Chapter 18: Nursing Care of a

Family with a Newborn

A. Profile of a Newborn
1. Vital Statistics- measured for newborn usually consist of the baby’s weight, length and head and
chest circumference
 Note: Macrosomic- baby weighs more than 9-10lbs

2. Vital signs
 Temperature
- Temperature of newborns is about 99F (37.2C) because they have been in their
mother's warm uterus; temperature will fall almost immediately to below normal
because of heat loss, the temperature of birthing rooms, and the infant's immature
temperature-regulating mechanisms if the baby is not protected from hear loss at
birth.

a) Convection
The flow of heat from the newborn's surface to cooler surrounding air;
eliminating drafts, such as from air conditioners, is an important way to.
reduce convection heat loss

b) Radiation
The transfer of body heat to a cooler solid object not in contact with the
baby, such. as a cold window of air conditioner; moving an infant as far
form the cold surface as possible helps reduce this type of heat loss

c) Conduction
The transfer of body heat to a cooler solid object in contact with a baby;
example: baby placed on the cold base of a warming unit quickly
 d) Evaporation
Loss of heat through conversion of a liquid to a vapor; newborns are wet
when born, so they can lose a great deal of heat as the amniotic fluid on their
skin evaporates; put newborn on mothers skin immediately and cover with
blanket

Ways Babies Stay Warm:

1. Constrict blood vessels
2. Brown fat
3. Increase metabolic rate through kicking and crying

Note: Brown fat- A special tissue found in mature

newborns, apparently helps to conserve or produce
body heat by increasing metabolism as well as
regulating body temperature similar to that of a
hibernating animal

Note: Newborns are acidotic because they release lactic acid

 Pulse
The heart rate of a fetus in utero average 110-160 bpm; immediately after birth, as the
newborn struggles to initiate respirations, the heart rate may be as rapid as 180 bpm;
within 1 hour after birth, as the newborn settles down to sleep, the heart rate stabilizes
to an average 120-140 bpm; the heart rate of a newborn often remains slightly
irregular because of immaturity of the cardiac regulatory center in the medulla, and
transient murmurs may results from the incomplete closure of fetal circulation shunts;
you should be able to palpate femoral pulses in a newborn

 Respiration
Respiratory rate of a newborn in the first few minutes of life may be as high as 90
breaths/min; rate will settle to an average of 30-60 breaths/min over the next hour;
respiratory depth, rate, and rhythm, are likely to be irregular, and short periods of
apnea (without cyanosis), sometimes called periodic respirations, are also common
and normal during this time; coughing and sneezing reflexes are present at birth to
clear the airway; newborns are obligate nose breathers, however, and show signs of
acute distress if their nostrils become obstructed
  Blood Pressure
BP of a newborn is approximately 80/46; by the 10th day it rises to about 100/50 and
remains at the level for the infant year; not routinely measured in newborns because of
the size of their arms (unless a cardiac anomaly is suspected); cuff width should be no
more than 2/3s the length of the upper arm or thigh

3. Physiologic Functions
 Cardiovascular System 
As soon as the umbilical cord is clamped, which stimulates a neonate to take in
oxygen through the lungs, fetal cardiovascular shunts begin to close; with the first
breath, BP decreases in the pulmonary artery (artery leading from the heart to the
lungs); the peripheral circulation of a newborn remains sluggish for at least the first 24
hours; because of this slowed peripheral blood flow, it is common to observe cyanosis
in the infant's feet and hands (acrocyanosis) and for a newborn's feet to feel cold to the
touch

 A newborn’s blood volume is 80 to 110 ml/kg of body weight or about 300

ml total.

 Normal hemoglobin level of newborn: 17-18 g/100 ml of blood

  Normal hematocrit level of newborn: 45% and 50%

 Vitamin K is usually administered IM into the lateral anterior thigh

immediately after birth --> anticoagluation factors --> prevents intracranial
hemorrhage

 Respiratory System
A first breath is a major undertaking because it requires a tremendous amount of
pressure (40-70 cm H2O) for a newborn to be able to inflate alveoli for the first time;
some fluid present in the lungs from intrauterine life makes a newborns birth breath
possible; within 10 minutes after birth, most newborns have established easy
respirations as well as a good residual volume; ababy born by c-section does not have
as much lung fluid expelled at birth as one born vaginally and so typically has more
difficulty establishing effective respirations, because the excessive fluid blocks air
exchange space

 Gastrointestinal System
Usually sterile at birth but bacteria may be cultured from the tract in most babies
within 5 hours afterbirth and from all babies at 24 hours of life; most of these bacteria
enter the tract through the newborns mouth from airborne sources; others may come
from vaginal secretions at birth; a newborn has limited ability to digest everything
taken in, especially fat and starch because lipase and amylase remain deficient for the
first few months of life; bacteria is necessary for production of Vit K

 The first stool of a newborn is usually within 24 hours after birth; consists of
meconium, a sticky, tarlike, blackish-green, odorless material formed from
mucus, vernix, lanugo, hormones, and carbohydrates; about the second or
third day of life, newborn stool changes in color and consistency -->
transitional stool

 Bowel contents appear both loose and green; they may resemble diarrhea to
the untrained eye

 By the 4th day of life, breastfed babies pass three or four light yellow stools
per day; sweet smelling because breast milk is high in lactic acid

 A newborn placed under phototherapy lights as therapy for jaundice will

have bright green stools because of increased bilirubin excretion
  Grey stools means bile duct obstruction

 Blood-flecked stools usually indicate an anal fissure

 If mucus is mixed with stool or the stool is watery and loose, a milk allergy,
lactose intolerance, or some other condition interfering with digestion or
absorption should be suspected

 Urinary System
Average newborn voids within 24 hours after birth; newborns who do not void within
this time need to be assessed for the possibility of urethral stenosis or absent kidneys
or ureters; the kidneys of newborns do not concentrate urine well, making newborn
urine usually light colored and odorless; the first voiding may be pink or dusky
because of uric acid crystals that were formed in the bladder in utero

 Immune System
 Newborns have limited immunologic protection at birth because they are not able to
produce antibodies until about 2 months; newborns are born with passive antibodies
(IgG) passed to them from their mother that crossed the placenta; newborns are
routinely administered Hep B vaccine before they leave their birth setting to promote
antibody formation against the disease

 Neuromuscular System
Term newborns demonstrate neuromuscular function by moving their extremities,
attempting to control head movement, exhibiting a strong cry, and demonstrating
newborn reflexes; limpness or total absence of a muscular response to manipulation is
never normal and suggests narcosis, shock, or cerebral injury; newborns occasionally
makes twitching or flailing movements of the extremities in the absence of a stimulus
because of the immaturity of the nervous system: these are common and normal;
absence of muscular response to manipulation is NOT normal

1) Blink reflex- A baby's eyes close in response to bright light or loud noise
2) Rooting reflex- A baby's tendency, when touched on the cheek, to turn toward
the touch, open the mouth, and search for the nipple
3) Sucking reflex- When a newborn's lips are touched, the baby makes a sucking
motion; diminishes around 6 months
4) Swallowing reflex- Reflex that enables the newborn baby to swallow liquids
without choking
5) Extrusion reflex- A newborn extrudes any substance that is placed on the
anterior portion of the tongue; fades around 4 months
6) Palmar grasp reflex- Newborns grasp an object placed in their palm by quickly
closing their fingers on it
7) Step (walk)-in-place reflex- Newborns who are held in a vertical position with
their feet touching a hard surface will take a few quick, alternating steps.
Diminished by 3 months
8) Placing reflex- elicited by touching the anterior lower leg against a surface such
as the edge of a table. Newborn makes few quick lifting leg motions, as if to
step onto table
9) Plantar grasp reflex- When an object touches the sole of a newborn’s foot at the
base of the toes, the toes grasp in the same manner as the fingers. Diminished
about 8 to 9 months of age.
10) Tonic neck reflex- When newborns lie on their backs, their heads usually turn to
one side or the other; the arm and the leg on the side toward which the head
turns, extend, and the opposite arm and leg contract
11) Moro reflex- Infant reflex where a baby will startle in response to a loud sound
or sudden movement; hold in supine position and head drops backward;
newborn should abduct and extend arms and legs in response
12) Babinski reflex- Reflex in which a newborn fans out the toes and the big doe
dorsiflexes when the sole of the foot is touched
 13) Magnet reflex- If pressure is applied to the soles of the feet of a newborn lying
in a supine position, he or she pushes back against the pressure
14) Crossed extension reflex- When a newborn is lying supine, if one leg is
extended and the sole of that foot is irritated by being rubbed with a sharp
object, such as a thumbnail, the infant raises the other leg and extends it as if
trying to push away the hand irritating the first leg.
15) Trunk Incurvation reflex- When a newborn lies in a prone position and is
touched along the paravertebral area on the back by a probing finger, the
newborn flexes the trunk and swings the pelvis toward the touch.
16) Landau reflex- When a newborn is supported in a prone position by a hand, the
newborn should demonstrate some muscle tone. A newborn may not be able to
lift the head or arch the back in this position but neither should the infant sag
into an inverted “U” position.
17) Deep tendon reflex- Both a patellar and a biceps reflex are intact in a newborn

 Senses
1) Hearing
Fetus is able to hear in utero; by 25-27 weeks gestation hearing is functional; as
soon as amniotic fluid drains or is absorbed form the middle ear by way of the
eustachian tube within hours after birth, hearing becomes acute; newborns
 appear to recognize their mothers voice almost immediately and calm to the
sound of it as if they have heard it in utero

2) Vision
A pupillary reflex or ability to contract the pupil is present from birth; newborns
demonstrate they can see by blinking at a strong light (blink reflex) or by
following a bright light or toy a short distance with their eyes as soon as they
are born; be certain parents know they newborns cannot follow an object past
the midline or appears to lose track of objects easily; teach also that newborns
focus best on black and white objects at a distance of 9-21 inches

3) Touch
The sense of touch is also well developed at birth. Newborns quiet down at a
soothing touch, cry at painful stimuli, and show sucking and rooting reflexes
that are elicited by touch

4) Taste
A newborn has the ability to discriminate taste because taste buds are developed
and functioning even before birth; a fetus in utero, for example, will swallow
amniotic fluid more rapidly than usual if glucose is added to sweeten its taste;
after birth, a baby turns away from a bitter taste such as salt but readily accepts
the sweet taste of milk or glucose water
 5) Smell
The sense of smell is present in newborns as soon as the nose is clear of lung
and amniotic fluid; newborns probably turn toward their mothers' breasts partly
out of recognition of the small of breast milk and partly as a manifestation of the
rooting reflex

B. Assessment for Well-Being

1. APGAR Scoring- Appearance, Pulse, Grimace, Activity, Respiration

Respiratory Reflex
Heart Rate Effort Muscle Tone Irritability Color
2 Heart rate Strong, Maintains a position Cries or Body and extremities
>100 vigorous of flexion with sneezes when pink
beats per cry brisk movements a
stimulated
minute
(bpm)
1 Heart rate Weak cry, slow Minimal flexion of Grimaces when Body pink, extremities
extremities stimulated blue
present, but or difficult
<100 bpm respirations
0 No heart No Limp and flaccid No response to Body and extremities
rate respiratory stimulation blue (cyanosis) or
effort completely pale
(pallor)

2. Assessment of Gestational Age

Newborns are said to be term if they are born between 37 and 42 weeks of gestation or within 2
weeks of their due date. Gestational age for an infant born 5 days after the due date would be
recorded as 40 + 5; an infant born 3 days before the due date would be recorded as 40 − 3.
 Gestation Age (In Weeks)
Finding 0–36 37–38 39 and Over
Sole creases Anterior transverse Occasional creases Sole covered with
crease only in anterior two creases
thirds
Breast nodule 2 4 7
diameter
(mm)
Scalp hair Fine and fuzzy Fine and fuzzy Coarse and silky
Ear lobe Pliable; no cartilage Some cartilage Stiffened by thick
cartilage
Testes and Testes in lower canal; Intermediate Testes pendulous,
scrotum scrotum small; few scrotum full;
rugae extensive rugae
 Brazelton Neonatal Behavioral Assessment Scale
is a rating scale of six different categories of behavior: habituation, orientation,
motor maturity, variation, self- quieting ability, and social behavior and was devised by
Brazelton in the early 1970s (Brazelton, 1973) to evaluate a newborn’s behavioral
capacity or ability to respond to set stimuli.

3. Appearance of a Newborn
 Cyanosis
Generalized mottling (spots or smears of color) of the skin is a common finding in
newborns; the lips, hands, and feet are likely to appear blue from immature peripheral
circulation (acrocyanosis) --> normal through the first 24-48 hours after birth

Mucus obstructing a newborn's respiratory tract causes sudden cyanosis and apnea -->
relieved by suctioning (suction mouth before the nose because suctioning the nose first
may trigger a reflex gasp, possibly leading to aspiration)

Note: Central cyanosis is cyanosis of the trunk, is always a cause for concern -->
indicates decreased oxygenation that could be occurring as the result of a temporary
 respiratory obstruction, and also could reflex a serious underlying respiratory or
cardiac disease

 Hyperbilirubinemia
Caused by the accumulation of excess bilirubin in blood serum; in the average
newborn, the skin and sclera of the eyes begin to appear noticeably yellow on the
second or third day of life as a result of a breakdown of fetal RBCs (physiological
jaundice); light therapy to break up bilirubin

Note: Cephalohematoma is A collection of blood under the periosteum of the skull

bone caused by pressure at birth

Note: Acute Bilirubin Encephalopathy (Kernicterus) is above normal indirect bilirubin

levels are potentially dangerous because, if enough indirect bilirubin leads the
bloodstream, it can interfere with the chemical synthesis of brain cells, resulting in
permanent cell damage

 Pallor
Potentially serious in newborns because it usually occurs as the result of anemia,
which may be caused by a number of circumstances such as low iron, blood
incompatibility, fetal-maternal transfusion, inadequate blood flow, excessive blood
 loss, internal bleeding; if identified as having anemia -> need therapy such as
supplemental iron

 Harlequin Sign
Occasionally, because of immature blood circulation, a newborn who has been lying
on his or her side appears red on the dependent side of the body and pale on the upper
side; this is a transient phenomenon and of no clinical significance; fades immediately
as the newborns position is changed

 Hemangiomas
Vascular tumors of the skin and occur in three distinct types

Type Description Location Treatment

Nevus flammeus • Two types: • Port • Port wine:

○ Benign macular purple wine: ○ May
or dark-red lesion (also face, spontaneously
called a port-wine stain) thighs fade
(see Fig. 18.14A) • Stork ○ Cosmetically
 ○ Light-pink patches: stork bites: cover
bites or telangiectasia nape of ○ Laser later in
(see Fig. 18.14B). neck life
• Present at birth • Stork bites: do not
fade; no treatment
because usually
covered by hair

Infantile • Elevated areas formed by Can occur • Educate parent

hemangiomas immature capillaries and anywhere about expected

(also called endothelial cells (see Fig. on the increase in size for
strawberry 18.14C) infant; up to one year and
hemangiomas) • Appear at birth or within 2 most that they are likely
weeks after birth common to resolve with
• Size may enlarge up to 1 on scalp, time.
 year of age. face, neck • Propranolol
• After 1 year of age, (Inderal) and
hemangiomas tend to be corticosteroids can
absorbed and shrink in size. be used to reduce
By the time the child is 7 size.
years old, 70% have • Surgical excision
involuted to a reasonable is rarely done due
level; most involution to risk for
completed by 10 years complications.
Cavernous • Caused by dilated vascular Most • Surgical removal if
hemangioma spaces commonly they interfere with
• Raised and irregular shape; appear on sight or breathing
resemble a strawberry the face, • Steroids, interferon
hemangioma (see Fig. behind the alfa-2a, vincristine,
 18.14D) ears, and or radiation may
• Do not disappear with time the neck reduce size of
• Some may have additional lesions; risk vs.
lesions on internal organs such as benefit must be
the spleen or liver
considered

• Hematocrit levels to
assess for blood loss if
child has internal
cavernous lesions

 Mongolian Spot
are collections of pigment cells (melanocytes) that appear as slate- gray patches across
the sacrum or buttocks and possibly on the arms and legs of newborns.
 Vernix Caseosa
A white, cream cheese-like substance that serves as a skin lubricant in utero; document
color of vernix at birth, because it takes on the color of the amniotic fluid (yellow
vernix implies the amniotic fluid was stained from excessive bilirubin or a blood
dyscrasia may be present; green vernix suggests meconium was present in the
amniotic fluid); until the first bath, when vernix is washed away, handle newborns
with gloves; never rub it away harshly

 Lanugo
The fine, downy hair that covers a term newborn's shoulders, back, upper arms, and
possibly also the forehead and ears; postterm infants rarely have lanugo; following
birth, lanugo is rubbed away by the friction of bedding and clothes against the
newborns skin; by 2 weeks of age it has totally disappeared

 Desquamation
Within 24 hours after birth, the skin of most newborns begins to dry; this is a
temporary reaction to suddenly living in an air-filled rather than a liquid-filled
environment and so needs no treatments; parents may apply lotion; newborns who are
postterm and have suffered intrauterine malnutrition may have such extremely dry skin
that is has a leathery appearance
 Milia
Sebaceous glands in a newborn are immature, so at least one pinpoint white papule (a
plugged or unopened sebaceous gland) is usually found on a cheek or across the bridge
of the nose; disappear by 2-4 weeks of age; caution parents to avoid scratching or
squeezing the papule

 Erythema Toxicum
Some degree of rash is present in most term newborns; rash usually appears in the first
to fourth day of life; begins with small papules, increases in severity to become
erythematous, and then disappears; sometimes called a flea-bite rash; one of the rash's
chief characteristics: lack of pattern and pinpoint lesions

 Forceps marks
Forceps used during birth may leave a circular or linear contusion matching the rim of
the forceps on the infant's cheek; disappears in 1-2 days

 Skin Turgor
Newborns skin should be like an adult and feel resilient if the underlying tissue is well
hydrated
4. The Head
A newborn’s head usually appears disproportionately large because it is about one fourth of the
total body length compared with an adult, whose head is one eighth of total height. Other
features include:
The forehead appears large and prominent.
The chin appears to be receding, and it quivers easily if the infant is
startled or cries.
If a newborn has hair, the hair should look full bodied; both poorly
nourished and preterm infants have thin, lifeless hair.
If internal fetal monitoring was used during labor (see Chapter 24), a
newborn may have a pinpoint ulcer at the point where the monitor was
attached.

 Fontanelles- are the spaces or openings where the skull bones join
 Sutures- he separating lines of the skull; may override at birth because of the extreme
pressure exerted on the head during passage through the birth canal
 Molding- The part of the infant's head the engaged the cervix (usually the vertex)
 molds to fit the cervix continuous during labor; after birth, this area appears prominent
and asymmetric; assure parents the head will restore to its normal shape within a few
days after birth
 Caput Succedaneum- edema of the scalp that forms on the presenting part of the head;
it occurs in about 30% of cephalic births and can either involve wide areas of the head,
or be so confined that it's the size of a large egg
 Cephalohematoma- Collection of blood between the periosteum of a skull bone and
the bone itself, caused by rupture of a periosteal capillary because of the presence of
birth
 Craniotabes- A localized softening of the cranial bones probably caused by pressure of
the fetal skull against the mother's pelvic bone in utero

5. The Eyes
To inspect the eyes of a newborn, lay the infant in a supine position and lift the head; this
maneuver usually causes the baby to open his or her eyes; rare to see tears in newborns; the
irises of the eyes look gray or blue the surrounding sclera may appear light blue due to its
thinness; the iris will not assume its permanent color until about 3-12 months; eyes should
appear clear, without redness or purulent discharge; pressure during birth sometimes ruptures a
conjunctival capillary of the eye, resulting in a small subconjunctival hemorrhage on the sclera;
this appears as a red spot, usually on the inner aspect of the eye, or as a red ring around the
cornea
6. The Ears
A newborns external ear is not as completely formed as it will be eventually, so the pinna tends
to bend forward easily; in a term newborn, the pinna should be strong enough to recoil after
bending; a small tag of skin is sometimes found just in front of an ear

All newborns must be tested by a commercial standardized response to sound or confirmation

they can hear before discharge from their birth setting

7. The Nose
A newborn's nose usually has milia present and tends to appear large for the face; always test for
choanal atresia (blockage at the rear of the nose) when examining a newborn by closing the
infant's mouth wile compressing one naris at a time with your fingers; note any discomfort or
distress with breathing with one side is blocked

8. The Mouth
A newborns mouth should open evenly when he or she cries; if it doesn't, facial nerve injury is
suggested; the tongue may appear short or "tongue tied" because the frenulum membrane is
attached close to the tip; highly unusual for newborns to have teeth but sometimes one or two
(natal teeth) will have erupted
9. The Neck
The neck of a newborn appears short and often chubby, with creased skin folds; the head should
rotate or turn freely on it; should not have rigidity; when lying prone, newborns can raise the
head slightly, usually enough to lift the nose out of mucus or spit-up milk; the trachea usually
appears prominent on the front of the neck; the thymus gland also appears enlarged because of
the rapid growth of glandular tissue early in life

10. The Chest

The chest is most newborns looks small because the head is so large in proportion to it (an
important finding at birth so the largest diameter of the baby is born first); both right and left
sides should appear symmetric; not until a child is 2 years of age does the chest measurement
exceed that of the head; the clavicles should appear straight and feel smooth; a crepitus or an
actual separation of one or the other clavicle suggests a fracture occurred at birth (usually with
large infants) and calcium is now being deposited at that point; a supernumerary nipple (usually
found below and in line with the normal nipples) may be present

11. The Abdomen

 The contour of a newborn abdomen looks slightly protuberant; ascaphoid or sunken appearance
suggests missing abdominal contents or a diaphragmatic hernia; bowel sounds or proof the
bowel is beginning peristalsis should be present within 1 hour after birth

12. Male Genitalia

The scrotum is most male newborns is edematous and has rough rugae on the surface; it may be
deeply pigmented in dark-skinned newborns; both tests should be palpable in the scrotum;
always elicit a cremasteric reflex by stroking the internal side of the though while inspecting
testes (as the skin on the thigh is stroked, the testis on that side moves perceptibly upward);
inspect the tip of the penis to be certain the urethral opening is at the tip of the glans; the most
newborns, the prepuce (foreskin) slides back poorly from the meatal opening, so don't try to
retract it

13. Female Genitalia

The vulva in female newborns may appear swollen because of the effect of maternal hormones
during intrauterine life; some females newborns also have a mucus vaginal section, sometimes
blood tinged (psuedomenstruation), which is caused, by the action of maternal hormones; the
discharge disappears in 1-2 days and should not be mistaken for an infection or taken as in
indication that trauma has occurred

14. The Back

 A newborn normally assumes the position maintained in utero for days after birth, so the back is
held rounded with the arms and legs flexed across the abdomen and chest; the spina of a
newborn typically appears flat in the lumbar and sacral areas because the curves seen in an adult
appear only after a child is able to sit and walk; inspect the base of a newborn's spine carefully to
be certain there is no pinpoint opening, dumpling, or sinus tract in the skin --> spina bifida

15. The Extremities

The arms and legs of a newborn appear short in proportion to the trunk; the hands typically held
clenched into fists; test the upper extremities for muscle tone by unflexing the arms for approx. 5
seconds then letting them return to their flexed position (occurs immediately with good muscle
tone); arms and legs should move symmetrically; newborn legs appear bowed as well as short;
sole of the foot is flat