G1 Study Guide

St.
Paul University Philippines

Tuguegarao City, Cagayan 3500
School of Nursing and Allied Health Sciences

College of Nursing
2 Semester, AY 2022-2023
nd
CARE OF MOTHER, CHILD AND ADOLESCENTS (WELL CLIENTS)
NCM 107 (Group 1)

Case Scenario: Welcome to the New Member of the Family
GUIDE QUESTIONS
1. Are your assessment finding normal with baby boy Calland? Describe the
normal, characteristics of a term newborn.
➢ Baby boy Calland’s vital signs consists of a Temperature of 98.2°F (36.8°C),
heart rate 136 beats per minute, and respirations 74 breaths per minute.
His anthropometric measures consist of his Height 18.5-inch, head
circumference of 34 cm, chest circumference of 32 cm, and weight 3,500
grams. Based on the guide of what a normal vital sign of a newborn
should have, most of baby calland's vital signs were normal except for
his respirations which is above the normal range. Although some
newborns have very fast breathing in the first few hours of life because
of a lung condition called transient tachypnea of the newborn (TTN).
"Transient" meaning it doesn't last long.
➢ According to the mother, while changing her son’s diaper, she noticed a
black sticky stool. A black sticky stool is normal for newborns who are
younger than 1 week. During the first 24 hours of life, a newborn will
pass meconium and the color of the stool should change from black to
dark green, then yellow. Meconium is a thick, black stool. It comprises
cells, amniotic fluid, bile, and mucus that the baby ingested while in the
womb. It is sterile, so it usually does not smell.
➢ Before discharge, the mother noticed that her baby appears to have
yellow skin and sclera. When a baby is first born, the skin is a dark red
to purple color. As the baby starts to breathe air, the color changes to
St. Paul University Philippines

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red. This redness normally starts to fade in the first day. A baby's hands
and feet may stay bluish in color for several days. This is a normal
response to a baby's underdeveloped blood circulation. But blue coloring
of other parts of the body isn't normal. Some newborns develop a yellow
coloring of the skin and whites of the eyes called jaundice. This may be
a normal response as the body gets rid of older red blood cells. But it
may indicate a problem, especially if it worsens.
2. How do you determine the gestational age of a newborn

➢ Specific findings on physical assessment provide clues to a newborn’s
gestational age. The Ballard or Dubowitz test may be performed if the
mother did not have prenatal care or if there is another question
regarding maturity of the newborn. Gestational rating scales such as the
Ballard or Dubowitz use extensive criteria to assess gestational age.
3. How do you assess using the APGAR score?

➢ The Apgar score is a test given to newborns soon after birth. This test
checks a baby's heart rate, muscle tone, and other signs to see if extra
medical care or emergency care is needed. Between 7-10 is normal; score
between 4-6 needs proper reevaluation as the infant does require
monitoring for 5 minutes.This scoring system provided a standardized
assessment for infants after delivery. The Apgar score comprises five
components: 1) color, 2) heart rate, 3) reflexes, 4) muscle tone, and 5)
respiration, each of which is given a score of 0, 1, or 2
4. How do you assess a newborn for normal growth and development
➢ Take the baby's Anthropometric measurement (weight, height, head size)

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➢ checked at one minute and five minutes after birth for heart and
respiratory rates, muscle tone, reflexes, and color.
➢ Such as: Apgar scoring, Birthweight, Physical examination, Gestational
assessment, Physical maturity, Neuromuscular maturity
5. What is your plan of Care for Baby boy Calland?
➢ In planning a care for baby boy Calland, we should prepare for the
phase of his Brith and for the postpartum period. Routine newborn
care is essential to aid babies in the transition period right after birth.
While most babies are born with minimal difficulties requiring little or
no support, a small number of them necessitate some intervention at
the time of delivery. Having an interprofessional team that consists of
a pediatrician, primary care provider, labor and delivery nurse, and an
obstetrician can help identify infants in need of resuscitation.

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STUDY GUIDE
NORMAL CHARACTERISTICS OF A TERM NEWBORN
Appearance and Physiology

A term baby is one born between 37 and 42 weeks’ gestation. The dermis is well
formed and the skin is usually smooth, with adequate subcutaneous fat and good
muscle tone. The skin is generally well perfused although transient mild blueness
of the feet and hands is normal at birth. Vital signs a normal newborn should have
been stable body temperature of 97.0°F to 98.6°F (36.1°C to 37°C), a heart rate of
120 to 160 beats per minute. And respiratory rate of 40-60 breaths per minute.
Normal anthropometric measurements of a newborn are length of 45-55 cm (18-
22 inch), head circumference of 33-35 cm, chest circumference of 30.5-33 cm, and
weight of 6-8 lbs or 2700-4000 grams.
Reflexes
Appropriate neurological development is indicated by the presence of primitive or
primary reflexes. Some, such as the sucking reflex, are essential to survival. These
reflexes can be elicited in the healthy term infant and should disappear with
increasing maturity. Their absence in the neonate is suggestive of depression of
the central nervous system. Similarly, persistence of primitive reflexes beyond
infancy may be a sign of central nervous system pathology.
Feeding
Breastfeeding is the optimal method of infant nutrition and provides all the fluid
and nutrient requirements for the infant. It also encourages proximity to the mother
thus helping maintain body temperature and normal heart and respiratory rate.
Some babies will not be breast fed, either from maternal choice or from necessity.

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For these babies safe, suitable breast milk substitutes are available. See Chapters
43 and 44 for further information on infant feeding.
Elimination
The infant will usually pass urine and meconium within 24 hours of birth. Once milk
feeding starts the stools change from dark green meconium to brownish (changing
stools) then to yellow, usually at around 5 days of life. Urinary output is usually
approximately 100–200 mL/kg/day by 7 days of life. However, as the renal cortex
is relatively immature at birth the neonate has limited ability to concentrate urine
and conserve water or electrolytes. A dehydrated infant will therefore still produce
an adequate volume of urine. Urate crystals appear as a brick-red deposit in the
nappy and are usually harmless.
ASSESSMENT OF GESTATIONAL AGE

DUBOWITZ
• The original tool used for gestational assessment was the Dubowitz Scoring
System. It contained 20 items combining neurologic and physical parameters
that successfully estimated gestational age in infants older than 34 weeks
(Dubowitz, Dubowitz, & Goldberg, 1970).
• The tool was revised in 1999, increasing the number of items on the
neurologic exam. The test expanded the neurologic exam to include behavior
states, tone, primitive reflexes, motility, and some aspects of behavior
(Dubowitz, Ricci, & Mercuri, 2005).
BALLARD
• The Ballard Maturational Score (BMS), developed in the late 1970s (Ballard,
Novak, & Driver, 1979), is commonly used for determining gestational age.
The original BMS contained 12 items based on the Dubowitz Scoring System.

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As more low-birth-weight infants were born and survived the initial neonatal
period, an instrument that could accurately measure their gestational age
was needed to plan initial care.
• In 1991, the BMS was reevaluated and expanded resulting in the
development of a New Ballard Score, which is what most organizations are
using today. Criteria were broadened to provide greater accuracy when
evaluating extremely premature neonates (Ballard et al., 1991).
• The BMS is most accurate if performed between 10 and 36 hours of age.
Assessment of newborns younger than 26 weeks’ gestation is best
conducted within the first 12 hours (Gagliardi, Brambilla, Bruno, Martinelli, &
Console, 1993).
• The examination is separated into two parts: Neuromuscular maturity
assessment and Physical maturity assessment with each having 6
characteristics to assess and the scores may range from -1 to 5.
o BALLARD SCORING
▪ To establish a baby’s gestational age, the total score obtained
from both criteria (part) is compared with the rating scale.
▪ Higher scores indicate a more mature gestational age, and
lower scores indicate a less mature gestational age.

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NEUROMASCULAR MATURITY ASSESSMENT
a.) Posture and Tone – total body muscle tone is reflected in the infants
preferred posture at rest and resistance to stretch of individual muscle
groups
- Make sure infant is quiet, the more mature an infant is, the
greater their tone will be, a more flexed position indicates
greater tone
- Before 30 weeks – hypotonic, little or no flexion seen
- 30 – 38 weeks – varying degrees of flexed extremities
- 38 – 43 weeks – may appear hypertonic
b.) Square Window – wrist flexibility and/or resistance to extensor stretching
resulting in angle or flexion at wrist
- Flex hand down to wrist – measure the angle between the
forearm and palm
- Before 26 weeks – wrist can’t be flexed more than 90
degrees
- Before 30 weeks - wrist can be flexed no more than 90
degrees

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c.) Arm Recoil – measures the angle of recoil following a brief extension of the
upper extremity
- For 5 seconds, flex the arms while infant is in the supine
position, pulling the hands fully extend the arms to the side,
then release (measure the degree of arm flexion & strength)
(recoil)
- Before 28 weeks – no recoil
- 28 – 32 weeks – slight recoil
- 32 – 36 weeks – recoil does not pass 90 degrees
- 36 – 40 weeks – recoils to 90 degrees
- After 40 weeks – rapid full recoil
d.) Popliteal Angle – assesses maturation of passive flexor tone about the knee
joint by testing resistance to extension of the leg.
- The angle decreases with advancing gestational age
- Before 26 weeks – angle 180 degrees
- 26 – 28 weeks – angle 160 degrees
e.) Scarf Sign – tests the passive tone of the flexors about the shoulder girdle
- Increased resistance to this maneuver with advancing
gestational age
- Before 28 weeks – elbow passes torso
- 28 – 34 weeks – elbow passes opposite nipple line
- 34 – 36 weeks – elbow can be pulled past midline, no
resistance
- 36 – 40 weeks – elbow to midline with some resistance
- After 40 weeks – doesn’t reach midline

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f.) Heel to Ear – measures passive flexor tone about the pelvic girdle by testing
passive flexion or resistance to extension of the posterior hip flexor muscles
- Breech infants will score lower than normal
- Before 34 weeks – no resistance
- After 40 weeks – great resistance; may be difficult to
perform
PHYSICAL MATURITY ASSESSMENT
a.) Skin – Examine the texture, color, and opacity. As the infant matures: more
subcutaneous tissue develops, veins become less visible and the skin
becomes more opaque
- Before 28 weeks – gelatinous, red, friable
- 28 – 37 weeks – skin over abdomen thin, translucent, pink
with visible veins

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- 37 – 39 weeks – smooth, pink, increased thickness, rare

veins over abdominal wall
- 40 weeks – vessels have now appeared, skin may be
leathery with deep cracking
- Differential Skin Findings:
o Scalp Electrode
o Forcep Marks
o Vacuum Bruising
o Milia – exposed sebaceous glands (no treatment
necessary)
o Sebaceous hyperplasia – more yellow than milia,
result of maternal androgen in utero (resolves in
time)
o Mongolian Blue – Grey Spots – most common in
Asian, Hispanic, and African descent (gradual fade
over the first years)
o Skin tags – most common on ears (usually tied off or
clipped)
o Salmon patches or nevus simplex
o Angel Kisses
o Stork bites
o Erythema toxicum – white or yellow papule or pustule
with erythematous base (no treatment necessary)
o Café Au Lait spots – increased amount of melanin,
may increase in age. Presence of 6 or more – greater
than 0.5cm in size may be indicative of
neurofibromatosis

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b.) Lanugo
- After 20 weeks – begins to appear
- 28 weeks – abundant
- After 28 weeks – thinning, starts to disappear from the face
first
- 38 weeks – bald areas slight amount may be present on
shoulders
c.) Vernix
- Before 34 weeks – vernix thick and covers entire body
- 34 – 38 weeks – vernix is absorbed gradually, portions over
shoulder and neck is the last to be absorbed
- 38 – 40 weeks – vernix only present in folds of skin
- After 40 weeks – no vernix present
d.) Plantar Surface
- Before 28 weeks – no creases
- 28 – 32 weeks – virtually no sole creases, faint thin red lines
over anterior aspect of foot
- 34 – 37 weeks – 1-2 anterior creases
- 37 – 39 weeks – creases now over the anterior 2/3 of the
sole
o Bilateral Club feet
o Syndactyly
o Polysyndactyly
e.) Breast
- Before 28 weeks – nipples imperceptible

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- 28 – 32 weeks – nipple barely visible, no areola

- 32 – 37 weeks – well defined nipple areola
- 38 – 40 weeks – well defined nipple raised areola
f.) Eyes – are evaluated as either fused as seen in extremely premature infants
or open.
- Before 26 weeks – eyes are fised
o Congenital Cataracts
o Eyelid Edema
o Subconjunctival Hemorrhage
g.) Ears
- Before 34 weeks – pinna is very immature cartilage, not
present, lies flat, remains folded
- 34 – 37 weeks – pinna curved with soft recoil
- 37 – 40 weeks – formed, firm, instant recoil
- After 40 weeks – thick cartilage ear stiff
o Ear Tags
o Ear Pits (Preauricular pits)
o Lop Ear
o Prominent Ear
h.) Genital
- MALE
o Before 28 weeks – scrotum empty and flat
o 28 – 30 weeks – testes undescended into scrotal sac
o 30 – 36 weeks – testes descending with a few rugae
over the scrotum

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o 36 – 39 weeks – testes have descended into scrotum

which is now pendulous and complete with rugae
- FEMALE
o Before 28 weeks – clitoris prominent labia flat
o 28 – 32 weeks – prominent clitoris, enlarging labia
minora
o 33 – 36 weeks – labia majora widely spaced with
equally prominent labia minora
o 36 – 39 weeks – labia extends over the labia minora
but not over the clitoris
o 39 weeks – labia majora completely covers the labia
minora and clitoris
o Hydrocele
o Undescended testicles
o Hypospadias
o Hymenal Tag
APGAR SCORING
What is Apgar Score?
Apgar is a quick test performed on a baby at 1 and 5 minutes after birth.

The 1-minute score determines how well the baby tolerated the birthing process.
The 5-minute score tells the health care provider how well the baby is doing outside
the mother's womb.
How the Test is Performed


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The Apgar test is done by a doctor, midwife, or nurse. The provider examines
the baby's:
BREATHING EFFORT:
• If the infant is not breathing, the respiratory score is 0.

• If the respirations are slow or irregular, the infant scores 1 for respiratory
effort.
• If the infant cries well, the respiratory score is 2.
• Heart rate is evaluated by stethoscope.
This is the most important assessment:
• If there is no heartbeat, the infant scores 0 for heart rate.

• If heart rate is less than 100 beats per minute, the infant scores 1 for heart
rate.
• If heart rate is greater than 100 beats per minute, the infant scores 2 for
heart rate.

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MUSCLE TONE:
• If muscles are loose and floppy, the infant scores 0 for muscle tone.
• If there is some muscle tone, the infant scores 1.
• If there is active motion, the infant scores 2 for muscle tone.
• Grimace response or reflex irritability is a term describing response to
stimulation, such as a mild pinch:
This is the most important assessment:
• If there is no reaction, the infant scores 0 for reflex irritability.

• If there is grimacing, the infant scores 1 for reflex irritability.
• If there is grimacing and a cough, sneeze, or vigorous cry, the infant scores
2 for reflex irritability.
SKIN COLOR:
• If the skin color is pale blue, the infant scores 0 for color.
• If the body is pink and the extremities are blue, the infant scores 1 for color.
• If the entire body is pink, the infant scores 2 for color.
ESSENTIAL NEWBORN CARE
Care of the Newborn at Birth
• Newborn care is immediately done after birth in a separate space near

the birthing area.
• Equipment such as radiant heat table, warm blankets, resuscitation,
eye care, suction, weighing scale and equipment for oxygen
administration are already prepared and ready to use.

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• Newborn identification and registration is an important step after the

immediate newborn care to avoid switching of babies or kidnapping
in the healthcare facility.
• An identification band is placed around the newborn’s arm or leg
which contains the mother’s hospital number, the mother’s full name,
sex, date, and time of infant’s birth.
• The newborn’s footprints are then taken and kept for permanent
identification.
• The birth registration of the infant is taken care of by the physician
or nurse-midwife who supervised in the delivery.
• The mother’s name, the father’s name, and the infant’s name and
birthdate, as well as the place, are recorded.
• The newborn’s chart is also a mine of information when it comes to
the newborn’s welfare.
• Essential information such as the time of the infant’s birth, the Apgar
score, eye care given, immunizations, and the general condition of the
infant must be reflected on the chart.
Care of the Newborn in the Postpartum Period
• Newborn care varies among cultures and in some areas in the world.
• During the initial feeding, a term newborn could be fed immediately after
birth while a formula-fed one should be fed at 2 to 4 hours of age.
• Bathing is done an hour after birth to gently wash away the vernix caseosa,
and this is done daily.
• Areas such as the newborn’s face, skin folds, and diaper area are the areas
that need washing regularly.
• The nurse must supervise the bathing together with the parents.

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• The bath water must be pleasantly warm as well as the room to prevent
chilling.
• Bathing should be before feeding and not after it to prevent aspiration and
vomiting.
• Equipment needed during bathing are a basin of water, washcloth, soap,
towel, diaper, a clean shirt, and comb.
• Start bathing the infant from the cleanest area (the eyes) towards the dirtiest
area (the diaper area), and soap is never used for the baby’s face, only for
the body.
• Do not soak the cord when you wash the skin around it.
• Instruct the parents that the sleeping position of the infant must be flat on
the back to prevent SIDS, but never place a pacifier on the infant during
sleep.
• During diaper change, the area must be washed and dried well to prevent
diaper rash.
• Petroleum jelly or a mild ointment is applied on the buttocks to avoid
accumulation of ammonia and remove meconium.
• Vaccination for Hepatitis B and Vitamin K administration is also essential in
the postpartal period.
REFERENCES:
✓ Silbert-Flagg, J. & Pillitteri, A. (2018). Maternal & Child Health Nursing: care of the
childbearing and childrearing family, (8th edition)
✓ https://medlineplus.gov/ency/article/003402.htm
✓ https://www.aksharpediatrics.care/medical-library/newborn/newborn-characteristics/
✓ https://www.stanfordchildrens.org/en/topic/default?id=newborn-appearance-90-
P02691
✓ https://nursekey.com/appearance-and-characteristics-of-the-well-term-neonate/
✓ https://nursekey.com/newborn-physical-assessment/#A2-19 ›
https://www.slideserve.com/kimberly/neonatal-gestational-age-assessment

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St.

Paul University Philippines

School of Nursing and Allied Health Sciences

CARE OF MOTHER, CHILD AND ADOLESCENTS (WELL CLIENTS)

NCM 107 (Group 1)

School of Nursing and Allied Health Sciences

CARE OF MOTHER, CHILD AND ADOLESCENTS (WELL CLIENTS)

2. How do you determine the gestational age of a newborn

3. How do you assess using the APGAR score?

School of Nursing and Allied Health Sciences

CARE OF MOTHER, CHILD AND ADOLESCENTS (WELL CLIENTS)

School of Nursing and Allied Health Sciences

CARE OF MOTHER, CHILD AND ADOLESCENTS (WELL CLIENTS)

NORMAL CHARACTERISTICS OF A TERM NEWBORN

Appearance and Physiology

School of Nursing and Allied Health Sciences

CARE OF MOTHER, CHILD AND ADOLESCENTS (WELL CLIENTS)

ASSESSMENT OF GESTATIONAL AGE

School of Nursing and Allied Health Sciences

CARE OF MOTHER, CHILD AND ADOLESCENTS (WELL CLIENTS)

School of Nursing and Allied Health Sciences

CARE OF MOTHER, CHILD AND ADOLESCENTS (WELL CLIENTS)

NEUROMASCULAR MATURITY ASSESSMENT

School of Nursing and Allied Health Sciences

CARE OF MOTHER, CHILD AND ADOLESCENTS (WELL CLIENTS)

School of Nursing and Allied Health Sciences

CARE OF MOTHER, CHILD AND ADOLESCENTS (WELL CLIENTS)

PHYSICAL MATURITY ASSESSMENT

School of Nursing and Allied Health Sciences

CARE OF MOTHER, CHILD AND ADOLESCENTS (WELL CLIENTS)

- 37 – 39 weeks – smooth, pink, increased thickness, rare

School of Nursing and Allied Health Sciences

CARE OF MOTHER, CHILD AND ADOLESCENTS (WELL CLIENTS)

School of Nursing and Allied Health Sciences

CARE OF MOTHER, CHILD AND ADOLESCENTS (WELL CLIENTS)

- 28 – 32 weeks – nipple barely visible, no areola

School of Nursing and Allied Health Sciences

CARE OF MOTHER, CHILD AND ADOLESCENTS (WELL CLIENTS)

o 36 – 39 weeks – testes have descended into scrotum

What is Apgar Score?

Apgar is a quick test performed on a baby at 1 and 5 minutes after birth.

How the Test is Performed

School of Nursing and Allied Health Sciences

CARE OF MOTHER, CHILD AND ADOLESCENTS (WELL CLIENTS)

• If the infant is not breathing, the respiratory score is 0.

This is the most important assessment:

• If there is no heartbeat, the infant scores 0 for heart rate.

School of Nursing and Allied Health Sciences

CARE OF MOTHER, CHILD AND ADOLESCENTS (WELL CLIENTS)

This is the most important assessment:

• If there is no reaction, the infant scores 0 for reflex irritability.

ESSENTIAL NEWBORN CARE

Care of the Newborn at Birth

• Newborn care is immediately done after birth in a separate space near

School of Nursing and Allied Health Sciences

CARE OF MOTHER, CHILD AND ADOLESCENTS (WELL CLIENTS)

• Newborn identification and registration is an important step after the

Care of the Newborn in the Postpartum Period

School of Nursing and Allied Health Sciences

CARE OF MOTHER, CHILD AND ADOLESCENTS (WELL CLIENTS)

School of Nursing and Allied Health Sciences

CARE OF MOTHER, CHILD AND ADOLESCENTS (WELL CLIENTS)

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