Immediate Care Of The Newborn

IMMEDIATE CARE OF THE NEWBORN The most critical period in a newborn is the first twenty-four hours after birth. It entails the highest mortality in life and a high mortality rate is a characteristic of the whole neonatal period. This is due to the sudden change in environment from the relatively protected mother's womb, where he is, to all purposes, a parasite, to a completely independent existence. A good antenatal material history is essential in the assessment of the newborn. The age and parity of the mother, blood type, history of any illness and drugs taken during pregnancy will be helpful in anticipating complications, as would the course and manner of delivery. Some maternal conditions that may likely produce a high risk infant are the following: toxemia, diabetes, intrauterine growth retardation, prematurity, abnormal presentation, ablation placenta and placenta previa, blood dyscrasia, multiple gestation, and elderly primigravida. Immediate Newborn Care EQUIPMENT Cotton balls or disposable washcloths Neutral soap 70 % alcohol

Petrolatum gauze Protective ointment

PROCEDURE Nursing Action

Rationale

WEIGHT, TEMPERATURE, AND BLOOD PRESSURE 1. Weigh infant and record weight. 1. Infant may lose 5% - 10% of birth weight because of minimal intake of nutrients and fluid and loss of excess fluid. 2. Take axillary temperature by placing thermometer in axilla and pressing infant’s arm gently but firmly against it for 10 min. Prevent undue exposure; provide warm environment (24o – 27o C [75O – 80O F)].

2. Use of rectal thermometer predisposes to irritation of rectal mucosa.

3. Take blood pressure, if indicated. BATHING TECHNIQUE (BATH WATER (37O – 38O C [98O – 100O F]) 1. Use cotton balls or soft, disposable washcloths to wipe eyes, face, and outer ears. Eyes are wiped from inside corner outward. 2. Use a neutral soap – check pH. Clear water may be used if infant’s skin is dry.

3. Hypotension may be present and require remedial action.

1. Start from cleanest area to most soiled. 2. Prevents irritation of skin. The use of hexachlorophene to prevent staphylococcal infection is controversial. Hexachlorophene may cause brain damage if a sufficient quantity is absorbed through the skin.

3. Wash infant’s head, using gentle circular motions.

3. Prevent cradle cap from forming, especially over the frontal areas.

4. Tilt head back to cleanse neck.

4. Exposes neck fold for more thorough cleansing.

5. Bathe torso and extremities quickly.

5. Prevents unnecessary exposure and chilling.

6. Inspect umbilical cord. Check area for bleeding or foul odor. A drying agent, such as 70% alcohol or merthiolate, may be applied several times daily (according to institutional policy). Do not cover with diaper. Dressings are not used.

6. Minimizes colonization by bacteria.

7. Cleanse genital area of male infants.

7.

a.

Cleanse penis without retracting foreskin.

a.

Edema and constriction of the penis may result if foreskin is retracted.

b.

Circumcision care – keep area clean. Place sterile petrolatum gauze over area for first 24 hours; change after voiding. Observe hourly for bleeding. Position infant and diaper to avoid friction

b.

Prevents infection and promotes healing. Bleeding can be controlled by pressure or by application of adrenaline solution. Prevents discomfort.

a.

Removes vernix and other discharge.

b.

Front-to-back cleansing prevents contamination of vagina.

8. Cleanse genital area of female infants. 8. a.

Wash vulva from front to back.

b.

Wipe vulva with cotton ball, using 1 stroke in a front to back direction.

9. Bathe buttocks, using gentle, patting motion. Keep area clean and dry to prevent diaper rash. If rash does occur, protective ointment (zinc oxide or A & D) may be used. Exposure t buttocks to air ir heat lamp is helpful.

9. Area is susceptible to skin breakdown because of acid reaction of urine and feces.

STOOL OBSERVATION 1. Observe stool pattern – meconium during first 2 – 3 d. 2. Transitional stools – change from tarry black to greenish black, to greenish brown to brownish yellow to greenish yellow. 3. Number, color, and consistency are recorded daily.

1. Material composed of epithelial and epidermal cells, lanugo, and bile pigments 2. Changes reflect intake of milk – stools are composed of both meconium and milk stools. 3. For early identification of abnormalities. a.

No stool within 48 hours indicates an intestinal obstruction. Passage of meconium only (without other stool) suggest obstruction in the ileum Thick, putty-like meconium may indicate cystic fibrosis. Diarrhea may be caused by overfeeding or by gastroenteritis. Blood in the stool is an indication of intestinal bleeding.

b. c. d. NUTRITIONAL CONSIDERATIOINS e. 1. Provide for nutritional intake. 2. Promote feeding method of choice.

1. Infants vary in their readiness to feed. 3. Test blood glucose using enzymatic strip test (according to institutional policy).

2. Although recommendations may be made, family decision should be respected and continuity of care provided.

4. Instruct the parent in technique of bottle-feeding. a.

Hold baby in semiupright position.

3. Infant may be hypoglycemic and require feeding sooner than usual 4 – 6 h wait.

b.

Position bottle so that neck of bottle is filled.

4.

c.

Insert nipple into baby’s mouth so that baby’s tongue is under nipple.

d.

a.

Gravity assists flow of milk into stomach.

b.

Prevents the baby fro swallowing air.

c.

Sucking and swallowing reflexes are used in feeding.

d.

Allows air to escape from stomach, preventing distention or milk regulation.

Burp during feeding by holding infant upright.

COMMUNITY AND HOME CARE CONSIDERATIONS 1. Preparation for home care: instruction is given

concerning infant bathing and care, preparation formula, and infant feeding. Written formula with instructions for preparation is provided to parents. 2. Provide ample opportunity for parent contact and care of infant while nursing support is available. Take every opportunity to teach.

1. Instruction fro infant acre is a combined responsibility of the medical and nursing staffs.

2. Early attachment results in improved parent-child relationships.

3. Arrange home visits as necessary. Newborn Care in the Delivery Room ☺ ☺ ☺ ☺

Maternal History or Labor Data Apgar Scoring Brief Physical Examination Nursing Interventions

Normal Fullterm Infants Admission Policies for Normal Fullterm Infants All healthy fullterm infants should be admitted to the transition section of the nursery where they can be observed while they recover from the shock of being born. Physical examination should be accomplished within 24 hours after delivery. Histories The prenatal and delivery histories should be reviewed. It is vital that the house officer understand the meaning of all factors on the prenatal and delivery sheets Physical Examination Each infant should receive a physical examination and the results should be recorded. Junior house officers should examine newborns under senior supervision until they can easily recognize deviations from normal. Abnormalities may present singularly or in clusters as a syndrome. When a congenital malformation is noted, careful examination of the infant for associated anomalies is indicated. If infants are born by difficult delivery, abnormal presentation, or cesarean section, observe for birth injury.

PHYSICAL EXAMINATION

EXAMINATION GENERAL CONDITION (COLOR, TONE, CRY, ACTIVITY, MATURITY, B.P., TEMP.) SKIN (RASHEES, BIRTH MARK, HEMANGIOMA HEAD, FONTANEL, SUTURES (INCLUDING CEPHALOHEAMTOMA, CAPUT SUCCEDANEUM) EYES (CATARACT, DISCHARGES, RED REFLEX, ETC.)

DATE ______________ LOCATION _________________ DOB _______________ SEX ________ M. R. NO. ______ NAME _________________________________________ NURSERY ADMISSION

DISCHARGE

EARS, NOSE, MOUTH, PALATE NECK THORAX (INCLUDING BREAST DEVELOPMENT, RETRACTIONS

LUNGS (RESP, RATE, AERATION, ETC.)

HEART (RATE RHYTHM, MURMURS, ETC.) FEMORAL PULSES ABDOMEN (LIVER, SPLEEN, KIDNEYS, MASSES, ETC.) UMBILICAL CORD, UMBIL. ART. 1 OR 2 GENITALIA (INCLUDING HERNIA) ANUS (PATENCY) BACK EXTREMITIES (INCLUDING CLAVICLES AND HIP) REFLEXES (INCLUDING MORO’S, GRASP, SUCK, ETC.) PHYSICAL EXAMINATION

IMPRESSION

WEIGHT (gm)

PLAN: __ ROUTINE CARE __ OBSERVATION CARE __ INTENSIVE CARE

LENGTH (cm)

HEAD CIRC. (cm)

ESTIMATED GESTATION (wks)

SIGNATURE ______________ M. D. DATE _________ TIME _________

WEIGHT

HEAD CIRC.

LENGTH

BLOOD GROUP

NEONATAL COMPLICATIONS, DISPOSITION: SIGNATURE ______________ M. D. DATE __________ TIME _________

Gestational Age The gestational age of each infant should be estimated by the following:

1.

Obstetric history. The number of weeks from the first day of the mother’s last menstrual period until delivery of the infant is determined. This is the gestational age in weeks.

2.

Amniotic fluid assay or sonography

Initial Newborn Assessment ☺ ☺ ☺ ☺ ☺ ☺

Stimulate & dry infant Assess ABCs Encourage skin-to-skin contact Assign APGAR scores Give eye prophylaxis & vitamin K Keep newborn, mother, & partner together whenever

Initial and Ongoing Assessment ☺ ☺ ☺ ☺ ☺ ☺

Extensive Initial Assessment Assessments every 8 hours Bathing Assisting with Feedings Protecting the Infant Preventing Infection

Nursing Care ☺ ☺ ☺ ☺

Check eye patches frequently Check positioning of equipment Record irradiance of bulb Monitor temperature, skin integrity, intake and output

General Management of the Newborn The immediate care of all newborns should include initial care, clinical appraisal, resuscitaion, temperature regulation, and physical examination. Initial Care This is done in the delivery room or where the delivery took place with good lighting conditions. The first objective is the establishment of a clear airway. Gentle suctioning can clear the secretions from the mouth, then the pharynx and nose. The latter is suctioned last in order to avoid a sudden inspiratory gasp which may result in aspiration of the amniotic fluid in the mouth. As the airway is cleared the patency of the posterior nares can be ascertained. Newborn Identification and Registration Infant identification is important, because there always exists the possibility that a newborn may be kidnapped from a maternity sevice. Identification Band Some of the identification must be attached to all newborns before they are removed from the delivery or birthing room. One traditional form is a plastic bracelet or bead necklace with permanent locks that need to be cut to be removed. A number that corresponds to teh mother's full name, and the sex, date, and time of the infant's birth are the information necessary for identification. If an identification band is attached to a newborn's arm or leg, two bands should be used. A newborn's wrist and hand, as well as ankle and foot, are not too different in width, which enables the bands to slide off with little movement. Footprinting and Fingerprinting After the attachment of the identification bands, the infant's footprints and fingerprints may be taken and thereafter kept with the baby's chart for permanent identification. If footprints and fingerprints will be obtained, care should be taken in securing them, since they will be part of the permanent record. If footprints and fingerprints are required, these should be obtained on babies who are born outside the hospital when they are admitted to the hospital for follow-up care in the same way. Footprinting and fingerprinting have in the past been recommended for purposes of neonate identification. Newly developed techniques, such as sophisticated blood typing, appear to be more reliable means of identification, however. Individual hospitals may want to continue the practice of footprinting and fingerprinting, but universal use of this practice is no longer recommended.

Birth Registration The infant's name, the mother's name, the father's name (if the mother chooses to revela this), and the birth date and place must be recorded. Official birth information is important in proving eligibility for school and later for voting, passports, Social Security benefits, and so on. Document Birth Record Be certain the birth record lists the following: ☺ ☺ ☺ ☺ ☺ ☺ ☺ ☺ ☺ ☺

the time of birth the time the infant breathed whether respirations were spontaneous or aided the child's Apgar score at 1 and 5 minutes of life whether eye prophylaxis was given whether vitamin K was administered the general condition of hte infant the number of vessels in the umbilical cord whether cultures were taken (they are taken at some point sterile delivery technique was broken or the mother has a history of vaginal or uterine infection) whether the infant (1) voided and (2) passed a stool (the latter items are helpful if, later on, the diagnosis of bowel obstruction or absence of a kidney is considered.

Many nurses indicate a three-vessel cord. Do not mistake this drawing for a "smiling face" and assume it is not important. Nursing Care Newborn infants should be wrapped in a clean blanket avoiding unnecessary exposure to prevent infection and chilling. A dose of vitamin K (1 mg I.M. or 0.5 mg in preterm) is given to prevent prothrombin deficiency. High dosage (5 mg or more) may cause hyperbilirubinemia. The eyes are protected against ophthalmia neonatorum by instillation of freshly prepared 1% silver nitrate (Crede’s prophylaxis) or an antibiotic ophthalmic ointment. The proper care of the skin is an important procedure for prevention of infection. The skin is cleansed using mild soap and water, and merthiolate is applied to the cord and umbilical area. Sterile cord dressing is used. The infant’s clothing is kept to a minimum. The temperature may be taken per rectum or axilla at birth and at least every four hours until stabilized and then every eight hours thereafter. Normal temperature is 36 to 37 degrees Celsius. There is no need for daily weighing especially of healthy term infants. Breastfeeding should always be recommended unless the babies are too weak to suck as in the preterm and other high risk infants in which case mother’s milk may be given by dropper or gavage. Nursing Interventions In most health care facilities, the delivering physician or nurse-midwife hands the newborn to the nurse moments after birth to begin care. Be certain to don gloves to care for newborns to avoid touchin gthe vernix caseosa as part of following universal precautions. Holding a warm, sterile blanket, grasp the infant through the blanket by placing one hand under the back and other around a leg. Newborns are slippery because they are wet from amniotic fluid and the vernix. Keep Newborn Warm Rub infants dry so that little body heat is lost by evaporation. Then swaddle them loosely with the blanket in order that respiratory effort is not compromised, and lay them on hteir side in warmed bassinet or unwrapped on a radiant heat table. To help conserve heat, place a cap on the infant's head and be certain all nursing care is accomplished as quickly as possible, with minimal exposure of the newborn to chilling air. Any extensive procedures, such as resuscitation, should be done under a radiant heat source to reduce heat loss. As soon as it is apparent the infant is breathing well, ask which parent wants to hold the child and place him or her in the parent's arm. This helps conserve heat as well as encourage bonding. If a mother wishes to begin breastfeeding immediately after birth, she can be encouraged to do so. Reassess a newborn's temperature. Axillary temperatures are recommended for newborns to prevent bowel perforation. During the first day of life, a newborn's temperature is usually taken every 4 hours. Thereafter, unless it is elevated or subnormal, or the infant appears to be in distress, once a day while in a health care facility is enough.

Promote Adequate Breathing Pattern and Prevent Aspiration Mucus should be suctioned from a newborn's mouth by a bulb syringe as soon as the head is born. As soon as the baby is bor, he or she should be held for a few seconds with the head slightly lowered for further drainage of secretions. It is important that mucus be removed from the mouth and pharynx before the first breath to prevent aspirations of the secretions. When an infant is born with meconium-stained amniotic fluid, it is important that the infant be not only suctioned but also intubated so that deep tracheal suction can be accomplished before the first breath. This action prevents meconium, which is very irritating to lung tissue from being drawn into the lungs with the first breath. Record the First Cry A crying infant is a breathing infant, because the sound of crying is made by a current of air passing over the larynx. Vigorous crying also helps to blow off the extra carbon dioxide that makes all newborns slightly acidotic and thus helps to correct this condition. Although gentleness is necessary to make an infant's transition from intrauterine life to extrauterine life as untraumatic as possible. It is important to note what time of after birth the child first grasped and cried and whether he or she was able to maintain respirations unaided. The newborn who does not breathe spontaneously or who takes a few quick gasping breaths but is unable to maintain respirations needs resuscitation as an emergency measure. An infant with grunting respirations needs careful observation for respiratory distress syndrome. Inspect and Care for Umbilical Cord The umbilical cord pulsates for a moment after the infant is born as a last flow of blood passes from the placenta into the infant. Two Kelly clamps are then applied to the cord about 8 in from the infant's abdomen, and the cord is cut between the clamps. The infant cord is then clamped again by cord clamp, such as Hazeltine or a Kane clamp. The Kelly clamp on the maternal end of the cord should not be released after cord cutting; otherwise, blood still remaining in the placenta will leak out. This loss is not important, because the mother's circulation does not connect to the placenta. Inspect the infant's cord to be certain it is clamped securely. If the clamp loosens before thrombosis obliterates the umbilical vessels, hemorrhage will result. The number of cord vessels should be counted and noted immediately after cutting of the cord. Cords begin to dry almost immediately, and by the time of the infant's first thorough physical examination in the nursery, the vessels may be obscured. Within a few minutes after the cord is cut, assess the cord for possible bleeding; apply antibiotic ointment or triple dye as required by agency policy to help reduce infection. Until the cord falss off, at about 7th to 10th day of life, the infant should be sponge bathed rather than immersed in a tub of water. Be certain the diaper is foldedbelow the level of the umbilical cord so that when it becomes wet, the cord does not become wet also. After the cord falls off, a small, pink, granulating area about a quarter of an inch in diameter may remain. This should also be left clean adn dry unitl it has healed (about 24 to 48 hours). If it has remained as long as a week, it may require cautery with silver nitrate to speed healing. Administer Eye Care Although the practice may shortly become obsolete, every state requires newborns receive prophylactic treatment against gonorrheal conjunctivitis of the newborn. Such infections are acquired from the mother as the infant passes through birth canal. Silver nitrate is the drug that was exclusively used for prophylaxis in the past; today, erythromycin ointment is the drug of choice. Erythromycin ointment has the advantage of eliminating not only the organism of gonorrhea but that of chlamydia as well. To instill ointment, the face of the newborn should be dried first with a soft gauze square so that the skin is not slippery. The best procedure to open a newborn's eyes is to shade them from the overhead light and open one eye at a time by pressure on the lower and upper lids. Use an individual tube or package of ointment to avoid transmitting infection from one neworn to another. With one eye open, squeeze a line of ointment along the lower conjunctival sac from the inner canthus outward, then close the eye to allow the ointment to spread across the conjunctiva.

NURSING CARE OF THE NEWBORN AND FAMILY IN THE POSTPARTAL PERIOD A newborn should be kept in either a birthing room or a careful watch nursery for optimal safety for the first few

hours of life. After this period of careful watch, certain principles of care always apply. Initial Feeding A term newborn who is to be brerast-fed may be fed immediately after birth. A baby who is to be formula-fed routinely receives a first feeding of about 1 oz of sterile water at 4 to 6 hours of age. This is a test feeding to be certain that the infant can swallow without gaggling and aspirating and to rule out the presence of a tracheoesophageal fitsula that would cause the infant to aspirate the feeeding. After this initial feeding of water, the formula-fed infant is offered formula about 4 hours. Both formulafed and breast-fed infants do best on a demand schedula; infants may need to be fed as often as every 2 hours for the first few days of life. Bathing In most hospitals, newborns receive a complete bath to wash away vernix caseosa within an hour after birth. Thereafter, they are bathed once a day, although the procedure may be limited to washing only the baby's face, diaper area, and skin fold. Wear gloves when handling newborns until a first bath to avoid exposing your hands to body secretions; babies of HIV-positive mothers should be bathed immediately to decrease possibility of HIV transmission. Bathing of the infant may be done by the nurse at the mother's bedside or by one of the parents. The room should be warm (about 75 degrees Fahrenheit [24 degrees Celscius]) to prevent chilling. BAth water should be around 98 to 100 degrees Fahrenheit (37 to 38 degrees Celsius), a temperature that feels pleasantly warm to the elbow or wrist. If sopa is used, it should be mild and without a hexachlorophene base. Bathing should take place prior to, not after, a feeding to prevent spitting up or vomitting and possible aspirations. The equipment needed consists of a basin of water, soap, washcloth, towel, comb, and clean diaper and shirt. These items should be assembled beforehand, so the baby is not left exposed while the bather goes for more equipment. Teach parents that when giving a bath, it should proceed from the cleanest to the most soiled areas of the bod, that iss, from the eyes and face to the trunk and extremities and, last, to the diaper area. Wipe the eyes with clear water from the inner canthus outward, using a clean portion of the washcloth for each eye to prevent spread of infectio to the other eye. Wash the face in clean water also to avoid skin irritation by soap, which may be used on the rest of the body. Teach parents to wash the infant's hair daily with the bath. The easiest way to do this is, first, soap the hair with the baby lying in the bassinet, then hold the infant in one arm over the basin of water as you would a football. Splash water from the basin against the head to rinse the hair. Dry the hair well to prevent chilling. Each area of the baby's body should be washed and rinsed so that no soap is left on the skin (soap is drying and newborns are susceptible to desquamation) and then dried. Wash the skin around the cord, taking care not to soak the cord. A wet cord remains in place longer thatn a dry one and furnishes a breeding ground for bacteria. Give particular care to the creases of skin, where milk tends to collect if the child spits up after feeding. In male infants, the foreskin of the uncircumcised penis should not be forced back or constriction of the penis may result. Wash the vulva of female infants, wiping from front to back to prevent contamination of the vagina or urethra by rectal bacteria. Most health care agencies do not apply powder or lotion to newborns because some infants are allergic to these products. In addition, many adult talcum powders contain zinc stearate, which is irritating to the respiratory tract; these should always be avoided. If the newborn's skin seems extremely dry, and portals for infection are becoming apparent, a lubricant added to thebathwater or applied directly to the baby's skin should relieve the condition. Diaper Area Care With each change of diapers, the area should be washed with clear water and dried well. Washing the skin prevents the ammonia in urine from irritating the infant's skin and causing a diaper rash. After the cleaning, an ointment, such as petroluem jelly may be applied to the buttocks. The ointment keeps ammonia way from the skin and also facilities the removal of meconium, which is sticky and tarry. Wear gloves for diaper care as part of universal precautions against infection. Metabolic Screening Tests By state law, every infant must be screened for phenylketonuria by a blood test after birth. If blood testing was not done before discharge, the parents must be made aware this was not done, so that they can return to the hospital or an ambulatory setting in 2 days' time for this. Always assess at first newborn health supervision visits whether parents did bring the baby for this testing. Hepatitis B Vaccination

The Centers for Disease Control (1993) have recommended that all newborns receive a first vaccination against hepatitis B within 12 hours after birth. Infants whose mothers are HBsAg+ also receive concurrently hepatitis B immunoglobulin (HBIG). Infants will receive their second vaccination at 1 month and their third one at 6 months. Circumcision Circumcision is the surgical removal of the penis foreskin. In only a few males, the foreskin is so constricted (phimosis) that it obstructs the urinary metal opening; otherwise, there is no valid medical indication for circumcision of the newborn male. The reasons supporting circumcision were easier hygiene, since the foreskin does not have to be retracted during bathing, and possibly fewer urinary tract infections. The procedure should not be done immediately after birth because the infant’s vitamin K level, which would prevent hemorrhage, is at a low point, and the chold would be exposed to unnecessary cold. It is best performed during the first or second day of life after the baby has synthesized enough vitamin K to reduce the chance of faulty blood coagulation. Assessment of Family’s Readiness to Care for Newborn at Home It is important to assess how prepared a family is to care for their newborn at home. They may need to make changes in their usual routine such as shifting their usual dinner time. Sleep schedules are disrupted: infants wake during the night for one or more feedings for about the 4 months of life. Nursing Interventions Daily Care Neonates thrive on a gentle rhythm of care, a sense of being able to anticipate what is to come next. Parents should decide what is the best daily at home routine for them and their new child. There are no fixed rules. There is no set time an infant must be bathed or even a rule that requires a bath every day. You aim in helping a mother and father plan their schedule of care is to arrive at one that (1) offers a degree of consistency (a mother cannot expect an infant to stay awake until midnight five nights a week, then go to sleep at 7 PM the next); (2) appears to satisfy the infant; and (3) gives the parents a sense of well-being and contentment with their child. Sleep Patterns Parents may be concerned because they think the baby is sleeping too much or too little. A newborn sleeps an average of 16 hours of every 24 in the first week home and an average of 4 hours at a time. By 4 months of age, the child sleeps an average of 15 hours of every 24 and 8 hours at a time (through the night). Encourage parents to position infants on alternate sides after feedings to keep respiratory secretions or mucus from collecting or pooling in one lung or the other and to prevent flattering of one side of the head. Crying Many new parents are not prepared for the amount of time a newborn spends crying. Almost all infants have a period during the day when they are wide awake and invariably fussy. New parents need to recognize this as normal and not worry that their child is ill. Parents might use this fussy time for bathing or playing with the infant, arranging their schedule accordingly. The most typical time of wakefulness is between 6 PM and 11 PM, which unfortunately is a time when parents may be tired and least able to tolerate crying. Parental Concerns Related to Breathing Some parents report that their newborns have stuffy noses or make snoring noises in their sleep and that they sneeze occasionally. A new parent who did not room with her child at the hospital may wake at night, notice this breathing pattern, and grow alarmed that the child is in respiratory distress. If these are the only symptoms the infant has, this is normal newborn respiratory pattern. Continued Health Maintenance for the Newborn There is no need for parents to continue to weigh a newborn while at home. This practice only causes worry, because weight fluctuates day by day. Be certain that parents have an appointment for a visit for a first newborn assessment in 4 to 6 weeks. Car Safety Automobile accidents are a safety problem all during childhood. Frequently, infants are injured in car accidents because they are laid on the seat of a car rather than placed in an infant’s car seat. Infant car seats are

important from the beginning, however, because in an accident, centrifugal force will cause the infant to exert a force equal to as much as 450 lb, making it impossible for a passenger to hold onto him or her. While an infant is less than 21 lb or 26 inches long, the best type of car seat is an “infant-only” seat that faces the back of the car. The ideal model has a five-point harness with broad straps, which help to spread the force of a collision over the chest and hips, and a shield, which cushions the head. Parents should dress an infant to clothing with pant legs when the infant must be placed in a car seat, because the harness crotch strap must pass between the legs for a snug and correct fit. Advise parents not to use a sack sleeper or papoose bunting, nor should they wrap the baby in a bulky blanket while in the seat. To support the baby’s head, parents can use a rolled-up receiving blanket, towel, or diaper on each side of the head. To provide extra warmth, they can cut holes in a blanket for the harness and crotch straps to pass through. Teach parents how to put the blanket in the seat and pull the straps through the blanket holes. Place the baby in the seat, buckle him in, and then fold the blanket over him for warmth. Drape a second blanket over the seat if needed. References: Maternal and Child Health Nursing, 2nd Ed. By Adele Piliteri Textbook of Pediatric and Child Health, 2nd Ed. By Fe del Mundo Guidelines for Perinatal Care, 2nd Ed., American Academy of Pediatric & American College of Obstetricians & Gynecology Manual of Nursing Practice, 7th Ed., The Lippincott