NURSING CARE of a POSTPARTAL FAMILY
three separate phases.
▪ The postpartal period, or puerperium (from the
Latin puer, for “child,” and parere, for “to bring
forth”), refers to the 6-week period after
childbirth.
▪ It is a time of maternal changes that are both
retrogressive (involution of the uterus and vagina)
and progressive (production of milk for lactation,
restoration of the normal menstrual cycle, and
beginning of a parenting role).
▪ The physical care of the postpartum mother
involves providing comfort and relief from any
discomfort from delivery, such as the use of sitz
baths and cool compresses to soothe the perineal
area.
▪ Mothers may often experience temporary
difficulty in passing stool in the early postpartum
period. This can be addressed with the use of stool
softeners and encouraging fluid intake and a high-
fiber diet.
Baby-Friendly Ten Steps
• Have a written breastfeeding policy that is routinely
communicated to all health care staff.
• Train all health care staff in the skills necessary to
implement this policy.
• Inform all pregnant women about the benefits and
management of breastfeeding.
• Help mothers initiate breastfeeding within one hour of
birth.
• Show mothers how to breastfeed and how to maintain
lactation, even if they are separated from their infants.
• Give newborn infants no food or drink other than
breast-milk, unless medically indicated.
• Practice “rooming in”—allow mothers and infants to
remain together 24 hours a day.
• Encourage breastfeeding on demand.
• Give no pacifiers or artificial nipples to breastfeeding
infants.
• Foster the establishment of breastfeeding support
groups and refer mothers to them on discharge from
Development of Parental Attachment, Bonding, and
the hospital or birth center.
Pychological Changes of the Postpartal Period
▪ The postpartum period is a time of transition,
during which a couple gives up concepts such as
“childless” or “parents of one” and moves to not
only trying out their new role but also determining
whether they “fit” their new role. Nurses can help
couples acknowledge the extent of the change so
that they can gain closure on their previous
lifestyle.
Behavioral Adjustment: Phases of The Puerperium
▪ Reva Rubin, a nurse, divided the puerperium into
1. Taking-In Phase
➢ The time when the new parents review their
pregnancy and the labor and birth.
➢ time of reflection
➢ During this 1- to 3-day period, a woman is largely
passive.
➢ Prefers having a nurse attend to her needs and
make decisions.
➢ Wants to rest to regain her physical strength and
experience a calm atmosphere around her to quiet
and contain her swirling thoughts.
➢ Encouraged her to talk about the birth.
2. Taking-Hold
➢ a time of initiation of action and greater
independence as evidenced by performing self-
care
➢ a woman begins to initiate action.
➢ prefers to get her own washcloth or to make her
own decisions.
➢ begins to take a stronger interest in her infant and
begins maternal role behaviors.
➢ give a woman a brief demonstration of baby care
and then allow her to care for her child herself—
with watchful guidance.
➢ She needs praise for the things she does well to
ease the feeling of insecurity of her ability to care
for her new child.
3. Letting-Go Phases
➢ woman finally redefines her new role
➢ gives up the fantasized image of her child and
accepts the real one; she gives up her old role of
being childless or the mother of only one or two.
➢ requires some grief work and readjustment of
relationships.
Positive Family Relationships
Attachment or bonding -when a woman has
successfully linked with her newborn, it is termed.
▪ Skin-to-skin contact soon after birth facilitates the
early attachment and binding phase. Ideally occur
within the first hour of any birth.
En Face Position- looking directly at her
newborn’s face, with direct eye contact. Sign a
woman is beginning effective attachment.
Engrossment- fathers can be observed staring at a
newborn for long intervals in this same way. This
 action alerts caregivers to how actively the father, ➢ 50% of women experience some feelings of
as well as the mother, is beginning bonding overwhelming sadness or “baby blues” .
➢ They may burst into tears easily or feel let down
and irritable. This phenomenon may be caused by
Rooming-In
hormonal changes, particularly the decrease in
➢ Occurs when the infant remains in the woman’s estrogen and progesterone that occurred with
room and the mother and child are together 23 out delivery of the placenta.
of 24 hours a day. ➢ Breastfeeding has been shown to help elevate
➢ A hospital must provide “rooming-in,” or space to baby blues and counteract the effects of the
keep the infant with the parents to qualify as hormonal drop that occurs after childbirth.
“baby friendly”.
Sibling Visitation
PHYSIOLOGIC CHANGES of the POSTPARTAL
➢ Visit can help to relieve some of the impact of PERIOD
separation and also help to make the baby a part of
the family.
➢ Assess to be certain siblings are free of contagious
diseases and have them wash their hands.
➢ may need to caution a woman that the opinions of
a new brother or sister expressed by her older
children may not be complimentary.

MATERNAL CONCERNS AND FEELINGS IN THE

POSTPARTAL PERIOD
Abandonment

➢ Many mothers, if given the opportunity, admit to

feeling abandoned and less important after giving
birth than they did during pregnancy or labor.
➢ You can help a woman move past these feelings
by verbalizing the problem: “How things have
changed! Everyone’s asking about the baby today
and not about you, aren’t they?”
➢ When a newborn comes home, a father or partner
may express much the same feelings as he or she
feels resentful of the time the mother spends with REPRODUCTIVE SYSTEM CHANGES
the infant.
➢ You can help parents or partners move past this Involution- is the process whereby the
competitive stage by pointing out positive reproductive organs return to their nonpregnant
parenting behaviors, positive self-care behaviors, state.
and the warm infant response to their behaviors.
Disappointment

➢ Another common feeling parents or partners may

experience is disappointment in the baby.
➢ The baby is not the same as they pictured it.
➢ Comment on the child’s good points, such as long
fingers, lovely eyes, and healthy appetite.
Postpartal Blues
The Uterus
➢ Involution of the uterus involves two processes:
-First, the area where the placenta was implanted is
sealed off to prevent bleeding.
 -Second, the organ is reduced to its approximate consisting of blood, fragments of decidua, white
pregestational size. blood cells, mucus, and some bacteria is called
lochia.
➢ Sealing of the placenta site is accomplished by
➢ Separation of the placenta and membranes occurs
rapid contraction of the uterus immediately after
in the spongy layer or outer portion of the decidua
delivery of the placenta. Same contraction process
basalis of the uterus.
reduces the bulk of the uterus.
➢ it takes approximately 6 weeks (the entire
➢ The postpartal period primarily a period of healthy
postpartal period) for the placental implantation
change.
site to be healed.
➢ Immediately after birth, the uterus weighs about
➢ first 3 days after birth, a lochia discharge consists
1,000 g. At the end of the first week, it weighs 500
almost entirely of blood, with only small particles
g.
of decidua and mucus.
➢ By the time involution is complete (6 weeks),
Lochia Rubra- because of its mainly red color.
weighs approximately 50 g.
Lochia Serosa- flow becomes pink or brownish.
Lochia Alba- colorless or white with streaks of
brownish mucus.
-present in most women until the third week after
birth
Type of Color Postpartal Composition
Lochia Day
Lochia rubra Red 1–3 Blood,
fragments of
decidua, and
mucus

Lochia serosa Pink 3–10 Blood, mucus,

and invading
leukocytes
Lochia alba White 10–14 (may Largely mucus;
last 6 weeks) leukocyte
count high
➢ Uterine involution. The uterus decreases in size at
a predictable rate during the postpartal period.
The Cervix
After 10 days, it recedes under the pubic bone and
is no longer palpable. ➢ Immediately after birth, a uterine cervix feels soft
➢ Uterus of a breastfeeding mother may contract and malleable to palpation.
even more quickly because oxytocin, which is ➢ internal and external os are open.
released with breastfeeding, stimulates uterine ➢ After a vaginal birth, the external os usually
contractions. remains slightly open and appears slit-like or
➢ Involution will occur most dependably in a stellate (star shaped), whereas previously, it was
woman who is well nourished and who ambulates round, suggests that childbearing has taken place.
early after birth as gravity may play a role.
➢ The first hour after birth is potentially the most
dangerous time for a woman. If her uterus should
become relaxed during this time (uterine atony),
she will lose blood very rapidly because no
permanent thrombi have yet formed at the
placental site. The Vagina
Afterpains- in some women, contraction of the ➢ After a vaginal birth, the vagina feels soft, with
uterus after birth causes intermittent cramping. few rugae, and its diameter is considerably greater
Lochia than normal.
➢ Hymen is permanently torn.
Lochia- layer adjacent to the uterine cavity ➢ Because a woman who is breastfeeding may have
becomes necrotic and is cast off as a vaginal delayed ovulation.
discharge similar to a menstrual flow. This flow,
 ➢ Cause slight vaginal bleeding during sexual
intercourse until about 6 weeks’ time.
➢ If a woman practices Kegel exercises, the strength
and tone of the vagina will increase more rapidly;
important for the sexual enjoyment of both a
woman and her partner.
The Perineum
➢ Edematous and tender immediately after birth
because of the great amount of pressure
experienced during birth.
➢ Because of the great amount of pressure
experienced during birth, may give ice or warm
packs or a gentle pillow or doughnut pad to sit on.
➢ Pain relivers such as acetaminophen or
ibuprofen, and administer according to the
prescription orders when deemed necessary or by
maternal request.
SYSTEMIC CHANGES
The Hormonal System
➢ Pregnancy hormones begin to decrease as soon as
the placenta is no longer present.
➢ Levels of human chorionic gonadotropin (hCG)
and human placental lactogen (hPL) are almost
negligible by 24 hours.
➢ By week 1, progestin, estrogen, and estradiol are
all at prepregnancy levels.
➢ Follicle-stimulating hormone (FSH) remains low
for about 12 days and then begins to rise as a new
menstrual cycle is initiated.
The Urinary System
➢ During pregnancy, as much as 2,000 to 3,000 ml
of excess fluid accumulates in the body so
extensive diaphoresis (excessive sweating) and
diuresis (excess urine production) begin almost
immediately after birth to rid the body of this
fluid.
➢ Increases the daily urine output of a postpartal
woman from a normal level of 1,500 ml to as
much as 3,000 ml/day during the second to fifth
day after birth.
➢ Because during a vaginal birth, the fetal head
exerts a great deal of pressure on the bladder and
urethra decreases a woman’s ability to sense when
she has to void.
➢ To prevent permanent damage to the bladder from
overdistention, assess a woman’s abdomen
frequently in the immediate postpartal period.
The Circulatory System
➢ Blood volume returns to its normal prepregnancy
level by the first or second week after birth.
➢ The usual blood loss with a vaginal birth is 300 to
500 ml. With a cesarean delivery, it is 500 to
1,000 ml.
➢ Women usually continue to have the same high
level of plasma fibrinogen during the first
postpartal weeks as they did during pregnancy.
This is a protective measure against hemorrhage,
increases the risk of thrombus.
➢ The white blood cell count may be as high as
30,000 cells/mm3 (mainly granulocytes)
compared to a normal level of 5,000 to 10,000
cells/mm3 if labor is long and difficult; a defense
against infection and an aid to healing.
➢ Any varicosities that are present from pregnancy
will recede, but they rarely return to a completely
prepregnant appearance.
The Gastrointestinal System
➢ Digestion and absorption begin to be active again
soon after birth unless a woman has had a
cesarean delivery.
➢ Hemorrhoids (distended rectal veins) are often
present.
➢ Bowel sounds are active, but passage of stool
through the bowel may be slow because of the
still-present effect of relaxin (a hormone which
softens and lengthens the cervix and pubic
symphysis for preparation of the infant’s birth
during pregnancy) on the bowel.
The Integumentary System
➢ After birth, the stretch marks on a woman’s
abdomen (striae gravidarum) still appear
reddened and may be even more prominent than
during pregnancy, when they were tightly
stretched.
➢ Excessive pigment on the face and neck
(chloasma) and on the abdomen (linea nigra) will
become barely detectable by 6 weeks’ time.
➢ If diastasis recti (overstretching and separation of
the abdominal musculature) occurred, the area
will appear as a slightly indented bluish streak in
the abdominal midline.
➢ Modified sit-ups help to strengthen abdominal
muscles and return abdominal support to its
prepregnant level.
RETROGRESSIVE CHANGES OF THE
PUERPERIUM
Exhaustion
➢ For the last several months of pregnancy, she
probably experienced some difficulty sleeping.
➢ has “sleep hunger”
➢
Weight Loss
➢ The rapid diuresis and diaphoresis during the
second to fifth days after birth usually result in a
weight loss of 5 lb (2 to 4 kg), in addition to the
approximately 12 lb (5.8 kg) lost at birth.
➢ The weight a woman reaches at 6 weeks after
birth becomes her baseline postpartal weight
unless she continues active measures to lose the
weight.
VITAL SIGN CHANGES
➢ Reflect the internal adjustments that occur as a
woman’s body returns to its prepregnant state.
Temperature
➢ Temperature is always taken orally or
tympanically (never rectally) during the
puerperium because of the danger of vaginal
contamination and the discomfort involved in
rectal intrusion.
➢ A woman may show a slight increase in
temperature during the first 24 hours after birth
because of dehydration that occurred during labor.
If she takes in adequate fluid during the first 24
hours, this temperature elevation will return to
normal.
➢ Any woman whose oral temperature rises above
100.4°F (38°C), excluding the first 24-hour
period, is considered by criteria of the Joint
Commission on Maternal Welfare to be febrile,
and such a high temperature may indicate that a
postpartal infection is present.
➢ Occasionally, when a woman’s breasts fill with
milk on the third or fourth postpartum day during
lactogenesis II, her temperature will rise for a
period of hours because of the increased vascular
activity involved; this process is termed
engorgement.
➢ An infection of the breast during lactation is
termed mastitis.
➢ Mastitis can interfere with lactation, and
sometimes, an infant will refuse to nurse on the
affected side.
Pulse
➢ A woman’s pulse rate during the postpartal period
is usually slightly slower than usual.
➢ Stroke volume increases to accommodate the
increased blood volume returning to the heart.
➢ This increased stroke volume reduces the pulse
rate to between 60 and 70 beats/min.
➢ By the end of the first week, the pulse rate will
have returned to normal.
Blood Pressure
➢ a decrease in this can also indicate bleeding.
➢ an elevation above 140 mmHg systolic or 90
mmHg diastolic may indicate the development of
postpartal hypertension of pregnancy, an unusual
but serious complication of the puerperium.
➢ To evaluate blood pressure, compare a woman’s
pressure with her prepregnancy level if possible
rather than with standard blood pressure ranges;
otherwise, if her blood pressure rose during
pregnancy, a significant postpartal decrease in
pressure could be missed.
➢ If blood pressure is greater than 140/90 mmHg,
withhold the agent ( oxytocics) and notify the
woman’s primary care provider to prevent
hypertension and, possibly, a cerebrovascular
accident.
➢ If the pulse rate is increased by more than 20
beats/min and blood pressure is 15 to 20 mmHg
lower than formerly, the woman might be
susceptible to dizziness and fainting when she
ambulates.
➢ Advise her to always sit up slowly and “dangle”
on the side of her bed before attempting to walk.
PROGRESSIVE CHANGES OF THE PUERPERIUM
Lactation
➢ The early lactation process, which is driven by
hormones from the hypothalamus to the pituitary
gland in order to secrete the lactation hormones, is
identified by four phases of lactogenesis (human
milk production).
➢ Prolactin hormone is responsible for milk
production, and oxytocin is responsible for the let-
down reflex arch.
➢ The lactogenesis I (milk synthesis) process begins
around 16 weeks gestation as the glandular
luminal cells in the breast begin secreting
colostrum, a thin, watery prelactation secretion.
 ➢ Lactogenesis II is triggered at birth by the
delivery of the placenta, when the progesterone
hormone (prolactin is no longer inhibited) and
other circulating pregnancy hormones suddenly
decrease and oxytocin sharply increases as a result
of the infant suckling.
➢ Oxytocin helps the uterus to shrink to its
prepregnancy size; some mothers will feel uterine
cramps initially when breastfeeding until the
uterus fully involutes. Lactogenesis II is often
when mothers feel that their “milk has come in”
(engorgement) and occurs from birth to 5 to 10
days postpartum; this is often termed “transitional
milk.”
➢ Lactogenesis III can occur from day 10 until
weaning postpartum, when the “mature milk”
supply is now driven by the circulating lactation
hormones oxytocin and progesterone.
➢ Lactogenesis IV occurs after complete weaning
and the breasts involute to their prelactation state.
Other hormones are associated with breastfeeding,
such as endorphins and oxytocin, and may help to
mitigate and reduce the risk of developing
postpartum depression.
➢ Breast milk forms in response to the decrease in
estrogen and progesterone levels that follows
delivery of the placenta (which stimulates
prolactin production and, consequently, milk
production) and an increase in prolactin and
oxytocin.
➢ feeling of tension in the breasts on the third or
fourth day after birth is termed primary
engorgement.
AMERICAN ACADEMY OF PEDIATRICS TEN
STEPS TO SUPPORT PARENTS’ CHOICE TO
BREASTFEED
1. Make a commitment to the importance of breastfeeding.
2. Train all staff in skills necessary to support
breastfeeding.
3. Inform women and families about the benefits and
management of breastfeeding.
4. Assess infants during early follow-up visits.
5. Encourage mothers to breastfeed on demand.
6. Show mothers how to breastfeed and how to maintain
lactation when they will be away from their babies.
7. Use appropriate anticipatory guidance that supports
exclusive breastfeeding until infants are about 6 months
old.
8. Support breastfeeding by providing accurate
information about maternal issues.
9. Communicate support for breastfeeding in the office
environment.
10. Expand the network of support for breastfeeding.
RETURN OF MENSTRUAL FLOW
➢ The resulting decrease in hormone concentrations
causes a rise in production of FSH by the
pituitary, which leads, with only a slight delay, to
the return of ovulation. This initiates the return of
normal menstrual cycles.
➢ A woman who is not breastfeeding can expect her
menstrual flow to return in 6 to 10 weeks after
birth. If she is breastfeeding, a menstrual flow
may not return for 3 or 4 months (lactational
amenorrhea) or, in some women, for the entire
lactation period.
NURSING CARE OF A WOMAN AND FAMILY
DURING THE FIRST 24 HOURS AFTER BIRTH
➢ Skin-to-skin cuddling with the newborn should be
encouraged as well as offering the newborn the
breast to try to suckle.
➢ Hemorrhage is still a possibility for the first 2 or 3
days after birth, until the myometrial vessels have
sclerosed.
NURSING DIAGNOSES AND RELATED
INTERVENTIONS
Provide Pain Relief for Afterpains
➢ It’s usually helpful to assure a woman that this
type of discomfort, although painful, is normal
and rarely lasts longer than 3 days. If necessary,
either ibuprofen (such as Motrin), which has anti-
inflammatory and antiprostaglandin properties, or
a common analgesic such as acetaminophen (such
as Tylenol) is effective for pain relief. As with any
abdominal pain, heat to the abdomen should be
avoided because it could cause relaxation of the
uterus and subsequent uterine bleeding. Remind
the woman that the total 24-hour dose for
acetaminophen is 3,000 mg so she does not take
an excessive amount after returning home.
Relieve Muscular Aches
 ➢ A backrub is usually effective for relieving an
aching back or shoulders, but some woman may
appreciate a mild analgesic such as acetaminophen
for the pain.
➢ Assess a woman who states she has intense
warmth or pain in the calf of her leg on standing is
Homans sign and could indicate that
thrombophlebitis is present.
Administer Cold and Hot Therapy
➢ Applying an ice or cold pack to the perineum
during the first 24 hours reduces perineal edema
and the possibility of hematoma formation and
also reduces pain and promotes healing and
comfort.
➢ Ice to the perineum after the first 24 hours is no
longer therapeutic. Dry heat in the form of a
perineal hot pack or moist heat with a sitz bath are
both effective ways to increase circulation to the
perineum, provide comfort, reduce edema, and
promote healing.
Promote Perineal Exercises
➢ The most effective exercise consists of contracting
and relaxing the muscles of the perineum 5 to 10
times in succession, as if trying to stop voiding
(Kegel exercises).
➢ aids comfort by improving circulation to the area
and decreasing edema.
Give Suture Line Care for Women With An
Episiotomy
➢ You can assure a woman that discomfort is normal
and does not usually last longer than 5 or 6 days.
➢ providers prescribe a soothing anesthetic cream or
spray to be applied to the suture line to reduce
discomfort.
➢ A cortisone-based cream or warm sitz bath helps
to decrease inflammation and relieve tension in
the area.
Provide Perineal Care
➢ To reduce these risks, teach a woman to include
perineal care as part of her daily bath or shower
and after every voiding or bowel movement.
➢ A second common method of cleaning is to spray
the perineum with clear tap water from a spray
bottle.
Promote Perineal Self-Care
➢ Remind her of the importance of applying any
cream or medication that has been prescribed.
Promote Rest in the Early Postpartal Period
➢ If a woman has discomfort from hemorrhoids,
perineal stitches, or afterpains, be certain to
supply adequate pain relief so she can rest
comfortably or sleep.
➢ Although a woman may choose any position to
sleep, she may enjoy being able to sleep on her
stomach, something she was not able to do during
the latter part of pregnancy.
Promote Rest Throughout the Puerperium
➢ sleeping while her baby naps or asking for respite
time from baby care so she can nap.
➢ extreme fatigue is also associated with the
development of postpartal depression.
Promote Adequate Fluid Intake
➢ You may need to encourage an individual woman
to drink more fluid because she is restricting fluid
in the hope of preventing her breasts from
becoming engorged or is beginning to diet in the
hope of bringing her body more quickly back to
its nonpregnant slim state.
Promote Urinary Elimination
➢ Encourage a woman to walk to the bathroom and
void at the end of the first hour after birth to help
prevent bladder distention.
➢ If the woman still has not been able to void by 4 to
8 hours after birth, and bladder distention is
present, she will need to be catheterized to relieve
bladder pressure.
➢ Some women experience urinary incontinence
during the postpartal period, probably resulting
from poor perineal tone and sensation. Suggest
Kegel exercises to strengthen perineal muscles
and eliminate incontinence in the future.
Prevent Constipation
➢ Constipation occurs because of relaxation of the
abdominal wall and the intestine, now that they
are no longer compressed by the bulky uterus.
➢ To prevent constipation, early ambulation, a diet
with adequate roughage, and an adequate fluid
intake are all helpful measures.
➢ Many women are prescribed a stool softener such
as docusate sodium (Colace) beginning with the
first day after birth.
➢ If a woman has not moved her bowels by the third
postpartum day, a mild laxative or cathartic may
be prescribed.
Assess Peripheral Circulation
 ➢ As a rule, women who ambulate quickly feel
stronger and healthier by the end of their first
week and have fewer bowel, bladder, and
circulatory complications than those who do not.
➢ To determine if peripheral circulation is adequate,
assess a woman’s thigh for skin turgor.
➢ if peripheral circulation is adequate, assess a
woman’s thigh for skin turgor. Assess for edema
at the ankle and over the tibia on the lower leg.
➢ Assess also for redness in the calf area because
thrombophlebitis can be present even with a
negative Homans sign.
Prevent/Alleviate Breast Engorgement
➢ encouraging her newborn to attempt to latch at the
breast is the main treatment for relief of the
tenderness and soreness of primary breast
engorgement.
➢ application of warm compresses or standing under
a warm shower beneficial to relieve the
discomfort of engorgement.
➢ Good support from a bra also offers relief because
it prevents unnecessary strain on the supporting
muscles of the breasts and positions the breasts in
good alignment.
Promote Breast Hygiene
➢ Teach a woman to wash her breasts daily with
clear water and gentle soap at the time of her bath
or shower and then dry them with a soft towel.
MUSCLE-STRENGTHENING EXERCISES
st
Abdominal breathing- 1 day after birth.
Chin-to-chest- 2nd day after birth.
Perineal contraction- 3rd day after birth.
Arm raising- Arm raising helps both the breasts and the
abdomen return to good tone and is a good exercise to add
on the fourth day.
Abdominal crunches- It is advisable to wait until the 10th
or 12th day after birth.
MATERNAL IMMUNIZATIONS
➢ recommend that each pregnant woman receive a
Tdap and seasonal influenza vaccine with each
pregnancy.
➢ Determine if this was provided prenatally to the
women, and if not, inform her primary provider of
the need to administer the Tdap and seasonal
influenza (if applicable) vaccines prior to
discharge.
➢ If a woman does not have an adequate rubella
antibody titer and anticipates further pregnancies,
she should also be asked if she wants a rubella
immunization before discharge.
➢ Women who are Rh negative and who have had
an Rh-positive infant will receive Rho (D)
immunoglobulin (RhIG) or Rh antibodies to
prevent isoimmunization concerns in a future
pregnancy.
POSTPARTAL EXAMINATION
➢ Every woman should have a checkup by her
primary care provider at 4 to 6 weeks after birth
(the end of the postpartal period) to assure herself
and her healthcare provider that she is in good
health and has no residual problems from her
pregnancy or signs of postpartum depression.
SIX-WEEK PHYSICAL ASSESSMENT
Area of Assessment Data Collection
History Assess chief concern, family profile
(support system, bonding, self-esteem,
family integrity), interval history, and
review of systems (urinary system for pain,
frequency, or stress incontinence along
with gastrointestinal tract and reproductive
tract in particular). Assess maternal intake
because some new mothers are too
fatigued to eat well.
Physical Expected Findings
Examination
General appearance Alert; positive mood. If not, woman is
probably still extremely fatigued.
Weight Achievement of prepregnant weight; if not,
this will be her baseline postpregnant
weight.
Hair Healthy, firm hair; excess loss of hair from
early postpartal period has halted.
Eyes Pink and moist conjunctiva; if pallor
persists, diet may be inadequate in iron.
Breasts Full and firm to palpation; blue
(Breastfeeding veins prominent under skin. Areola
woman)
darkens and nipple elongates. No
palpable nodules or lumps. If
erythematous or extremely tender,
mastitis or nipple fissure may be
 present. An occasional filled milk
gland may present as a lump;
reexamine after breastfeeding. Nursing Care Planning Based on 2020 National Health
Nonbreastfeeding Return to prepregnant size; no palpable Goals
woman nodules or lumps.
Abdomen Striae less prominent; linea nigra fading, A number of 2020 National Health Goals speak directly to
muscle tone improving. No distended the newborn period:
bowel from constipation. No distended
bladder from retention. No history of pain, • Increase the proportion of mothers who breastfeed their
frequency, or blood on urination. Urinary
symptoms probably reflect urinary babies in the early postpartal period from a baseline of
infection that needs specific treatment. 74% to 81.9%.
Perineum and uterus Lochia no longer present; cervix closed;
uterus has returned to prepregnant size. • Increase the proportion of mothers who continue
Pap test is normal. Ask woman to bear exclusive breastfeeding until their babies are 3 months old
down during pelvic examination to observe
for uterine prolapse, rectocele, or from a baseline of 33.6% to 46.2%.
cystocele. If involution is not complete,
reason for subinvolution must be • Increase the percentage of healthy full-term infants who
investigated. are put to sleep on their backs from a baseline of 69% to
Lower extremities Varicosities barely noticeable 75.9%.
Rectum Hemorrhoids receded to prepregnant size
or are no longer observable. • Reduce the proportion of young children aged 3 to 5
Mental Positive interaction with infant,
appropriate personal hygiene (clean hair, years with dental caries in their primary teeth (which
etc.). No indication of postpartal could originate from nighttime bottle feeding) from a
depression or psychosis is present. baseline of 33.3% to 30%.
Laboratory Reports
Laboratory Values Hct: 37%; Hgb: 11-12 g/100mL. If these • Reduce the perinatal mortality rate to no more than 5.9
are low, reassess diet; possibly iron
supplement may be needed.
per 1,000 live births from a baseline of 6.6 per 1,000 live
Immunization Status Assess need for humas papillomavirus births.
(HPV) [Gardasil] or rubella vaccine.

➢ Nurses can help the nation achieve these goals by

encouraging women to not only begin
NURSING CARE of a FAMILY with a NEWBORN breastfeeding but to also continue breastfeeding
through the first 6 months of life, by advising
➢ Within minutes after being plunged into this
parents of the importance of placing infants in
strange environment, a newborn has to initiate
their own beds and on their backs to sleep, and
respirations and adapt a circulatory system to
advising parents of the danger of tooth decay from
extrauterine oxygenation. Within 24 hours,
allowing a baby to drink from a bottle of milk or
neurologic, renal, endocrine, gastrointestinal, and
juice while falling asleep.
metabolic functions must be operating
competently for life to be sustained.
Neonatal Period (the time from birth through the THE PROFILE OF A NEWBORN
first 28 days of life)
Assessing the Average Newborn
Vital Statistics
➢ Vital statistics measured for a newborn usually
consist of the baby’s weight, length, and head and
chest circumferences.
Weight
➢ As long as newborns are breathing well, they are
weighed nude and without a blanket soon after
birth in the birthing room.
➢ Measurements such as body length and head,
chest, and abdominal circumferences are also
done but can be obtained later because performing
 these measurements while an infant is still damp
exposes the newborn unnecessarily to chilling.
➢ A newborn’s weight is important because it helps
to determine maturity as well as establish a
baseline against which all other weights can be
compared.
➢ Following this initial weight, an infant is weighed
nude once a day, at approximately the same time
every day, during a hospital or birthing center
stay.
➢ Plotting weight this way helps identify newborns
who are at risk because they are less than usual
weight.
➢ If a term newborn weighs more than 4.7 kg, the
baby is said to be macrosomic, a condition that
usually occurs in conjunction with a maternal
illness, such as gestational diabetes.
Length
➢ A newborn’s length at birth in relation to weight is
a second important determinant used to confirm
that a newborn is healthy.
➢ mature female newborn is 49 cm (19.2 in.);
mature males, is 50 cm (19.6 in.);
Head Circumference
➢ tape measure drawn across the center of the
forehead and then around the most prominent
portion of the posterior head (the occiput).
Chest Circumference
➢ Chest circumference is measured at the level of
the nipples.
➢ The chest circumference in a term newborn is
about 2 cm (0.75 to 1 in.) less than head
circumference.
VITAL SIGNS
Temperature
➢ temperature of newborns is about 99°F (37.2°C) at
birth because they have been confined in their
mother’s warm and supportive uterus.
➢ the temperature of birthing rooms (approximately
68° to 72°F [21° to 22°C])
The majority of heat loss occurs because of four separate
mechanisms:
Convection- flow of heat from the newborn’s body
surface to cooler surrounding air. Eliminating drafts, such
as from air conditioners, is an important way to reduce
convection heat loss.
Radiation- is the transfer of body heat to a cooler solid
object not in contact with the baby, such as a cold window
or air conditioner. Moving an infant as far from the cold
surface as possible helps reduce this type of heat loss.
Conduction- transfer of body heat to a cooler solid object
in contact with a baby. For example, a baby placed on the
cold base of a warming unit quickly loses heat to the
colder metal surface. Covering surfaces with a warmed
blanket or towel is necessary to help minimize conduction
heat loss.
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. To prevent this type of heat loss, lay a
newborn on the mother’s abdomen immediately after birth
and cover with a warm blanket for skin-to-skin contact.
Drying the infant—especially the face and hair—also
effectively reduces evaporation because the head, which is
a large surface area in a newborn, can be responsible for a
great amount of heat loss. Covering the hair with a cap
after drying further reduces the possibility of evaporation
cooling.
➢ Newborns can conserve heat by constricting blood
vessels and moving blood away from the skin.
Brown fat (found in the intrascapular region, the
thorax, and behind the kidneys) 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.
➢ able to increase their metabolic rate and produce
more heat include kicking and crying.
➢ If chilling is prevented by these methods, a
newborn’s temperature stabilizes at 98.6°F (37°C)
within 4 hours after birth.
Pulse
➢ The heart rate of a fetus in utero averages 110 to
160 beats/min.
➢ Immediately after birth, the heart rate may be as
rapid as 180 beats/min.
➢ Within 1 hour after birth, as the newborn settles
down to sleep, the heart rate stabilizes to an
average of 120 to 140 beats/min.
➢ 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 result from the incomplete closure
of fetal circulation shunts.
➢ During crying it rises to 180 bpm, decreases
during sleep ranging from 90-110 bpm.
 ➢ newborn’s heart rate is best determined by
listening for an apical heartbeat for a full minute
rather than assessing a pulse in an extremity or
over the carotid artery.
➢ Always palpate for femoral pulses and document
that they are present because their absence
The Gastrointestinal System
suggests possible coarctation (narrowing) of the
aorta, which is a cardiovascular abnormality.
Respiration
➢ The respiratory rate of a newborn in the first few
minutes of life may be as high as 90 breaths/min.
➢ over the next hour, this rate will settle to an
average of 30 to 60 breaths/min.
➢ Coughing and sneezing reflexes are present at
birth and help clear the airway.
Stools
➢ Newborns are obligate nose breathers.
Blood Pressure
➢ The blood pressure of a newborn is approximately
80/46 mmHg at birth. By the 10th day, it rises to
about 100/50 mmHg and remains at that level for
the infant year.
PHYSIOLOGIC FUNCTIONS
Cardiovascular System
➢ the lungs are responsible for oxygenating blood
that was formerly oxygenated by the placenta.
➢ The peripheral circulation of a newborn remains
sluggish for at least the first 24 hours, which can
cause cyanosis in the infant’s feet and hands
(acrocyanosis) and for a newborn’s feet to feel
cold to the touch.
Blood Values
BLOOD VALUES NORMAL VALUES
blood volume 80 to 110 ml/kg
hemoglobin 17 to 18 g/100 ml
hematocrit 45% and 50%
red blood cell 6 million cells/mm3
bilirubin level 1 and 4 mg/100 ml
white blood cell count 15,000 to 30,000 cells/mm3 at
birth (40,000 cells/mm3 if the
birth was stressful)
The Urinary System
Blood Coagulation
➢ Vitamin K used to prevent and treat hemorrhagic
disease in newborns. It is a necessary component
for the production of certain coagulation factors
(II, VII, IX, and X) and is produced by
microorganisms in the intestinal tract
The Respiratory System
➢ Some fluid present in the lungs from intrauterine
life makes a newborn’s first breath possible
because fluid eases surface tension on alveolar
walls and allows alveoli to inflate more easily than
if the lung walls were dry.
➢ Although the gastrointestinal tract is usually
sterile at birth, bacteria may be cultured from the
tract in most babies within 5 hours after birth and
from all babies at 24 hours of life.
➢ The accumulation of bacteria is helpful because
bacteria in the gastrointestinal tract are necessary
for digestion through probiotics and for the
synthesis of vitamin K.
➢ The first stool of a newborn is usually passed
within 24 hours after birth. It consists of
meconium, a sticky, tar-like, blackish-green,
odorless material formed from mucus, vernix,
lanugo, hormones, and carbohydrates that
accumulated in the bowel during intrauterine life.
➢ If a newborn does not pass a meconium stool by
24 to 48 hours after birth.
➢ About the second or third day of life, newborn
stool changes in color and consistency. Termed a
transitional stool, bowel contents appear both
loose and green; they may resemble diarrhea to
the untrained eye.
➢ By the fourth day of life, breastfed babies pass
three or four light yellow stools per day that have
a soft consistency. They are not foul smelling
because breast milk is high in lactic acid, which
reduces the amount of putrefactive organisms in
the stool.
➢ newborn who receives formula usually passes two
or three bright yellow stools a day of soft
consistency. These have a more noticeable odor.
➢ A newborn placed under phototherapy lights as
therapy for jaundice will have bright green stools
because of increased bilirubin excretion.
➢ average newborn voids within 24 hours after birth.
➢ A single voiding in a newborn is only about 15 ml
and may be easily missed in an absorbent diaper.
➢ The daily urinary output for the first 1 or 2 days is
about 30 to 60 ml total.
➢ By week 1, total daily volume rises to about 300
ml.
 ➢ first voiding may be pink or dusky because of uric
acid crystals that were formed in the bladder in
utero.
The Immune System
➢ Newborns have limited immunologic protection at
birth because they are not able to produce
antibodies until about 2 months (the reason most
immunizations are not administered until 2
months of age).
➢ Newborns are born with passive antibodies
(immunoglobulin G) passed to them from their
mother that crossed the placenta.
➢ administered a hepatitis B vaccine.
The Neuromuscular System
➢ Limpness or total absence of a muscular response
to manipulation is not normal and suggests
narcosis, shock, or cerebral injury.
NEWBORN REFLEXES
REFLEXES MEANING
Blink Reflex to protect the eye from any object coming near it
by rapid eyelid closure.
Rooting Reflex If a newborn’s cheek is brushed or stroked near
the corner of the mouth, the infant will turn the
head in that direction. This reflex serves to help
a newborn find food; when a mother holds the
child and allows her breast to brush the
newborn’s cheek, the reflex causes the baby to
turn toward the breast. Disappears at about 6 th
week.
Sucking Reflex Newborn’s lips are touched, the baby makes a
sucking motion, helps a newborn find food.
begins to diminish at about 6 months of age.
Swallowing Gag, cough, and sneeze reflexes also are present
Reflex in newborns to maintain a clear airway.
Extrusion In order to prevent the swallowing of inedible
Reflex substances, a newborn extrudes any substance
that is placed on the anterior portion of the
tongue. Fades at 4 months.
Palmar Grasp This reflex disappears at about 6 weeks to 3
Reflex months of age
Step (Walk)-in- Newborns who are held in a vertical position
Place Reflex with their feet touching a hard surface will take a
few quick, alternating steps. Disappears by 3
months
Placing Reflex elicited by touching the anterior lower leg
against a surface such as the edge of a table.
Plantar Grasp When an object touches the sole of a newborn’s
Reflex foot at the base of the toes, the toes grasp in the
same manner as the fingers. disappears at about
8 to 9 months
Tonic Neck AKA “boxer” or “fencing reflex.” When the arm
Reflex and leg on the side toward which the head is
turned extend, and the opposite arm and leg
contract. Purpose not known.
Moro (startle) Elicited with a loud noise or by jarring the
Reflex bassinet. Reflex simulates the action of someone
trying to ward off an attacker and then covering
up to protect the body. Strong at first 8 weeks,
fades by end of 4th & 5th mos.
Babinski Reflex When the sole of a newborn’s foot is stroked in
an inverted “J” curve from the heel upward, a
newborn fans the toes (positive Babinski sign).
Last until at least 3 mos.
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.
Crossed When a newborn is lying supine, if one leg is
Extension extended and the sole of that foot is irritated by
Reflex 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.
Trunk When the paravertebral area is stroked, the
Incurvation newborn flexes his or her trunk toward the
Reflex direction of the stimulation.
Landau Reflex When a newborn is supported in a prone position
by a hand, the newborn should demonstrate
some muscle tone.
Deep Tendon Both a patellar and a biceps reflex are intact in a
Reflexes newborn.
The Senses
➢ So important for survival, are already fully
developed at birth.
Hearing
➢ Newborns appear to recognize their mother’s
voice almost immediately and calm to the sound
since they have heard it in utero.
➢ By 25 to 27 weeks gestation, hearing is functional
and the fetus can hear the mother’s heartbeat and
voice.
Vision
➢ pupillary reflex or ability to contract the pupil is
present from birth.
➢ blink or squint reflex in response to a bright light
in utero by 26 weeks gestation.
Touch
➢ sense of touch is also well developed at birth.
Taste
➢ newborn has the ability to discriminate taste
because taste buds are developed and functioning
even before birth.
➢ Fetus will swallow amniotic fluid more rapidly
than usual if glucose is added to sweeten its taste
decreases if a bitter flavor is added.
Smell
 ➢ sense of smell is present in newborns as soon as Color- All infants appear cyanotic at the moment of birth,
the nose is clear of lung and amniotic fluid. grow pink with or shortly after the first breath.
Acrocyanosis (cyanosis of the hands and feet) is so
APGAR SCORING common in newborns that a score of 1 in this category can
be thought of as normal.
➢ At 1 minute and 5 minutes after birth, newborns
Respiratory Evaluation- Good respiratory function has
are observed and rated according to an Apgar
the highest priority in newborn care, so the assessment for
score, an assessment scale used as a standard for
newborn evaluation since 1958. it is ongoing at every newborn contact. For this
➢ The newborn is considered to be “vigorous” if the
assessment, a newborn is observed and then scored on
each of five criteria.
initial scores are 7 and above. If the five-minute
score is less than 7, coring is done every five
minutes thereafter until the score reaches 7. The
numbers in the left-hand column represent the
number of points that are assigned to each
parameter when the criteria in the corresponding
column are met.

Total score: 0 indicates no respiratory distress; 1-3 indicates mild

distress; 4-6 indicate moderate distress; 7-10 indicate severe distress
Heart Respirato Muscle Reflex Color
Rate ry Effort Tone Irritabili Grading of neonatal respiratory distress based on the Silverman-
ty Andersen index. A controlled clinical trial of effects of water mist on
2 Heart Strong, Maintains Cries or Body and obstructive respiratory signs, death rate and necroscopy findings among
rate vigorous a position sneezes extremiti premature infants.
>100 cry of flexion when es pink
beats with brisk stimulate
per movemen d
minut ts THE BRAZELTON NEONATAL BEHAVIORAL
e
(bpm) ASSESSMENT SCALE
1 Heart Weak cry, Minimal Grimaces Body
rate slow or flexion of when pink, ➢ rating scale of six different categories of behavior:
presen difficult extremiti stimulate extremiti habituation, orientation, motor maturity, variation,
t, but respiration es d es blue self-quieting ability, and social behavior and was
s
0 No No Limp and No Body and
devised by Brazelton in the early 1970s to
heart respiratory flaccid response extremiti evaluate a newborn’s behavioral capacity or
rate effort to es blue ability to respond to set stimuli.
stimulatio (cyanosis
n ) or
➢ takes 20 to 30 minutes to complete.
complete ➢ the infant is scored on best performance rather
ly pale than on average performance.
(pallor)
Heart Rate- heart rate also may be obtained by observing
and counting the pulsations of the umbilical cord at the
abdomen if the cord is still uncut. THE APPEARANCE OF A NEWBORN

Respiratory Effort- counted by observing chest The Skin

movements. Difficulty with breathing might be anticipated
in a newborn whose mother received large amounts of
analgesia or general anesthetic during labor or birth.
The Color
Muscle Tone- Muscle tone is tested by observing their
resistance to any effort to extend their extremities.
Reflex Irritability- One of two possible cues is used to
evaluate reflex irritability: response to a suction catheter in
the nostrils or response to having the soles of the feet
slapped.
➢ newborn’s skin includes color, any birthmarks,
and general appearance.
➢ Most term newborns have a ruddier complexion
for their first month than they will have later in
life because of the increased concentration of red
blood cells in their blood vessels and a decrease in
the amount of subcutaneous fat, which makes
blood vessels more visible.
Cyanosis- The lips, hands, and feet are likely to appear Nevus flammeus- Present at birth.
blue from immature peripheral circulation (acrocyanosis).
Location: • Port wine: face, thighs • Stork bites: nape of
Acrocyanosis is a normal finding at birth through the first
neck.
24 to 48 hours after birth.
Treatment: • Port wine: ○ May spontaneously fade ○
Central cyanosis, or cyanosis of the trunk, is always a
Cosmetically cover ○ Laser later in life • Stork bites: do
cause for concern. Indicates decreased oxygenation that
not fade; no treatment because usually covered by hair.
could be occurring as the result of a temporary respiratory
obstruction and also could reflect a serious underlying
respiratory or cardiac disease. In newborns, always suction
the mouth before the nose because suctioning the nose
first may trigger a reflex gasp, possibly leading to
aspiration.
Hyperbilirubinemia- caused by the accumulation of
excess bilirubin in blood serum. Skin and sclera of the Infantile hemangiomas (also called strawberry
eyes begin to appear noticeably yellow on the second or hemangiomas)- Appear at birth or within 2 weeks after
third day of life as a result of a breakdown of fetal red birth.
blood cells (called physiologic jaundice). Location: Can occur anywhere on the infant; most
Occurs because, as the high red blood cell count built up common on scalp, face, neck.
in utero is being reduced, heme and globin are released. Treatment: Surgical excision is rarely done due to risk for
Cephalohematoma is a collection of blood under complications.
the periosteum of the skull bone caused by
pressure at birth.
Acute bilirubin encephalopathy or kernicterus-
above normal indirect bilirubin levels are
potentially dangerous because, if enough indirect Cavernous hemangioma- Caused by dilated vascular
bilirubin (about 20 mg/100 ml) leaves the spaces.
bloodstream, it can interfere with the chemical
Location: Most commonly appear on the face, behind the
synthesis of brain cells, resulting in permanent cell
ears, and the neck.
damage.
Treatment: Surgical removal if they interfere with sight or
Pallor- Pallor in newborns is potentially serious because it
breathing.
usually occurs as the result of anemia.
The Harlequin Sign- 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, as if a line had been drawn down
the center of the body. The odd coloring fades Mongolian Spots
immediately if the infant’s position is changed or the baby
kicks or cries. ➢ collections of pigment cells (melanocytes) that
appear as slate collections of pigment cells
Birthmarks (melanocytes) that appear as slate. Tend to occur
➢ It is important to be able to differentiate the most often in children of Asian, Southern
various types of hemangiomas that occur because European, or African ethnicity and disappear by
some are more serious than others. school age without treatment.

Hemangiomas- are vascular tumors of the skin and occur Vernix Caseosa
in three distinct types. ➢ white, cream cheese–like substance that serves as
a skin lubricant in utero.
➢ Handle newborns with gloves to protect yourself
VASCULAR DISORDERS OF THE NEWBORN from exposure to vernix.
Lanugo
➢ the fine, downy hair that covers a term newborn’s
shoulders, back, upper arms, and possibly also the
forehead and ears.
Desquamation
➢ Within 24 hours after birth, the skin of most newborns
begins to dry; evident on the palms of the hands and
soles of the feet.
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 of every
newborn. Disappear by 3 to 4 weeks of age.
Erythema Toxicum
➢ rash usually appears in the first to fourth day of
life but may appear as late as 2 weeks of age.
➢ sometimes called a flea-bite rash because the
lesions are so minuscule.
Forceps Marks
➢ leave a circular or linear contusion matching the
rim of the forceps blade on the infant’s cheek.
➢ mark disappears in 1 to 2 days, along with the
edema that accompanies it.
Skin Turgor
➢ Grasp a fold of the skin between your thumb and
fingers and evaluate if it feels elastic. When
released, the skin should fall back to form a
smooth surface.
The Head
Fontanelles
➢ The anterior fontanelle is located at the junction
of the two parietal bones and the two fused frontal
bones. Normally closes at 12 to 18 months of age
➢ The posterior fontanelle is located at the junction
of the parietal bones and the occipital bone.
Closes by the end of the second month.
Sutures
➢ Sagittal suture between the parietal bones
overrides, the fontanelles are less perceptible than
usual. The overriding subsides in 24 to 48 hours.
➢ Wide separation suggests increased intracranial
pressure because of abnormal brain formation,
abnormal accumulation of cerebrospinal fluid in
the cranium (hydrocephalus), or an accumulation
of blood from a birth injury such as subdural
hemorrhage.
Molding
➢ You can assure parents the head will evolve to a
more rounded shape within a few days after birth.
➢
Caput Succedaneum
➢ edema of the scalp that forms on the presenting
part of the head.
Cephalohematoma
➢ collection of blood between the periosteum of a
skull bone and the bone itself, is caused by rupture
of a periosteal capillary because of the pressure of
birth.
Craniotabes
➢ localized softening of the cranial bones probably
caused by pressure of the fetal skull against the
mother’s pelvic bone in utero.
➢ The condition corrects itself without treatment
after a few months as the infant ingests calcium
from milk.
The Eyes
➢ It’s rare to see tears in a newborn because their
lacrimal ducts do not fully mature until about 3
months of age.
➢ The iris will assume its permanent color between
3 and 12 months of age.
➢ Pressure during birth sometimes ruptures a
conjunctival capillary of the eye, resulting in a
small subconjunctival hemorrhage on the sclera.
The Ears
➢ A newborn’s external ear is not as completely
formed as it will be eventually, so the pinna tends
to bend forward easily. In a term newborn,
however, the pinna should be strong enough to
recoil after bending.
The Nose
➢ A newborn’s nose usually has milia present and
tends to appear large for the face.
The Mouth
➢ A newborn’s mouth should open evenly when he
or she cries. If one side of the mouth curves more
than the other, facial nerve injury may have
occurred. The tongue may appear short or “tongue
tied” because the frenulum membrane is attached
close to the tip.
➢ It is highly unusual for a newborn to have teeth,
but sometimes one or two (called natal teeth) will
have erupted.
The Neck
➢ The neck of a newborn appears short with creased
skin folds. The head should rotate or turn freely on
it. If the neck is rigid, congenital torticollis,
caused by injury to the sternocleidomastoid
muscle during birth, might be present.
➢ but may not be observable until it is stronger at
The Chest
➢ chest in 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). The chest averages 2 cm (0.75 to 1
in.) smaller in circumference than the head and is
as wide in the anteroposterior diameter as it is
across. Both right and left sides should appear
symmetric. At around 2 years of age, the chest
measurement typically exceeds that of the head.
➢ A crepitus (crackling) or an actual separation of
one or both clavicles suggests a fracture occurred
during birth (can happen with large infants).
➢ Occasionally, the breasts may secrete a thin,
watery fluid popularly termed witch’s milk.
➢ Fluid should never be expressed from infants’
breasts because the manipulation could introduce
bacteria and lead to mastitis (infection of the
breast).
➢ Fluid should never be expressed from infants’
breasts because the manipulation could introduce
bacteria and lead to mastitis (infection of the
breast).
➢ An abnormal sound, such as grunting, suggests
respiratory distress syndrome, and a high,
crowing sound on inspiration suggests stridor or
immature tracheal development, both conditions
that need immediate consultation.
The Abdomen
➢ The contour of a newborn abdomen looks slightly
protuberant (protruding; bulging).
➢ For the first hour after birth, the stump of the
umbilical cord appears as a white, gelatinous
structure marked with the blue and red streaks of
the one umbilical vein and the two arteries. After
the first hour of life, the cord will begin to dry,
shrink, and turn brown as if it were the dead end
of a vine. By the second or third day, it will have
turned black. On day 6 to 10, it breaks free,
leaving a granulating area a few centimeters wide
that will heal during the following week.
➢ There should be no bleeding at the base of the
cord and it should not appear wet, moist or
odorous cord suggests infection.
➢ To finish an abdominal assessment, elicit an
abdominal reflex. Stroking each quadrant of the
abdomen with a finger should cause the umbilicus
to move or “wink” in that direction. This
superficial abdominal reflex, a test of spinal
nerves T8 through T10, is usually present at birth,
about the 10th day of life.
❖ Identification and registration
o Identification band (mother’s hospital number; the
•mother’s name; and the sex, date, and time of the
infant’s birth)
o Birth registration
• [infant’s name, the mother’s name, the father’s name
(if the mother chooses to reveal this), and the birth date
and place are recorded.]
o Birth record documentation
• Time of birth
• Time the infant breastfed
• Whether respirations were spontaneous or aided
• Apgar score at 1 minute and at 5 minutes of life
• Whether eye prophylaxis was given
• Whether vitamin K was administered
• General condition of the infant
• Number of vessels in the umbilical cord
• Whether cultures were taken
• Whether the infant voided and whether he or she
passed a stool
❖ Ineffective thermoregulation
o Keep infant warm and dry.
o Skin-to-skin contact
❖ Ineffective airway clearance
o Promote adequate breathing pattern.
o Prevent aspiration.
o Record first cry.
❖ Risk for infection
o Inspect, care of umbilical cord
o Administer eye care.
o Infection precautions
❖ Initial feeding
❖ Bathing
•Check to be certain the mother’s room is warm (about 75°F
[24°C]) to prevent chilling. Supply bath water at 98° to 100°F
(37° to 38°C), a temperature that feels pleasantly warm to the
elbow or wrist, plus a washcloth, towel, comb, and clean
diaper and shirt. Cleanest parts of the body to the most soiled
areas—that is, from the eyes and face to the trunk and
extremities and, last, to the diaper area.
❖ Sleeping position
 •place infant on the back to sleep; use a firm sleep surface;
breastfeeding; room sharing without bed sharing; routine
immunizations; consideration of using a pacifier; avoidance
of soft bedding, overheating; and exposure to tobacco smoke,
alcohol, and illicit drugs
❖ Diaper area care
❖ Metabolic screening tests
❖ Hepatitis B vaccination
•first
vaccination against hepatitis B within 12
hours after birth; a second dose will then be
administered at 1 month and a third one at 6
months.
❖ Vitamin K administration
•a vitamin necessary for blood coagulation. A single dose of
0.5 to 1.0 mg of vitamin K
❖ Circumcision
 NUTRITIONAL NEEDS of a NEWBORN The newborn has a high requirement of protein, which is
necessary for the formation of new cells, during this
ASSESSING THE NEWBORN FOR ADEQUATE period to provide for a rapid growth of new cells as well as
NUTRITION maintenance of existing cells. The nutritional allowance of
➢ Sleeps between feedings. protein for the first 2 months of life is 2.2 g per kilogram
➢ Loses no more than 10% of birth weight. of body weight. Both human milk and commercial
➢ Good skin turgor. formulas provide all the essential amino acids necessary to
➢ Voids six to eight times/day two to three bowel form protein. Histidine, an amino acid that appears to be
movements. essential for infant growth but is not necessary for adult
growth, is found in both milk forms. Unaltered cow’s milk
is not recommended for newborns because it contains
ASSESSING NUTRITIONAL STATUS IN A about 16% of its calories as protein, whereas human milk
NEWBORN contains about 8%. This means cow’s milk can create such
a rich solute load (i.e., the amount of urea and electrolytes
❖ Indicator of adequate fluid intake
that must be excreted in the urine) that a newborn’s
o Wetting a diaper six to eight times a day
kidneys could be overwhelmed. In addition, cow’s milk
o Sleeping between feedings
can cause microscopic bleeding of the gastrointestinal
o No excessive crying
tract, leading to blood loss and anemia. These problems
o Gaining weight
occur because the protein in cow’s milk, casein, differs
❖ Breastfeeding from that in human milk, lactalbumin, both in composition
o Physiology of breast milk production and in amount. This is important because the amount of
o Colostrum casein present in milk determines its curd tension. Because
o True/mature breast milk of the increased amount of casein in cow’s milk, the curd
❖ Advantages is large, tough, and difficult to digest, whereas in human
o Mother milk, the curd is softer and digests easily. This is the
o Infant rationale behind recommending formula-fed infants be
given a commercial formula containing albumin rather
NUTRITIONAL ALLOWANCES FOR A NEWBORN
than cow’s milk. Cow’s milk products, such as yogurt and
NEED
cottage cheese, should not be introduced until 9 to 12
CALORIES months of age because of this same reason.

Growth in the neonatal period and early infancy is more FAT

rapid than in any other period of life (U.S. Department of
Linoleic acid, an essential fatty acid, is necessary for brain
Agriculture, 2016); therefore, the caloric requirements
growth and skin integrity in infants. When the amount of
exceed those at any other age. For example, an infant up to
linoleic acid is sufficient, the infant can then manufacture
2 months of age requires 100 to 120 calories per kilogram
docosahexaenoic acid (DHA), an omega-3 fatty acid, and
of body weight (50 to 55 kcal/lb) every 24 hours to
arachidonic acid (ARA), an omega-6 fatty acid, both of
provide an adequate amount for maintenance and growth.
which are important for brain growth. Breast milk contains
After 2 months of age, this amount gradually declines
a generous supply of all three of these fatty acids.
until the requirement at 1 year is 100 kcal/kg (45 kcal/lb)
Commercial formulas contain varying amounts depending
per day. In contrast, the adult caloric requirement is 42
on the brand and type of fats included in the formula.
kcal/kg (20 kcal/lb) per day (U.S. Department of
Because fat is so important for brain and nerve growth,
Agriculture, 2016). During growth spurts, more calories
use of fat-free milk for long periods in newborns and
are needed to supply additional energy. Commercial infant
infants (when other sources of food are not being offered)
formulas are designed to provide approximately the same
can result in linoleic acid deficiency. Therefore, parents
number of calories as breast milk, 20 calories per ounce.
should not feed fat-free milk as a means of preventing
They contain about 9% to 12% of their calories as protein
obesity in newborns or young infants. In addition, fat-free
and 45% to 55% of calories as lactose carbohydrate. The
milk does not contain sufficient calories for a newborn; it
balance (34% to 46%) is fat, of which linoleic acid
only has about half as many calories as commercial
accounts for about 4%.
formulas or breast milk.

PROTEIN
CARBOHYDRATE
Lactose, the disaccharide found in human milk and added Iron
to commercial formulas, appears to be the most easily
A newborn (37 or more weeks gestation age) whose
digested of the carbohydrates. Lactose also improves
mother had adequate iron intake during pregnancy will be
calcium absorption and aids in nitrogen retention. It
born with iron stores that, theoretically, will last for the
produces stools consisting predominantly of gram-positive
first 3 months of life, until the newborn begins to produce
rather than gram-negative bacteria and therefore decreases
adult hemoglobin. Because not all mothers eat an iron-rich
the possibility of gastrointestinal illness (which usually
diet during pregnancy (and socioeconomic level is not a
results from gramnegative organisms). Adequate lactose
good criterion for judging the quality of a diet), the AAP
also allows protein to be used for building new cells rather
recommends infants who are formula fed ingest an iron-
than for calories, encouraging normal water balance and
enriched formula for the entire first year of life) (U.S.
preventing abnormal metabolism of fat. Lactose
Department of Agriculture, 2016). Some women who
intolerance, which can occur in older children, is rarely
breastfeed are also advised to supplement iron to ensure
present in newborns; they typically use the calories
their infant does not develop iron-deficiency anemia (U.S.
provided by lactose well.
Department of Agriculture, 2016).
FLUID
Fluoride
It is important to maintain a sufficient fluid intake in
Fluoride is essential for building sound teeth and for
newborns because their metabolic rate is so high (and
preventing tooth decay. Because teeth are already set in
metabolism requires water). In addition, a newborn’s body
their primary form during pregnancy, it is important for
surface area is large in relation to body mass. This means a
women to drink fluoridated water during pregnancy. A
baby loses water by evaporation much more readily than
lactating mother should continue drinking fluoridated
does an adult, and, because the kidneys of a newborn are
water (although only a small amount of fluoride passes
not yet capable of fully concentrating urine, a newborn
into breast milk), and formulas should be prepared with
cannot conserve body water by this mechanism to prevent
fluoridated water. This is an essential point to remember
dehydration. Another difference between newborns and
because a mother may think she is helping her child by
adults is that body water is distributed differently. In a
using bottled, “natural” water in formula rather than
newborn, 30% to 35% of body weight is extracellular
chlorinated (and fluoridated) water from a tap. If a mother
fluid; in an adult, this proportion is only 20%.
is breastfeeding and a source of fluoridated water is not
Consequently, if a newborn’s extracellular fluid store is
available (the family drinks well, spring, or bottled water
depleted through loss of fluid or inadequate fluid intake,
or the tap water is not fluoridated), a fluoride supplement,
as much as 35% of a newborn’s fluid component may be
0.25 mg daily, may be given to the infant beginning at 6
lost. Because of all these factors, a newborn needs 150 to
months of age. VITAMINS
200 ml/kg (2.5 to 3.0 oz/lb) of water intake every 24 hours
(adults require 2,400 ml per day or less than 1 oz/lb). This Although both breast milk and commercial formulas
requirement can be supplied completely by breastfeeding contain sufficient vitamins for growth, the AAP now
or formula feeding. Fruit juice is not recommended for recommends that breastfed newborns be given a
infants younger than 6 months because it supplies no supplement of 400 international units per day of vitamin
protein and, if not pasteurized, can carry infectious D, beginning in the first few days of life. Newborns who
organisms (American Academy of Pediatrics [AAP], are fully or partially formula fed also benefit from a daily
2012c). 400 international units vitamin D supplement (U.S.
Department of Agriculture, 2016).
MINERALS
A number of minerals are particularly important to early
growth. PHYSIOLOGY OF BREAST MILK PRODUCTION
Calcium Breast milk is formed in the acinar or alveolar cells of the
mammary glands (Fig. 19.1). With the delivery of the
Calcium is important to the newborn because a newborn’s
placenta following birth, the level of progesterone in a
skeleton grows so rapidly. Because milk is high in
woman’s body falls dramatically, stimulating the
calcium, tetany resulting from a low calcium level seldom
production of prolactin, an anterior pituitary hormone.
occurs in infants who suck well, regardless of whether
Prolactin acts on the acinar cells of the mammary glands
they are fed human milk or commercial formula (U.S.
to stimulate the production of milk. In addition, when an
Department of Agriculture, 2016).
infant sucks at a breast, nerve impulses travel from the
nipple to the hypothalamus to stimulate the production of
prolactinreleasing factor. This factor stimulates further
active production of prolactin. Other anterior pituitary
hormones, such as adrenocorticotropic hormone, thyroid-
stimulating hormone, and growth hormone, probably also
play a role in growth of the mammary glands and their
ability to secrete milk. Regardless of the gestational age of
the infant, the mother should be able to produce a
sufficient quantity of breast milk for the infant, providing
she empties the breasts through breastfeeding or
expressing milk (manually or by using a breast pump). A
hospital-grade breast pump is recommended to establish
and maintain lactation if the infant is unable to latch and
transfer breast milk through breastfeeding
Colostrum, a thin, watery, yellow fluid composed of
protein, sugar, fat, water, minerals, vitamins, and maternal
antibodies, is secreted by the acinar breast cells starting in
the fourth month of pregnancy. For the first 3 or 4 days
after birth, colostrum production continues. Because it is
high in protein and fairly low in sugar and fat, colostrum
is easy to digest and capable of providing adequate
nutrition for a newborn until it is replaced by transitional
breast milk on the second to fourth day. True or mature
breast milk is produced by the 10th day. Milk flows from
the alveolar cells, where it is produced, through small
tubules to reservoirs for milk, the lactiferous sinuses,
located behind the nipple. This constantly forming milk is
called fore milk. Its availability depends very little on the
infant’s sucking at the breast. As the infant sucks at the
breast, oxytocin, released from the posterior pituitary,
causes the collecting sinuses of the mammary glands to
contract, forcing milk forward through the nipples, making
it available for the baby. This action is called a let-down
reflex. A let-down reflex may also be triggered by the
sound of a baby crying or by thinking about the baby.
New milk, called hind milk, is formed after the let-down
reflex. Hind milk, which is higher in fat than fore milk, is
the milk that makes a breastfed infant grow most rapidly.
The release of oxytocin has a second advantage in that, by
causing smooth muscle contraction, it helps contract the
uterus. As a result, a woman may feel a small tugging or
cramping in her lower pelvis during the first few days of
breastfeeding (i.e., afterpains) (U.S. Department of
Agriculture, 2016).
ADVANTAGES OF BREASTFEEDING Little
controversy exists that breastfeeding is the ideal nutrition
for human infants. It is contraindicated in only a few
circumstances, such as:
• An infant with galactosemia (such infants cannot digest
the lactose in milk)
• Herpes lesions on a mother’s nipple
• Maternal exposure to radioactive compounds (such as
occurs with thyroid testing)
• Mothers receiving antimetabolites or chemotherapeutic
agents
• Mothers receiving prescribed medications that would be
harmful to an infant, such as lithium or methotrexate •
Women with maternal active, untreated tuberculosis, who
need to be evaluated individually depending on the stage
of their disease
• Women who are positive for HIV, who are advised not
to breastfeed in the United States until further studies
confirm the risk of not breastfeeding outweighs the risk of
breast milk transmission of the virus (Academy of
Breastfeeding Medicine Protocol Committee, 2010a). In
developing countries, women who are HIV positive may
be advised to breastfeed because commercial formula is
not available.
• Women whose toxicology screens for substance abuse
are positive, who need to be evaluated on an individual
basis regarding recommendations to breastfeed Cigarette
smoking is not a contraindication to breastfeeding, but
women should be aware some nicotine is carried in breast
milk. Nicotine has the potential to decrease a mother’s
milk supply (Reece-Stremtan & Marinelli, 2015). If the
infant is exposed to secondhand smoke, it could lead to an
increase in respiratory illnesses. The nurse needs to be
aware of a number of other situations that call for
individual planning in consultation with a lactation
consultant.
Advantages of Breastfeeding for Women
The release of oxytocin from the posterior pituitary gland
aids in uterine involution.
• Breastfeeding may serve a protective function in
preventing breast cancer and possibly ovarian cancer.
• A woman may return to her prepregnant weight sooner,
and if menstruation is delayed, this may serve as a
temporary family planning method.
• Successful breastfeeding can have an empowering effect
because it is a skill only a woman can master.
• Breastfeeding reduces the cost of feeding and
preparation time for infant feeding.
• A long-term effect may include a decreased risk of hip
fractures and osteoporosis in the postmenopausal period
for the woman (U.S. Department of Agriculture, 2016).
• Breastfeeding provides an excellent opportunity to
enhance a true symbiotic bond between mother and child.
Although this does readily occur with breastfeeding, a
woman who holds her baby to formula feed can form this
bond as well.
Nursing Diagnoses: Newborn Nutrition
• Effective breastfeeding related to well-prepared
mother and a healthy newborn
• Risk for ineffective breastfeeding related to nipple
soreness
• Imbalanced nutrition, less than body requirements,
related to poor newborn sucking response
• Risk for impaired parenting related to need to
formula feed newborn
Outcomes: Newborn Nutrition
• After birth, a teaching plan addressing the
nutritional needs of both the woman and her
newborn should be developed.
• .Parents who choose formula feeding need to plan
ways to make feeding time an intimate or special
one for both themselves and the baby.
Nursing Care to Promote Adequate Newborn
Nutrition
• Education for breastfeeding
• Provide immediate support if
problems arise.
• Provide information regarding
techniques for burping the
breastfed baby.
• Support for a mother who is
breastfeeding multiple infants.
• Pain related to engorgement or sore nipples
• Prevent or relieve engorgement.
• Promote healing of sore nipples.
Breastfeeding
• During the first few days of transition, it is
important for the mother to wake up the sleepy
newborn to breastfeed. As the newborn grows, the
composition of the mother’s breast milk will
change over time and during each feeding, to
satisfy the newborn’s nutritional needs.
Breastfeeding is based on the supply-demand
principle; the more the newborn nurses and
requires, the greater the milk supply the mother
will produce.
• During the first few days of transition, it is
important for the mother to wake up the sleepy
newborn to breastfeed.
• As the newborn grows, the composition of the
mother’s breast milk will change over time and
during each feeding, to satisfy the newborn’s
nutritional needs.
• Breastfeeding is based on the supply-demand
principle; the more the newborn nurses and
requires, the greater the milk supply the mother
will produce.
Benefits to Breastfeeding:
Infant
• Enhance cognitive development
• Receive antibodies and immunological
factors that helps protect against respiratory
tract infections and acute otitis media
• Immune factors encourage maturation and
increase protection against gastrointestinal
tract infections and diseases
• Lower risk of certain allergies
• Decrease risk of sudden infant death
syndrome.
Mother
• Decrease risk of some cancers (ovarian,
uterine, breast)
• Promotes involution of uterus, thereby
decreasing the risk of postpartum
hemorrhage
• Increase weight loss and body returning to
pre-pregnancy state
• Supports bonding and attachment with
newborn
• Convenience and portability of feeding
newborn any time with limited preparation
• Cost effective
Contraindications to Breastfeeding
• Cancer therapy, including radioactive
isotopes
• Active or untreated infectious tuberculosis
• HIV-infected mothers in high-income
countries
• Herpes lesions on both breasts
• Mothers diagnosed with T-cell leukemia
virus type 1
• Newborns diagnosed with galactosemia
• Substance use and some medications
Breastfeeding Technique
Nurses should teach mothers about their newborn’s
feeding cues. The newborn will show early signs of
feeling hungry. These signs include:
• Football Position
• Smacking, licking and sucking of lips
• Increased movements of tongue This position works well if you:
• Stirring and opening mouth
• are learning to breastfeed
• Rooting reflex
• have difficulty maintaining a latch
• Hand to mouth movements
• have a small baby
• Flexed arms with clenched fists over
• have large breast
chest
• have flat or sore nipples
• have a Caesarean birth
• The first milk is called the colostrum and lasts two
to three days.

• It is thick, yellow and rich in proteins, minerals,

and immunological properties.
• The colostrum will change into hindmilk, which is
thick and whitish in colour.

• The hindmilk is rich in fat and calories to support

growth and development of the newborn.
• Breastmilk changes over time and at each feed
according to the newborn’s needs.
• It is important for effective breastfeeding to
ensure the newborn feeds long enough to receive
the full amount of breast milk, both colostrum and
hindmilk.
Side-Lying Position
This position works well if you:
• find it too painful to sit
• want to rest when you breastfeed
• have a large breast
• had a Caesarean birth

Breastfeeding positions

• Cross Cradle Position

This position works well if you:
• are learning to breastfeed
• have a small baby

Breastfeeding positions for multiples

• Double Football Hold
This position works well if:
• you are learning to breastfeed
• you have small or premature babies
• Cradle Position • you have large breasts
• you had a Caesarean birth
This position works well:
• after you are comfortable with breastfeeding

• Combination Cradle/Football Hold
This position works well if:
• one or both babies have difficulty latching on
• Criss-Cross or Double-Cradle Hold
This position works well if:
• you are comfortable with breastfeeding
• your babies are latching well
• your babies are alert and awake
• Parallel Hold
This position works well if:
• one or both babies have difficulty latching on
• V-Hold (A Variation of the Double-Cradle Hold)
This position works well for:
• nighttime feedings
Bottle Feeding
Advantages of Bottle Feeding
• Partner, family and friends can participate in
feeding the newborn.
• Allows mothers to go back to work and participate
in other activities.
• Lactoferrin is an iron-binding protein in
breast milk that interferes with the growth of
pathogenic bacteria.
• Macrophages, responsible for producing
interferon (a protein that protects against
viruses), help interfere with virus growth.
• The presence of Lactobacillus bifidus in
breast milk interferes with the colonization of
pathogenic bacteria in the gastrointestinal
tract, thus reducing the incidence of diarrhea.
Disadvantages of Bottle Feeding
• Increased preparation time
• Increased financial cost in comparison to
breastfeeding
• Increased risk of infection due to improper
cleaning and lack of antibodies in formula
• Formula-fed newborns should be fed on demand
or every three to four hours with at least six to
eight feedings in 24 hours.
• Bottle-feeding the newborn is similar to
breastfeeding.
• The nurse should ensure the mother is in a
comfortable position, encourage skin-to-skin
contact during feeding, and hold the newborn
close to promote eye contact, interaction, and
bonding.
• The newborn should be sitting in a semi-reclined
or upright position
Three Types of Formula
• Powder
• Liquid concentrated
• Ready-to-feed
Formula Preparation and Safety
• Follow the specific directions on the formula
label. For example, type and amount of water
recommended to ensure the newborn
receives proper nutritional values
 • Formula should be used within the time
specified on the label and prior to the
expiration date
• Unused formula at the end of each feeding
must be discarded because saliva from the
newborn can cause bacterial growth.
Step 3
Face your baby’s nose to your nipple. Stroke your baby’s
lower lip with your nipple. Wait until baby’s mouth is
wide open like a yawn.

• Formula should not be microwaved as there is risk

of burning the newborn’s mouth due to uneven
heating
• Follow manufacturer’s instructions for proper use
and cleaning of equipment. For example,
thoroughly wash bottles, nipples, and other parts
in hot soapy water Step 4
• Bottle-feeding equipment and formula should be
approved by Food and Drug Regulation Bring your baby, chin first to your breast. Her mouth
guidelines should cover lots of the dark area (areola) below the nipple
(about 1.5 inches).
https://www.google.com/search?q=paced+bottle+feedi
ng+youtube&oq=bottle+feeding+you+tube+&aqs=chr
ome.2.69i57j0i13i30j0i10i22i30j0i10i15i22i30j0i5i13i
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TF-8#fpstate=ive&vld=cid:b10f4692,vid:iKSSi5pi57I
• After breastfeeding, the newborn should be
burped to release any air that may have been
swallowed during breastfeeding.
https://www.google.com/search?q=b+urping+the+bab Tips
y+you+tube&oq=b+urping+the+baby+you+tube&aqs If your baby falls asleep after a few minutes:
=chrome..69i57j69i64l2.9265j0j7&sourcaeid=chrome
&ie=UTF- • Squeeze your breast to help the breast milk flow.
8#fpstate=ive&vld=cid:773c8fdf,vid:m50PTFmmlxw Do not squeeze so hard that it hurts
• Take your baby’s clothes off or change her diaper
• Gently massage your baby’s back, feet, or hands
Steps to a good latch
• A good latch ensures the newborn receives
adequate breast milk from the mother. If your baby no longer has strong “deep and slow”
• The nurse should help the mother into a sucks and your breast feels softer:
comfortable position, undress the newborn leaving
the diaper on and place the newborn skin to skin • Offer the second breast.
on the mother. • your baby may only breastfeed a short time on the
Step 1 second breast.
• At next breastfeeding, offer the breast that feels
• Get comfortable and find a breastfeeding position that fullest.
that works well for you.

Attaching Baby at the breast

https://www.youtube.com/watch?v=wjt-Ashodw8
Breastfeeding Positions
Step 2 https://www.youtube.com/watch?v=xWPbykBKEA
Hold your breast in your hand. Thumb is on top and
fingers are below your breast.
SLEEPING POSITION
 • Sudden infant death syndrome (SIDS) is the
sudden, unexplained death of an infant
younger than 1 year of age.
• Although the specific cause of SIDS cannot
be explained, these interventions have been
shown to decrease the incidence of the
syndrome: place infant on the back to sleep;
use a firm sleep surface; breastfeeding; room
sharing without bed sharing; routine
immunizations; consideration of using a
pacifier; avoidance of soft bedding,
overheating; and exposure to tobacco smoke,
alcohol, and illicit drugs

Safe Sleep
https://www.youtube.com/watch?v=rZ2NXdZ_sH
o&t=10s

METABOLIC SCREENING TESTS

• Newborns born in a hospital or birthing center
are routinely screened for more than 30
metabolic or inherited disorders by a
screening technique that requires a small
blood sample obtained by a heel stick and
then dropped onto special filter paper
(Tluczek & De Luca, 2013).
• 2 to 3 days’ time. Always assess at a
newborn’s first health supervision visit that
screening was done.

Newborn screening

https://www.google.com/search?q=newborn+screen
ing+test+you+tube&oq=newborn+screening+test
+you+tube+&aqs=chrome..69i57j33i10i160l3.181
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8#fpstate=ive&vld=cid:37906c7b,vid:1WOZ07NIS
bw

HEPATITIS B VACCINATION
All newborns born in a hospital or a birthing center
receive a first vaccination against hepatitis B within
12 hours after birth; a second dose will then be
administered at 1 month and a third one at 6 months.
Infants whose mothers are positive for the hepatitis B
surface antigen (HBsAg) also receive hepatitis B
immune globulin (HBIG) at birth.
 QUESTIONS:
QSEN Checkpoint Question 17.1
Leana Cooper has expressed that she is excited to “get to
know” her new baby. The nurse determines which of the
following actions will support Leana’s transition into a
postpartal taking-hold phase?
a. Tell her that she did well in labor and that it was “all
worth it.”
b. Encourage her to take as much time as she needs to
recover from her labor.
c. Help her to give her new baby a bath. d. Encourage her
and her husband to choose their baby’s name as soon as
possible.
RATIONALE: C. The taking-hold phase means a woman is
interested in actively caring for her baby. The nurse should
encourage her to participate in the care of her baby by
bathing the baby. Telling her she did well or encouraging
the naming of the baby does not help to usher in the
taking-hold phase.
QSEN Checkpoint Question 17.2
The nurse observes Leana Cooper holding her newborn.
Which position would best reassure the nurse that
interventions aimed at promoting bonding have been
successful?
a. She looks directly at her infant’s face and talks to him.
b. She holds the infant over her shoulder and gently burps
him.
c. She sits in a rocking chair and slowly rocks her new
infant.
d. She lies in bed and places the infant on her stomach.
RATIONALE: A. The nurse assesses that an “en face”
position suggests she is interested in becoming acquainted
with the newborn.
QSEN Checkpoint Question 17.3
The nurse wants to prepare Leana to assess her own health
after discharge. Which statement by her would make the
nurse worry that she needs added information?
a. “I know about lochia; I’ll use tampons just like I do for
my periods.”
b. “I admit I don’t like having lochia, but I understand its
purpose.”
c. “I know to wash my hands after I change perineal pads
and before handling the baby.”
d. “I’ll look for the color of my lochia to change from red
to pink.”
RATIONALE: A. The nurse should teach Leana that
tampons should not be used postpartum to help prevent
infection.
QSEN Checkpoint Question 17.4
The nurse is performing massage of Leana’s fundus 2 days
postpartum. What assessment finding should prompt the
nurse to contact Leana’s primary care provider
immediately?
a. Leana’s fundal height is two fingerbreadths below her
umbilicus.
b. Leana’s uterus does not become firm when massaged.
c. Firm massage of Leana’s fundus results in pain.
d. The fundus is located midline on Leana’s abdomen.
RATIONALE: B. If the uterine fundus does not grow firm
with massage, extreme atony, possibly retained placenta
fragments, or an excess amount of blood loss may be
occurring; the nurse should notify the woman’s primary
care provider. A uterine fundus decreases in size at a rate
of one fingerbreadth a day. The fundus should be located
midline. Firm massage will result in pain, but this is not
acceptable nursing practice.
QSEN Checkpoint Question 17.5
Many new mothers are not prepared for how much time
newborns spend crying (as many as 16 of 24 hours); trying
to quiet a newborn can lead to extreme fatigue in a
postpartal parent. To investigate the effect of newborn
crying on new mothers’ ability to rest, researchers
conducted a systematic review of studies concerned with
newborn crying. Results of the literature review revealed
that infant crying during the first 3 months postpartum is
responsible for disrupting new mothers’ circadian
rhythms, reducing opportunities to rest, and exacerbating
tiredness. Incremental exhaustion from infant crying
diminishes a parent’s ability to concentrate, raises the fear
of harming the children, triggers depressive symptoms,
and burdens parent–child interaction (Nugent, 2013). The
Neonatal Behavioral Assessment Scale (NBAS) focuses
on the dynamic relationship of a newborn with its parents,
rather than a passive state, and that newborns are
extremely sensitive to their new surroundings and parents
(Nugent, 2013). The NBAS uniquely identifies and assess
a newborn’s 18 reflex behavioral and social competencies
and helps to provide a window into the infant’s
temperament to aid the parents in their parenting
techniques. Based on current research, which comment by
Leana would make the nurse worry that she may have a
difficult time getting enough sleep after she returns home
and understanding her newborn’s behavior?
a. “I didn’t think I’d like breastfeeding, but in reality, it’s
very enjoyable.”
b. “I walk my dog daily; I’m looking forward to walking
the baby as well.”
c. “My husband knows nothing about newborns, but he is
usually a fast learner.”
d. “I know that the baby will sleep just fine because I’ve
read everything I can about the subject.”
RATIONALE: D. The nurse worries about Leana’s
comment that the baby will sleep fine. This statement may
suggest that Leana is unprepared for the fact that her infant
may spend more time crying than sleeping. Her
expectations for her own levels of rest may be unrealistic.
QSEN Checkpoint Question 17.6
The nurse cares for Leana Cooper at a 6-week postpartum
visit. The nurse reads in Leana’s electronic health record
that her fundal height has ben progressing in a healthy and
predicted manner. What should her fundal height be
during this current visit?
a.at least six finger breadths below the umbilicus
b.no longer palpable over the symphysis pubis
c.four centimeters below the top of the iliac crest
d.still palpable above her pubic hair line
RATIONALE: B. The nurse records that Leana’s uterine
fundus sinks below the symphysis pubis at about 10 days
after birth. This is a normal finding.
QSEN Checkpoint Question 18.1
Beth Ruiz, like all newborns, is in danger of losing body
heat by conduction. The nurse is taking action to ensure
that Beth’s body temperature is maintained to protect her
health and comfort. Under which condition is heat loss by
conduction most likely to occur?
a. A fan is operating in the room.
b. Beth is wet from amniotic fluid at birth.
c. She pulls off the cap the nurse put on her head.
d. The nurse place her on a scale that has not been
prewarmed.
RATIONALE: D. The nurse is aware that conduction is the
transfer of body heat to a cold object that touches the
infant. Each of the other factors can result in heat loss, but
none involves heat loss by conduction.
QSEN Checkpoint Question 18.2
A Moro reflex is the single best assessment of neurologic
ability in a newborn. Unit protocols should specify what
action for eliciting a Moro reflex in Beth?
a. Turn her onto her abdomen and see if she can turn her
head.
b. Make a sharp noise, such as clapping your hands.
c. Lift her head while she is supine and allow it to fall
back 1 in.
d. Gently shake Beth’s bassinette until she responds by
flailing out her arms.
RATIONALE C. The nurse should lift the baby’s head and
allow it to fall back 1 in. to elicit a Moro reflex. This
action best initiates a Moro reflex. Making a noise or
shaking a crib is less effective way to test the reflex.
QSEN Checkpoint Question 18.3
Beth Ruiz had Apgar scores of 6 at 1 minute and 8 at 5
minutes after birth. Which of the following are the five
areas assessed with Apgar scoring?
a. Heart rate, respiratory effort, muscle tone, reflex
irritability, and color
b. Respiratory rate, abdominal tone, reflexes, color, and
head circumference
c. Color, breathing rate, cry, amount of brown fat, and
response to loud noise
d. Abdominal tone, persistence, reflexes, blood pressure,
and response to pain
RATIONALE: A. Using the apgar test, the nurse assesses
heart rate, respiratory effort, muscle tone, reflex
irritability, and color.
QSEN Checkpoint Question 18.4
Beth Ruiz has milia on her nose. What teaching point
would constitute a quality and safety risk?
a. “These will disappear on their own, so you don’t need
to take any action.”
b. “Wash Beth the same way that the nurse first taught
you.”
c. “Try to gently scratch off these spots in a few days.”
d. “Make sure that you keep Beth bundled warmly.”
RATIONALE: A. The nurse should advice Beth that milia
spots will disappear on their own, so she doesn’t need to
take any action.
QSEN Checkpoint Question 18.5
Mrs. Ruiz is preparing to take her new daughter home
and has asked an unlicensed care provider when Beth’s
dried umbilical cord will fall off. The nurse should confirm
that the care provider has stated what time?
a. Day 1
b. Days 2 to 3
c. Days 6 to 10
d. Day 30
RATIONALE: C. The nurse would confirm that a week is an
average time for a dried cord to detach.
QSEN Checkpoint Question 18.6
Shaken baby syndrome, or abusive head trauma caused
by a parent or caregiver shaking an infant in anger or
frustration, creates a potentially lethal situation because
forceful shaking can lead to subdural bleeding. To
investigate whether a nurseinitiated program could
reduce the incidence of abusive head trauma by shaking,
nurse researchers offered an educational program
including a leaflet explaining abusive head trauma,
helpful ways to cope safely with an infant’s crying, and an
8- minute video on the subject given to all new mothers
at their hospital. Results of the study showed a decrease
from 2.8 injuries per year (14 cases in 5 years prior to the
intervention) to 0.7 injuries per year (2 cases in 3 years)
or a 75% reduction in injuries following the intervention
(Altman, Canter, Patrick, et al., 2011). The nurse notices
Mrs. Ruiz grows irritated with Beth when Beth doesn’t
suck readily when she begins to breastfeed. Based on the
previous study, what is the best action for the nurse to
take?
a. Evaluate whether Beth can hear because this may be
the underlying problem.
b. List the dangers of shaken baby syndrome for Mrs.
Ruiz.
c. Discuss the fact that breastfeeding is a new skill, so
infants take time to learn this.
d. Suggest that Mrs. Ruiz ask the physician for a sedative
so she can better tolerate newborn crying.
RATIONALE: C. Shaking infants is potentially dangerous
because it can cause head injury; the nurse educating
about newborn abilities helps parents better understand
a newborn reacts the way he or she does. This approach
is likely more effective than the nurse immediately
addressing shaken baby syndrome, which may be a
premature and “heavy-handed” approach. A sedative is
contraindicated with breastfeeding.
QSEN Checkpoint Question 19.2
The AAP (Hagan, Shaw, & Duncan, 2017) recommends
infants be exclusively breastfed for 6 months. To discover
the characteristics of women who were exclusively
breastfeeding at the time of hospital discharge,
researchers studied all term hospital births in the
province of Ontario, Canada, for a year. From this pool of
over 90,000 infants, 56,865 were identified as still being
exclusively breastfed at discharge. Characteristics of
women who were exclusively breastfeeding were older
age, nonsmoking, higher income, and no pregnancy
complications or reproductive assistance. They also had a
single rather than twin infants and had attended prenatal
classes. Patients of obstetricians were less likely to
exclusively breastfeed than those cared for by midwives
or family physicians. Women who had a planned cesarean
birth were more apt to breastfeed than those who had an
unplanned cesarean birth. Based on the previous findings,
which statement by Linda would be the best indicator
that she will be successful at exclusive breastfeeding?
a. “I enjoyed going for prenatal visits.”
b. “I wish my husband earned more money.”
c. “I can’t wait until discharge when I can have a
cigarette.”
d. “I like having my first baby at 23; I’m young enough to
adjust.”
RATIONALE: A. The nurse sees having prenatal care as an
indication that Linda will successfully breastfeed. Prenatal
care is associated with success at exclusive breastfeeding.
Smoking, young age, and low income are negatively
associated.
QSEN Checkpoint Question 19.3
Linda asks the nurse why breastfeeding is so beneficial for
her newborn. The nurse would want her to know breast
milk has which of the following characteristics?
a. It is more nutritious than formula because it never
needs to be warmed.
b. It will provide immunity as well as nutrients for her
newborn.
c. It will protect her child from gastrointestinal cancer.
d. It will ensure her baby will never be obese as an adult.
RATIONALE: B. The nurse should teach Linda that breast
milk provides not only nutrition but also aspects of
immunity. Breastfeeding may reduce the risk of obesity
but does not ensure the infant will never become obese.
It does not necessarily prevent cancer.
QSEN Checkpoint Question 19.4
The discharge coordinator is discussing some of the
statements made by Linda. Which of the following would
indicate she needs further teaching about breastfeeding
from the nurse?
a. “I know breastfeeding is recommended for the first
year of my baby’s life.”
b. “To prevent nipple pain, I may need to vary the
position I use to feed.”
c. “While breastfeeding, I need to drink at least 12 glasses
of fluid a day.”
d. “I recognize that breastfeeding may help me lose some
pregnancy weight.”
RATIONALE: C. The nurse determines that Linda stating
that she should drink 12 glasses of fluid a day warrants
further teaching. Drinking 12 glasses of fluid a day is
extreme; 6 to 8 is a better recommendation.
QSEN Checkpoint Question 19.5
When teaching Linda about newborn feeding, the nurse
would include which statement(s) to reflect safety and
evidence-based practice? Select all that apply.
a. Breastfeeding exclusively for 6 months can reduce the
risk of obesity later in life.
b. Maternal benefits of breastfeeding include a decreased
risk of breast and ovarian cancer.
c. Benefits to the infant from formula feeding include
increased calcium density in the spine.
d. Once breastfeeding is established, pacifier use may
help to decrease the risk of sudden infant death
syndrome.
RATIONALE: A, B, D. The nurse should teach that
breastfeeding exclusively for 6 months can reduce the
risk of obesity later in life and decrease the risk of breast
and ovarian cancer for the mother, and a pacifier can be
used to decrease the risk of sudden infant death
syndrome once breastfeeding is established. Formula
feeding does not increase calcium density of the spine.
QSEN Checkpoint Question 19.6
Linda’s husband, Paul, plans to offer their baby bottled
breast milk once daily when Linda returns to work.
Educational literature available on the unit should include
which guideline?
a. He should stop feeding bottled milk if he notices the
baby has loose yellow stools.
b. He should microwave the milk for a full minute to be
certain it is absolutely sterile.
c. He should prop the bottle so the baby continues to
enjoy breastfeeding best.
d. After the baby drinks from a bottle, he should discard
any milk still in the bottle.
RATIONALE: D. Educational literature should include the
fact that discarding leftover milk discourages the growth
of pathogens. The presence of yellowish stools is
consistent with breast milk. A microwave should not be
used to warm breast milk, and propping a bottle risks for
aspiration.