CASE 6

INTRODUCTION

The arrival of a new baby, especially the first, always marks a new beginning for a mother. It comes with a lot of
challenges, more so if the mother is less knowledgeable about baby care. Take things such as cleaning the baby for the
first time, or feeding, it is not easy. The baby is still fragile and slippery and needs special care. But if the mother is not
ready for all these, or maybe does not have any knowledge on what to do, the baby’s life might be endangered since the
baby needs special care which only the mother can give.

Newborns are considered to be tiny and powerless beings, completely dependent on others for their adaptation in the
external environment. Newborn period is from the time of birth to 28 days of life. Approximately 8to 90% of infants
make the transition from intrauterine to extra uterine life with no assistance necessary. However, for the remaining few
newborns, some assistance may be required.

The most physical changes take place in the neonate during the transition period. Newborns need support to initiate
breathing and maintain thermoregulation. Essential newborn care is a complex procedure that requires specialized
knowledge and skills in an emotionally stressful situation. Knowledge and skill about essential newborn care provide
quality implementation of care among newborn.

Objectives

General Objectives

• At the end of this case presentation, the participants and the audience will be:

• Educated about the process of newborn care and the management that must be done, its nursing management
and acquired the proper knowledge, skills and attitude in providing care to the neonate.

Specific Objectives

Knowledge

• Recognize the care needed by the newborn after delivery

• Identify the predisposing and precipitating factors.

• Discuss normal from abnormal findings in newborn assessment

Skills

• Identify appropriate nursing diagnosis according to the needs of the neonate.

• Implement a nursing care plan in managing the neonate’s signs and symptoms using the nursing process.
 • Document correctly the neonate’s condition, nursing interventions and evaluation.

Attitude

• Recognize the newborn’s needs using a holistic approach.

• Facilitate Discharge planning

• Provide comprehensive care that considers the patient's social, emotional and physical needs.

Nursing Health History

A. Biographic Data

Patient’s Name: Belle’s Baby Girl

Address: NA

Age: NA

Sex: Female

Marital Status: Single

• Occupation: NA

• Religion: NA

• Source of Information: Belle

• Attending Physician: NA

• Date of Admission:NA

• Time of Admission: NA

• Chief Complaint: slight caput succedaneum

Chief Complaint

• slight caput succedaneum

Physical Examination

Anthropometric Measurements was taken as follows:

Upon assessment, the newborn’s measurements were identified as normal as it enters the normal reference value of
each measurement.

• APGAR SCORING was also done to  helps find breathing problems and other health issues. It is part of the
special attention given to a baby in the first few minutes after birth. The scoring includes appearance, pulse rate,
grimace, activity and respiration rate. Upon assessment Belle’s baby girl had a score of 9/10 which is a good
APGAR score.

• HEAD AND NECK ASSESSMENT was done to examine the shape of the head, fontanelles on the baby’s skill and
the bones across the upper chest. Upon assessment, Belle’s baby girl appears to have a slight caput
succedaneum and with anterior fontanel not depressed nor bulging. The neck moves freely, no torticollis.

• SKIN ASSESSMENT was done to look at the skin color, texture, nails, and any rashes.Upon assessment, Belle’s
baby girl skin appears to be bright red in color with soft downy hair on the body, jaundice and cyanosis not
noted.

• FACE ASSESSMENT was done to look at the eyes, ears, nose and cheeks of the neonate. Upon assessment, Both
eyes are symmetrical without opacity or white spots; tearless when crying. Ears are well formed and no
presence of anomalies, upper borders are in line with the outer canthus of the eyes. Both nares are patent with
white papules commonly seen over the nose.

• MOUTH ASSESSMENT was done to inspect the roof of the mouth (palate), tongue, and throat. Upon
assessment, Mouth moist and lips pinkish in color with palate intact, no drooling.

• BREAST ASSESSMENT was done to examine the thickness and size of breast tissue and the darker ring around
each nipple (areola). Upon assessment, Baby’s nipple observed to have fluid leak or witch milk.

• LUNG ASSESSMENT was done to inspect the sounds the baby makes when they breathe. This also looks at the
breathing pattern. Upon auscultation, there are no signs of respiratory distress; nasal flaring, grunting, retraction
not noted.

• ABDOMINAL ASSESSMENT was done to look at any masses or hernias. Upon inspection of the abdomen, no
gross distention or bulging observed.
• GENITAL ASSESSMENT was done to  check the size of the clitoris and the labia and how they look. Genitalia
shows slight edematous labia and clitoris, with vernix caseosa between folds and with occasional blood-tinged
vaginal discharge.

• Intact, straight and flat spine with no masses nor dimple or sac. Dark, flat pigmentation of the lower back noted
and with a patent anal opening.

• ARMS AND LEGS ASSSESSMENT was done to check the baby’s movement and development. Upon assessment
Belle’s baby has good muscle tone, arms equal in length, legs equal in length.

• PLANTAR CREASES ASSESSMENT was done to check the creases on the soles of the feet. Upon assessment,
normal palm creases and plantar creases cover the entire sole was noted

ANATOMY AND PHYSIOLOGY

• Changes in the newborn at birth refer to the changes an infant's body undergoes to adapt to life outside the
womb.

• LUNGS, HEART, AND BLOOD VESSELS

• The mother's placenta helps the baby "breathe" while it is growing in the womb. Oxygen and carbon dioxide
flow through the blood in the placenta. Most of it goes to the heart and flows through the baby's body.

• At birth, the baby's lungs are filled with fluid. They are not inflated. The baby takes the first breath within about
10 seconds after delivery. This breath sounds like a gasp, as the newborn's central nervous system reacts to the
sudden change in temperature and environment.

• Once the baby takes the first breath, a number of changes occur in the infant's lungs and circulatory system:

• Increased oxygen in the lungs causes a decrease in blood flow resistance to the lungs.

• Blood flow resistance of the baby's blood vessels also increases.

• Fluid drains or is absorbed from the respiratory system.

• The lungs inflate and begin working on their own, moving oxygen into the bloodstream and removing carbon
dioxide by breathing out (exhalation).

• BODY TEMPERATURE

A developing baby produces about twice as much heat as an adult. A small amount of heat is removed through
the developing baby's skin, the amniotic fluid, and the uterine wall. After delivery, the newborn begins to lose
heat. Receptors on the baby's skin send messages to the brain that the baby's body is cold. The baby's body
creates heat by burning stores of brown fat, a type of fat found only in fetuses and newborns. Newborns are
rarely seen to shiver.

• LIVER 

In the baby, the liver acts as a storage site for sugar (glycogen) and iron. When the baby is born, the liver has
various functions:
 It produces substances that help the blood to clot.

It begins breaking down waste products such as excess red blood cells.

It produces a protein that helps break down bilirubin. If the baby's body does not properly break down bilirubin,
it can lead to newborn jaundice.

GASTROINTESTINAL TRACT

A baby's gastrointestinal system doesn't fully function until after birth. In late pregnancy, the baby produces a
tarry green or black waste substance called meconium. Meconium is the medical term for the newborn infant's
first stools. Meconium is composed of amniotic fluid, mucus, lanugo (the fine hair that covers the baby's body),
bile, and cells that have been shed from the skin and intestinal tract. In some cases, the baby passes stools
(meconium) while still inside the uterus.

URINARY SYSTEM

• The developing baby's kidneys begin producing urine by 9 to 12 weeks into the pregnancy. After birth, the
newborn will usually urinate within the first 24 hours of life. The kidneys become able to maintain the body's
fluid and electrolyte balance.

• The rate at which blood filters through the kidneys (glomerular filtration rate) increases sharply after birth and in
the first 2 weeks of life. Still, it takes some time for the kidneys to get up to speed. Newborns have less ability to
remove excess salt (sodium) or to concentrate or dilute the urine compared to adults. This ability improves over
time.

IMMUNE SYSTEM

• The immune system begins to develop in the baby, and continues to mature through the child's first few years of
life. The womb is a relatively sterile environment. But as soon as the baby is born, they are exposed to a variety
of bacteria and other potential disease-causing substances. Although newborn infants are more vulnerable to
infection, their immune system can respond to infectious organisms. Newborns do carry some antibodies from
their mother, which provide protection against infection. Breastfeeding also helps improve a newborn's
immunity.

SKIN

• Newborn skin will vary depending on the length of the pregnancy. Premature infants have thin, transparent skin.
The skin of a full-term infant is thicker.

• Characteristics of newborn skin:

• A fine hair called lanugo might cover the newborn's skin, especially in preterm babies. The hair should disappear
within the first few weeks of the baby's life.

•  A thick, waxy substance called vernix may cover the skin. This substance protects the baby while floating in
amniotic fluid in the womb. Vernix should wash off during the baby's first bath.
• The skin might be cracking, peeling, or blotchy, but this should improve over time.
DRUG STUDY
 NURSING CARE PLAN

Name of Patient: Belle’s Baby Girl Impression/Diagnosis

Age & Sex: Newborn/F Ward/Bed:

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 NURSING CARE PLAN

Name of Patient: Belle’s Baby Girl Impression/Diagnosis

Age & Sex: Newborn/F Ward/Bed:

DEFINING NURSING OUTCOME NURSING RATIONALE EVALUATION

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DISCHARGE PLAN/ HEALTH TEACHING

EVALUATION: 
The baby was assessed and given nursing care and treatment.
Immediately after Belle’s delivery, the baby was dried thoroughly and kept warm. Identification band was placed at the
right ankle. Cord clamping and cutting in aseptic manner after the pulsation had stopped.

where head circumference is revealed to be 34 cm, chest circumference is 32 cm, abdominal circumference is 30 cm,
baby’s length is 47 cm and wieght is 3,200 grams. It was then followed by a vital signs check up where temperature is
36.5°C, pulse rate is 140 bpm, respiratory rate is 48 breaths/min. In addition, APGAR score of 9/10 was
noted.Terramycin ointment was applied to both eyes to avoid possible bacterial eye infections. Vit. K and Hepatitis
vaccine were injected to provide protection against bleeding and perinatal infection, respectively. Head assessment was
done and all findings are normal. Upon auscultation and inspection, no abnormalities were noted.

Additional findings includes: slight caput succedaneum, slight edematous labia and clitoris with vernix caseosa,
occasional blood-tinged vaginal discharge, intact, straight and flat spine with no masses, dark, flat pigmentation of the
lower back, patent anal opening, good muscle tone, equal length in arms and legs, palm creases and plantar creases
covering the entire sole, which are all normal.

The goals in the nursing care plan of the newborn were met because the infant’s slight caput succedaneum resolved
within 3-4 days and it did not change in color and have any further damage. The clamped cord stump was alsofree from
bleeding and it did not have any foul odor and discharges. The objectives of this case were reached as facilitation of
discharge planning was done, complete care during and after delivery was provided as well as comprehensive
information for the patient's well being.

HEALTH TEACHING
We counseled Belle about the significance of the first breastfeeding and immunizations to a healthy, and long-term
development of her baby. Also, we taught her about the importance of warmth, proper timing for breastfeeding, proper
nutrition, different contraindications in newborn care, proper skin care and bed bath, care of umbilical cord, care of
eyes, clothing of baby, and general care. We also told Belle to watch out for any untoward signs and symptoms in
newborn like persistent crying, wheezing, diarrhea, difficulty in breathing, presence of blood in stool, grunting, bad odor
or drainage from umbilical cord, and Jaundice .

QUESTIONS:

1. What is the rationale of drying the newborn thoroughly?

• -Thorough drying of the newborn right after birth is very essential because immediate and thorough drying for
30 seconds to one minute warms the newborn and stimulates breathing.

2. Should the vernix caseosa be wiped off after the delivery? Why?
 • --The World Health Organization (WHO) recommends waiting at least 6 hours before bathing the newborn baby
and ideally waiting about 24 hours. The WHO also recommends not wiping off the vernix at birth. The vernix has
a few benefits for the baby after delivery. This includes:
• It acts as a natural moisturizer. Vernix could help prevent your newborn’s skin from becoming dry. Its high
water content helps lock moisture into the skin and reduces moisture loss.
• It may have antibacterial properties. Vernix could protect your newborn baby from getting a skin infection
shortly after birth.
• It has antioxidant properties. Vernix contains antioxidants like vitamin E and melanin, which help slow down cell
damage due to free radicals

3. When is the ideal time to clamp and cut the cord? Why?
• -delaying cutting or clamping the umbilical cord may help infants develop mentally. It is ideal to clamp and cut
the cord after it stops pulsating because this allows the baby to receive extra oxygenated blood from your
placenta, which has important health benefits.

4. Discuss the significance of performing APGAR Scoring. Is 9/10 APGAR Score normal? Why? 
• -The Apgar score describes the condition of the newborn infant immediately after birth, this checks a baby's
heart rate, muscle tone, and other signs to see if extra medical care or emergency care is needed. The Apgar
score is based on a total score of 1 to 10. The higher the score, the better the baby is doing after birth. In belle’s
baby, the score is 9/10 which tells us that she is in good condition, no intervention required except to give
newborn support.

5. What are the 5 signs to be assessed in APGAR Scoring?

• - A Appearance (skin color)
• -P Pulse (heartbeat)
• -G Grimace (reflex irritability)
• -A Activity (muscle tone)
• -R Respiratory rate (breathing ability)

6. What is the importance of Crede’s prophylaxis? How should the medication be administered?
• - Crede’s Prophylaxis is when eyedrops or ointment containing an antibiotic medication (2% silver nitrate) are
placed in a newborn's eyes after birth. This is required by law, in the majority of states, to protect the baby from
neonatal conjunctivitis caused by Neisseria gonorrhoeae in the maternal body. The medication is administered
from the inner canthus to the outer canthus of the neonate’s eye.

7, What is the importance of Vit. K injection? Give the dosage, route and site of administration?
• -The vitamin K given at birth provides protection against bleeding that could occur because of low levels of this
essential vitamin.
• -Dosage: 0.5mg- 1 mg
• -Route: Intramuscular
• -Site: anterolateral thigh (vastus lateralis)

 8, Why is Hepa vaccine given? Give the dosage, route and site of administration.
•  -Hepa B vaccine protects babies from a potentially serious disease called hepatitis B. It also Protects other
people from the disease because children with hepatitis B usually don't have symptoms, but they may pass the
disease to others without anyone knowing they were infected. 
9. What is the significance of Newborn Screening? How it is being done?
• -Newborn screening helps in early identification of several genetic, endocrine and metabolic diseases. The
Newborn Screening test is done by collecting a few drops of blood from the baby's heel. Ideally, newborn
screening should be done two days after birth or before discharge from the hospital. The blood sample is placed
on a special filter paper card.

10. Based on the scenario, are the results of anthropometric measurements normal? Explain briefly.
-The newborn’s anthropometric measurements were all normal given that:

Measurements Belle’s Baby Normal Reference

Head circumference 34 cm 33-35 cm

Chest Circumference 32 cm 30.5-33 cm
Abdominal Circumference 30 cm 30-31 cm
Length 47 cm 46-56 cm
Weight 3,200 grams 2500-4000 grams
Temperature 36.5 degrees Celsius 36.5-37.2 degrees Celsius
CR 140 bpm 120-160 bpm
RR 48 breaths/min 40-60 breaths/min

11. Differentiate between physiologic and pathologic jaundice. Give the management for each.
• -Physiologic jaundice is caused by a combination of increased bilirubin production secondary to accelerated
destruction of erythrocytes, decreased excretory capacity secondary to low levels of ligandin in hepatocytes, and
low activity of the bilirubin-conjugating enzyme uridine diphosphoglucuronyltransferase (UDPGT).
• MANAGEMENT:
•  
• Pathologic neonatal jaundice occurs when additional factors accompany the basic mechanisms described
above. Examples include immune or nonimmune hemolytic anemia, polycythemia, and the presence of bruising
or other extravasation of blood.
• MANAGEMENT:
12. Formulate your Nursing Care Plan and Drug Study.