Care of the Normal Newborn

Apgar Scoring b469 r180

- Evaluate physical condition of the newborn at birth

- Score: 1 & 5 min after birth. Other at 10 min to those under 6
- Score from 0-10. The total Apgar score is the sum of the scores for the five signs.

Sign 0 points 1 point 2 points

Activity - No movement -Active motion
A (Muscle tone) - limp; flaccid
- Some flexion of arms & legs
-Kicking, moving
-At least 100 /min
Pulse
P (heart rate)
- No heart rate - Fewer than 99/min * Assessed by auscultation or fingers
in the umbilical cord
Grimace - No response to airways - grimace - Vigorous cry; cough, or sneeze
G (reflex response) being suctioned. when you suction
- body pink
- extremities blue
- Baby’s whole body is
Appearance
A (color)
completely bluish-gray or -Acrocyanosis (bluish hand & feet) -pink all over
pale *Due to cephalocardio development
(oxygenated blood goes 1st to neck,
head, last limbs)
- Weak crying, sound like whimpering.
- Slow or irregular breathing
Respiration - good strong cry
R (breathing)
-Not breathing
-They don’t count the respiration, it - Normal rate & effort breathing
goes with the baby’s cry

Interpretation
- 9 9 8 refer to the score, is given for the OB doctor, nurse, neonatologist, the person who is responsible for the baby.
- Score 8 -10 baby in good condition. Nasopharyngeal suctioning & may some oxygen near the face
(“blow-by” oxygen mask over baby’s face not in the baby’s face) in order to pink a little faster.
- Score 4 – 7 baby in moderate distress. Some form of resuscitation is initiated.
- Score 0 – 3 baby in severe distress. Need full resuscitation measures, need to transfer to NEICU - Neonatal ICU

- Each section is awarded 2.

- Is rare to get 10, because color.

Pulmonary System Transition b647 r272

First baby must take that first breathe

- Surfactant: mixture of lecithin & sphingomyelin) critical for alveolar stability.

Function of respiration switches

- The placenta take the fetal respiration.
- Even when the head is born, he is still breathing through the placenta.

Management
- When the baby is fully out, there is the transition
- Make sure the airway is clear using a bulb syringe (have always at crib side)

How do you suction the baby:

- mouth first, at the side of the cheeks
- then nose if you aspirate the nose first is going to trigger the reflex to aspirate, and the thing that you want out is
going to go dipper to the lung. Position on the entrance of the nose
- Dip suction, if baby have meconion, a little catheter that goes to the baby’s mouth before the body is born.

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Cardiac System Transition b651 r272

Foramen Ovale
Shunts blood from right atrium to left atrium, enables oxygen rich blood to by-pass the lungs and circulate into the body
● Functional closure 1-2 hours after birth. Closes permanently withing 6 months.

Ductus Arteriosus
Blood from the superior vena cava passes through the right ventricles and pulmonary artery through the ductus arteriosus
into the descending aorta on its way to get oxygenated in the placenta.
● Functional closure within 15 hours. Fibrosis within 3 weeks

Closure of Ductus Venosus

Blood bypasses the liver through the ductus venosus and goes directly to the inferior vena cava.
● Closure of the bypass forces perfusion of the liver.
Fibrosis of the ductus venosus occurs within 2 months.

Common variations b652

- Resting heart rate in the first week is 120 – 160 bpm
- During sleep drop to 80 bpm
- May accelerate to 180 bpm

Murmurs
- Murmurs are produced by turbulent blood flow. b653
- 90% are transcient and no associated w/ anomalies.
- They are produced when: atrial/ ventricular septal defect.
- Usually picked up at 4-6 weeks of age.
- Murmurs are sometimes absent even in malformed hearts.

Acrocyanosis b685
- Acrocyanosis (bluish hand & feet)
*Due to cephalocardio development (oxygenated blood goes 1st to neck, head, last limbs)

Nursing Responsibilities
Dry and Stimulate
Suction (if needed)
Assess heart rate
Weight and identify
- Weight b681

Newborn Thermoregulation b653 r293

Heat production
- Brown adipose tissue

Heat loss
- Convection
- Radiation
- Evaporation
- Conduction

Response to heat

Nursing Interventions to Prevent Hypothermia

- Dry infant, remove wet blankets
- Apply a hat and warm blankets
- Avoid placing infant on cold surfaces
- Avoid placing infants in drafts
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- Place under radiant warmer if temperature is unstable: naked with diaper

Temperature b683 r291

- Axillary: 36.5-37c (97.7 - 98.6 F)
- Rectal: 36.6-37.2c (97.8 – 99 F)

- First temperature is rectal: to assess patency of the anus.

- Others are axilliary, pole under bb arm

Temperature regulation b653 d/81 2:30

• Maintain neutral thermal environment (T that prevents heat loss) and prevent cold stress.
- Place infant under radiant warmer
- Warm oxygen, equipment, and linen before contact with infant.
- Generally, infant can be weaned to an open bassinet when his or her T is stable & bb is gaining weight.
• Assess bb T q2-3h & prn.

• Lack of subcutaneous fat to insulate body.

- Large body surface area in proportion to body weigh. Lose heat faster
- small muscle mass
- absent sweat or shiver mechanisms
- increase insensible fluid loss
- increase risk of hypothermia

● If baby is in a slightly low room temperature, wrap & give to mom to heat skin-to-skin & cover w/blanket
● But is temperature is 96, bb is very cold. Take bb back to the nursery, take cloths off, put under radiant warmer
● If temperature is still low, call doctor = infection sign. bb can not maintain temperature

● Bath, give a bath when temperature is 97.7 or 98 (when bb is in transition)

Vital signs b

- VS let you know what is going on with the baby. Consider only: temperature, heart rate, respiration •no: BP
- Normal bb VS do not include BP

Temperature: (sign of infection) If bb is sleeping could be higher.

- Axillary: 36.5 - 37c (97.7 - 98.6 F)
- Rectal: 36.6 - 37.2c (97.8 – 99 F)

Heart rate: (count one full minute)

- Apical: 120 – 160 bpm. Varies with sleeping or crying. Calm down, change diaper, feed & take again

Respiration: 30 - 60 breaths/min (count one full minute)

Blood Pressure: special order. 80/40.varies. Arm/Thigh D/82

- First count respirations, when is calm

- Heart rate
- Temperature, make him fuzzy

Newborn Sleep Cycle

Sleep states b664

- Deep or quiet sleep → •regular breathing •eye closed
- REM-Active rapid eye movement → irregular respirations (stop 5-10 sec) •eye closed w/ rapid movement.

Alert states: Active awake: best time to feed bb. After 30-60mif of delivery best time to initiate breast feeding.
Sucking: ↑oxytocin for contraction of the placenta, ↓risk of maternal bleeding.
- Drowsy
- Wide awake
- Active awake

Crying the only way that he can communicate: wet, hungry, uncomfortable, stomach ache. b703

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Nursing Assessment of the newborn

Newborn Measurements b681

Weight
- 2,500 – 4,000 g
- 5 lb 8 oz – 8 lb 13 oz
- Average: 3405 g
- 7 lb 8 oz

Length
- 48–52 cm (18 - 22 in)
- Average: 50cm (20in)

- The bb lost in the first week 10% of body weight due to fluid shift.
- If loose more weight: investigate if he is feeding properly, dehydrate.
- Preterm loose 15% in the first week.

HEAD b687 ati354 r268

Head circumference
- 32–37 cm (12.5-14.5)
- Approx. 2-3 cm larger than chest circumference
- Measure the widest part around: occiput, brows, ears.

Fontanells b687 d/83

- Good indicator of bb condition.
- Anterior (diamond shape) & posterior (triangle) → Fontanelles: open, flat, % soft.
•bulging = ICP-increased cranial pressure •depress = dehydration
- You can feel the heart rate in the fontanelles
- Anterior fontanelle swell when cry or poop

Molding Caput Succedaneum Cephalhematoma

- Asymmetry of the head resulting from
pressure in the birth canal
- The overriding sutures will disappear in
few day.
* High risk for jaundice
- Collection of fluid, edematous swelling of
the scalp.
- Crosses suture line
- Appears at birth or shortly thereafter
- Disappears within 12h or few days.
- Collection of blood between cranial bone
and periosteal membrane
- Does not cross suture line
- Disappears 2-3 weeks or months

Chest circumference b703 r269 b/84

- Average: 32cm (12.5 in)
- Range: 30-35cm (12-14 in)
- Measure around the nipples
- Evident xiphoid process
- Breast enlargement “witch’s milk” → do not touch may cause a breast access. •cause: maternal hormones
- Sternal retractions → bad. Respiratory distress, extra effort in respiration
- Extra nipple are harmless.

Eyes b689
- Symmetry in appearance,
- normal placement

Ears b702
- Without lesions, cysts, nodules
- Sinus tract
- Low set ears → •Dawn’s syndrome. Eyes alignment w/ ears •renal abnormalities → check the kidneys

Nose b701
- Patent nares bilaterally,
- Sneezing (common), reflex to clear airway
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Mouth
- Palpate soft and hard palate → cleft palate
- Teeth → if they are loose, remove, prevent aspiration.
- Epstein’s pearls → small, hard, white cysts. May be present in the hard palate
- Tongue → frenulum: tissue that tied underside the tonge. Do not cut: portal of entry for infection. b702

Abdomen d/85
- Round, full, symmetrical, plus bowel sounds . Distention indicate GI anormality.
- Measure around umbilicus cord.
- Check umbilicus → two arteries (2 little dots), one vein in cord (big dot).
- Dry in a week
- Teach parents: every time that change diapers, rub the umbilical cord with alcohol
- Brachial and femoral pulses → brachial in the arm: strong
- Hernia: common in blacks

Back
- Spine intact → intact, straight and flexible
- No sacral dimples, no hairy → spine bifida
- Lanugo → preterm babies

Anus
- Patent anus → 1st temperature: rectal. •Meconion in the 1st day of life
- Stool and urine by 24 hours after birth

Male Findings b706 r270 d/85 4:00

- Testes palpable in scrotum
- Undescended testes
- Epispadius → urethral opening on the dorsum of the penis.
- hypospadias → urethra opens inferior to its normal location
- Scrotum pendulous → edema in baby’s scrotum

Female Finding:
- Labia & clitoris edematous
- Hymenal tag → extra skin in the vaginal area.
- Vaginal discharge → thick, whitish mucus.
- Pseudomenstruation → withdrawal of maternal hormones

Skin Assessment d/86 b684 s370

- Acrocyanosis → bluish discoloration of hands and feet, few hr after birth
- Vernix caseosa → cheesy white substance, more in folds.
- Milia → small sebaceous glands. Forehead, nose and chin.
- Erythema toxicum (newborn rash) → Peak incidence 24-48 h

Birthmarks
- Mongolian spots → bluish areas on dorsal areas of buttocks. Confuse with bruising
- Telangiectacic nevi (stork bites) → red spots on eyelids, nose, neck b686
- Nevus flammeus (pork wine stain) → capillary angioma, nonelevated. Not grow, not fade w/ time, not blanch.
- Nevus vasculosus (strawberry mark) → capillary hemangioma in the head. Raised, delineated, dark-red.
Grow rapidly in 2-3week reach full size at 1-3 months, and then start to resolve.

- Posterm bb → dry, cracked skin

- Preterm bb → lanugo & vernix caseosa

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Neurologic System b707 s374

Normal reflexes

- Blink → Blink as response to light

- Sucking → is elicited when a object in bb mouth, or lips. bb suck while sleeping.
- Rooting → when side of bb mouth or cheek is touched. Response: bb turn toward that side & opens the lips to
suck (if not fed recently)
- Grasp (plantar and palmer) → Stimulation bb palm with a finger/ object. Resp.: bb grasps and holds firmly enough
to be lifted momentarily from the crib. •lessen at 3-4 months
- Moro → Bb is startled y a loud noise or lifted slightly above the crib & suddenly lowered. Resp.: bb straighten
arms & hands outward while the knees flex. Finger form a C, bb may cry. Until 6 months.

- Babinski → fanning & hyperextension of big toe. Older than 24 month is abnormal

** This two not part of a regular assessment

- Stepping → bb held upright with one foot touching a flat surface Resp.: bb put one foot in front of the other and
walks. Lost at 4-8 weeks.
- Tonic neck → or fencing → bb is supine and the head is turned to one side. Resp.: The extremities of the same side
straighten, the opposite side flex. Until 3rd month.

General Nursing Care

Erythromycin ointment (0.5%) b725 ati374

- Prophylactic to gonorrhea in the newborn is by law. Effective Chlamydia, STD
- Ophthalmic ointment: apply in low conjunctival surface of each eye.
- Start in the inner cantus to out. • After close eye & spread •Wipe excess after 1 min.
- Immediately after birth. Only once.

Vitamin K prophylaxis (0.5–1.0 mg) b724 ati375

- Phytonadione (Aquamephyton) : neonate is at risk for hemorrhagic disorders: coagulation factors synthesized in the
liver depend on Vit K, which is not synthesized until intestinal bacteria are present.
- Administer Aquamephyton in the lateral aspect of the middle third of the vastus lateralis tight muscle. Aspirate first if
blood is present in the syringe, try again.
- In the birthing area or within 1hr.

First bath
- Baby has to be at least 98 degrees
- Under the radiant warmer.
- Sponge bath, without touching the cord.
- Dry

Gestational Age Assessment

Dubowitz Tool (IS NOT IN USE FOR MANY HOSPITALS) DO NOT CONSIDER.

Newborn Nutrition b746

Calorie requirements:
- 50 to 55 kcal/ lb/ day or 105-108 kcal/ kg/ day

Breast Milk
- Baby are healthier, less complications, prevent GI problems
- Colostrum → Yellowish or creamy, thicker fluid that contain protein and high antibodies. Start early in pregnancy.
Give bb passive immunity.
- Transitional → Produced after colostrums until 2 weeks postpartum. Have more calories than colostrums.
- Mature milk → 10% solids(carbohydrates, proteins, fats) for energy & growth. Content varies w/ time of feeding.
- Fore milk → at the beginning of the feeding. High in water: vit + proteins
- Hind milk → Released after letdown, higher fat concentration.

Frequency
- 1.5 to 3 hours
- Determined by baby cues

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Newborn Stools b661

Meconium → Thick, tarry black or dark-green appearance. Formed in utero from the amniotic fluid, intestinal
secretions, and shed mucosal cells.

Transitional → Thin brown to green, part meconium and part fecal material. Passed next day or two.

Breast fed stools→ Pale yellow (or pasty green). More liquid & frequent.

Formula fed stools → Paler.

Frequency → Varies from one every 2-3 days, to as many 10/day.

Constipation → bb is not as long the stool is soft