Newborn
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APGAR Scoring Newborn’s first assessment
Evaluates viability of the newly born Determines need for immediate recusitation Performed by RN, Peds, neonatologist Done potentially at 1,2,5, 10 minutes and thereafter until stable Most term newborns evaluated at 1 and 5 minutes Score written as: 8/9, range 0-10
Asphyxia
Arises from inadequate or absent respiration
Impairment of oxygen/carbon dioxide exchange Hypoxemia, hypercarbia, respiratory acidosis
APGAR Scoring 0
1
2
Color
Absent
Body pink, extremities blue
Pink
Tone
Flaccid
Flexed
Reflexes
Absent
Some flexion Grimace
Respiratory effort
Absent
Heart rate
Absent
Slowirregular <100
Lusty cry Strong cry >100
Asphyxia (continued)
Management
Tactile stimulation Positive pressure ventilation with 100% oxygen
Assessment findings
Poor tone, gasping or absent respirations, bradycardia, cyanosis, low Apgar score
1
Resuscitation and Stabilization in the Delivery Room
Dry and provide warmth, tactile stimulation Clear airway Resuscitation for compromised infants
Function of respiration switches from the placenta to the lungs Factors responsible for onset of breathing
Hypercapnia Hypoxia Acidosis Environment (cold, light, noise)
Fluid in the lungs must be cleared Pulmonary arterioles dilate, PVR level falls
Resuscitation for compromised infants (continued)
Place under radiant warmer, stimulate Position to ensure a patent airway Suction using appropriate technique Evaluate respirations, heart rate, color
Pulmonary System Transition
Resuscitation and Stabilization in the Delivery Room (continued)
Administer oxygen if indicated Bag-mask ventilation if apneic Medications may be indicated if infant does not respond
Cardiac System Transition
Pressure in right side of the heart falls and pulmonary venous return to left atrium increases
Foramen ovale closes due to these changes
Ductus arteriosis constricts and closes functionally by 96 hours Ductus venosis constricts and closes functionally by two to three days
2
Thermoregulation
Body heat lost easily due to large body surface area in relation to weight Limited neonatal fat stores Limited capacity for heat production
Dry infant, remove wet blankets Apply a hat and warm blankets Avoid placing infant on cold surfaces Avoid placing infants in drafts
Normal axillary temperature is 97°F–99.5°F
Brown-fat metabolism is primary heat source
Nursing Interventions to Prevent Hypothermia
Thermoregulation (continued)
Hypothermia is <97.0
Goal is to keep infant in a neutral thermal environment
Nursing Interventions to Prevent Hypothermia (continued)
Use heat source when bathing infants Place under radiant warmer if temperature is unstable
3
Metabolic Transition
Infant’s source of nutrition from the placenta terminates at birth Blood sugar reaches its lowest point one to three hours after birth Glucose stabilizes by four to six hours after birth Range of 45–80 mg/dl is normal
First Period of Reactivity
First minutes after birth Characteristics
Alert, active, sucking activity, tachycardia, tachypnea, transient rales and nasal flaring
Implications for the family
Infant alert and responsive Allow quiet time for family to be together Introduce breastfeeding
Gastrointestinal System
At birth abdomen is flat and bowel sounds are absent Abdomen becomes rounded and soft with onset of respirations Bowel sounds usually audible within 15 minutes of birth
Period of Decreased Activity
Follows first period of reactivity Characteristics
Less alert and active, sleep may occur, vital signs normalize
4
Period of Decreased Activity
Second Period of Reactivity
(continued)
Implications for the family
Family may stay together or infant may be taken to nursery for assessment Opportunity for parents to have quiet time Mother may use this time to rest
Infant awakens and shows increased responsiveness to the environment Characteristics
Implications for the family
Assessment After Transition
Peristalsis increases and meconium may be passed, gagging, spitting up Allow time together if mother is rested Parents may begin to have questions or need assistance with newborn care
Assessment After Transition (continued)
Temperature
Normal axillary temperature 97°F–99.5°F
Cardiovascular system
Normal heart rate 120–150 bpm Observe color, pulse, murmurs
Respiratory system
Normal rate is 30–60/minute Nose-breather Observe for flaring, grunting, retracting Auscultate for rales
5
General Nursing Care
Eye prophylaxis
Vitamin K administration
Vitamin K prophylaxis (0.5–1.0 mg)
Eye prophylaxis
Prevents gonorrhea and chlamydia Erythromycin or tetracycline ointment IM into lateral thigh Prevents bleeding due to Vitamin K deficiency
First bath
Institute measures to prevent hypothermia First bath
General Assessment
Position
Acrocyanosis Jaundice
Body size Reactivity Identification
Weight 2,500–4,300 g
Length 45–54 cm
Color
Flexion of upper and lower extremities Symmetrical movement
Physical Examination
Head circumference 33–38 cm
Vital signs
6
Gestational Age Assessment
Neuromuscular maturity
Posture Square window Arm recoil Popliteal angle Scarf sign Heel-to-ear
Skin Assessment
Physical maturity
Skin Lanugo Plantar surface Breasts Eye and ear Genitalia
Normal findings: color pink Common variations
Milia Erythema toxicum Mongolian spots Birthmarks
Mongolian spot
Common problems
Petechiae Blisters, lesions Plethara Abnormal hair distribution Birthmark
Head, Eyes, Nose, and Throat Assessment
Normal findings
Head, Eyes, Nose, and Throat Assessment (continued)
Symmetry in appearance, normal placement Anterior fontanel open
Caput succedaneum
Cephalhematoma
Common variations
Molding Caput succedaneum Cephalhematoma Teeth
7
Head, Eyes, Nose, and Throat Assessment (continued)
Common problems
Low-set ears Discolored sclera (yellow, bluish) Cleft lip, palate Absent red reflex Microcephaly, hydrocephaly Craniostenosis Features characteristic of FAS
Cardiovascular Assessment
Normal findings
Color pink Normal rate and rhythm
Common variations
Respiratory System Assessment
Normal findings
Symmetrical expansion
Common variations Accessory nipples Gynecomastia
Common problems
Retractions Tachypnea Rales
Clearing the infant’s mouth with a bulb syringe
Cardiovascular Assessment (continued)
Common problems
Persistent murmurs Cyanosis Tachycardia, bradycardia
Murmurs Acrocyanosis
8
Abdominal Assessment
Normal findings
Abdominal Assessment (continued)
Round, full, symmetrical, plus bowel sounds Two arteries, one vein in cord
Common variations
Hernia
Genital and Anal Assessment
Common problems
Two-vessel cord Distension, absent bowel sounds Discharge/leakage from the cord Abdominal mass
Genital and Anal Assessment (continued)
Normal findings
Patent anus Testes descended Stool and urine by 24 hours after birth
Common problems
Undescended testes Epispadius, hypospadius Imperforate anus
Common variations
Hydrocele Hymenal tag and vaginal discharge
9
Musculoskeletal Assessment
Musculoskeletal Assessment (continued)
Normal findings
Normal findings
Normal reflexes (suck, rooting, grasp, Moro, Gallant, gag, Babinski’s)
Common problems
Hip click Club foot
Neurologic System
Brachial plexus injury (Erb’s palsy) Spina bifida Anencephaly Absent or abnormal reflexes Seizure activity
Common problems
Common variations
Normal tone, flexion, symmetrical movement
Fracture (clavicle most common) Hip dysplasia Syndactyly/polydactyly Asymmetrical movement Simian crease
Periodic Shift Assessment
Vital signs Weight Feeding and elimination Hydration status Respiratory and cardiac function Hip movements
10
Factors Placing the Infant at Risk
Physical
Psychological
Birth injuries, congenital conditions, temperature control Interferences in interaction between parents, newborn
Family Environment Illness and infection
11
Evaluates viability of the newly born Determines need for immediate recusitation Performed by RN, Peds, neonatologist Done potentially at 1,2,5, 10 minutes and thereafter until stable Most term newborns evaluated at 1 and 5 minutes Score written as: 8/9, range 0-10
Asphyxia
Arises from inadequate or absent respiration
Impairment of oxygen/carbon dioxide exchange Hypoxemia, hypercarbia, respiratory acidosis
APGAR Scoring 0
1
2
Color
Absent
Body pink, extremities blue
Pink
Tone
Flaccid
Flexed
Reflexes
Absent
Some flexion Grimace
Respiratory effort
Absent
Heart rate
Absent
Slowirregular <100
Lusty cry Strong cry >100
Asphyxia (continued)
Management
Tactile stimulation Positive pressure ventilation with 100% oxygen
Assessment findings
Poor tone, gasping or absent respirations, bradycardia, cyanosis, low Apgar score
1
Resuscitation and Stabilization in the Delivery Room
Dry and provide warmth, tactile stimulation Clear airway Resuscitation for compromised infants
Function of respiration switches from the placenta to the lungs Factors responsible for onset of breathing
Hypercapnia Hypoxia Acidosis Environment (cold, light, noise)
Fluid in the lungs must be cleared Pulmonary arterioles dilate, PVR level falls
Resuscitation for compromised infants (continued)
Place under radiant warmer, stimulate Position to ensure a patent airway Suction using appropriate technique Evaluate respirations, heart rate, color
Pulmonary System Transition
Resuscitation and Stabilization in the Delivery Room (continued)
Administer oxygen if indicated Bag-mask ventilation if apneic Medications may be indicated if infant does not respond
Cardiac System Transition
Pressure in right side of the heart falls and pulmonary venous return to left atrium increases
Foramen ovale closes due to these changes
Ductus arteriosis constricts and closes functionally by 96 hours Ductus venosis constricts and closes functionally by two to three days
2
Thermoregulation
Body heat lost easily due to large body surface area in relation to weight Limited neonatal fat stores Limited capacity for heat production
Dry infant, remove wet blankets Apply a hat and warm blankets Avoid placing infant on cold surfaces Avoid placing infants in drafts
Normal axillary temperature is 97°F–99.5°F
Brown-fat metabolism is primary heat source
Nursing Interventions to Prevent Hypothermia
Thermoregulation (continued)
Hypothermia is <97.0
Goal is to keep infant in a neutral thermal environment
Nursing Interventions to Prevent Hypothermia (continued)
Use heat source when bathing infants Place under radiant warmer if temperature is unstable
3
Metabolic Transition
Infant’s source of nutrition from the placenta terminates at birth Blood sugar reaches its lowest point one to three hours after birth Glucose stabilizes by four to six hours after birth Range of 45–80 mg/dl is normal
First Period of Reactivity
First minutes after birth Characteristics
Alert, active, sucking activity, tachycardia, tachypnea, transient rales and nasal flaring
Implications for the family
Infant alert and responsive Allow quiet time for family to be together Introduce breastfeeding
Gastrointestinal System
At birth abdomen is flat and bowel sounds are absent Abdomen becomes rounded and soft with onset of respirations Bowel sounds usually audible within 15 minutes of birth
Period of Decreased Activity
Follows first period of reactivity Characteristics
Less alert and active, sleep may occur, vital signs normalize
4
Period of Decreased Activity
Second Period of Reactivity
(continued)
Implications for the family
Family may stay together or infant may be taken to nursery for assessment Opportunity for parents to have quiet time Mother may use this time to rest
Infant awakens and shows increased responsiveness to the environment Characteristics
Implications for the family
Assessment After Transition
Peristalsis increases and meconium may be passed, gagging, spitting up Allow time together if mother is rested Parents may begin to have questions or need assistance with newborn care
Assessment After Transition (continued)
Temperature
Normal axillary temperature 97°F–99.5°F
Cardiovascular system
Normal heart rate 120–150 bpm Observe color, pulse, murmurs
Respiratory system
Normal rate is 30–60/minute Nose-breather Observe for flaring, grunting, retracting Auscultate for rales
5
General Nursing Care
Eye prophylaxis
Vitamin K administration
Vitamin K prophylaxis (0.5–1.0 mg)
Eye prophylaxis
Prevents gonorrhea and chlamydia Erythromycin or tetracycline ointment IM into lateral thigh Prevents bleeding due to Vitamin K deficiency
First bath
Institute measures to prevent hypothermia First bath
General Assessment
Position
Acrocyanosis Jaundice
Body size Reactivity Identification
Weight 2,500–4,300 g
Length 45–54 cm
Color
Flexion of upper and lower extremities Symmetrical movement
Physical Examination
Head circumference 33–38 cm
Vital signs
6
Gestational Age Assessment
Neuromuscular maturity
Posture Square window Arm recoil Popliteal angle Scarf sign Heel-to-ear
Skin Assessment
Physical maturity
Skin Lanugo Plantar surface Breasts Eye and ear Genitalia
Normal findings: color pink Common variations
Milia Erythema toxicum Mongolian spots Birthmarks
Mongolian spot
Common problems
Petechiae Blisters, lesions Plethara Abnormal hair distribution Birthmark
Head, Eyes, Nose, and Throat Assessment
Normal findings
Head, Eyes, Nose, and Throat Assessment (continued)
Symmetry in appearance, normal placement Anterior fontanel open
Caput succedaneum
Cephalhematoma
Common variations
Molding Caput succedaneum Cephalhematoma Teeth
7
Head, Eyes, Nose, and Throat Assessment (continued)
Common problems
Low-set ears Discolored sclera (yellow, bluish) Cleft lip, palate Absent red reflex Microcephaly, hydrocephaly Craniostenosis Features characteristic of FAS
Cardiovascular Assessment
Normal findings
Color pink Normal rate and rhythm
Common variations
Respiratory System Assessment
Normal findings
Symmetrical expansion
Common variations Accessory nipples Gynecomastia
Common problems
Retractions Tachypnea Rales
Clearing the infant’s mouth with a bulb syringe
Cardiovascular Assessment (continued)
Common problems
Persistent murmurs Cyanosis Tachycardia, bradycardia
Murmurs Acrocyanosis
8
Abdominal Assessment
Normal findings
Abdominal Assessment (continued)
Round, full, symmetrical, plus bowel sounds Two arteries, one vein in cord
Common variations
Hernia
Genital and Anal Assessment
Common problems
Two-vessel cord Distension, absent bowel sounds Discharge/leakage from the cord Abdominal mass
Genital and Anal Assessment (continued)
Normal findings
Patent anus Testes descended Stool and urine by 24 hours after birth
Common problems
Undescended testes Epispadius, hypospadius Imperforate anus
Common variations
Hydrocele Hymenal tag and vaginal discharge
9
Musculoskeletal Assessment
Musculoskeletal Assessment (continued)
Normal findings
Normal findings
Normal reflexes (suck, rooting, grasp, Moro, Gallant, gag, Babinski’s)
Common problems
Hip click Club foot
Neurologic System
Brachial plexus injury (Erb’s palsy) Spina bifida Anencephaly Absent or abnormal reflexes Seizure activity
Common problems
Common variations
Normal tone, flexion, symmetrical movement
Fracture (clavicle most common) Hip dysplasia Syndactyly/polydactyly Asymmetrical movement Simian crease
Periodic Shift Assessment
Vital signs Weight Feeding and elimination Hydration status Respiratory and cardiac function Hip movements
10
Factors Placing the Infant at Risk
Physical
Psychological
Birth injuries, congenital conditions, temperature control Interferences in interaction between parents, newborn
Family Environment Illness and infection
11
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