborns have some mucus in their mouths. Newborns delivered by cesarean birth usually have an increased amount

Neck

The neck of a newborn is short and often chubby, with creased skin folds

The neck is not strong enough to support the total weight of the head but in a sitting position, a newborn should make a momentary effort at head control

Chest

The chest in some newborns looks small because the head is large in proportion

In both female and male infants, the breasts may be engorged. Occasionally, the breasts of newborn babies secrete a thin, watery fluid popularly termed witch’s milk

Abdomen

The contour of a newborn abdomen looks slightly protuberant.

A scaphoid or sunken appearance may indicate missing abdominal contents or a diaphragmatic hernia

Anogenital Area

Male Genitalia

The scrotum in most male newborns is edematous and has rugae

It may be deeply pigmented in African American or dark-skinned newborns

Female Genitalia

The vulva in female newborns may be swollen because of the effect of maternal hormones

The discharge disappears as soon as the infant’s system has cleared the hormones

Back

The spine of a newborn typically appears flat in the lumbar and sacral areas.

A newborn normally assumes the position maintained in utero

Extremities

The arms and legs of a newborn appear short. The hands are plump and clenched into fists.

A newborn’s arms and legs should move symmetrically (unless the infant is demonstrating a tonic neck reflex)