NEW BORN CAREObjectives Describe the normal characteristics of a term newborn. Assess a newborn for normal growth and development. Formulate nursing diagnoses related to a newborn or the family of a newborn. Identify expected outcomes for a newborn and family during the first 4 weeks of life. Plan nursing care to augment normal development of a newborn, such as ways to aid parent-child

bonding Implement nursing care of a normal newborn, such as administering a first bath or instructing parents on

how to care for their newborn. Evaluate expected outcomes to determine effectiveness of nursing care and outcomes achievement. Use critical thinking to analyze ways that the care of a term newborn can be more family centered. Integrate knowledge of newborn growth & development and immediate care needs with the nursing

process to achieve quality maternal and child health nursing care.

The Neonate From birth through the first 28 days of life Also called “the newborn period” Adaptation to extrauterine life requires rapid and profound physiologic changes This includes aeration of the lungs, rerouting of the circulation and activation of the GI tract Behavioral states: quiet sleep, active sleep, drowsy, alert, fussy, and crying 2/3 of all deaths that occur during the 1st year of life occur during this period; more than half occur in

the 1st 24 hours after birth---an indication of how hazardous this time is for an infant How well a NB makes major adjustments depends on his or her:

o Genetic compositiono The competency of the recent intrauterine environmento The care received during the neonatal periodo

PRINCIPLES IN IMMEDIATE NEW BORN CARE1st day of life

1. initiation and maintenance of respiration (used bulb syringe initiate a/w)2. establishment of extra uterine circulation3. control of body temp4. intake of adequate nourishment5. establishment of waste elimination6. prevention of infection7. establishment of an infant parent relationship8. dev’t care that balances rest and stimulation or mental dev’t 9.

Immediate care of the newborn. A-airway (most neonatal deaths with in 24 h caused by inability to initiate a/w, lung function begins after birth only)

B-body temperature C-check/asses the newborn D-determined identification

I. Establish and Maintain a Patent Airway / Effective RespirationNursing Interventions:

1. Wipe the mouth and nose secretions after delivery of the head2. Suction secretions from the mouth and nose properly.

Catheter Suctioning 1.) Place head to side to facilitate drainage

2.) Suction mouth 1st before nose -neonates are nasal breathers

3.) Period of time -5-10 sec suctioning, gentle and quickProlonged and deep suctioning can lead to hypoxia, laryngo spasm, brady cardia due to stimulation vagal nerve

4.) Evaluate for patency-cover nostril and baby struggles there’s a need for additional suctioning

“If not effective, requires effective laryngoscopy to open a/w. After deep suctioning an endotracheal tube can be inserted and oxygen can be administered by an (+) pressure bag and mask with 100% oxygen at 40-60b/m.”

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Nsg alert:No smokingAlways humidify to prevent drying of mucosaOver dosage of oxygen can lead to scarring of retina leading to blindness ( retro lentalfibrolasia or retinopathy of

prematurity) When mecomium stained (greenish) never administer oxygen with pressure ( O2 pressure will push mecomium inside)

3. Stimulate the baby to cry if baby does not cry spontaneously or if baby’s cry is weak. “A crying infant is a breathing infant. Effective cry means effective breathing”

Do not slap the buttocks but rub the soles of the feet Do not stimulate the NB to cry unless the secretions have been suctioned to prevent

aspiration The normal infant cry is loud & lusty. Observe for the ff. abnormal cry:

High-pitched cry : hypoglycemia, increased ICPWeak cry: prematurityHoarse cry: laryngeal stridor

4. Oral mucus may cause the NB to choke, cough or gag during the first 12 to 18 hours of life. Place the neonate in a position that would promote drainage of secretions

Trendelenburg (contraindicated to Increased ICP) Side-Lying

5. Keep the nares patent. Remove mucus and other particles w/c can cause obstruction as newborns are “obligatory nasal breathers” until they are about 2-3 weeks old.

6. Give O2 as needed. Oxygen should be given for 20-30 minutes when the neonate remains cyanotic or tachycardic after initial suctioning and stimulation.

* asphyxiation → hypoxia → hypercapnia(↑ CO2) → acidosis → coma → death• Observe precaution in giving oxygen• Do not give more than 40% O2 as this may lead to retrolental fibroplasia (blood vessels of the eyes become

spastic leading to blindness)• Use pulse oximeter and monitor O2 concentration every hour

7. If the heart rate falls below 60 bpm, cardiac massage may need to be carried out.

II. Maintain Appropriate Body Temperature Temp Regulation

goal in temp regulation is to maintain it not less than 97.7% F (36.5 C) maintenance of temp is crucial on preterm and SGA (small for gestational age) - babies prone to

hypothermia or cold stresso Neonates have “physiologic resilience” wherein they tend to adopt or take temperature of their

own environment. (poikilothermic) “cold stress (hypothermia) is more dangerous than hyperthermia” Effects of cold stress Cold stress metabolic acidosis CNS depression Coma Death

o Every NB is born slightly acidotic. Any new build-up of acid may lead to life-threatening metabolic acidosis, which can be lethal even to normal newborn infants.

o The average NB temp.@ birth is around 37.2°C.o NB lose heat easily because:

They have immature temp.-regulating system Of very little amount of subcutaneous fat to provide heat They have a larger body surface area that results in more heat loss They have little ability to conserve heat by changing posture and no ability to adjust its own

clothingMethods of Heat Loss in Newborn

• Convection – the flow of heat from the NB’s body surface to cooler surrounding air; ex: windows, air conditioners

• Conduction- the transfer of a body heat to a cooler solid object in contact with a baby; ex: baby placed on a cold counter

• Radiation – the transfer of body heat to a cooler solid obj. not in contact with a baby; ex: cold window or air con

• Evaporation – loss of heat through conversion of a liquid to a vapor; ex: after delivery, newborns are wet, with amniotic fluid on their skin, tsb

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To Prevent Hypothermia

1. Dry and wrap baby2. Mechanical pressure – radiant warmer

pre-heated first isolette (or square acrylic sided incubator) 3. Prevent an necessary exposure – cover baby4. Cover baby with tin foil or plastic5. Embrace the baby- kangaroo care

6. Delay initial bath until temp. has stabilized for at least 2 hours.7. Maintain ambient temp. of nursery at 24°C or 75°F.8. Perform any extensive examination or procedure under radiant heat to prevent heat loss and expose only the part of the body to be examined.9. Note the presence of any cyanosis: 2 types of cyanosis: a.) central cyanosis

b.) peripheral cyanosis hands & feet are cyanotic, due to cold environment and poor circulation

Characteristic of NewbornThe end of your journey has come after 40 weeks. The fruit of your labour (literally) will soon be in your hands.

There are a few things you might want to know about your new arrival. Typically, a newborn baby has the following characteristic appearance:

Weight: Average 2.8 kg for Indian babies (range 2.5 – 3.2 kg). Babies below 2.5 kg at birth are considered to be low birth weight and need special evaluation.

Length:  Approximately 50 cm. Remember, small women have small babies and many genetic factors also play a role in determining the length of the baby.

Head: Your baby’s head appears large for the body and may have an elongated shape or appear to have some ‘bumps’. This is due to changes called molding, which occurs in labour and delivery. Small bumps called ‘caput’ usually disappear in 1 – 2 days. Soon the head gets rounder. The head circumference is 33 – 35 cm.

Effects of Hypothermia ( Cold stress)

1.) Hypoglycemia- 45-55 mg/dl normal50- borderline2.) met acidosis- catabolism of brown fats (best insulator of newborns body) will form ketones3.) high risk for kernicterus- bilirubin in brain leading to cerebral palsy4.) additional fatigue to allergy stressful heart

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Soft spots or Fontanelles:  There are 2 areas on the head where bone formation is incomplete at birth. The larger one, in front of the head closes by 6 – 18 months. The smaller one at the back usually closes by 6 weeks.

Hair: As all people vary, so does their hair. Your baby may have lots of hair or none at all! It depends on familial and racial factors.

Heart beats: Usually the heart rate is 120 – 140 beats per minute.

Respiratory rate (breathing): It is faster than adults, usually 30 – 40 breaths / minute. Breathing may be noisy or stop for many seconds. This is not uncommon.

Colour: Depending on the parents, the skin colour of newborn varies. In general, newborn babies look flushed and pink all over. However, the palms and soles of the feet may look dusky or little bluish soon after birth.

Axillary temperature measurement. The thermometer should remain in place for 3 minutes. The nurse presses the newborn’s arm tightly but gently against the thermometer and the newborn’s side, as illustrated

III. Perform Initial Assessment APGAR Scoring System

o Developed by Dr. Virginia Apgar in 1958 o It is a standardized method for evaluation of the newborn and serves as a baseline for future evaluations.o It is taken twice: initially @ 1 minute, and then @ 5 minutes after birth

Special Considerations: 1st 1 min – determine general condition of babyNext 5 min- determine baby’s capabilities to adjust extra uterinelyNext 15 min – dependent on the 5 min

APGAR Scoring System 0 1 2

Appearance(Color)

Pale or blue all over

Body pink,extremities blue

Pink all over

Pulse/♥ rate absent Below 100 Above 100 G rimace/Reflex

IrritabilityNo response grimace Sneezes,gags,

coughs,vigorous cry and foot withdrawal

A ctivity / Muscle Tone

Limp, flaccid Some flexion of the extremities Active motion/well-flexed

R espiratory Effort absent Slow,irregular,weak cry Good, strong,lusty cryAPGAR result0 – 3 = severely depressed, need CPR, admission NICU4 – 6 = moderately depressed, needs add’l suctioning & O27 - 10 =good/ healthy

Silvermann & Anderson Scoring Systemo Devised in 1956 and is a test used to evaluate or estimate the degrees of respiratory distress in newborns or the

respiratory status of premature infants.o A NB is observed and then scored on each of five criteria ---0,1 or 2. The scores are then added. (the scores of this

system are interpreted as opposite of the Apgar)

The Silverman & Anderson Scoring System  0 1 2Chest Movement Synchronized respirations Lag on inspiration Seesaw respirations

Intercostal Retraction none Just visible Marked

Xiphoid Retraction none Just visible MarkedNares Dilatation none minimal MarkedExpiratory Grunt none Audible by stethoscope Audible by unaided ear

Silvermann and Anderson Scoring Interpretation 0 : no respiratory distress 4-6 : moderate respiratory distress 7-10 : severe respiratory distress

IV. Proper Identification of the Newborn Proper Id is made in the delivery room before mother and baby are seperated.

o Identification Bando Footprints

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o Others – fingerprints, crib card, bead bracelet Birth certificate A final identification check of the mother and infant must be performed before the infant can be allowed to leave the

hospital upon discharge to ensure that the hospital is discharging the right infant.V. Preventing Infection

Ophthalmia neonatorum Any conjunctivitis with discharge occuring during the first two weeks of life. It typically appears 2-5 days after birth,

although it may appear as early as the first day or as late as the 13th. silver nitrate (used before) – 2 drops lower conjunctiva (not used now)

Administering Erythromycin or Tetracycline Ophthalmic Ointment These ointments are the ones commonly used nowadays for eye prophylaxis because they do not cause eye irritation and

are more effective against Chlamydial conjunctivitis. Apply over lower lids of both eyes, then, manipulate eyelids to spread medication over the eyes. Wipe excess ointment after one minute Č sterile cotton ball moistened Č sterile water.

Principles of cleanliness at birth: Clean hands Clean perineum Nothing unclean to be introduced into the vagina Clean delivery surface Cleanliness in cutting the umbilical cord Cleanliness for cord care of the newborn baby

Handwashing Before entering the nursery or caring for a baby In between newborn handling or after the care of each baby Before treating the cord After changing soiled diaper Before preparing milk formula.

VI. Preventing Hemorrhage As a preventive measure, 0.5mg (preterm) to 1 mg (full term) Vit. K or Aquamephyton is injected IM in the NB’s vastus

lateralis (lateral anterior thigh)muscle Vit-K – to prevent hemorrhage R/T physiologic hypoprothrombinemia

Aquamephyton, phytomenadione or konakion .1 ml term IM, vastus lateral or lateral ant thigh .05 ml preterm baby

Vit K – synthesized by normal flora of intestine Vit K – meds is synthetic due intestine is sterile

Credes Prophylaxis – Dr. Crede -prevent opthalmia neonatorum or gonorrheal

conjunctivitis- how transmitted – mom with gonorrhea

drug: erythromycin ophthalmic ointment- inner to outer

*It is part of the routine care of the NB to give prophylactic eye treatment against gonorrheal conjunctivitis or ophthalmia neonatorum within the first hour after delivery.* Neisseria gonorrhea, the causative agent,maybe passed on to the fetus when infected vaginal and cervical secretions enter the eyes as the baby passes the vaginal canal during delivery. This practice was introduced by Crede, German gynecologist in 1884. Silver Nitrate,

Procedure for vitamin K injection. Cleanse area thoroughly with alcohol swab and allow skin to dry. Bunch the tissue of the upper outer thigh (vastus lateralis muscle) and quickly insert a 25-gauge 5/8-inch needle at a 90-degree angle to the thigh. Aspirate, then slowly inject the solution to distribute the medication evenly and minimize the baby’s discomfort. Remove the needle and gently massage the site with an alcohol swab.

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Care of the Cord The cord is clamped and cut approx. within 30 sec after birth. In the DR, the cord is clamped twice

about 8 inches from the abdomen and cut in between. When the NB, is brought to the nursery, another clamp is applied ½ to 1 in from the abdomen and the

cord is cut a second time. The cord and the area around it are cleansed w/ antiseptic solution. The manner of cord care depends on hospital protocol or the discretion of the birth attendant in home

delivery, what is impt. Is that principles are followed. Cord clamp is removed after 48 hours when the cord has dried. The cord stump usually dries and falls

off within 7-10 days leaving a granulating area that heals on the next 7-10 days. Leave cord exposed to air. Do not apply dressing or abdominal binder over it. The cord dries and

seperates more rapidly if it is exposed to air. Report any unusual signs & symptoms that indicate infection:

o Foul odor in the cordo Presence of dischargeo Redness around the cordo The cord remains wet and does not fall off within 7-10 dayso Newborn fever

“Tetanus microorganism thrives in anaerobic environment so you actually prevent infection if cord is exposed to air”.

3 cleans in communityo clean hando clean cordo clean surface

betadine or povidone iodine – to clean cordcheck AVA, then draw 3 vessel cord

If 2 vessel cord- suspect kidney malformation- leave about 1” of cord - if BT or IV infusion – leave 8” of cord best access - no nerve- check cord every 15 min for 1st 6 hrs – bleeding .> 30 cc of bloodbleeding of cord – Omphalagia – suspect hemophilia

Cord turns black on 3rd day & fall 7 – 10 days Faiture to fall after 2 weeks- Umbilical granulation Mgt: silver nitrate or catheterization

- clean with normal saline solution not alcohol- don’t use bigkis – air- persistent moisture-urine, suspect patent uracus – fistula bet bladder and normal umbilicus

dx: nitrazine paper test – yellow – urine mgt: surgery

Immediate Care of the Newborn

A irwayB ody temperatureC heck/ assess the newbornD etermine identification

Stimulate & dry infant Assess ABCs Encourage skin-to-skin contact

Full bath – safely given when cord fall

Dressing the Umbilical Cord – strict asepsis to

Bathing- oil bath – initial - to cleanse baby & spread vernix caseosaFx of vernix caseosa

1. insulator2. bacterio- static

Babies of HIV + mom – immediately give full bath to lessen transmission of HIV

- 13 – 39% possibly of transmission of HIV

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Assign APGAR scores Give eye prophylaxis & Vit. K Keep newborn, mother, & partner together whenever

Newborn Assessment and Nursing Care

Physical Assessment Temperature - range 36.5 to 37 axillary Common variations

o Crying may elevate temperature Stabilizes in 8 to 10 hours after delivery

o Temperature is not reliable indicator of infection A temperature less than 36.5

Temp: rectal- newborn – to rule out imperforate anus- take it once only, 1 inch insertion

Imperforate anus1. atretic – no anal opening 2. agenetialism – no genital3. stenos – has opening4. membranous – has opening

Earliest sign: 1. no mecomium2. abd destention3. foul odor breath4. vomitous of fecal matter5. can aspirate – resp problem

Mgt: Surgery with temporary colostomy

Heart Rate range 120 to 160 beats per minute Common variations

Heart rate range to 100 when sleeping to 180 when crying Color pink with acrocyanosis Heart rate may be irregular with crying Although murmurs may be due to transitional circulation-all murmurs should be followed-up

and referred for medical evaluation Deviation from range Faint sound

Cardiac rate: 120 – 160 bpm newborn Apical pulse – left lower nippleRadial pulse – normally absent. If present PDAFemoral pulse – normal present. If absent- COA - coartation of aorta

Respiration - range 30 to 60 breaths per minute Common variations

Bilateral bronchial breath sounds Moist breath sounds may be present shortly after birth

Signs of potential distress or deviations from expected findings Asymmetrical chest movements

Apnea >15 seconds Diminished breath sounds Seesaw respirations Grunting Nasal flaring Retractions Deep sighing Tachypnea - respirations > 60 Persistent irregular breathing Excessive mucus

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Persistant fine crackles Stridor

Breathing ( ventilating the lungs) check for breathlessness

if breathless, give 2 breaths- ambu bag 1 yr old- mouth to mouth, pinch nose

< 1 yr – mouth to nose force – different between baby & child

infant – puff Circulation

Check for pulslessness :carotid- adult Brachial – infants

CPR – breathless/pulseless Compression – inf – 1 finger breath below nipple line or 2 finger breaths or thumb CPR inf 1:5 Adults 2:30

Blood Pressure-not done routinely

Factors to consider Varies with change in activity level Appropriate cuff size important for accurate reading 65/41 mmHg

General Measurementso Head circumference - 33 to 35 cmo Expected findingso Head should be 2 to 3 cms larger than the chest o Abdominal circumference – 31-33 cmo Weight range - 2500 - 4000 gms (5 lbs. 8oz. - 8 lbs. 13 oz.)o Length range - 46 to 54 cms (19 - 21 inches)

Anthropometic measurement normal length- 19.5 – 21 inch or 47.5 – 53.75cm, average 50 cmhead circumference 33- 35 cm or 13 – 14 “Hydrocephalus - >14”Chest 31 – 33 cm or 12 – 13”Abd 31 – 33 cm or 12 – 13”

Signs of increased ICP

1.) abnormally large head2.) bulging and tense fontanel3.) increase BP and widening pulse pressure #3 & #4 are Cushings triad of 4.) Decreased RR, decreased PR ICP5.) projective vomiting- sure sign of cerebral irritation6.) high deviation – diplopia – sign of ICP older child

4-6 months- normal eye deviation>6 months- lazy eyes

7.) High pitch shrill cry-late sign of ICp

Skin o Skin reddish in color, smooth and puffy at birth o At 24 - 36 hours of age, skin flaky, dry and pink in coloro Edema around eyes, feet, and genitalso Venix Caseosa -whitish, cheese-like substance, covers the fetus while in utero and lubricates

the skin of the NB. The skin of the term or postterm nb has less vernix and is frequently dry; peeling is common, esp. on the hands & feet

o Lanugo -moderate in full term; more in preterm; absent in postterm; shed after 2 weeks in time of desquammation

o Turgor good with quick recoilo Hair silky and soft with individual strandso Nipples present and in expected locations

Skin color blue – cyanosis or hypoxia White – edema Grey – infYellow – jaundice , carotene

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o Cord with one vein and two arterieso Cord clamp tight and cord dryingo Nails to end of fingers and often extend slightly beyond

Acrocyanosis o Bluish discoloration of the hands and feet maybe present in the first 2 to 6 hours after birtho This condition is caused by poor peripheral circulation, w/c results in vasomotor instability & capillary

stasis, esp. when the baby is exposed to cold.

Mongolian Spots

Mottling

Physiologic Jaundiceo Hyperbilirubinemia not associated with hemolytic disease or other pathology in the newborn.

Jaundice that appears in full term newborns 24 hours after birth and peaks at 72 hours. Bilirubin may reach 6 to 10 mg/dl and resolve in 5 to 7 days.

o If jaundice occurs within 2 days – pathologic jaundiceo If jaundice occurs at 3rd-7th days of life – physiologic jaundiceo Jaundice is first detectable on the face (where skin overlies cartilage) and the mucus membranes of

the mouth and has a head-to-toe progression. o *Evaluate it by blanching the tip of the nose, the forehead, the sternum, or the gum line. This

procedure must be done with appropriate lighting. Another are to assess is the sclera.o Jaundice maybe related to breastfeeding, hematomas, immature liver function, bruises from forceps,

blood incompatibility, oxytocin induction or severe hemolysis process

If the central circulation is adequate, the blood supply should return quickly when the skin is blanched with a finger. Blue hands and nails are poor indicator of oxygenation in NB. The nurse should assess the face & mucus membranes for pinkness reflecting adequate oxygenation

Patch of purple-black or blue-black color distributed over coccygeal and sacral regions of infants of African-American or Asian descent. Not malignant. Resolves in time. They gradually fade during the first or second year of life. They maybe mistaken for bruises and should be documented in the NB’s chart.

lacy pattern of dilated blood vessels under the skinOccurs as a result of general circulation fluctuations. It may last several hours to several weeks or may come and go periodically.Mottling maybe related to chilling or prolonged apnea.

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Care of Newborn in Jaundice Phototherapy o Is the exposure of the NB to high intensity light.o Maybe used alone or in conjunction w/ exchange transfusion to reduce serum bilirubin levels.o Decreases serum bilirubin levels by changing bilirubin from the non-water soluble form to

water-soluble by products that can be excreted.Nursing Interventions:

1. Exposing as much of the NB’s skin as possible however genitals are covered & the nurse monitors the genitals area for skin irritation

2. Eyes are covered with patches or eye shields and are removed at least once per shift to inspect the eyes3. Monitor temp. closely & ↑ fluids to compensate water loss4. NB is repositioned q 2° and stimulation is provided.• NB will have loose green stools and green colored urine.

Exchange Transfusion o Is the withdrawal and replacement of newborn’s blood with donor blood.

Milia

Erythema toxicum

Harlequin Signo The color of the newborn's body appears to be half red and half pale. This condition is transitory and

usually occurs with lusty crying. Harlequin Coloring may be associated with to an immature vasomotor reflex system.

BIRTH MARKS Telangiectatic nevi (stork bites)

Milia which are exposed to sebaceous glands, appear as raised white spots on the face, esp. across the nose.No treatment is necessary, bec they will clear within first month. Infants of African heritage have a similar condition called transient neonatal pustular melanosis.

Is an eruption of lesions in the area surrounding a hair follicle that are firm, vary in size from 1-3 mm, and consist of a white or pale yellow papule or pustule w/ an erythematous base.

It is often called “newborn rash” or “flea-bite” dermatitis

The rash may appear suddenly, usually over the trunk and diaper area and is frequently widespread.

The lesions do not appear on the palms of the hands or soles of the feet.

The peak incidence is 24-48 hours of life. Cause is unknown and no treatment

necessary

Nsg Resp: 1. cover eyes – prevent retinal damage 2. cover genitals – prevent priapism –

painful continuous erection 3. change position regularly – even

exposed to light 4. increase fld intake – due prone to

dehydration 5. monitor I&O – weigh baby 6. monitor V/S – avoid use of oil or lotion

due- heat at phototherapy = bronze baby syndrome-transient S/E of phototherapy

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Nevus Flammeus (port-wine stain)

Nevus vasculosus (strawberry mark)

HEADo Head circumference should be 2 cm greater than chest circumferenceo Assess fontanelles and sutures - observe for signs of hydrocephalus and evaluate neurologic

statuso Craniosynostosiso Microcephalyo macrocephaly

Appear as pale pink or red spots and are frequently found on the eyelids, nose, lower occipital bone and nape of the neck

These lesions are common in NB w/ light complexions and are more noticeable during periods of crying. These areas have no

A capillary angioma directly below the epidermis, is a non-elevated, sharply demarcated, red-to-purple area of dense capillaries.

Macular purple The size & shape vary, but it commonly appears on the

face. It does not grow in size, does not fade in time and does not blanch. The birthmark maybe concealed by using an opaque cosmetic cream.

If convulsions and other neurologic problem accompany the nevus flammeus,----5th cranial nerve involvement.

A capillary hemangioma, consists of newly formed and enlarged capillaries in the dermal and subdermal layers.

It is a raised,clearly delineated, dark-red, rough-surfaced birthmark commonly found in the head region.

Such marks usually grow starting the second or third week of life and may not reach their fullest size for 1 to 3 months; disappears at the age of 1 yr. but as the baby grows it enlarges.

Birthmarks frequently worry parents. The mother maybe especially anxious, fearing that she is to blame (“Is my baby marked because of something I did?”) Guilt feelings are common when parents have misconceptions about the cause. Identify and explain them to the parents.

Providing appropriate information about the cause and course of birthmarks often relieves the fears and anxieties of the family. Note any bruises, abrasions,or birthmarks seen on admission to the nursery.

3 types Hemangiomasa.) Nevus Flammeus – port wine stain – macular purple or dark red lesions seen on face or thigh. NEVER disappear. Can be removed surgicallyb.) Strawberry hemangiomas – nevus vasculosus – dilated capillaries in the entire dermal or subdermal area. Enlarges, disappears at 10 yo.c.) Cavernous hemangiomas – communication network of venules in SQ tissue that never disappear with age.

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Face, Mouth, Eyes, and Ears o Assess and record symmetryo Assess for signs of Down syndrome.o Low set earso Assess history for risk factors of hearing losso Test for Moro reflex- elicited by a loud noise or lifted slightly above the crib and then suddenly lowered.

In response, the NB straightens arms and hands outward while the knees flexed. Slowly the arm returns to the chest as in embrace. The fingers spread, forming a C and the newborn may cry. This lasts up to 6 months of age.

o Check for presence of gag, swallowing reflexes, coordinated with sucking reflexo Check for clefts in either hard or soft palateso Check for excessive droolingo Check tongue for deviation, white cheesy coating

Eyeso Assess for PERLA (pupils equal and reactive to light and accommodation)o Assess cornea and blink reflexo Note true eye color does not occur before 6 months o May have blocked tear duct

Heart and Lungs Assess and maintain airway Assess heart rate, rhythm - evaluate murmur: location, timing, and duration

o Examine appearance and size of chesto Note if there is funnel chest, barrel chest, unequal chest expansion

Assess breath sounds and respiratory efforts - evaluate color for pallor or cyanosis Breasts are flat with symmetric nipples - note lack of breast tissue or discharge

Abdomen Abdomen appears large in relation to pelvis

o Note increase or decrease in peristalsiso Note protrusion of umbilicus

Measure umbilical hernia by palpating the opening and recordo Note any discharge or oozing from cordo Note appearance and amount of vessels

Auscultate and percuss abdomeno Assess for signs of dehydrationo Assess femoral pulseso Note bulges in inguinal areao Percuss bladder 1 to 4 cm above symphysiso Voids within 3 hours of birth or at time of birth

Genitalso Pseudomenstruation: the discharge w/c can become tinged w/ blood and is caused by withdrawal of

maternal hormoneso Smegma: a white cheeselike substance is often present between labia. Removing it may traumatize tender

tissueo Phimosis : tight foreskin or prepuce; w/c sometimes lead to early circumcisiono Cryptoorchidism: undescended testes ;if the testes did not go downo Orchidopexy: repair of undescended testes before 2 y/oo Penis: urethra should be at the tip of the peniso Hypospadias : if the opening is at the ventral surfaceo Epispadias: if the opening is at the dorsal surfaceo Hydrocele – swelling due to accumulation of serous fluid in the tunica vaginalis of the testis or in the

spermatic cordAnus

o Inspect anal area to verify that it is patent and has no fissureo Digital exam by physician or nurse practitioner if neededo Note passage of meconium

Extremitieso Tic dwarfism : very short armso Amelia : absence of armso Phocomelia : absence of long armo Polydactilism: more fingers; extra digits on either hands or feet

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o Syndactilism: webbing; fusion of fingers or toeso *Inspect the hands for normal palmar creases. A single palmar crease called SIMIAN line is frequently

present in Down’s syndromeo Adactyl : no footo Down’s syndrome: inward rotation of little fingerso Clubfoot/ talipes deformity – inward rotation of foot fingers.o Erb-Duchenne paralysis (Erb’s palsy) : resulting from injury to the 5th and 6th cervical roots of the brachial

plexus; usually from a difficult birth; it occurs commonly when strong traction is exerted on the head of the NB in an attempt to free a shoulder lodged behind the symphysis pubis in the presence of shoulder dystocia.

Clubfoot

Nursing Role Be knowledgeable about normal newborn variations and responses that indicate further investigation

o Respiratory distresso Central cyanosiso Thermoregulation problemso Dehydration

Teaching During physical and behavioral assessment, identify family's need for teaching

o Involve family early in care of infanto Process establishes uniqueness and allays concern

Teaching o Feeding cueso Alert stateo Cord careo Sleeping

Neurological Status

A, The asymmetry of gluteal and thigh fat folds seen in infant with left developmental dysplasia of the hip.

B, Barlow's (dislocation) maneuver. Baby's thigh is grasped and adducted (placed together) with gentle downward pressure.

C, Dislocation is palpable as femoral head slips out of acetabulum.

D, Ortolani's maneuver puts downward pressure on the hip and then inward rotation. If the hip is dislocated, this maneuver forces the femoral head over the acetabular rim with a noticeable “clunk.”

B, To determine the presence of clubfoot, the nurse moves the foot to the midline. Resistance indicates true clubfoot.

o Nurse examines feet for evidence of talipes deformity (clubfoot)

o Intrauterine positions can cause feet to appear to turn inward - "positional" clubfoot

o To determine presence of clubfoot, nurse moves foot to midline - if resists, it is true clubfoot

TALIPES – “clubfoot” a.) Equinos – plantar

flexion – horsefoot

b.) Calcaneous – dorsiflexion – heal lower that foot anterior posterior of foot flexed towards anterior leg

c.) Varus- foot turns in

d.) Valgus- foot turns out

Equino varus- most

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Assessment begins with period of observation Observe behaviors - note:

o State of alertnesso Resting postureo Cryo Quality of muscle toneo Motor activityo Jitteriness – feeling of extreme nervousnesso Differentiate causative factors

Examine for symmetry and strength of movements Note head lag of less than 45 degrees Assess ability to hold head erect briefly

Reflexes Immature central nervous system (CNS) of newborn is characterized by variety of reflexes

o Some reflexes are protective, some aid in feeding, others stimulate interactiono Assess for CNS integration

Protective reflexes are blinking, yawning, coughing, sneezing, drawing back from pain Rooting and sucking reflexes assist with feeding“?What reflexes should be present in a newborn? Reflexes are involuntary movements or actions. Some movements are spontaneous, occurring as part of the baby's usual activity. Others are responses to certain actions. Reflexes help identify normal brain and nerve activity. Some reflexes occur only in specific periods of development. The following are some of the normal reflexes seen in newborn babies””

BABINSKI reflex

Tonic neck reflex

Grasp reflex

Palmar & Plantar Grasp Reflex

Moro reflex

Babinski reflex - When the sole of the foot is firmly stroked, the big toe bends back toward the top of the foot and the other toes fan out. This is a normal reflex up to about 2 years of age.

Tonic neck reflex - When a baby's head is turned to one side, the arm on that side stretches out and the opposite arm bends up at the elbow. This is often called the "fencing" position. The tonic neck reflex lasts about six to seven months.

Grasp reflex - Stroking the palm of a baby's hand causes the baby to close his/her fingers in a grasp. The grasp reflex lasts only a couple of months and is stronger in premature babies. Palmar & Plantar

The Moro reflex is often called a startle reflex because it usually occurs when a baby is startled by a loud sound or movement. In response to the sound, the baby throws back his/her head, extends out the arms and legs, cries, then pulls the arms and legs back in. A baby's own cry can startle

TALIPES – “clubfoot” a.) Equinos – plantar

flexion – horsefoot

b.) Calcaneous – dorsiflexion – heal lower that foot anterior posterior of foot flexed towards anterior leg

c.) Varus- foot turns in

d.) Valgus- foot turns out

Equino varus- most

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Step reflex -

Rooting Reflex

Suck reflex -

ASSESSMENT OF PHYSICAL MATURITY CHARACTERISTICS OF NEWBORN Observable characteristics of newborn should be evaluated while not disturbing baby Gestational assessment tools examine the following physical characteristics

o Resting postureo Skino Lanugoo Sole (planar) creaseso Breast tissueo Ear form and cartilage distributiono Evaluation of genitals

Male genitals

Female genitals

The Moro reflex is often called a startle reflex because it usually occurs when a baby is startled by a loud sound or movement. In response to the sound, the baby throws back his/her head, extends out the arms and legs, cries, then pulls the arms and legs back in. A baby's own cry can startle

This reflex is also called the walking or dance reflex because a baby appears to take steps or dance when held upright with his/her feet touching a solid surface.

Root reflex - This reflex begins when the corner of the baby's mouth is stroked or touched. The baby will turn his/her head and open his/her mouth to follow and "root" in the direction of the stroking. This helps the baby find the breast or bottle to begin feeding.

Rooting helps the baby become ready to suck. When the roof of the baby's mouth is touched, the baby will begin to suck. This reflex does not begin until about the 32nd week of pregnancy and is not fully developed until about 36 weeks. Premature babies may have a weak or immature sucking ability because of this. Babies also have a hand-to-mouth reflex that goes with rooting and sucking and may suck on fingers or hands.

A, Preterm newborn’s testes are not within the scrotum. The scrotal surface has few rugae. score 2 B, Term newborn’s testes are generally fully descended.

The entire surface of the scrotum is covered by rugae. Score 3.

A, Newborn has a prominent clitoris. The labia majora are widely separated, and the labia minora, viewed laterally, would protrude beyond the labia majora. Score 1. The gestational age is 30 to 35 weeks.

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Neuromuscular Components

Square window sign

Assessment of Gestationa

l Age -Ballards & Dobowitz

Findings Less 36 weeks (Preterm) 37 - 38 39 and upSole creases Anterior transverse crease only Occasional creases 2/3

in Covered with creases

Breast nodules 2mm 4mm or 3.5 mm > 5 or 7mmScalp hair Fine & fuzzy Fine & fuzzy Coarse & silkyEar lobe Pliable Some cartilage Thick cartilage Testes and Scrotum testes in lower canal

Scrotum – small few rugaeSome intermediate Testes pendulus

Scrotum full extensive rugae

Signs of Preterm BabiesBorn after 20 weeks, after 37 weeks -frog leg or laxed positon -hypotonic muscle tone- prone resp problem-scarf sign – elbow passes midline pos.- square window wrist – 90 degree angle of wrist - heal to ear sign- abundant lanugo-

Signs of Post term babies:> 42 weeks- classic sign – old man’s face- desquamation – peeling of skin

B, The clitoris is still visible.The labia minora are now covered by the larger labia majora. Score 2. The gestational age is 36 to 40 weeks

C, The term newborn has well-developed, large labia majora that cover both clitoris and labia minora. Score 3.

A, This angle is 90 degrees and suggests an immature newborn of 28 to 32 weeks’ gestation. Score 0.

B, A 30- to 40-degree angle is commonly found from 39 to 40 weeks’ gestation. Score 2-3.

C, A 0-degree angle can occur from 40 to 42 weeks. Score 4. (C) Used with permission from V.Dubowitz, MD, Hammersmith Hospital, London, England.

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- long brittle finger nails- wide & alert eyes

BIRTHMARKS: 1. Mongolian spots – stale gray or bluish discoloration patches commonly seen across the sacrum or buttocks due to

accumulation of melanocytes. Disappear by 1 yr old 2. MIlla – plugged or unopened sebaceous gland . white pin point patches on nose, chin or cheek.3. Lanugo – fine, downy hair – common preterm 4. Desquamation – peeling of newborn, extreme dryness that begin sole and palm. 5. Stork bites (Talengeictasi nevi) – pink patches nape of neck

hair will grow as child grows old 6. Erythema Toxicum – (flea bite rash)- 1st self limiting rash appear sporadically & unpredictably as to time & place. 7. Harlequin sign – dependent part is pink, independent part is blue

(side lying – bottom part is dependent pink) 8. Cutis Marmorato – transitory mottling of neonates skin when exposed to cold. 9. Hemangiomas – vascular tumors of the skin

3 types Hemangiomasa.) Nevus Flammeus – port wine stain – macular purple or dark red lesions seen on face or thigh. NEVER disappear. Can be removed surgicallyb.) Strawberry hemangiomas – nevus vasculosus – dilated capillaries in the entire dermal or subdermal area. Enlarges, disappears at 10 yo.c.) Cavernous hemangiomas – communication network of venules in SQ tissue that never disappear with age. - MOST DANGERIOUS – intestinal hemorrhage Skin color blue – cyanosis or hypoxia

White – edema Grey – infYellow – jaundice , carotene

Vernix Caseosa – white cheese like for lubrication, insulator

Babies with special needs

Some babies may need some extra attention from you and the doctor after birth. These include:

Low birth weight babies (less than 2.5kg). Babies born too early (premature). Babies with pathological jaundice. Babies with infection. Those needing an operation soon after birth. Those with low blood sugar. Babies of diabetic mothers.

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