Bulacan State University

City of Malolos Bulacan

COLLEGE OF NURSING

CARE OF MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)

NCM 107 Hand- out No: 5 part 1

CARE OF NEWBORN
1. AIRWAY
 Maintain respiration at 30-50 bpm without retraction and grunting
 Suction secretion gently by a bulb syringe- M (mouth) first, then N (nose) before the first
breath to prevent aspiration
 Vigorous suctioning using catheters causes vasovagal response- bradycardia
2. WARM
 Rub dry; swaddle and loose blanket; place in warm or unwrapped in radiant heat warmer.
 Take axillary temperature at the end of 1st hour of life, then every 4 hours for the 1st 24 hours of
life, once a day, onwards, (to prevent bowel perforation); If rectal, the purpose is to detect
imperforate anus.
3. MONITOR CHARACTER OF CRYING
 Vigorous crying blows off extra carbon dioxide, making all newborns slightly acidotic
 Note for the time of gasping and crying after birth
4. UMBILICAL CORD
 Assess umbilical cord pulsation
 Note the number of vessels of the cord- 2 arteries, 1 vein- immediately after cutting
 Assess cord for possible bleeding
 Sponge bath is advised until the cord falls off on the 7th- 10th day of life
 Avoid using creams, lotions or oils near the cord, (to hasten drying and prevent infections)
 Dabbing with rubbing alcohol once or twice a day may help hasten drying
5. EYE CARE
 Crede treatment- gonorrheal conjunction prophylaxis
 Erythromycin ointment or drops may be used; (Silver Nitrate was the drug of choice in the
past)
 Penicillin ophthalmic ointment or drops may be used and is effective against gonorrheal strains
(but was discouraged due to development of PCN sensitivity at an early age)
 Use individual tube or package per infant. Instill or squeeze ointment along the lower eyelid
from the inner canthus outward.
6. INITIAL FEEDING
 May breastfeed immediately after birth (The Philippine Milk Code EO 51 promotes
breastfeeding, and the Breastfeeding and Rooming- in Act of 1992 RA 7600 also promotes
breastfeeding and requires immediate rooming in of the newborn)
 For baby who is to be formula- fed, give 1oz of sterile water first at 4-6 hours of age, then
every 4 hours; 3 or 4 subsequent feedings with glucose water then formula may be started
7. BATHING
 Complete bath within an hour after birth to remove vernix caseosa (current practice in some
settings delays bathing after an hour and vernix caseosa is spread throughout the newborn’s
 body for temperature maintenance)
 Once a day, thereafter limiting to face, diaper area and skin folds only
 Room temperature- 24C (75F)
 Bath water: 98-100F (37-38C)
 Mild soap without hexachlorophene base
 Bathe prior to, NOT AFTER, a feeding (to prevent spitting, vomiting or aspiration)
 Proceed from cleanest to dirtiest are of the body (eyes and face to the trunk and extremities,
LAST- diaper area
 Wash eyes using clean water from inner cantus outward using separate clean portion of
washcloth portion of the washcloth for each eye
 DON’T SOAK THE CORD, (wet cord is a good breeding ground of bacteria)
 No tub bath until cord has fallen off
 Wash skin creases as milk tends to collect in these areas during spitting
 Don’t retract forcefully the foreskin of uncircumcised penis to prevent constriction
8. VITAMIN K ADMINISTRATION
 1 mg (1M) of Vitamin K (phytomenadione or Aquamephyton), immediately after birth to
prevent hemorrhagic disease
 Injected at vastus lateralis (anterolateral thigh muscle)
 Larger IV doses- development of hyperbilirubinemia and kernicterus
9. IDENTIFICATION
 Foot stamping
 Name tag

APGAR SCORING
Criteria Indicator 0 1 2
A: Appearance Color Pale or Blue Acrocyanosis Totally Pink
(Body Pink;
Extremities Blue)
P: Pulse Heart rate Absent <100 >100
G: Grimace Reflex Irritability No Response Grimace Vigorous Cry
A: Activity Muscle Tone Limp Some Flexion Active Movement
R: Respiration Respiratory Effort Absent Slow and Regular Good Cry

ADVANTAGES OF BREAST (HUMAN MILK)

 It contains necessary nutrients in sufficient quantity and quality
 Growth rates of breastfed are better during 3 to 4 months of life
 Anti- infective properties (Colostrum contains plenty of antibodies 2-4 days postpartum)
 More protein (globulin); more vitamin (Vit A); more salt (salt and potassium); more immune
bodies (IgA); and less fat and sugar than mature milk.
 High lactose content stimulates growth of lactobacillus bifidus (responsibility for the acidity of
the intestinal content, thus inhibiting the growth of many pathogenic bacteria during diarrhea)
 Antibodies to E. coli (most common cause of diarrhea in newborn and early infancy)
 Large amount of lactoferrin which binds iron and inhibits growth of E. coli, staphylococci and
 Candida albicans
 Lysozyme is bacteriostatic against enterobacteriaceae and staph species
 Anti-staphylococcus factor (inhibits systemic staph. Infection which causes diarrhea,
pneumonia, abscesses and sepsis)
 Secretory IgA protects intestinal Mucosae
 Contains cellular components (macrophages, lymphocytes, neutrophils and epithelial cells)
which provides immunological protection)
 Prevents hypersensitivity and allergy
 Lactational Amenorrhea Method of family planning
 Maternal and child bonding is fostered
 Protective effect against necrotizing enterocolitis
 Less otitis media due to position assumed during breastfeeding
 Decreased incidence of dental caries
 Safe, always at the right temperature, convenient, no pathologic organism and always available

STOOL
Meconium Transitional Stool Milk Stool (breast) Milk Stool
(Cowsmilk)
Within 24- 48 hours From 48 to 3rd day 4 to 5 days onwards 4 to 5 days onwards
Thick, black- green, Yellow brown to Golden yellow and Pale yellow to light
sticky stool greenish brown stool pasty, sour smelling brown more formed
with foul odor

ASSESSMENT OF REFLEXES
EYES
Blinking or Corneal
 Infant blinks with sudden appearance of bright light or approach of an object towards the
cornea
 Persists throughout life
Pupillary
 Pupils constrict (bright light shines toward it)
 Persist throughout life
Doll’s Eye
 As the head is moved slowly (right or left), the eyes lag behind and do not immediately adjust
to the new position of the head
 Disappears as fixation develops
 If persist; indicates neurologic damage

NOSE
Sneeze
 Spontaneous response of nasal passages to irritation or obstruction
 Persist throughout life
Glabellar
 Tapping briskly on the bridge of the nose (glabella)
 Eyes close tightly

MOUTH AND THROAT

Sucking
 Strong sucking movements of the circumoral area (response to stimulation)
 Persist throughout infancy (even without stimulation)
Gag
 Stimulation of posterior pharynx causes the infant to gag
 Persist throughout life
Rooting
 Touching or stroking the cheek along the side of the infant’s mouth causes the head to turn
towards that side and the infants begins to suck
Extrusion
 Tongue is touched or depressed and infant responds by forcing it outward
Yawn
 Spontaneous response to decreased oxygenation by increasing the amount of inspired air
 Persist throughout life
Cough
 Irritation of the mucus membrane of the larynx or tracheobronchial tree causes coughing
 Persist throughout life, usually present after the first day of birth

EXTREMITIES
Grasp
 Touching palms of hands or sole of feet (near base of digits) causes flexion (hands and toes)
 Palmar grasp: lessen after 3 months (replaced by voluntary movement)
 Plantar grasp: lessen by 8 months
Babinski
 Stroking outer sole of foot (upward from heel and across ball of foot) causes toes to
hyperextend and hallux to dorsiflex

GENERAL
Moro reflex
 Abrupt or change of equilibrium causes sudden extension and abduction of extremities and
fanning of fingers (index and thumb forming a C-shape); followed by flexion and adduction of
extremities
Startle reflex
 Sudden loud noise causes abduction (arms) with flexion (elbows)
 Hands remain clenched
Perez reflex
 Infant is prone on a firm surface and the thumb is pressed along spine from the sacrum to the
neck
 Responses: crying, flexing extremities, elevating pelvis and head, lordosis of the spine as well
as defecation and urination may occur
Asymmetric tonic neck reflex
  When infants head is turned to one side; the arm and the leg extend on that side, and the
opposite arm and leg flex
Trunk incurvation/ Galant reflex
 Stroking the infants back along the side of spine causes the hips to move toward stimulated ide
Dance/ Step reflex
 The infant is held so that sole of foot touches a hard surface and then there is reciprocal flexion
and extension of the leg that stimulates walking
Crawl
 When placed on the abdomen, the infant makes crawling movement with arms and legs
Placing
 Infant is held upright under the arms while the dorsal side of foot is briskly placed against a
hard object, the resulting effect is that the leg lifts as if the foot were stepping on a table
 Age of disappearance varies

PHYSICAL ASSESSMENT
GENERAL MEASUREMENTS
Head Circumference: 33-35cm (about 2-3cm larger than chest circumference
Chest Circumference: 30.5-33 cm
Head to heel length: 46-54 cm
Birth weight: 2,500- 3,400 gm
Common Variations
 Molding after birth may alter head circumference
 Head and chest circumference may be equal for first 1-2 days after birth

VITAL SIGNS
Temperature Heart Rate Respirations Blood Pressure
Axilla: 36.5C- 37F Apical:120-140 bpm 30-60 bpm Oscillometric:
(97.9F-98F) 65/41mmHg in arm and
calf
Common Variations Signs of Distress (POTENTIAL)
 Crying: increases body temperature,  Hypothermia (<36C)
increases blood pressure, heart and  Hyperthermia (>37.2C)
respiratory rate  Bradycardia: resting rate below 80-100
 Radiant warmer will falsely increase bpm
axillary temperature  Tachycardia: rate above 160-180 bpm
 Sleep: decreases respiratory and heart rate  Irregular rhythm
 During the 1st period of reactivity (6-8  Tachypnea: rate above 60 bpm
hours), respiratory rate can reach 80bpm  Apnea:20 sec or more
and heart rate can reach 180 bpm  Oscillometric systolic pressure in calf 6-
 Placing the cuff on the thigh may agitate 9mmHg less than in the upper extremity:
the infant; thigh BP may be higher than sign of coarctation of aorta
the arm or calf by 4-8 mmHg
 GENERAL APPEARANCE
 Posture: flexion of head and extremities (rest on chest and abdomen)
Common Variation Signs of Distress (POTENTIAL)
 Frank breech: extended legs, thigh fully  Limp posture, extension of extremities
rotated and abducted, flattened occiput,
and extended neck

SKIN
 At birth: bright red, puffy, smooth
 2nd- 3rd day: pink, flaky and dry
 Lanugo: appears 6 weeks of life at shoulder and back
 Acrocyanosis: hands and feet
 Cutis marmorata: transient mottling of skin when exposed to decrease temperature
 Vernix caseosa
Common Variations
 Neonatal jaundice (Physiologic Jaundice) after the 1st 24 hours
 Ecchymoses or petechiae caused by birth trauma
 Milia: tiny white papules on cheeks, chin, and nose
 Erythema toxicum: pink popular rash with vesicles (thorax, back buttocks and abdomen).
Appears in 24-48 hours and subsides after several days.
 Harlequin color change- outlined color change as infant lies on side: lower half becomes pink
and upper half is pale
 Mongolian spots: irregular areas of deep blue pigmentation in sacral and gluteal regions

HEAD
 Anterior fontanel: diamond shape (2.5-4cm); closes at 12-18 months
 Posterior fontanel: triangular shape (0.5-1cm); closes at 2 months
 Fontanel: should be flat and firm.
Common Variations Signs of Distress (POTENTIAL)
 Molding following vaginal delivery  Fused sutures
 Bulging fontanel because of crying and  Bulging or depressed fontanels when
coughing quiet
 Caput succedaneum: edema of soft scalp  Widened sutures and fontanels
tissue  Craniotabes: snapping sensation along the
 Cephalhematoma (uncomploicated): lamdoid sutures (resembles of ping-pong
hematoma between the periosteum and balls)
skull bone

EYES
 Lids usually edematous
 Color: slate gray, dark blue and brown
 Absence of tears
 Corneal reflex (response to touch)
 Pupillary reflex (response to light)
 Blink reflex (response to touch or light)
 Rudimentary fixation on objects and ability to follow to midline
 Common Variations
 Subconjunctival (scleral) hemorrhages

EARS
 Pinna in line with outer canthus of the eye
 Pinna flexible, cartilage present
 Startle reflex is elicited by loud, sudden noise
Common Variations
 Inability to visualize tympanic membrane
(filled aural canals)
 Pinna flat against head
 Irregular shape or size
Signs of Distress (POTENTIAL)
 Low set ears and minor abnormalities
(chromosomal defect and kidney
anomaly)
 Absence of startle reflex in response to
loud noise

NOSE
 Nasal Patency
 Thin white mucus
 Sneezing
Common Variations Signs of Distress (POTENTIAL)
 Flattened and bruised  Non-patent canals
 Thick, bloody discharge
 Alae nasi (nasal flaring)

MOUTH AND THROAT

 Intact, high arched palate
 Uvula in midline
 Frenulum of the tongue
 Frenulum of the upper lip
 Sucking Reflex (strong and coordinated)
 Other reflexes: Rooting, Gag and Extrusion
 Absent or minimal salivation
 Vigorous cry
Common Variations
 Natal teeth: teeth present at birth; benign but may be associated with congenital defects
 Epstein pearls: small, white epithelial cyst (midline of hard palate)

CHEST
 Antero-posterior and lateral diameter equal
 Slight sternal retractions (evident during inspiration)
 Xiphoid process evident
 Breast enlargement
 LUNGS
 Abdominal respirations
 Cough reflex: absent at birth; present by 1-2 days
 Bilateral equal bronchial breath sounds
Signs of Distress (POTENTIAL)
 Retractions
 Grunting
 Stridor

HEART
 S2 slightly sharper and higher pitch than S1
 Apex: 4th to 5th, lateral to left sternal border
Common Variations
 Sinus arrhythmia: heart rate increases with inspiration and decreases with expiration
 Transient cyanosis when crying or straining

ABDOMEN
 Cylindrical in shape
 Liver: palpable 2-3cm below right costal margin
 Spleen: tip palpable at end of first week of age
 Kidneys: palpable 1-2 cm above umbilicus
 Umbilical cord: bluish white at birth, 2 arteries and 1 vein
 Femoral pulses; equal bilaterally

FEMALE GENITALIS
 Edematous labia and clitoris
 Urethral meatus behind clitoris
 Vernix caseosa between labia
 Urination within 24 hours
Common Variations
 Pseudomenstruation: blood- tinged or mucoid discharge

MALE GENITALIA
 Urethral opening at the tip of glans penis
 Testes palpable in each scrotum
 Scrotum usually large, edematous, pendulous, and covered with rugae; usually pigmented
(dark skinned)
 Smegma
 Urination within 24 hours
Signs of Distress (POTENTIAL)
 Hypospadias (urethral opening at ventral surface)
 Epispadias (urethral opening at dorsal surface)
 BACK AND RECTUM
 Spine intact, no openings, masses or prominent curves
 Trunk incurvation reflex
 Anal reflex
 Patent anal opening
 Passage of meconium within 48 hours

EXTREMITIES
 Complete fingers and toes
 Full range of motion
 Nail beds pink, with transient cyanosis (immediately after birth)
 Creases on anterior 2/3 of sole
 Sole usually flat
 Symmetry of extremities
 Equal bilateral muscle tone (especially resistance to opposing flexion)
 Equal bilateral branchial pulses
Signs of Distress (POTENTIAL)
 Polydactyly
 Syndactyly
 Phocomelia (hands or feet attached close to trunk)
 Hemimelia (absence of distal part of extremity)

NEUROMUSCULAR
 Extremities maintain some degree of flexion
 Extension of extremity followed by previous position of flexion
 Head lag while sitting; momentary ability to hold head erect
 Turns head from side to side (prone)
 Holds head in horizontal line with back (prone)
Common Variations
 Quivering or momentary tremors

GENERAL CONSIDERATIONS:
PEDIATRIC PHYSICAL ASSESSMENT/ EXAMINATION

 Begins at the head and proceeds to the toes.

 Painful or frightening procedures should be the last priority
 Involve parents/ significant others by requesting them to hold or stay with the child (decreases
anxiety).
 Establish a trusting relationship
Infants  Responsive to human faces
(1-6 months)  Increasing interest in the environment
 If asleep or resting in the parent’s arm: auscultate the heart, lungs and
abdomen
  If awake: put the baby on the examination table with the parents nearby
 Evaluate also the primitive reflexes
 Refocus an unhappy infant by speaking calmly in a soft voice.
 Use distracting methods such as rattles or pacifiers
Infants  Same with 1-6 months
(6-12 months)  Consider that at this age, infant experiences stranger anxiety
 Distract by giving toys or objects
 Assess the child while being held on parents lap
Toddlers  Most challenging to assess and least cooperative
 Before doing an assessment sit or stand near the child’s parents
 Offers toys, books and encourage the child to participate in the procedure
 Ask the parent to assist or hold the child
Preschoolers  More cooperative and like to see the parents frequently
 Reinforce the child’s interest by allowing them to participate
 Praise the child
School-age  Asks questions the child can respond to
Children  Encourage parental support and reinforce the child’s participation in the
procedure
 Prefers simple drape over underpants or colorful gown
 Be sensitive to client’s modesty
 Opportunity to teach the child on body and personal care
Adolescents  Comfortable with straightforward and uncondescending approach
 Ask who should be present during assessment
 Incorporate genital examination in the middle of the assessment (abdominal
to genital examination and discussions)
 Drape appropriately during the examination