Newborn

Newborn BSN II – A – 07

What does a newborn baby look like? •During your pregnancy, you learned to know your baby by stroking (caressing) your belly and feeling your baby move. Now that your baby is born, you can enjoy the miracle of seeing, hearing, and touching him. All babies are alike in some ways, such as needing sleep, feedings, and love. In most other ways, your baby is not like any other baby. •Your baby was born with his own special personality and appearance (the way he looks). Your baby's nose or ears may look like those of a family member, and the color of his hair may surprise you. Take the time to enjoy and learn more about your baby. Sit in a quiet room with your baby. Hold and stroke him. Undress your baby and look at him from head to toe. You may notice things about your baby that you did not see right after birth. Head: Your newborn baby's head may not be perfectly round right after birth. Going through labor and delivery can cause your baby's head to have an odd shape. The head may have molded into a narrow, long shape to go through your birth canal. It may have a bump on one side. Your baby may have bruising or swelling on his head because of the birth process. This is usually normal. If your baby's odd head shape was caused by labor and delivery, do not worry. His head should look rounder and more even in one or two weeks. Your baby's head may have one or more of the following: Caput (KA-putt): Fluid is squeezed into your baby's scalp during labor and delivery. Because of this your baby may have swelling on the top or side of his head, or all around his scalp. "Goose egg": You may feel a goose egg (soft swelling) on your baby's head. This swelling is caused by tiny blood vessels that broke under the scalp during labor and delivery. Fluid from the blood vessels then squeezes into the scalp during birth. The swelling may increase during the first week of your baby's life. A goose egg may take as long as two to three months to go away. Molding: Molding happens when the skull bones in your baby's head move during labor and delivery. The head becomes long and narrow, helping it get through the birth canal more easily. Your baby may have more molding if his head is large or if your labor was long. Babies born feet first may have less molding. A cesarean section baby may have little or no molding. Fontanels: Fontanels are soft spots on your baby's skull where the bones have not grown together yet. They are protected by a tough tissue (membrane). The purpose of the soft spots is to make room for the brain to grow. Your baby's brain grows very quickly his first year. Soft spots are usually flat, but may bulge when your baby cries or

Hair: Your baby may be born with a little or a lot of hair. Your baby's hair may begin to fall out by the time he is four weeks old. This is common. By the time your baby is six months old, he should have new hair. Your baby's new hair may be a much different color than the hair color he was born with. Your baby's shoulders and back may be covered with lanugo . This is a fine coating of soft hair. Lanugo is more common on premature (born too early) babies. This type of hair should rub or fall off your baby within the first month. This hair can be very light or quite dark. Eyes: Your baby's eyelids may be puffy. He may have blood spots in the white areas of one or both eyes. These are often caused by the pressure on your baby's face during delivery. Eye medicines that your baby needs after birth to prevent infections (in-FEK-shuns) may cause your baby's eyes to look red. The swelling and redness in your baby's eyes is usually gone in three days. It may take up to three weeks before blood spots in your baby's eyes are gone. The iris is the colored part of the eye. Most light-skinned babies are born with blue-gray eyes. The eye color of lightskinned babies may change during the first year. Dark-skinned babies usually have brown eyes that do not change color. If your baby will not open his eyes for you, the lights in the room may be too bright. Try dimming the lights to encourage your baby to open his eyes. It is common for your baby to cry without making tears. A newborn baby's eyes usually make just enough tears to keep his eyes wet. By seven to eight months old, your baby's eyes will develop so they can make more tears. Tears drain into small ducts at the inside corners of each eye. These ducts are called lacrimal tear ducts. A blocked tear duct is common in newborns. A possible sign of a blocked tear duct is a yellow sticky discharge in one or both of your baby's eyes. Your baby's caregiver may show you how to massage your baby's tear ducts to unplug them. Most newborn babies like to look at things that are eight to fifteen inches from their face. During times when your baby is very awake and alert, show him pictures. Most babies like pictures that are black and white, or dark and light colors. Use a heavy black marker to draw a picture of a face on a white piece of paper. Show your baby bulls-eyes and stripes made with very dark and very light colors. If your baby begins to cry or hold his hand out toward the picture, put it away. Your baby may be telling you that he is tired and does not want to look at pictures now. Instead of using pictures, sit face to face with your baby. Your baby loves your face and smile best of all. Ears: At birth, one or both of your baby's ears may be folded over. This is because your baby was crowded while growing in the uterus (womb). Ears may stay folded for a short time before unfolding on their own. There is no need to tape the ear into a normal position. Some babies are born with ears that will always stick out a little. Nose: Your baby's nose may be large, pushed in, or flat because of the tight squeeze during labor and delivery. The nose will change as your baby's face grows. It may take a week or longer before your baby's nose seems more normal.

Mouth: Look inside your baby's mouth when he is crying. Your baby may have small white bumps on his gums. These bumps are usually normal cysts, which are fluid-filled sacs and will soon go away on their own. Yellow-white spots may be present on the roof of your baby's mouth. These spots are known as "Epstein's pearls" and will also go away without special care. Some babies are born with one or more teeth. These teeth do not have roots and may need to be removed by a dentist. This will keep your baby from choking on or swallowing the teeth. Other babies are born with normal teeth, which have simply shown up early. These teeth only need to be removed if they cause tongue sores or become loose. Your baby may get a lip callus (thickened skin) or "sucking pad" on his upper lip during the first month. It is caused by your baby's sucking and should go away within your baby's first year. The sucking pad does not bother your baby, so you do not need to remove it. Skin: At birth, your baby's skin may be covered with a waxy coating called vernix. As the vernix comes off and the skin dries, your baby's skin will peel. Babies who are born after their due date may have a large amount of skin peeling. This is normal. Peeling does not mean that your baby's skin is too dry. You do not need to put lotions or oils on your newborn's skin to stop the peeling or to treat rashes. Your baby's skin may be pink, yellowish, or tan. It may look blotchy or marbled when your baby is upset or cold. At birth or during his first few months, your baby may have one or more of the following: Erythema toxicum: These are red splotches with yellow-white bumps in the center that look like bug bites. They may appear anywhere on your baby's body except the soles of the feet and palms of the hands. The rash may appear within three days after birth. No treatment is needed for the rash. It usually goes away in one or two weeks. Milia: These are small white or yellow bumps that appear on the faces of most newborns. Blocked skin pores cause milia. Many milia may break out across your baby's nose, cheeks, chin, and forehead. Do not squeeze or scrub milia. Rubbing creams or ointments on milia may make them worse. When your baby is one to two months old, his skin pores begin to naturally open. When this happens, his milia will go away. Newborn acne: Some babies get newborn acne when they are three to five weeks old. Your baby's cheeks may feel rough and may be covered with a red, oily rash. Wash your baby's face with warm water. Do not use baby oil, creams, ointments, or other products. These will only make this rash worse. Keep your baby's fingernails short to keep him from scratching his cheeks. No special treatment will clear up newborn acne. Like milia, newborn acne

Birthmarks: It is common for babies' skin to have birthmarks. Birthmarks come in different sizes, shapes, and colors. Some birthmarks shrink or fade with time. Other birthmarks may stay on your baby's skin for his entire life. Café au lait spots: These are flat skin patches that are a light brown or tan color. Café au lait spots look like small puddles of coffee and cream. This is a common birthmark that babies may get anywhere on the body. The spots may get smaller as your baby grows. Ask your baby's caregiver to check these spots during each visit. Moles: Moles are also called nevi . Moles are dark-brown or black. They may be on your baby's skin when he is born, or may form later. Most moles are harmless and do not need to be removed. Ask your baby's caregiver to check these spots during each visit. Mongolian spots: These spots are commonly seen on the buttocks (rear end), backs, or legs of dark-skinned babies. Mongolian spots may be green, blue, or gray colored, and may look like bruises. Mongolian spots are harmless, and usually go away by the time your child is school-aged. Port wine stain: These are large, flat birthmarks that are pink, red, or purple colored. A port wine stain is caused by too many blood vessels under the skin. A port wine stain may fade in time, but will not go away without surgery. Ask your baby's caregiver to check these spots during each visit. Stork bite: A stork bite is a common birthmark, especially on light-skinned babies. It is also called a "salmon patch". Stork bites are flat, irregular patches that may be light or dark pink. Stork bites can usually be seen on the eyelids, lower forehead, or bridge (top) of a baby's nose. They may also be found on the back of a baby's head or neck. Most stork bites fade and go away by your baby's first birthday. Even after your baby's stork bites fade, they may darken for a short time when he cries or strains. Strawberry hemangioma: This is a rough, raised, red spot caused by many blood vessels at top of the skin. Right after birth, the spot may be pale or white, and may turn red later. These spots may get larger during the first months of a baby's life, then shrink and go away. A strawberry spot may sometimes bleed on its own or because of a scratch or bump. Breasts: Your newborn boy or girl may have swollen breasts after birth. This is caused by hormones passed from mother to baby before birth. Hormones are special chemicals made by the body to control how different parts of the body work. Your baby's breasts may be swollen for a few weeks. Your baby's breasts may be swollen longer if you are breast feeding. This is because you pass hormones to your baby in your breast milk. Your baby's breasts may also have a milky discharge. Do not squeeze your baby's breasts. This will not stop the swelling and could cause an infection. Belly:

Genitalia: Female genitalia: A girl's external (outside) genitalia are called the labia majora (large outer lips), labia minora (small inner lips), and clitoris. These may look large and red. Your baby girl may also have a clear, white, pink, or blood-colored discharge from her vagina. Hormones passed from mother to baby before birth cause this. This discharge should go away within one to four weeks. Male genitalia: A boy's external genitalia are called the penis and scrotum. The rounded end of your boy's penis is called the glans. The prepuce or foreskin is the skin that covers the glans. Before birth the glans and foreskin grow as one piece of skin. Right after birth, your baby's glans and foreskin will be grown together. This is normal. Do not try to retract (pull back) the foreskin. With time, the foreskin slowly starts to come apart from the glans. If your baby had a circumcision (removal of his foreskin), talk to his caregiver. Ask the caregiver for information on how to care for it. It is common for a baby boy to have an erection of his penis. He may have an erection during diaper changes, when breast feeding, or when you are washing him. He may also have an erection when his diaper rubs against his penis. The scrotum is the pouch that protects your baby boy's testicles. It has fluid in it to cushion the testicles. Your baby may have extra fluid in his scrotum because of pressure during his birth. This extra fluid is called a hydrocele. Caregivers will check the hydrocele during visits. A hydrocele usually goes away in a few months. There are two testicles inside the scrotum. Sometimes one or both testicles do not come down from the baby's abdomen (belly) into the scrotum at birth. This is called "undescended testicles". Most testicles come down into the scrotum in one year. Surgery may be needed if the testicles do not come down by age five. Arms and legs: Newborn babies like to keep their arms and legs tucked close to their bodies. It makes them feel secure and reminds them of being inside your belly. You may need to gently straighten your baby's arms or legs so you can look at them. Your baby's hips should bend easily. If they do not, your baby may have a dislocated (bone is out of joint) hip. When caregivers do an exam on your newborn, ask them to check your baby's hips. Your baby has one large bone in his upper leg and two smaller bones in his lower leg. The lower leg bones are called the tibia and the fibula. The lower legs normally curve in because of how your baby was lying inside the uterus. Your baby's legs should straighten after he has been walking for many months. Your baby's feet were turned in many directions while inside the uterus. Your baby's feet should straighten out by the time he is 12 months (one year) old. Sometimes early treatment may be needed if your baby's feet are turning in too much.

   Newborn screening is the process of testing newborn babies for treatable genetic, endocrinologic, metabolic and hematologic diseases. Robert Guthrie is given much of the credit for pioneering the earliest screening for phenylketonuria in the late 1960s using blood samples on filter paper obtained by pricking a newborn baby's heel on the second day of life to get a few drops of blood.  Congenital hypothyroidism was the second disease widely added in the 1970s. The development of tandem mass spectrometry screening by Edwin Naylor and others in the early 1990s led to a large expansion of potentially detectable congenital metabolic diseases that affect blood levels of organic acids. Additional tests have been added to many screening programs over the last two decades. Newborn screening has been adopted by most countries around the world, though the lists of screened diseases vary widely. Disease qualification üCommon considerations in determining whether to screen for disorders: üA disease that can be missed clinically at birth üA high enough frequency in the population üA delay in diagnosis will induce irreversible damages to the baby üA simple and reasonably reliable test exists üA treatment or intervention that makes a difference if the disease is detected early

Newborn Screening Program in the Philippines The following tests are mandated in the R.A. 9288 or Newborn Screening program of 2004.Newborn screening is available in practicing health institutions (hospitals, lying-ins, Rural Health Units and Health Centers) with cooperation with DOH. If babies are delivered at home, babies may be brought to the nearest institution offering newborn screening. A negative screen mean that the result of the test is normal and the baby is not suffering from any of the disorders being screened. In case of a positive screen, the NBS nurse coordinator will immediately inform the coordinator of the institution where the sample was collected for recall of patients for confirmatory testing.. Babies with positive results should be referred at once to the nearest hospital or specialist for confirmatory test and further management. Should there be no specialist in the area, the NBS secretariat office will assist its attending physician.

Disorders Screened: Heel Prick Method for the newborn screening ØCH (Congenital hypothyroidism) - is a condition of thyroid hormone deficiency present at birth. Approximately 1 in 4000 newborn infants has a severe deficiency of thyroid function, while even more have mild or partial degrees. If untreated for several months after birth, severe congenital hypothyroidism can lead to growth failure and permanent mental retardation. Treatment consists of a daily dose of thyroid hormone (thyroxine) by mouth. Because the treatment is simple, effective, and inexpensive, nearly all of the developed world practices newborn screening to detect and treat congenital hypothyroidism in the first weeks of life. ØCAH (Congenital adrenal hyperplasia) - refers to any of several autosomal recessive diseases resulting from mutations of genes for enzymes mediating the biochemical steps of production of cortisol from cholesterol by the adrenal glands (steroidogenesis). Most of these conditions involve excessive or deficient production of sex steroids and can alter development of primary or secondary sex characteristics in some affected infants, children, or adults. Approximately 95% of cases of CAH are due to 21hydroxylase deficiency.

ØGAL (Galactosemia) - is a rare genetic metabolic disorder which affects an individual's ability to properly metabolize the sugar galactose. Lactose in food (such as dairy products) is broken down by the body into glucose and galactose. In individuals with galactosemia, the enzymes needed for further metabolism of galactose are severely diminished or missing entirely, leading to toxic levels of galactose to build up in the blood, resulting in hepatomegaly (an enlarged liver), cirrhosis, renal failure, cataracts, and brain damage. Without treatment, mortality in infants with galactosemia is about 75%. ØPKU (Phenylketonuria) - is an autosomal recessive genetic disorder characterized by a deficiency in the enzyme phenylalanine hydroxylase (PAH). This enzyme is necessary to metabolize the amino acid phenylalanine to the amino acid tyrosine. When PAH is deficient, phenylalanine accumulates and is converted into phenylpyruvate (also known as phenylketone), which is detected in the urine. PAH is found on chromosome number 12.Left untreated, this condition can cause problems with brain development, leading to progressive mental retardation and seizures. However, PKU is one of the few genetic diseases that can be controlled by diet. A diet low in phenylalanine and high in tyrosine can be a very effective treatment. There is no cure. Damage done is irreversible so early detection is crucial. ØG6PD Deficiency - is an X-linked recessive hereditary disease characterized by abnormally low levels of the glucose-6-phosphate dehydrogenase enzyme (abbreviated G6PD or G6PDH). It is a metabolic enzyme involved in the pentose phosphate pathway, especially important in red blood cell metabolism.

Newborn screening in the United States The following tests are mandated (required to be performed on every newborn born in the state) in most of the United States. According to the U.S. Centers for Disease Control, approximately 3,000 babies with severe disorders are identified in the United States each year using newborn screening programs at current testing rates. States vary, and not all tests are required in every state, and a few states mandate more than this. The first test to be universally mandated across the U.S. was the Guthrie test for phenylketonuria (PKU), and in many areas and hospitals, the newborn blood test is often erroneously referred to as a "PKU test", even though all states now universally test for congenital hypothyroidism, galactosemia, and increasing numbers of other diseases as well. üEndocrine disorders: Congenital adrenal hyperplasia (CAH), Congenital hypothyroidism üBlood cell disorders: sickle-cell disease (SS) üInborn errors of carbohydrate metabolism: Galactosemia üInborn errors of amino acid metabolism: Phenylketonuria (PKU), Maple syrup urine disease (MSUD), Homocystinuria üInborn errors of organic acid metabolism: Biotinidase deficiency

Behavioral Assessment of Newborn

  A short, easy-to-use, interactive observational tool. With the Newborn Behavioral Observations (NBO) system, professionals will have a structured set of 18 observations for infants from birth to approximately 3 months. Including parents as partners, professionals guide the observation, discuss the baby’s abilities and behaviors with parents, encourage parent insights and questions, and suggest specific ways to support the child’s development. (Appropriate use of the NBO tool in clinical practice requires training through the NBO training program.) A complete guide to the NBO system. Through realistic case studies, step-by-step how-to instructions, and color photos illustrating each NBO item, professionals will understand how to use the NBO effectively with a wide variety of families. Invaluable professional guidance. More than a tool, the handbook helps professionals improve their daily work with in-depth information on infant and parent development, cultural competence, premature and at-risk infants, family-centered care, and more. An essential resource from the co-author of the highly regarded Neonatal

Care of the Normal Newborn Infant The practical nurse has a unique opportunity of closely observing and providing care for the newborn infant after delivery. Because of the newborn infant's helplessness, his needs must be met initially by nursing personnel. Many nursing assessments and evaluations are conducted for the well-being of the infant. Nursing care does not stop with the newborn infant. Interaction with the parents is also important in the development of a family unit.

CARE OF THE NEWBORN IN THE DELIVERY ROOM There are several needs of a newborn infant that require close attention. Establishing and maintaining respirations are the two needs that must be met immediately. a. Establishing and Maintaining the Newborn's Airway. The physician suctions the infant before it is completely born with a bulb syringe or a DeLee trap. A DeLee trap is used if meconium was present in the amniotic fluid. The infant's mouth is suctioned first and then his nose. Once the infant is

Common characteristics of newborn respirations. (a) Nose breathers. Sleeps with mouth closed, does not have to interrupt feedings to breathe. (b) Irregular rate. (c) Usually abdominal or diaphragmatic in character. (d) Ranges from 40 to 60 breathers per minute. (e) Breathing is quiet and shallow. (f) Easily altered by external stimuli. (g) Periods of apnea less than 15 seconds is normal. (h) Acrocyanosis may occur during periods of crying. Acrocyanosis refers to cyanotic look of the baby's hands and feet when he is crying. When the baby stops crying, his hands and feet get pink again. (2) Signs and symptoms of newborn respiratory distress. (a) Increased rate or difficulty breathing-growing and seesaw breathing. In normal respirations, the infant's chest and abdomen rise. With seesaw respirations, the infant's chest wall retracts and his abdomen rises with inspirations. See fig. 8-3. (b) Sternal or subcostal retractions. (c) Nasal flaring. (d) Excessive mucus, drooling. (e) Cyanosis.

Figure 8-3. See-saw

Figure 8-2. Removing mucus from infant's nose. 

Maintaining Body Temperature. (1) Dry the infant thoroughly immediately after delivery. The infant is extremely vulnerable to heat loss because his body surface area is great in relation to his weight and he has relatively little subcutaneous weight. Heat loss after delivery is increased by the cool delivery room and the infant's wet skin. (2) Place the infant in a radiant heat warmer. (3) Place a stockinette cap on the infant's head to prevent heat loss through the head. (4) Wrap the infant snugly in a warm blanket. (5) Place the infant closely to the mother's skin. Skin-to-skin contact with the mother will help prevent heat loss. c. Identify the Infant After Delivery. (1) The infant must be properly identified before leaving the delivery room. An identification (ID) band is placed on the infant's wrist and leg. An identical band matching the infant's band is placed on the mother's wrist. (2) The infant's footprints or palm prints placed next to the mother's thumb print is rarely done in most facilities. Each facility has its own instant identification method. d. Establish Parent-Infant Bonding Process. (1) Parent-infant bonding is the initial step in the process of attraction and response between the newborn and the parents. This paves the way for development of love and affiliation that forms a strong family unit. (2) This process should begin as soon after delivery as possible. In the delivery room as soon as the infant is dry and identified, he should be given to the parents. The infant is more alert during the first hours (approximately four) after birth than in the immediate subsequent hours.

APGAR SCORING

The initial APGAR scoring is performed in the delivery room by the physician. APGAR scoring is a method of evaluating the condition of the  newborn at one minute and at five minutes after delivery. a.

Purpose. The APGAR scoring chart is used to evaluate the conditions of the baby at birth, determine the need for resuscitation, evaluate the  Purpose. effectiveness of resuscitative efforts, and to identify neonates at risk for morbidity and mortality. 

b. Objective Signs Used for Evaluation.  (1) Heart rate. (2) Respiratory effort. (3) Muscle tone. (4) Reflex irritability. (5) Color. c. Scoring. (1) Evaluations at each of the five categories are initially done at one minute after birth. (2) Each item has a maximum score of two and a minimum score of zero. (3) The final APGAR score is the sum total of the five items, with a maximum score of ten. The higher the final APGAR score, the better condition of the infant. (4) Evaluations at one minute quickly indicate the neonate's initial adaptation to extra uterine life and whether or not resuscitation is necessary. (5) The five-minute score gives a more accurate picture of the neonate's overall status, including obvious neurologic impairment or impending death.

PR OC ED UR E FOR ADMI SSION TO TH E NUR SERY a. Carry out the hospital policy for gowning and the three-minute scrub. If you are already wearing scrubs, it is not necessary to gown. If the initial  scrub has already been completed when coming on duty, a one-minute scrub is acceptable.  b. Receive the infant from the transporter. Take the infant from the transporter or the transporter's arms. Verify the ID bracelet on the infant's arm  and leg with the delivery room personnel. Make sure the information is accurate (i.e., mother's name, sex of the infant, date and time of birth, and  doctor's name). Take the report from the delivery room person. The report concerns pertinent information of the mother's labor and of the newborn's  birth.  c. Remove the delivery room blanket from the infant.  d. Weigh the infant. Place a protective paper cover over the scale first and make sure the scale is balanced. Place the infant on the scale. Document  the infant's weight on the:  (1)Nursing Notes (2) Delivery room record.  (3) Instant data card.  e. Place the infant in an open warmer for the remainder of the admission procedures to maintain adequate temperature.  (1) Measure the infant (see figure 8-5).  (a) Length (from top of head to the heel with the leg fully extended).  (b) Head circumference - repeat after molding and caput succedaneum are resolved.  (c) Chest circumference (at the nipple line).  (d) Abdominal circumference. (2) Record measurements in inches and centimeters.  (3) Document the information in the appropriate areas on Nursing notes, the delivery room record, and the instant data card.  (4) Take infant's vital signs and document on Nursing Notes and the delivery room record.  (a) Temperature-only the first one is done rectally, the remainder is axillary.  (b) Heart rate and respirations-count a full minute because of the irregularities in rhythm.

Figure 8-5. Measuring infant.

Figure 8-6. Taking infant's temperature.

Figure 8-7. Normal neonatal vital signs.

f. Aspirate fluids.  (1) Aspirate the infant's mouth and nose gently with a bulb syringe.  (2) Insert a number 5 French catheter into the baby's nares to check  for patency.  (3) Insert a number 8 French catheter in the baby's mouth down into  the stomach and gently aspirate stomach contents.  (4) Record the color and amount of aspirate on SF 510, Nursing  Notes and on the delivery record sheet.  g. Evaluate the infant's physical condition.  (1) Note the infant's cry, color, and activity for signs of respiratory  distress throughout the assessment.  (2) Do a complete head-to-toe assessment, looking for any gross  abnormalities on his hands, feet, palate, spine, and so forth.  (3) Document if the infant voids or passes meconium.  (4) Document presence of reflexes (dealt with more extensively in  the typical newborn).  (a) Moro.  (b) Sucking.  (c) Grasping.  (5) Count the number of vessels in the cord and document.  (6) Assess head for molding, caput succedaneum, or  cephalhematoma and document in appropriate records.  (7) Observe and record any birthmarks.

h. Place the infant on his side (see figure 8-8) to promote drainage of mucus. Note that he is supported  by a pillow to his backside. i. Provide for infant's safety while in open warmer.  j. Place the infant in an isolate if his temperature is below 98°F rectally. If the infant's temperature is  above 98ºF rectally, place him in an open crib.  NOTE: Step "j" is done after the initial assessment and procedures are completed.

ADMINISTRATION OF VITAMIN K

Vitamin K is given as a prophylaxis for hemorrhagic disease. It is administered intramuscular (IM) in the vastus lateralis muscle (see figure 8-9).

Figure 8-8. Infant placed on his side.

8-6. EYE PROPHYLAXIS FOR THE NEWBORN  This procedure is required by law in all states as prophylaxis against gonorrhea. The medications used are as follows: a. Erythromycin Ophthalmic Ointment. This has become the drug of choice and is received in a sterile syringe from the pharmacy. It is injected into each eye from the inner to outer canthus immediately after birth (see figure 8-10). It does not appear to cause much eye irritation. b. 1% Silver Nitrate Solution. Two drops are applied in each eye in the conjunctival sac, not the cornea. The infant eyes may or may not be irrigated after instillation, depending on local policy. The infant may get profuse discharge and chemical conjunctivitis for a few days with no residual damage. One percent silver nitrate solution is no longer recommended for use.

Figure 8-10. Administration of erythromycin ophthalmic ointment.

8-7. INITIAL BATH 

a. The amount of time required for the initial bath is determined by local policy. If the infant's temperature is greater than 98ºF rectally, the bath may be done after all admission procedures are done. Otherwise, wait until the infant's temperature has stabilized above 98ºF. b. The procedure for actually completing the bath is also determined by local policy. Allow the parent to participate if possible. Remove as much of the vernix as possible. Some may not come off during the first bath because it is so "sticky."

8-8. CORD CARE FOR THE NEWBORN INFANT  a. Inspect the cord frequently for signs of bleeding immediately after it has been cut. b. Apply triple dye (refer to local policy) to the cord after the infant has had his bath and has been determined to be stable. The dye prevents infection and helps the cord to dry. c. Swab the cord with alcohol at least three times per day (refer to local policy). The alcohol aids in drying. d. Observe for cord detachment. The cord detaches in ten to fourteen days. The cord dries faster when left uncovered. Have the parents roll the infant's diaper down some in front initially so the cord is not covered. e. Observe for signs of infection and report findings immediately. The signs of infection are purulent drainage, redness, and possible swelling (more than usual).

8-9. BONDING PROCESS  a. Bonding should be initiated in the delivery room. b. The significant other should be allowed to participate in as much of the care as possible during the admission process to develop the bond between him and the infant. c. Transport the infant back to the mother as soon as local policy allows to take advantage of the alert state newborns have during those first few hours after birth. (1) This is considered a critical time for both individuals to interact and get to know one another. (2) It is an excellent time to establish breast-feeding while the infant is awake. (3) Approximately the first four hours after delivery, the infant returns to a sleep state or less alert state.

8-10. INFANT BAPTISM  a. Baptism is performed for infants who are in imminent danger of death and whose parents are Roman Catholic or certain other Christian denominations. b. The nurse may perform the baptism by pouring a small amount of warmed water on the infant's head and saying, "I baptize thee in the name of the Father, and of the Son, and of the Holy Spirit." A record of the baptism is made in SF 510, Nursing Notes. The parents are notified about the baptism. 8-11. COMPLETE INSPECTION OF THE NEWBORN  A complete inspection of the newborn infant is performed within 24 hours after delivery. The goal is to compile a complete record of the newborn that will act as a database for subsequent assessment and care. a. Assemble necessary equipment.   (1) Pediatric stethoscope.   (2) Penlight.   (3) Tape measure.   (4) Rectal thermometer.   (5) Infant scale. b. Wash hands for a full three minutes. c. Approach and identify the infant. d. Provide for a warm, well-lighted, draft-free area, keeping the infant undressed for as short a time as possible. e. Place the infant on a flat, protected surface. f. Take the infant's temperature. The infant's temperature is taken rectally only on admission. Subsequent temperatures are to be taken by the axillary method. g. Determine the infant's apical heart rate. Count for a full minute. h. Determine the infant's respiratory rate. Count for a full minute. Note any signs of respiratory distress (retractions, grunting, nasal flaring) rate over 60 bpm, or periods of apnea. Auscultate the infant's lungs. i. Balance the scale. j. Weigh the naked infant. Most newborns weigh between six to nine pounds (2,700 and 4,000 grams). Record the weight in pounds and ounces, as well as in grams. k. Measure the infant's length from top of the head to the heel with the leg fully extended and record measurements. l. Measure the infant's head circumference and record measurements. The normal head circumference is 13 to 14 inches (33 to 35 cm). Cranial molding from a vaginal delivery may affect this measurement. The measurement should be repeated on the second and third day after delivery. m. Measure the infant's chest circumference at the nipple line and record the measurement. n. Observe the general contour of the infant's head. Gently palpate the sutures and fontanelles. The anterior fontanelle is approximately two inches long and is gem/diamond shaped. The posterior fontanelle is smaller than the anterior fontanelle. Normally, the fontanelle feels soft and is either flat or slightly indented. The anterior fontanelle usually bulges when the infant cries, coughs, or vomits. o. Observe the general appearance of the infant's neck. The infant's neck is usually short, thick, and covered with folds of tissue. The infant should be able to move his neck from side to side, from flexion to extension, and can hold his head in the midline position.

p. Observe the infant's eyes for symmetry of size and shape. Note the infant's eye movements. Strabismus caused by poor neuromuscular control is normal. An infant older than ten days should look in the direction in which you turn. Note the color of the infant's eyes. q. Inspect the infant's ears for structure, shape, and position. The ears should be firm with wee-formed cartilage. Tops of the auricles should be parallel to the outer canthus of the eye (refer to figure 7-5). r. Inspect the infant's nose for patency. s. Inspect the infant's mouth for cleft palate by gently depressing his tongue when he cries. Check the mucous membranes. Observe the soft and hard palate. Make sure they are in tact. t. Inspect the infant's skin and nails. Observe for jaundice, birthmarks, milia, petechiae, and lanugo. Observe the infant's hands and feet for normal creases. Observe the color of the infant's nail beds; they should be pink. Acrocyanosis may be present up to 24 degrees, especially when the infant is crying. u. Inspect the size, shape, and symmetry of the infant's chest. Normally, an infant's chest is circular or barrel-shaped. The breast tissue of both male and female infants may be slightly engorged during the first few days of life. v. Palpate the infant's peripheral pulses (femoral, brachial, and radial). w. Inspect the size and shape of the infant's abdomen. The abdomen should be cylindrical in shape. Sunken or distended abdomen should be reported. Check the umbilical cord for the number of vessels. x. Auscultate the infant's abdomen for bowel sounds. Bowel sounds should be present within one to two hours after birth. y. Observe for excessive drooling, coughing, gagging, or cyanosis during feeding. z. Place the infant on his abdomen and observe his spine for curves, masses, or abnormal openings. aa. Inspect the male infant's genitalia. The penis should be checked for location of the urinary meatus. The scrotum may appear edematous and proportionately large. bb. Inspect the female infant's genitalia. The labia majora may appear edematous and cover the clitoris and the labia minora. cc. Observe the infant's spontaneous or involuntary movements for symmetry, spasticity, or rigidity. Gently straighten his arm or leg. Release it and observe whether it returns to its normal position. If the extremity remains limp, the infant may be hypotonic. If the extremity is difficult to straighten and rapidly flexes when released, he may be hypertonic. dd. Dress the infant carefully and return him to his bassinet. ee. Record all significant nursing observations in the infants' health record. Report your observations to the Charge Nurse.

8-12. PHENYLKETONURIA TEST  A phenylketonuria (PKU) test is done to check for rising levels of phenylalanine. Phenylalanine is a naturally occurring amino acid essential to growth. After milk or formula (both contain phenylalanine) feedings begin, levels rise due to a deficiency of the liver enzyme that converts phenylalanine to tyrosine. Due to this metabolic deficiency, poisons build up in the bloodstream and cause mental retardation. If the infant is found to have rising levels of phenylalanine, many protein foods can be withheld from the diet and synthetic foods substituted. The following steps are performed to collect a blood specimen for a PKU test on the newborn infant.

a. Ensure that the infant has been on milk or formula feeding for three full days. Four days are preferred. b. Explain to the parents the purpose of the test c. Perform a heel stick to obtain needed specimen (see figure 8-11). d. Place one drop of blood on each of the three circles on the filter paper or in accordance with local policy. e. Label and transport the specimen to the laboratory. f. Notify the parents of follow-up care of the infant, if the infant is discharged prior to his third or fourth day of life. This test must be done. 8-13. GOALS OF NEWBORN NURSING CARE  a. To continue appraisal of the newborn throughout his hospital stay. (1) Observe and record the infant's vital signs. (2) Monitor weight loss or gain (daily by some local policy). (3) Monitor bowel and bladder function. (4) Monitor activity and sleep patterns. (5) Monitor interactions and bonding with parents. b. To provide safeguards against infection (that is, handwashing). c. To initiate feedings. d. To provide guidance and health instruction to parents. 8-14. DISCHARGE CONSIDERATION FOR THE NEWBORN AND FAMILY  a. Planning for discharge should begin at time of admission. An infant in normal health is discharged from the hospital at the same time as the mother. b. Instructions for parents (teaching should be continuous). (1) Feeding schedule. (2) Bathing routine. (3) Home care needs. (4) Umbilical cord stump care. (5) Infant safety in the car. c. Prior to discharge, a follow-up appointment date should be arranged for the newborn (local policy determines the date-two, four, or six weeks). d. A final identification check of the mother and the infant must be performed before the infant can be allowed to leave the hospital.

Growth and development

Sigmund Freud: Mechanism

Growth & Development Theories Defense

Sigmund Freud: Psychosexual Theory

Erik Erikson: Theory

Psychosocial

Jean Piaget: Theory

Cognitive

Lawrence Kohlberg: Theory of Moral Development

James Fowler: Spiritual Development

Although developmental change runs parallel with chronological age, age itself cannot cause development. The basic mechanisms or causes of developmental change are genetic factors and environmental factors. Genetic factors are responsible for cellular changes like overall growth, changes in proportion of body and brain parts, and the maturation of aspects of function such as vision and dietary needs. Because genes can be "turned off" and "turned on", the individual's initial genotype may change in function over time, giving rise to further developmental change. Environmental factors affecting development may include diet and disease exposure, as well as social, emotional, and cognitive experiences. However, examination of environmental factors also shows that young human beings can survive within a fairly broad range of environmental experiences. Rather than acting as independent mechanisms, genetic and environmental factors often interact to cause developmental change. Some aspects of child development are notable for their plasticity, or the extent to which the direction of development is guided by environmental factors as well as initiated by genetic factors. For example, the development of allergic reactions appears to be caused by exposure to certain environmental factors relatively early in life, and protection from early exposure makes the child less likely to show later allergic reactions. When an aspect of development is strongly affected by early experience, it is said to show a high degree of plasticity; when the genetic make-up is the primary cause of development, plasticity is said to be low. Plasticity may involve guidance by endogenous factors like hormones as well as by exogenous factors like infection.

Child playing with bubbles One kind of environmental guidance of development has been described as experience-dependent plasticity, in which behavior is altered as a result of learning from the environment. Plasticity of this type can occur throughout the lifespan and may involve many kinds of behavior, including some emotional reactions. A second type of plasticity, experience-expectant plasticity, involves the strong effect of specific experiences during limited sensitive periods of development. For example, the coordinated use of the two eyes, and the experience of a single three-dimensional image rather than the two-dimensional images created by light in each eye, depends on experiences with vision during the second half of the first year of life. Experience-expectant plasticity works to fine-tune aspects of development that cannot proceed to optimum outcomes as a result of genetic factors working alone. In addition to the existence of plasticity in some aspects of development, genetic-environmental correlations may function in several ways to determine the mature characteristics of the individual. Genetic-environmental correlations are circumstances in which genetic factors make certain experiences more likely to occur. For example, in passive genetic-environmental correlation, a child is likely to experience a particular environment because his or her parents' genetic make-up makes them likely to choose or create such an environment. in evocative genetic-environmental correlation, the child's genetically-caused characteristics cause other people to respond in certain ways, providing a different environment than might occur for a genetically-different child; for instance, a child with Down syndrome may be treated more protectively and less challengingly than a non-Down child. Finally, an active genetic-environmental correlation is one in which the child chooses experiences that in turn have their effect; for instance, a muscular, active child may choose after-school sports experiences that create increased athletic skills, but perhaps preclude music lessons. In all of these cases, it becomes difficult to know whether child characteristics were shaped by genetic factors, by experiences, or by a

Research issues and methods Establishing a useful understanding of child development requires systematic inquiry about developmental events. Different aspects of development involve different patterns and causes of change, so there is no simple way to summarize child development. Nevertheless, the answering of certain questions about each topic can yield comparable information about various aspects of developmental change. The following questions were suggested for this purpose by Waters and his colleagues. 1) What develops? What relevant aspects of the individual change over a period of time? 2) What are the rate and speed of development? 3) What are the mechanisms of development - what aspects of experience and heredity cause developmental change? 4) Are there normal individual differences in the relevant developmental changes? 5) Are there population differences in this aspect of development (for example, differences in the development of boys and of girls)? Empirical research that attempts to answer these questions may follow a number of patterns. Initially, observational research in naturalistic conditions may be needed to develop a narrative describing and defining an aspect of developmental change, such as changes in reflex reactions in the first year. This type of work may be followed by correlational studies, collecting information about chronological age and some type of development such as vocabulary growth; correlational statistics can be used to state the connection between the two. Comparative studies examining the extent and course of development over time are the basic method for studying developmental change. Such studies examine the characteristics of children at different ages. These methods may involve longitudinal studies, in which a group of children are re-examined on a number of occasions as they get older, or crosssectional studies, in which groups of children of different ages are tested once and compared with each other, or there may be a combination of these approaches. Some child development studies examine the effects of experience or heredity by comparing characteristics of different groups of children in a necessarily non-randomized design. Other studies can use randomized designs to compare outcomes for groups of children who receive different interventions or educational treatments.

Developmental milestones Milestones are changes in specific physical and mental abilities (such as walking and understanding language) that mark the end of one developmental period and the beginning of another. For stage theories, milestones indicate a stage transition. Studies of the accomplishment of many developmental tasks have established typical chronological ages associated with developmental milestones. However, there is considerable variation in the achievement of milestones, even between children with developmental trajectories within the normal range. Some milestones are more variable than others; for example, receptive speech indicators do not show much variation among children with normal hearing, but expressive speech milestones can be quite variable. A common concern in child development is developmental delay involving a delay in an age-specific ability for important developmental milestones. Prevention of and early intervention in developmental delay are significant topics in the study of child development. Developmental delays should be diagnosed by comparison with characteristic variability of a milestone, not with respect to average age at achievement. An example of a milestone would be eye-hand coordination, which includes a child's increasing ability to manipulate objects in a coordinated manner. Increased knowledge of age-specific milestones allows parents and others to keep track of appropriate development.

Aspects of child development What develops? Physical growth in stature and weight occurs over the 15-20 years following birth, as the individual changes from the average weight of 3.5 kg and length of 50 cm at full-term birth to full adult size. As stature and weight increase, the individual's proportions also change, from the relatively large head and small torso and limbs of the neonate, to the adult's relatively small head and long torso and limbs Speed and pattern of development The speed of physical growth is rapid in the months after birth, then slows, so birth weight is doubled in the first four months, tripled by age 12 months, but not quadrupled until 24 months.Growth then proceeds at a slow rate until shortly before puberty (between about 9 and 15 years of age), when a period of rapid growth occurs. Growth is not uniform in rate and timing across all body parts. At birth, head size is already relatively near to that of an adult, but the lower parts of the body are much smaller than adult size. In the course of development, then, the head grows relatively little, and torso and limbs undergo a great deal of growth Mechanisms of developmental change Genetic factors play a major role in determining the growth rate, and particularly the changes in proportion characteristic of early human development. However, genetic factors can produce the maximum growth only if environmental conditions are adequate. Poor nutrition and frequent injury and disease can reduce the individual's adult stature, but the best environment cannot cause growth to a greater stature than is determined by heredity Population differences Population differences in growth are largely related to adult stature. Ethnic groups that are quite tall in adulthood are also longer at birth and throughout childhood, as compared to groups that have short adult stature. Males are also somewhat taller, although this is more apparent in ethnic groups with strong sexual dimorphism in adulthood. Populations that are characteristically malnourished are also shorter throughout life. However, there are few population differences in growth rates or patterns, except that poor environmental conditions may delay puberty and the associated growth spurt. The markedly different age at puberty of boys and girls means that boys and girls of age 11 or 12 are at very different points in maturation and may reverse the usual sex difference in physical size. Individual differences Individual differences in height and weight during childhood are considerable. Some of these differences are due to family genetic factors, others to environmental factors, but at some points in development they may be strongly influenced by individual differences in reproductive maturation.