CARE OF MOTHER, CHILD, ADOLESCENT (WELL CLIENTS)

NCM7 21
NEONATAL GESSTATIONAL AGE - Woman who has given birth to one GESTATIONAL AGE
ASSESSMENT child past age of viability
MULTIGRAVIDA
AGE OF GESTATION (AOG)
- Woman who has been pregnant
• Gestation – is a term that describes
previously
the time between conception and
birth, during which a baby grows and MULTIPARA
develops in the pregnant parent's - Woman who has carried two or more
uterus. pregnancies to viability
• Gestational age – refers to how far NULLIGRAVIDA
along the pregnancy is and is - Woman who has never been and is
generally expressed as a not currently pregnant
combination of weeks and days. GTPAL or GTPALM
• Gestational age helps to estimate a - A more comprehensive system for
possible due date, inform obstetrical classifying pregnancy status
care and testing, and evaluate the provides greater detail on a woman’s GESTATIONAL AGE BY WEIGHT
baby's health at birth. pregnancy history
WHY GESTATIONAL AGE IS • T: Number of full-term infants born
IMPORTANT? (infants born at 37 weeks or after)
1. Assess fetal growth • P: Number of preterm infants born
2. Determine the baby's due date (infants born before 37 weeks)
3. Schedule and evaluate prenatal test • A: Number of spontaneous
and screenings miscarriages or therapeutic
4. Treat conditions that cause preterm abortions
and post-term birth • L: Number of living children
PARA
• M: Multiple pregnancies
- Number of pregnancies that have
reached viability, regardless of GROWTH FOR DATES CAN BE
whether the infants were born alive DETERMINED BY WEIGHT, LENGTH,
GRAVIDA AND HEAD CIRCUMFERENCE
- Woman who is or has been • A full-term pregnancy is considered
pregnant; present pregnancy between 39 0/7 and 40 6/7 weeks.
PRIMIGRAVIDA • Babies born between 37 0/7 weeks
- Woman who is pregnant for the first through 38 6/7 weeks are
time considered premature Utilizing the nursing processing
PRIMIPARA • Those born after 42 0/7 weeks are understanding the application of different
considered post-mature.
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therapeutic modalities in MCN strategies
(ANTE PARTAL).
1. Determining AOG’s
a) NAEGELE’S RULE
NAEGELE'S RULE
- is a standard way of calculating the
due date for a pregnancy when
assuming a gestational age of 280
days at childbirth.
FUNDAL HEIGHT
• A measure of the size of the uterus
used to assess fetal growth and
development during pregnancy. It is
measured from the top of mother’s
uterus to the top of the mother’s
symphysis pubis.
BARTHOLOMEW’S RULE
• To measure, instruct the woman to
lie supine and start measuring from
the symphysis pubis to the uterine
fundus.
• The distance between in centimeters
depicts the week of gestation
between the 20th to the 31st weeks of
pregnancy.
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• At 12 weeks, the uterine fundus
should be at the level of the
symphysis pubis.
• At 20 weeks, the uterine fundus
should be at the level of the
umbilicus.
• At 36 weeks, the uterine fundus
should be at the level of the xiphoid
process.
• Bartholomew’s rule = estimates AOG
by the relative position of the uterus
in the abdominal cavity.
• 3rd lunar mo.= Symphysis pubis= 12
weeks gestation
• 5th lunar month = Umbilicus= 20
weeks gestation
• Fundus 28 cm= 28 weeks gestation
• Xiphoid Process= 36 weeks of
gestation
BARTHOLOMEW’S RULE of 4
• To measure, instruct the woman to
lie supine and start measuring from
the symphysis pubis to the uterine
fundus.
• The distance between in centimeters
depicts the week of gestation
between the 20th to the 31st weeks of
pregnancy.
• At 12 weeks, the uterine fundus
should be at the level of the
symphysis pubis and umbilicus.
• At 16 weeks, the uterine fundus
should be halfway of the symphysis
pubis and umbilicus.
• At 20 weeks, the uterine fundus
should be at the level of the
umbilicus.
• At 36 weeks, the uterine fundus
should be at the level of the xyphoid
process.
• More than 36 weeks descent
• 37-40 weeks ideal AOG
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• Ex. The crown heel length is 16 cm,
the age of the fetus is about 4 weeks
intrauterine life
STAGES OF LABOR
FIRST STAGE OF LABOR
(Cervical Completion, Dilation, and
Effacement)
1. Begins with regular and rhythmic
true labor contractions and ends with
complete effacement (100%) and
dilation of the cervix (10 cm).
2. The length of the first stage varies
and is almost double in a
primiparous patient; this stage of
labor consists of two phases:
a. LATENT PHASE (early):
✓ Dilation from 0 to 3 cm;
effacement tends to precede
dilation in the primiparous
JOHNSON’S RULE
patient.
• Johnson’s Rule = used to determine ✓ At the end of the phase,
body weight in grams contractions typically occur
• FH – N X 155 regularly every 5 minutes on
• N= 11 (NOT ENGAGED) average and are mild via
• N= 12 (ENGAGED) palpation.
HASSE’S RULE b. ACTIVE PHASE:
• used to determine fetal length ✓ Dilation from 4 to 7 cm;
• crown heel length in centimeter completion of effacement
• (6-10 months) = month x 5 evolves over this period in
• (1-5 months) = month 2 multiparous patients.
• age of fetus is calculated by the ✓ Contractions are more
square root of crown heel length in frequent at every 2 to 5
minutes, lasting 40 to 60
centimeter
seconds and of moderate to
strong intensity (60 to 80 mm
Hg) via palpation.
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✓ Dilation averages 1.2
cm/hour in the nullipara and
1.5 cm/hour in the multipara.
c. TRANSITION (final segment of
active phase): Dilation from 8 to 10
cm with contractions occurring every
2 to 3 minutes, lasting 50 to 60
seconds and of moderate to strong
intensity (<90 mm Hg and typically
nonindentable by palpation). Some
contractions may last up to (but not
exceed) 120 seconds.
SECOND STAGE OF LABOR
(Fetal Expulsion)
1. Begins with complete effacement
and dilation ending with delivery of
the fetus.
2. The second stage may last from 1 to
4 hours in the nullipara and typically
less than 1 hour in the multipara.
Variance in time depends on
maternal pushing efforts, contraction
pattern, anesthesia, and fetal
descent.
THIRD STAGE OF LABOR
(Placental Expulsion)
1. Begins with delivery of the fetus and
ends with delivery of the placenta.
2. The third stage may last from a few
minutes to 30 minutes (typical).
Prolonged periods may be
attributable to abnormal placentation
(ie, placenta accreta).
FOURTH STAGE
(Immediate Postpartum)
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• This period lasts from delivery of the
placenta until the postpartum
condition of the woman has become
stabilized (typically 1 to 2 hours after
delivery).
SEVEN CARDINAL FETAL MOVEMENTS OF
LABOR
• When the biparietal diameter (BPD)
of the fetal head has passed through
the pelvic inlet, engagement occurs.
Once the fetus enters the pelvis,
seven “cardinal movements” are
performed to assist in proper
passage through the maternal pelvis
during labor and birth (Figure 37-4).
DESCENT
1. The downward movement of the fetus
through the birth canal.
2. Accomplished by force of uterine
contractions in the fundus and pressure of
the amniotic fluid; during second stage of
labor, “maternal bearing down” efforts
increase intraabdominal pressure, thus
augmenting effects of uterine contractions.
3. Station refers to the relationship of the
presenting part to the ischial spines.
Subsequently, station has a direct
correlation to the degree of descent, as
described below (Figure 37-5):
▪ FLOATING—fetal presenting part
is not engaged in pelvic inlet; may be
ballotable via cervical exam.
▪ ENGAGEMENT—fetal presenting
part enters the pelvis as the BPD
passes through the inlet.
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▪The pelvis is divided into sections
measured in centimeters; a 5 cm
scale is used (see Figure 37-6).
FLEXION
• Resistance to descent causes the
fetal head to flex down, leading to
convergence onto the chest. This
results in the smallest head
diameter, the suboccipitobregmatic,
to present through the canal. This
position relocates the posterior
fontanelle to the center of the cervix,
easily palpable on vaginal
examination. Flexion begins at the
pelvic inlet and continues until the
fetal head (or presenting part)
reaches the pelvic floor.
INTERNAL ROTATION
• To accommodate the birth canal, the
fetal occiput rotates 45 or 90
degrees from its original position
toward the symphysis. The rotation
is usually anteriorly, but if the pelvis
cannot accommodate the occiput
anteriorly due to a narrow forepelvis,
it will rotate posteriorly, resulting in
an occipitoposterior (OP) position of
the fetus. This movement results
from the shape of the fetal head and
maternal pelvis, as well as the
contour of the perineal muscles. The
ischial spines project into the
midpelvis, causing the fetal head to
rotate anteriorly to accommodate the
available space.
EXTENSION
• As the fetal head meets the pelvic
floor, it meets resistance from the
perineal muscles and is forced to
extend up and outward. The fetal
head becomes visible at the
vulvovaginal ring; its largest
diameter is encircled (crowning) and
later emerges from the vagina.
EXTERNAL ROTATION
• Initial phase is called restitution.
Once the fetal head realigns with the
shoulders, restitution is complete.
After restitution, the second phase of
external rotation occurs as the body
rotates so that the shoulders are in
the anteroposterior diameter of the
pelvis.
EXPULSION
• After delivery of the fetal head and
internal rotation of the shoulders, the
anterior shoulder resets beneath the
symphysis pubis. The posterior
shoulder is expelled, followed by the
anterior shoulder, leading to total
body expulsion.
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• 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)
• Protecting a woman’s health as
these changes occur is important for
preserving her future childbearing
function and for ensuring that she is
physically well enough to incorporate
her new child into her family.
• The period is popularly termed the
fourth trimester of pregnancy.
FOCUS ON NATIONAL HEALTH
GOALS
The first hour after birth is an extremely
dangerous one because of the possibility of
hemorrhage. It is also the optimal period
when breastfeeding should begin.
• Reduce the maternal mortality rate
to no more than 3.3/100,000
livebirths from a baseline of
7.1/100,000.
NURSING CARE OF APOSTPARTAL
FAMILY • Reduce the proportion of births
POSTPARTAL PERIOD/PUERPERIUM occurring within 24 months of a
• from the Latin PUER, for “child,” and previous birth to 6% from a baseline
PARERE, for “to bring forth” of 11%.
• refers to the 6-week period after • Increase to at least 75% the
childbirth proportion of mothers who
• is the period beginning after delivery breastfeed their babies in the early
and ending when the woman’s body postpartum period from a baseline of
has returned as closely as possible 64% and increase the proportion of
to its prepregnant state. mothers who still breastfeed at 6

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months to29% from a baseline of
50% (http://www.nih.gov).
Nurses can help the nation achieve these
goals by maintaining close observation in
the immediate post partal period to detect
maternal hemorrhage, encouraging and
supporting women who breastfeed, and
ensuring that women receive reproductive
life planning information if desired.
PHASES OF PUERPERIUM
1. TAKING-IN PHASE
• a time when the new parents
review their pregnancy and the
labor and birth
• a time of reflection
• 2- to 3-day period- woman is
largely passive
• prefers having a nurse minister
and makes decisions for her.
• dependence results partly from
her physical discomfort because
of afterpains or hemorrhoids;
partly from her uncertainty in
caring for her newborn; and
partly from the extreme
exhaustion that follows childbirth
2. TAKING-HOLD PHASE
• women who give birth without
any anesthesia may reach this
second phase in a matter of
hours after birth
• woman begins to initiate actions
and make her own decisions
• begins to take a strong interest
• Although a woman’s actions
suggest strong independence
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during this time, she often still role, especially if a woman is not
feels insecure about her ability to receiving support from her
care for her new child. partner
3. LETTING-GO PHASE • evidenced by tearfulness,
• woman finally redefines her new feelings of inadequacy, mood
role lability, anorexia, and sleep
• gives up the fantasized image of disturbance
her child and accepts the real
one • Thirty percent of women experience
• gives up her old role of being a more serious level of sadness after
childless or the mother of only birth or postpartal depression
one or two (or however many (Lipscomb & Novy, 2007)
children she had before this • Serious depression requiring formal
birth) counseling or psychiatric care also
4 POSTPARTAL/POSTPARTUM can occur in women during this time
(Engqvist et al., 2007
BLUES
• During the post partal period, as PHYSIOLOGIC CHANGES OF
many as 50% of women THEPOSTPARTAL PERIOD
experience some feelings of
overwhelming sadness
(Buultjens & Liamputtong, 2007)
• may burst into tears easily or feel
let down or irritable
• known as baby blues
• may be caused by hormonal
changes, particularly the
decrease in estrogen and
progesterone that occurs with
delivery of the placenta
• may be a response to
dependence and low self-esteem
caused by exhaustion, being
away from home, physical
• Involution is the process whereby
discomfort, and the tension
the reproductive organs return to
engendered by assuming a new
their nonpregnant state. A woman is
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in danger of hemorrhage from the
denuded surface of the uterus until
involution is complete (Poggi, 2007)
1. UTERINE CHANGES
A. Immediately after delivery, the fundus is
palpable halfway between the umbilicus and
symphysis pubis. At 1 hour postpartum, the
fundus is usually level with or slightly below
the level of the umbilicus. The fundus is
usually midline.
Within 12 hours of delivery, the fundus may
be ½ inch (1.3 cm) above the umbilicus and
by 24 hours, ¼ inch (1 cm) below the
umbilicus. After this, the level of the fundus
descends approximately 1 fingerbreadth (or
½ inch) each day, until by the10th to the
14th day, it has descended into the pelvic
cavity and can no longer be palpated.
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C. The amount of lochial flow can be scant
(less than 2.5 cm stain [1inch]/hour), light
(less than 10 cm stain [4 inches]/hour),
moderate (less than 15.2 cm stain [6
inches]/hour), or heavy (one pad saturated
within 1 hour). Lochial flow is considered to
be “excessive” if the perineal pad becomes
B. After delivery, LOCHIA—a vaginal
saturated in less than 15 minutes.
discharge that consists of fatty epithelial
cells, shreds of membrane, decidua, and
blood—is red or dark brown with clots
(lochia rubra) for approximately 1 to 3 days.
It then progresses to a paler pink or more
brown-tinged color of serosanguineous
consistency (lochia serosa) for 3 to 10 days,
followed by a whitish or yellowish color
(lochia alba) in the 10th to 14th day. Lochia
usually ceases by 3 weeks and the
placental site is completely healed by the
6th week.
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D. Immediately after delivery of the
placenta, the cervix has little tone or
resemblance to the prepregnant state. In
approximately 2 to 3 days, it appears more
like the prepregnant state and is dilated to 2
to 3 cm. By the end of the first postpartum
week, it is approximately 1 cm in diameter.
The cervical opening is more slit like than
the pre-pregnant dimple and remains that
way. The cervical opening does not return to
the prepregnant dimple following delivery
unless the cervix has never been dilated.
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2. THE VAGINAL WALLS, uterine
ligaments, and muscles of the pelvic floor
and abdominal wall regain most of their tone
during the puerperium. Immediately after
delivery, the vaginal walls are smooth and
swollen because the vaginal rugae are
absent. Rugae reappears approximately3
weeks postpartum. At approximately 6
weeks postpartum, involution of the vagina
is complete.
3. POSTPARTUM DIURESIS BEGINS
within 12 hours after birth and continues for
2 to 5 days postpartum, as extracellular
water accumulated during pregnancy is
excreted. Diuresis may also occur shortly
after delivery if urine output was obstructed
because of the pressure of the presenting
part, or if IV fluids were given during labor.
4. BREASTS
A. loss of the placenta, circulating With
levels of estrogen and progesterone
decrease and levels of prolactin
increase, thus initiating lactation in
the postpartum woman.
B. Colostrum—a thick, yellowish fluid
that contains more minerals and
protein but less sugar and fat than
mature breast milk and has a
laxative effect on the infant—is
secreted for the first 2 days
postpartum.
C. Mature milk secretion is usually
present by the third postpartum day,
but may be present earlier if a
woman breast-feeds immediately
after delivery. Usually by the end of
the second postpartum week milk is
present.
D. Breast engorgement with milk,
venous and lymphatic stasis, and
swollen, tense, and tender breast
tissue may occur between day 3 and
day 5 postpartum.
5. ENDOCRINE/METABOLIC
FUNCTION
A. Human chorionic gonadotropin
declines rapidly and is nonexistent
by the end of the first postpartum
week.
B. Thyroid levels are normal by 4 to 6
weeks postpartum.
C. Glucose levels are low secondary to
decreased human placental
lactogen, decreased cortisol,
decreased estrogen, and decreased
growth hormone. Blood glucose
levels of women with gestational
(type 2) diabetes may return to
normal limits shortly after birth.
6. OVARIAN FUNCTION
A. Estrogen and progesterone levels
decrease rapidly after delivery of the
placenta and are usually their lowest
by the seventh postpartum day.
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B. Estrogen reaches the follicular
phase by 3 weeks after birth, as long
as the woman is not lactating.
C. Ovulation may occur as early as 27
days after delivery. The average time
is 70 to 75 days postdelivery and
190 days postdelivery if
breastfeeding.
D. The start of menses after delivery is
individualized. Usually, the first
menses occurs approximately 7 to 9
weeks after delivery in non-nursing
mothers, although breastfeeding
women may not start their first
menses until as late as 18 months.
7. KIDNEYS AND BLADDER
FUNCTION
A. Mild proteinuria (+1 on urine
dipstick) is common for 1 to 2 days
after delivery in 40% to 50% of
postpartum women.
B. Spontaneous voiding should return
by 6 to 8 hours postpartum. Bladder
tone returns between 5 and 7 days
postpartum.
C. The catabolic process of involution
can cause an increase in blood urea
nitrogen levels during the
postpartum period.
D. Stress incontinence is common
during the first 6 weeks postpartum.
8. NEUROLOGIC FUNCTION
A. Discomfort and fatigue are common.
B. Afterpains and discomfort from the
delivery, lacerations, episiotomy, and
muscle aches are common for the
first 2 to 3 days postdelivery.
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C. Frontal and bilateral headaches are
common and are caused by fluid
shifts in the first week postpartum.
D. Non-rapid-eye-movement (REM)
sleep is absent after birth and
increases during the next 2 weeks.
REM sleep decreases as non-REM
sleep increases.
E. Carpal tunnel syndrome (resulting
from physiologic edema causing
pressure on the median nerve) is
usually relieved by postpartum
diuresis.
NURSING ALERT:
Postpartum eclamptic seizures can begin
more than 48 hours and less than 4 weeks
postdelivery. They are commonly preceded
by severe headache or vision disturbances
(spots before the eyes, double vision, etc.).
Extra care is taken to observe for these
symptoms, especially in women with
prenatal diagnosis of preeclampsia or
hypertension.
9. CARDIOVASCULAR FUNCTION
A. Most dramatic changes occur in this
system and can take between 6and
12 weeks to return to the
prepregnant state.
B. Cardiac output peaks to about 80%
immediately after birth (10 to
15minutes) then decreases rapidly,
reaching pre labor values by about
1hour postpartum. However, it can
remain elevated for as much as
48hours postpartum. Cardiac output
values return to normal by 2 to
3weeks postpartum.
C. Hematocrit increases and increased
red blood cell (RBC) production
stops.
D. Leukocytosis with increased white
blood cells (WBCs) common during
the first postpartum week.
10. RESPIRATORY FUNCTION
A. Returns to normal by approximately
6 to 8 weeks postpartum.
B. Basal metabolic rate increases for 7
to 14 days postpartum, secondary to
mild anemia, lactation, and
psychological changes.
C. Partial pressure of arterial oxygen
(PaO2), partial pressure of carbon
dioxide (PaCO2), and pH usually
return to normal by 3 weeks
postpartum.
11. GI/HEPATIC FUNCTION
A. GI tone and motility decreases in the
early postpartum period, commonly
causing gaseous distention of the
abdomen and constipation.
B. Normal bowel function, including
normal bowel movements, returns at
about 2 to 3 days postpartum.
C. Liver function returns to normal
approximately 10 to 14 days
postpartum.
D. Gallbladder contractility increases to
normal, allowing for expulsion of
small gallstones.
12. MUSCULOSKELETAL FUNCTION
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A. Generalized fatigue and weakness If diastasis recti (overstretching and 14. A GOOD METHOD TO
is common. separation of the abdominal musculature) REMEMBER HOW TO CHECK THE
B. Decreased abdominal tone is occurred, the area will appear as a slightly
common. POSTPARTUM changes is the use of the
indented bluish streak in the abdominal acronym BUBBLERS:
C. Diastasis recti heals and resolves midline. Modified sit-ups help to strengthen
by the 4th to 6th week postpartum. B—Breast
abdominal muscles and return abdominal
Until healing is complete, usually 1 support to its prepregnant level. Diastasis U—Uterus
to 2 weeks postpartum, abdominal recti, however, may require surgery to B—Bladder
exercises are contraindicated. correct (Hickey,Finch, & Khanna, 2011). B—Bowel
D. Joint instability returns to normal L—Lochia
between 6 and 8 weeks
E—Episiotomy
postpartum.
R—Emotional response
13. INTEGUMENTARY FUNCTION S—Homans’ sign
A. Striae lighten and melasma is NURSING ALERT:
usually gone by 6 weeks A positive Homans’ sign may indicate
postpartum. thrombophlebitis and should be reported to
B. B. Hair loss can increase for the the primary care provider. The woman
first 4 to 20 weeks postpartum and should be instructed not to massage her
then regrowth will occur, although legs.
the hair may not be as thick as it EMOTIONAL AND BEHAVIORAL
was before pregnancy.
(PSYCHOSOCIAL) STATUS
After birth, the stretch marks on a woman’s
abdomen (striae gravidarum) still appear 1. After delivery, the woman may progress
reddened and may be even more prominent through Rubin’s stages of taking in, taking
than during pregnancy, when they were hold, and letting go.
tightly stretched. Typically, in a White A. Taking In (extends over first 24 hours
woman, these will fade to a pale white over postpartum:
the next 3 to 6months; in a Black woman, i. May begin with a
they may remain as areas of slightly darker refreshing sleep after
pigment. Excessive pigment on the face and delivery.
Restorative sleep should occur within first
neck (chloasma) and on the abdomen
24 hours postdelivery.
(linea nigra) will become barely detectable
ii. Woman exhibits passive,
by 6 weeks’ time. dependent behavior.

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iii.
Woman is concerned with
sleep and the intake of
food, mainly for herself.
B. Taking Hold (if not in first 24 hours
postpartum then between days 2 and 4
postpartum):
i. Woman begins to initiate
action and to function more
independently. First sign
mother is in this phase is
alert interest in her infant.
ii. Woman may require more
explanation and reassurance
that she is functioning well,
especially in caring for her
infant.
iii. Openness to teaching on
care of self and neonate.
iv. Today, with early hospital
discharge, this phase may
occur earlier, or it may occur
after discharge.
C. Letting go:
i. Begins near the end of the
first week; no specific end
time noted.
ii. Is influenced by cultural
beliefs.
iii. Reestablishment of couple
relationship.
iv. As the woman meets
success in caring for then
eonate, her concern extends
to other family members and
to their activities.
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2. Some women may experience euphoria 6. Nursing research findings indicate that
in the first few days after delivery and set new mothers commonly identify postpartum
unrealistic goals for activities after discharge need such as coping with:
from the birthing place.
A. The physical changes and discomforts
3. Many women may experience temporary of the puerperium, including a need to
mood swings during this period because of regain their pre pregnancy figure.
the discomfort, fatigue, and exhaustion B. Changing family relationships and
following labor and delivery and because of meeting the needs of family members,
hormonal changes after delivery. including the infant.
C. Fatigue, emotional stress, feelings of
4. Up to 50% to 75% of mothers may
isolation, and being tied down.
experience postpartum (or maternity) blues.
D. A lack of time for personal needs and
They can last for a few hours to 1 to 2
interests.
weeks and usually peak at approximately
the 5th postpartum day. Women may exhibit POSTPARTUM CARE
irritability, poor appetite, insomnia,
tearfulness, or crying. This is a normal
reaction to the physiologic shifts that occur
postdelivery and isa temporary situation.
5. Postpartum depression is a more serious
problem. Research shows that women feel
a loss of control of all aspects of life and go
through a four-stage process that includes:
encountering terror, dying of self, struggling
to survive, and regaining control.
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•The first hour after delivery of the 4. Assess bowel and bladder
placenta (fourth stage of labor) is elimination.
acritical period; postpartum 5. Evaluate interaction and care skills
hemorrhage is most likely to occur at of the mother and family with infant.
this time. 6. Assess for breast engorgement and
SUBSEQUENT POSTPARTUM condition of the nipples if
ASSESSMENT breastfeeding.
1. Check firmness of the fundus at 7. Inspect legs for signs of
regular intervals. Perform fundal thromboembolism and assess
massage if the uterus is boggy {not Homans’ sign.
firm} 8. Assess incisions for signs of
infection and healing
9. A good method to remember how to
evaluate the episiotomy Is the use of
the acronym REEDA:
a) R—Redness
b) E—Edema
c) E—Ecchymosis (purplish patch
of blood flow)
d) D—Discharge
e) A—Approximation, or the
closeness of the skin edges.
REEDA is based on a 3-point
scale. A score of 3 indicates an
assessment of very poor wound
healing. On the first postpartum
day, the REEDA score may
2. Inspect the perineum regularly for range from 0 to 3; by the second
frank bleeding. postpartum week, the score
a. Note color, amount, and odor of should be 0 to 1.
the lochia. 10. If the patient is Rh negative,
NURSING CARE PLAN b. Count the number of perineal evaluate her need for Rho(D)
NURSING ASSESSMENT pads that are saturated in each 8- immune globulin (RhoGAM). If
IMMEDIATE POSTPARTUM hourperiod. indicated, administer the RhoGAM
ASSESSMENT 3. Assess vital signs at least twice daily
within72 hours of delivery.
and more frequently, if indicated.

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CARE OF MOTHER, CHILD, ADOLESCENT (WELL CLIENTS)
NCM7 21
11. If the woman is not rubella immune,
a rubella vaccination may be given
and pregnancy must be avoided for
at least 3 months.
NURSING DIAGNOSES
• Risk for Deficient Fluid Volume
related to blood loss and effects from
anesthesia
• Impaired Urinary Elimination related
to birth trauma
• Constipation related to physiologic
changes from birth
• Risk for Infection related to birth
process
• Fatigue related to labor
• Acute Pain related to perineal
discomfort from birth trauma a,
hemorrhoids, and physiologic
changes from birth
• Readiness for Enhanced Self-health
Management pertaining to
postpartum care
• Readiness for enhanced parenting
related to neonatal care
• Ineffective Breast-feeding related to
lack of knowledge and in experience.
NURSING INTERVENTIONS
MONITORING FOR HYPERTENSION AND
BLEEDING
1. Monitor vital signs every 4 hours during
the first 24 hours, then every 8to 12 hours
or as delineated by facility policy. Observe
for the following:
A. Decreased respiratory rate below 14
to 16 breaths/minute may occur after
BALANO 13 | Page Prepared by: Mary Grace Sescon-Penticostes, RN
receiving epidural opioids or opioid
analgesics.
B. Increased respiratory rate greater
than 24 breaths/minute may be
caused by increased blood loss,
pulmonary edema, or a pulmonary
embolus.
C. Increased pulse rate greater than
100 beats/minute (bpm) may be
present with increased blood loss,
fever, or pain.
D. Decrease in blood pressure (BP) 15
to 20 mm Hg below baseline
pressures may indicate decreased
fluid volume or increased blood loss.
2. Assess the woman for light-headedness
and dizziness when sitting upright or before
walking
A. Evaluate orthostatic BP
B. Have the woman lie in bed if
symptoms exist
C. Emphasize the importance of asking
for assistance before ambulating the
first time
3. Assess vaginal discharge for clots and
amount
4. Evaluate lower-extremity sensory function
and motor function before ambulation if the
woman had regional anesthesia
5. Encourage food and drink, as tolerated.
6. Maintain IV line, as indicated.
7. Monitor postpartum hemoglobin levels
and hematocrit.
PROMOTING URINARY ELIMINATION
1. Observe for the woman’s first void within
6 to 8 hours after delivery.
2. Palpate the abdomen for bladder
distention if the woman cannot void or if she
complains of fullness after voiding.
A. Uterine displacement from the
midline suggests bladder distention.
B. Frequent voidings of small amounts
of urine suggest urine retention with
overflow.
3. Catheterize the woman (in and out), if
indicated.
4. Instruct the woman to void every several
hours and after meals to keep her bladder
empty. An undistended bladder may help
decrease uterine cramping.
PROMOTING PROPER BOWEL
FUNCTION
1. Teach the woman that bowel activity is
sluggish because of decreased abdominal
muscle tone, anesthetic effects, effects of
progesterone, decreased solid food intake
during labor, and pre-labor diarrhea.
2. Inform the woman that pain from
hemorrhoids, lacerations, and episiotomies
may cause her to delay her first bowel
movement.
3. Review the woman’s dietary intake with
her.
4. Encourage adequate amounts of fresh
fruit, vegetables, fiber, and at least eight
glasses of water daily.
5. Encourage frequent ambulation.
6. Administer stool softeners, as indicated
CARE OF MOTHER, CHILD, ADOLESCENT (WELL CLIENTS)
NCM7 21
PREVENTING INFECTION
1. Observe for elevated temperature
above 100.4° F (38° C).
2. Evaluate episiotomy/perineum for
REEDA.
3. Assess for pain, burning, and
frequency on urination.
4. Administer antibiotics as ordered.
REDUCING FATIGUE
1. Provide a quiet and minimally
disturbed environment.
2. Organize nursing care to keep
interruptions to a minimum.
3. Encourage the woman to minimize
visitors and phone calls.
4. Encourage the woman to sleep while
the baby is sleeping and specifically
to nap or lie down and get off her
feet at least 30 minutes per day.
MINIMIZING PAIN
1. Instruct the woman to apply ice packs to
her perineal area for the first24 hours for
perineal trauma or edema, then to apply
heat to the area.
A. Take breaks between applications to
prevent tissue damage.
B. Commercial or handmade packs of
ice chips in a glove may be used.
C. Place a thin barrier between the ice
pack and her skin.
2. Initiate the use of sitz baths for perineal
discomfort after the first 24hours.
A. Use three times per day for 15 to 20
minutes.
3. Instruct the woman to contract her
buttocks before sitting to reduce perineal
discomfort.
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4. Assist the woman in the use of
positioning cushions and pillows while
sitting or lying.
5. Teach the woman to use a perineal bottle
and squirt warm water against her perineum
while voiding.
6. Provide pads with witch hazel or topical
creams or ointments, as indicated.
7. Administer pain medication, as indicated.
8. Check breasts for signs of engorgement
(swollen, tender, tense, shiny breast tissue).
a. If breasts are engorged and the
woman is breastfeeding:
i. Allow warm-to-hot shower
water to flow over the breasts
to improve comfort.
ii. Hot compresses on the
breasts may improve
comfort.
iii. The application of cool
cabbage leaves to the breast,
left in place for20 minutes,
may reduce symptoms of
engorgement.
iv. Express some milk manually
or by breast pump to improve
comfort and to make the
nipple more available for
infant feeding.
v. Nurse the infant.
vi. A mild analgesic may be
used to enhance comfort.
b. If breasts are engorged and the
mother is bottle-feeding:
i. Teach the woman to wear a
snug, supportive bra night and
day.
ii. Teach the woman to avoid
handling her breasts because
this action stimulates more milk
production.
iii. Teach the woman to avoid letting
warm water fall on her breasts
during showers because the heat
stimulates milk production.
iv. Suggest the application of ice
bags to the breasts to provide
comfort.
v. Moderately strong analgesics
may be needed to provide
comfort.
PROMOTING POSTPARTUM HEALTH
MAINTENANCE
1. Teach the woman to perform perineal
care—warm water over the perineum after
each voiding and after each bowel
movement several times per day to promote
comfort, cleanliness, and healing.
2. Promote sitz baths for the same purpose.
3. Teach the woman to apply perineal pads
by touching the outside only, thus keeping
clean the portion that will touch her
perineum.
4. Assess the condition of the woman’s
breasts and nipples. Inspect
nipples for reddening, erosions, or fissures.
Reddened areas may be improved with
vitamin A & D ointment, a lanolin cream
(always remove before breastfeeding), and
air-drying for 15 minutes, several times per
day. She may also be instructed to squeeze
a small amount of breast milk onto her
nipples for lubrication.
CARE OF MOTHER, CHILD, ADOLESCENT (WELL CLIENTS)
NCM7 21
7. Instruct the breastfeeding woman to add
between 500 and 750additional calories
daily for milk production. Inform her that she
also needs 2 to 3 quarts (2 to 3 L) of liquid
per day; 20 g more protein than before
pregnancy; additional calcium, phosphorus,
and vitamins D, A, C,E, B, and B2; and
additional niacin, zinc, and iodine.
8. Instruct the woman in postpartum
exercises for the immediate and later
postpartum period.
a. Immediate postpartum exercises can
be performed in bed.
i. Toe stretch (tightens calf
muscles)—while lying on your
back, keep your legs straight and
point your toes away from you,
then pull your legs toward you
and point your toes toward your
chest. Repeat 10 times.
ii. Pelvic floor exercise (tightens
perineal muscles)—contract your
buttocks for a count of 5 and
relax. Contract your buttocks and
press thighs together for a count
of 7 and relax. Contract buttocks,
press thighs together, and draw
in anus for a count of 10 and
relax.
iii. Kegel exercises (tightens vaginal
muscles)—contract vaginal
5. Teach the woman to wash her breasts muscles as if stopping stream of
with warm water without soap, which urine. Do 15 per day, increasing
prevents the removal of the protective skin 5 more each week to a maximum
oils. of 40 per day. When conditioned,
6. Teach the woman to wear a bra that patient can do 4 or 5 Kegels per
provides good support night and day. day for maintenance.
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iv. Abdominal breathing—lie on
back, knees bent, hands on
belly, feet flat. Suck in your belly,
trying to pull your navel toward
your spine. Hold 5seconds;
release. When you can do 10
(this can take a week), add a
head lift. Suck in your belly, then
hold it as you lift head toward
chest, counting slowly to 4.
Lower head for 4 slow counts;
release belly. Muscles are
working if fingers move down
when you suck in belly, not up.
Work up to10 repetitions.
v. Arm circles—stand with feet
approximately 12 inches (30.5
cm) apart, arms at sides.
Keeping arms at sides, draw
large circles with your shoulders
by moving them forward, up, and
back, and finish with a press
down. Do 10 to 20 repetitions.
Next, extend both arms as you
reach forward, up, back, and
down. Move slowly, breathe
deeply for 5 to 10repetitions.
vi. Short walks—start with 5
minutes at first, then increase 5
minutes per day as desired.
vii. Shoulder-side roll—lying on
back, fold left arm across chest.
Lift right arm and cross it over to
left side. Feel as if your right arm
is pulling you over so your right
shoulder lifts and you roll to left.
Continue to spiral movement as
rib cage turns, then hips. Use left
CARE OF MOTHER, CHILD, ADOLESCENT (WELL CLIENTS)
NCM7 21
arm to take pressure off breasts,
which may feel full. Lying on your
left side, roll hips back toward
right, followed by ribs, then
shoulders until you are on your
back. Repeat, other side.
Perform five slow repetitions
each side.
b. Exercises for the later postpartum
period can be done after the first
postpartum visit (1 to 2 weeks
postpartum)
i. Bicycle (tightens thighs,
stomach, and waist)—lie on your
back on the floor, arms at sides,
palms down. Begin rotating your
legs as if you were riding a
bicycle, bringing the knees all the
way in toward the chest and
stretching the legs out as long
and as straight as possible.
Breathe deeply and evenly. Do
the exercises at a moderate
speed and do not tire yourself.
ii. Buttocks exercise (tightens
buttocks)—lie on your stomach
and keep your legs straight.
Raise your left leg in the air, then
repeat with your right leg (feel
the contraction in your buttocks).
Keep your hips on the floor.
Repeat 10 times.
iii. Twist (tightens waist)—stand
with legs wide apart. Hold your
arms at your sides, shoulder
level, palms down. Twist your
body from side to front and back
BALANO 16 | Page Prepared by: Mary Grace Sescon-Penticostes, RN
again. Feel the twist in your
waist.
iv. Back bridge—begin by doing a
pelvic tilt while lying on your back
and flattening the lower back
against the floor. Then continue
to push your hips forward, lifting
them off the floor. Hold the pelvic
tilt for 4seconds so that your
back is flat, supporting your
weight with your upper back.
Lower your body slowly for 4
seconds so that upper back
touches floor first, then waist
touches, then pelvis.
v. All fours—begin on your hands
and knees. First do a pelvic tilt,
tucking in your buttocks and
sucking n your belly. Do not
allow your back to arch. Next,
keeping your pelvic tilt, lift your
left leg out behind you and
extend your right arm in front of
you. Slowly lower arm and leg. At
first, you will have to work hard
to keep your balance.
vi. Lift and laugh—this are a fun
exercise to do with your baby. Sit
with legs crossed, back straight,
belly sucked in. Cradle your baby
in your folded arms and lift until
your elbows are at shoulder
height. Laugh and cuddle as you
hold for 2 seconds. Slowly lower
your baby, keeping shoulders
even, if possible. Do 5 to 10
repetitions.
PROMOTING HEALTH MAINTENANCE
OF THE NEONATE
1. Encourage the parents to
participate in the daily care of the
infant.
2. Advise the parents to attend
parenting and baby care classes
offered during their stay at the birth
facility.
3. Teach the parents to bathe and
diaper the infant, perform
circumcision care, and initiate
either breast- or bottle-feeding.
4. Foster bonding by encouraging
skin-to-skin contact with the infant
(“kangaroo care”), eye contact, and
talking to and touching the infant.
5. Instruct the parents to contact the
infant’s health care provider for the
following:
a. Fever above 100° F
(37.8° C).
b. Loss of appetite for two
consecutive feedings.
c. Inability to awaken the
baby to his or her usual
activity state.
d. Vomiting all or part of two
feedings.
e. Diarrhea—three watery
stools.
f. Extreme irritability or
inconsolable crying.
6. Inform the parents that by law,
infants and young children in cars
are required to be in a car safety
seat that is located in the back seat
and that faces the back of the seat.
CARE OF MOTHER, CHILD, ADOLESCENT (WELL CLIENTS)
NCM7 21
Demonstrate and review the proper
technique for use of the car seat.
7. Provide positive reinforcement and
reassurance to the parents.
8. Provide written instructions and
educational material on discharge.
PROMOTING BREASTFEEDING
1. Assist the woman and infant in the
breastfeeding process.
a. Have the mother wash her hands
before feeding to help prevent
infection.
b. Encourage the mother to
assume a comfortable position,
such as sitting upright in the bed
or in a chair or lying on her side.
c. Have the woman hold the baby
so that she is facing the mother.
Common positions for holding
the baby are the cradle hold, with
the baby’s head and body
supported against the mother’s
arm, with buttocks resting in her
hand; the football hold, in which
the baby’s legs are supported
under the mother’s arm, and the
head is at the breast, resting in
the mother’s hand; and lying on
the side with the baby lying on
his or her side facing the mother
d. Teach the woman to bring the
baby close to her to prevent
back, shoulder, and arm strain.
e. Have the woman cup the breast
in her hand in a C position, with
bottom of the breast in the palm
of her hand and the thumb on
top; or the U position, with the
BALANO 17 | Page Prepared by: Mary Grace Sescon-Penticostes, RN
fingers and the thumb to the
sides of the breast and the
breast resting in the palm of the
hand.
f. Have the woman place her
nipple against the side of the
baby’s mouth, and when the
mouth opens, guide the nipple
and the areola into the mouth.
The baby should latch on so that
as much of the areola as
possible is in his or her mouth. If
the baby has latched on to the
nipple only, take the baby off the
breast by putting the tip of the
mother’s finger in the corner of
the baby’s mouth to break the
suction, and then reposition on
the breast to prevent nipple pain
and trauma.
g. Encourage the woman to
alternate the breast with which
she begins feeding at each
feeding to ensure emptying of
both breasts and stimulation for
maintaining milk supply.
h. Advise the mother to use each
breast at each feeding. Begin
with approximately 10 minutes at
each breast, then increase the
time at each breast, allowing the
infant to suck until he or she
stops sucking actively. Pinning a
safety pin to the bra as a
reminder of which breast to start
with at the next feeding is
helpful.
i. Have the mother breast-feed
frequently (8 to 12 times/ 24
hours) to help maintain the milk
supply. Although there is no time
limit on each breastfeeding
session, it is recommended to
last at least 10 to 15minutes on
each breast.
j. Have the mother air-dry her
nipples for approximately 15 to
20 minutes after feeding to help
prevent nipple trauma.
k. Have the mother burp the infant
at the end of the feeding to help
release the air in the stomach
and to make the infant less
fretful.
2. Alert the mother that uterine cramping
may occur, especially in multiparous
women, because of the release of oxytocin,
which can be worse in women with
lessened uterine tone. Commonly referred
to as afterpains.
3. Teach the mother to provide for adequate
rest and to avoid tension, fatigue, and a
stressful environment, which can inhibit the
letdown reflex and make breast milk less
available at feeding.
4. Advise the woman to avoid taking
medications and drugs without health care
provider approval because many
substances pass into the breast milk and
may affect milk production or the infant.
CARE OF MOTHER, CHILD, ADOLESCENT (WELL CLIENTS)
NCM7 21
EVALUATION: EXPECTED
OUTCOMES
• Vital signs within normal limits;
decreasing color and amount of
lochia.
• Voids freely and without discomfort.
• Lack of constipation; eats high-fiber
foods and uses stool softeners.
• Afebrile, no abnormal redness of
perineum, no purulent discharge or
foul odor of lochia.
• Verbalizes feeling rested
• Verbalizes decreased pain
• Incorporates postpartum care into
activities of daily living.
• Demonstrates confidence
performing infant care; shows signs
of maternal−child bonding.
• Demonstrates successful
breastfeeding; breasts and nipples
intact and without redness or cracks
BALANO 18 | Page Prepared by: Mary Grace Sescon-Penticostes, RN
POSTPARTUM PATIENT EDUCATION
1. Advise the woman that healing
occurs within 2 to 4 weeks; however,
evaluation by the health care
provider during the follow-up visit is
necessary.
2. Inform the woman that intercourse
may be resumed when perineal and
uterine wounds have healed and
when vaginal bleeding has stopped.
Inform the woman that normal
vaginal secretions may not occur for
up to 6 months. Also inform the
mother that for the first 3 months
following delivery, her sexual arousal
and desire may be diminished due to
infant needs and fatigue. Review
methods of contraception. Sexual
arousal may cause milk to leak from
her breasts. Breastfeeding is not a
reliable method of contraception.
3. Inform the woman that menstruation
usually returns within 4 to 8weeks if
bottle-feeding; if breastfeeding,
menstruation usually returns within 4
months, but may return between 2 care agency arrangement for
and 18 months postpartum. Nursing
mothers may ovulate even if they are
experiencing amenorrhea. Thus, a
form of contraception should be
used if pregnancy is to be avoided.
in 4. Counsel the woman to rest for at
least 30 minutes after she arrives
home from the birthing facility and to
rest several times during the day for
the first few weeks.
5. Advise the woman to confine her
activities to one floor if possible and
to avoid stair climbing as much as
possible for the first several days at
home.
6. Counsel the woman to provide quiet
times for herself at home and to help
her establish realistic goals for
resuming her own interests and
activities.
7. Encourage the couple to provide
times to reestablish their own
relationship and to renew their social
interests and relationships.
KEY POINTS FOR REVIEW
• The postpartal period (puerperium)
is the 6-week period after childbirth.
This is an important period, because
it marks the child’s introduction to
the family. Women move through an
initial “taking-in” phase, in which they
are dependent; a “taking-hold”
phase, in which they manifest
independence; and a “letting-go”
phase, in which the mother role is
finally defined.
• Rooming-in is the preferred health
postpartal families, because it allows
a new family the best chance for
quality interaction. The more time
new parents spend with a newborn,
the more likely it is that effective
bonding will occur. Help parents to
feel comfortable with their newborn
by offering anticipatory guidance and
role modeling infant care.
• “Postpartal blues” are a normal
accompaniment to childbirth. You
CARE OF MOTHER, CHILD, ADOLESCENT (WELL CLIENTS)
NCM7 21
can assure a woman that her
feelings are normal and offer
supportive care until the emotion
passes.
• A woman is at great risk for
hemorrhage in the postpartal period,
so assessments done during this
time are some of the most critical
assessments made in nursing. Do
not discount the importance of these
assessments because the overall
content of the postpartal period is so
focused on wellness.
• Lactation is the production of breast
milk. Colostrum is present
immediately after birth; milk forms on
the third to fourth postpartal day. A
feeling of fullness and firmness on
this day is termed filling; if warmth
and discomfort occur, it is termed
engorgement.
• Women need to learn about self-
care before health care agency
discharge, so that they can maintain
self-care at home. A follow-up
telephone call or home visit is
helpful. All women should
conscientiously return for a visit at 6
weeks after childbirth, to be certain
their reproductive organs have
returned to their nonpregnant state.
A menstrual flow should return within
6 to 10 weeks in the non-
breastfeeding mother, or 3 to 4
months in the breastfeeding mother.
• Women may need various comfort
measures to alleviate pain from
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sutures, uterine pain (afterpains),
and breast tenderness. Application
of cold or heat and administration of
analgesics are important nursing
interventions.
NURSING CARE OF THE NEWBORN
EARLY ESSENTIAL NEWBORN CARE
{UNANG YAKAP/ FIRST EMBRACE}
4 CORE STEPS:
1. Immediate and thorough drying
2. Skin-to-skin contact
3. Properly timed cord clamping
4. Non separation of mother and baby
- Early breastfeeding
- Kangaroo Mother Care
I. INITIAL CARE OF THE NEWBORN
A. ASSESSMENT
1. Observe or assist with initiation of
respirations
2. Assess APGAR Score
3. Note characteristics of cry
4. Monitor for nasal flaring, grunting,
retractions, and abnormal
respirations, such as a seesaw
respiratory pattern (rise and fall of
the chest and abdomen do not occur
together).
5. Assess for central cyanosis and
acrocyanosis
6. Obtain vital signs
7. Observe the newborn for signs of
hypothermia or hyperthermia.
8. Assess for gross anomalies
B. INTERVENTIONS
1. Suction the mouth first and then the
nares with a bulb syringe
2. Dry the newborn and stimulate
crying by rubbing the back
3. Maintain temperature stability; wrap
the newborn in warm blankets and
place a stockinette cap on the
newborn’s head
4. Keep the newborn with the mother to
facilitate bonding
5. Place the newborn at the mother’s
breast if breast-feeding is planned,
or place the newborn on the
mother’s abdomen
6. Place the newborn in a radiant
warmer
7. Position the newborn on the side
with a rolled blanket at the back to
facilitate drainage of mucus.
8. Ensure the newborn’s proper
identification
CARE OF MOTHER, CHILD, ADOLESCENT (WELL CLIENTS)
NCM7 21
9. Footprint the newborn and fingerprint transition period between C. BODY MEASUREMENTS
the mother on the identification sheet intrauterine and extrauterine (APPROXIMATE)
per agency policies and procedures; existence. These phases
1. Length: 18 to 22 inches (45 to 55
initiate other agency identification include the first period of
cm)
and safety procedures reactivity, period of
2. Weight: 2500 to 4000 g (5.5 to 8.75
10. Place matching identification decreased responsiveness,
lb)
bracelets on the mother and the and second period of
3. Head circumference: 33 to 35 cm
newborn. reactivity.
(13.2 to14 inches)
C. APGAR SCORING SYSTEM
D. HEAD
1. Assess each of 5 items to be scored
1. Head should be one fourth of the
and add the points to determine the
body length (cephalocaudal
newborn’s total score.
development).
- The newborn’s Apgar score
2. Bones of the skull are not fused.
is routinely assessed and
3. Sutures (connective tissue between
recorded at 1 minute and 5
the skull bones) are palpable and
minutes after birth, and at 10
may be overlapping because of
minutes if needed.
head molding, but should not be
II. INITIAL PHYSICAL B. VITAL SIGNS widened.
4. Fontanels are unossified
EXAMINATION 1. Heart rate (resting): 120 to 160 membranous tissue at the junction of
A. GENERAL GUIDELINES beats/minute(apical), 80 to the sutures
1. Keep the newborn warm during the 100beats/minute (if sleeping), up to
examination 180 beats/minute (if crying);
2. Begin with general observations, and auscultate at the fourth intercostal
then perform assessments that are space for 1 full minute to detect
least disturbing to the newborn first abnormalities
3. Initiate nursing interventions for 2. Respirations: 30 to 60
abnormal findings and document breaths/minute; assess for 1 full
findings minute.
4. The Ballard Scale may be used for 3. Assess heart rate and respiratory
gestational age assessment; in this rate first before assessing other vital
scale, scores are assigned to signs while the newborn is resting or
physical and neurological criteria sleeping.
- The phases of newborn 4. Axillary temperature: 96.8 °F (37 °C)
instability occur during the to 99 °F (37.2 °C)
first 6 to 8 hours after birth 5. Blood pressure: Usually not done in 5. Molding is asymmetry of the head
and are known as the term newborn, 80–90/40–50 mmHg. resulting from pressure in the birth

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CARE OF MOTHER, CHILD, ADOLESCENT (WELL CLIENTS)
NCM7 21
canal; molding disappears in about 7. Red reflex present
72 hours 8. Eyelids often edematous as a result
6. Masses from birth trauma of pressure during the birth process
a. Caput succedaneum is edema of and the effects of eye medication
the soft tissue over bone F. EARS
(crosses over suture line); it
subsides within a few days. 1. Symmetrical
b. Cephalhematoma is swelling 2. Firm cartilage with recoil
caused by bleeding into an area 3. Top of pinna on or above line drawn
between the bone and its from outer canthus of eye
periosteum (does not cross over 4. Low-set ears associated with Down
suture line); it usually is syndrome, renal anomalies, or other
absorbed within 6 weeks with no genetic or chromosomal syndromes
treatment. G. NOSE
7. Head lag 1. Flat, broad, in center of face
a. Common when pulling the 2. Obligatory nose breathing
newborn to a sitting position 3. Occasional sneezing to remove
b. When prone, the newborn should obstructions
be able to lift the head slightly 4. Nares are patent and should not
and turn the head from side to flare (flaring is an indication of
side. respiratory distress).
H. MOUTH
1. Pink, moist gums
2. Soft and hard palates intact
3. Epstein’s pearls (small, white cysts)
may be present on hard palate.
E. EYES 4. Uvula in midline
1. Slate gray (light skin), dark blue, or 5. Freely moving tongue, symmetrical,
brown-gray (dark skin) has short frenulum
2. Symmetrical and clear 6. Sucking and crying movements
3. Pupils equal, round, react to light symmetrical
and accommodation 7. Able to swallow
4. Blink reflex present 8. Root and gag reflexes present
5. Eyes cross because of weak - When assessing the
extraocular muscles newborn’s mouth, look for the
6. Ability to track and fixate presence of thrush(Candida
momentarily albicans), which are white
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patchy areas on the tongue between folds closer to term; may be L. ABDOMEN
or gums that cannot be absent after 42 weeks of gestation 1. Umbilical cord
removed with a washcloth; 3. Lanugo, fine body hair, might be a. Umbilical cord should have 3
these may be painful. seen, especially on the back. vessels—2 arteries and 1 vein; if
4. Milia, small white sebaceous glands,
I. NECK fewer than 3 vessels are noted,
appear on the forehead, nose, and notify the health care provider
1. Short and thick chin
2. Head held in midline (HCP).
5. Dry, peeling skin, increased in b. While a 2-vessel cord (1 artery, 1
3. Trachea midline postmature newborns
4. Good range of motion and ability to vein) may present no problems or
6. Dark red color (plethoric) common in concerns, there is a higher
flex and extend premature newborns
5. Assess for torticollis (head inclined correlation to intrauterine growth
7. Cyanosis may be noted with restriction (IUGR) and genetic or
to 1 side as a result of contraction of hypothermia, infection, and
muscles on that side of the neck) chromosomal problems.
respiratory, or neurological
J. CHEST abnormalities.
1. Circular appearance because 8. Acrocyanosis (peripheral cyanosis of
anteroposterior and lateral diameters hands and feet) is normal in the first
are about equal (approximately 30 to few hours after birth and may be
33 cm [12 to 13.2 inches] at birth) noted intermittently for the next 7 o
2. Diaphragmatic respirations—chest 10 days
and abdomen should rise and fall in 9. Assess for ecchymosis and
synchrony, not in seesaw pattern petechiae resulting from trauma of
3. Bronchial sounds heard on birth.
auscultation. 10. Assess skin turgor over the
4. Nipples prominent and often abdomen to determine hydration
edematous; milky secretion (witch’s status.
milk) common 11. Observe for forceps marks
5. Breast tissue present 12. Harlequin sign
6. Clavicles need to be palpated to a. Deep pink or red color develops
assess for fractures. over 1 side of newborn’s body
K. SKIN while the other side remains pale
1. Pinkish red (light-skinned newborn) or of normal color.
to pinkish brown or pinkish yellow b. Harlequin sign may indicate
(dark-skinned newborn) shunting of blood that occurs
2. Vernix caseosa, a cheesy white with a cardiac problem or may
substance, on entire body in preterm indicate sepsis.
newborns, but is more prominent 13. Birthmarks

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c. small, thin cord may be associated
with poor fetal growth.
d. Assess for intact cord, and ensure
that the cord clamp is secured.
e. Cord should be clamped for at least
the first 24 hours after birth; clamp
can be removed when the cord is
dried and occluded and is no longer
bleeding.
f. Note any bleeding or drainage from
the cord.
g. Cleansing of the cord needs to be
done; hospital protocol and HCP’s
preference determine the frequency,
technique, and skin preparation
used for cord care.
h. If signs of infection, such as
moistness, oozing, discharge, and a
reddened base, occur, antibiotic
treatment is prescribed.
2. Gastrointestinal
a. Monitor cord for meconium staining
b. Assess for umbilical hernia
c. Assess for abdominal depression
associated with diaphragmatic
hernia.
d. Assess for abdominal distention
associated with obstruction, mass, or
sepsis.
e. Monitor bowel sounds (present
within the first hour after birth).
3. Anus
a. Ensure that the anal opening is
present.
b. First stool meconium should pass
within first 24 hours
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M. GENITALS
1. Female
a. Labia may be swollen; clitoris
may be enlarged.
b. Smegma may be present (thick,
white mucus discharge).
c. Pseudo menstruation, caused by
the withdrawal of the maternal
hormone estrogen, is possible
(blood-tinged mucus).
d. Hymen tag may be visible
e. First voiding should occur within
24 hours
2. Male
a. Prepuce (foreskin) covers glans
penis
b. Scrotum may be edematous
c. Verify meatus at tip of penis
d. Testes are descended, but may
retract with cold
e. Assess for hernia or hydrocele
f. First voiding should occur within
24 hours.
N. SPINE
1. Straight
2. Posture flexed
3. Supportive of head momentarily
when prone
4. Chin flexed on upper chest
5. Well-coordinated, sporadic
movements
6. A degree of hypotonicity or
hypertonicity may indicate central
nervous system damage.
7. Assess for hair tufts and dimples
along the spinal column (may be
indicative of a possible opening)
O. EXTREMITIES
1. Flexed
2. Full range of motion; symmetrical
movements
3. Fists clenched
4. Ten fingers and 10 toes, all separate
5. Legs bowed
6. Major gluteal folds even
7. Creases on soles of feet
8. Assess for fractures (especially
clavicle) or dislocations (hip).
9. Assist HCP to assess for
developmental dysplasia of the hip;
when thighs are rotated outward, no
clicks should be heard (Ortolani’s
sign and Barlow’s sign are the 2
assessment tools for developmental
dysplasia of the hip).
10. Pulses palpable (radial, brachial,
femoral)
- Slight tremors noted in the
newborn may be a common
finding, but could also be a
sign of hypoglycemia,
hypocalcemia, or drug
withdrawal
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OTHER POINTERS TO REVIEW
PHYSIOLOGY OF THE NEONATE
- The first 24 hours of life
constitute a highly vulnerable
time, during which the infant
must make major physiologic
adjustments to extrauterine
life. Most neonates transition
without difficulty during the
first 6 to 10 hours of life.
TRANSITIONAL STAGES
- During the period of postnatal
transition, six overlapping
stages have been identified:
STAGE 1. Receives stimulation (during
labor) from the pressure of the uterine
contractions and from changes in pressure
when the membranes rupture.
STAGE 2. Encounters various foreign
stimuli—light, cold, gravity, and sound.
STAGE 3. Initiates breathing
STAGE 4. Changes from fetal circulation to
neonatal circulation
STAGE 5. Undergoes alteration in
metabolic processes, with activation of liver
and GI tract for passage of meconium
STAGE 6. Achieves a steady level of
equilibrium in metabolic processes
(production of enzymes, increased blood
oxygen saturation, decrease in acidosis
associated with birth, and recovery of the
neurologic tissues from the trauma of labor
and delivery).
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RESPIRATORY CHANGES
Factors Initiating Respiration
1. MECHANICAL—pressure changes
(eg, compression of the fetal chest
with delivery) from intrauterine life to
extrauterine life produce stimulation
to initiate respirations.
2. CHEMICAL—changes in the blood,
as a result of transitory asphyxia,
include:
a. Cessation of placental blood flow
b. Lowered oxygen level
c. Increased carbon dioxide level
d. Lowered pH—if asphyxia is
prolonged, depression of the
respiratory center (rather than
stimulation) occurs and
resuscitation is necessary.
3. Sensory—light (visual), sound
(auditory), olfactory, and tactile
stimulation, beginning in utero with
uterine contraction and when the
infant is touched and dried,
contribute to the initiation of
respiration by stimulating the
neonate’s respiratory center in the
brain.
4. Thermal—a drop in environmental
temperature from 98.6° F (37° C) to
70° to 75° F (21° to 23.9° C)
produced by sudden chilling of the
moist infant stimulates the
respiratory center in the brain.
5. First breath—maximum effort is
required to expand the lungs and to
fill the collapsed alveoli.
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a. Surface tension in the respiratory
tract and resistance in lung
tissue, thorax, diaphragm, and
respiratory muscles must be
overcome.
b. First active inspiration comes
from a strong contraction of the
diaphragm, which creates a high
negative intrathoracic pressure,
causing a marked retraction of
the ribs and distention of the
alveolar space. (Any remaining
fluid is reabsorbed rapidly if the
pulmonary capillary blood flow is
adequate because the fluid is
hypotonic and passes easily into
the capillaries.)
6. Contributing factors, such as
pulmonary blood flow, surfactant
production, and respiratory
musculature, also increase the
respiratory effort of the neonate.
CHARACTER OF NORMAL
RESPIRATIONS
1. First period of reactivity occurs
immediately after birth. Vigorous,
diffuse, purposeless movements
alternate with periods of relative
immobility/inactivity.
2. Respirations are rapid, as frequent
as 80 breaths/minute, accompanied
by tachycardia, 140 to 180
breaths/minute.
3. Relaxation occurs and the infant
usually sleeps; he or she then
awakes to a second period of
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activity. Oral mucus may be a major
problem during this period.
4. Respirations are reduced to 30 to 60
breaths/minute and become quiet
and shallow; respiration is carried
out by the diaphragm and abdominal
muscles.
5. Period of dyspnea and cyanosis may
occur suddenly in an infant who is
breathing normally; this may indicate
an anomaly or a pathologic
condition.
6. Pauses in respirations of less than
20 seconds are normal in the
neonatal period
CIRCULATORY CHANGES
1. Cord clamping causes increased
systemic vascular resistance (SVR),
an increase in blood pressure, and
increased pressures in the left side
of the heart.
2. Removal of the placenta = functional
closure of the ductus venosus shunt
and anatomic closure the first week
of life
3. With the neonate’s first breath, the
foramen ovale shunt closes.
Permanent closure occurs by 3
4. 4. Increased SVR, falling pulmonary
VR, and increased sensitivity to
rising arterial oxygen concentrations
in the blood = closure of ductus
arteriosus shunt. The shunt is
completely closed in all infants by
96hours of age with permanent
closure within 3 weeks to 3 months
of age.
5. Blood volume can be as high as 300
mL/kg immediately after birth, then
decrease to 80 to 85 mL/kg shortly
after birth.
Factors that influence blood volume:
a. Maternal blood volume (affected by
maternal diseases and iron intake).
b. Placental function.
c. Uterine contractions during labor.
d. Amount of blood loss associated
with delivery.
e. Placental transfusion at birth—
increase in blood volume of 60% if
cord is clamped and cut after
pulsation ceases
6. Residual cyanosis in hands and feet
(acrocyanosis) is present for 1 to2
hours after birth because of sluggish
circulation.
7. Normal apical pulse rate 110 to 160
bpm; may rise to 180 bpm when the
infant is crying or drop to 80 to 110
bpm during deep sleep.
8. BP is 65 to 95/30 to 60 mm Hg at
birth (slightly higher in legs).
9. BP measurement is best
accomplished with a Doppler device
while the infant is at rest.
10. Coagulability is temporarily
diminished because of lack of
bacteria in the intestinal tract that
contributes to the synthesis of
vitamin K.
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a. Coagulation time is 5 to 8 contact with cooler BASAL METABOLISM
minutes (glass tubes), 5 to 15 surface/object 1. Surface area of infant, especially the
minutes (room temperature), or head, is large in comparison to
30 minutes (silicone tube). weight.
b. Bleeding time is 2 to 4 minutes. 2. Basal metabolism per kilogram of
c. Prothrombin 50%, decreasing to body weight is higher than that of an
adult.
20% to 30% (approximately 13
3. Calorie requirements are high—117
to18 seconds). calories per kilogram of bodyweight
11. Values for blood components in the per day.
neonate: RENAL FUNCTION
a. Hemoglobin, 14.5 to 22 g/dL. - Neonatal kidneys have
b. Hematocrit, 14% to 72%. functional deficiency in
c. Reticulocytes, 4% to 6%. concentrating urine and
d. Leukocytes, 9,000 to coping with fluid and
34,000/mm3. electrolyte fluctuations. Low
arterial BP and increased
TEMPERATURE REGULATION renal vascular resistance led
1. Mechanism not fully developed; heat 4. Decreased adipose tissue, thinner to the following effects:
production low. skin, blood vessels closer to the skin • Decreased ability to
2. Infant responds readily to results in increased heat loss. concentrate urine
environmental heat and cold stimuli. 5. Infant develops mechanisms to because of low tubular
3. Heat loss of 35.6° F to 37.4° F (2° C counterbalance heat loss.
• resorption rate and low
to 3° C) may occur at birth by a. VASOCONSTRICTION—blood
levels of antidiuretic
radiation, convection, evaporation directed away from skin
hormone.
surfaces.
and conduction • Limited ability to maintain
b. INSULATION—from
a. RADIATION—transfer of heat water balance by
subcutaneous adipose tissue.
from neonate to cooler object not excretion of excess water
c. HEAT PRODUCTION—by non-
in direct contact with the infant. or retention of needed
shivering thermogenesis (brown
b. CONVECTION—transfer of heat water.
fat metabolism) elicited by the
when flow of cool air passes over sympathetic nervous system’s • Decreased ability to
infant’ skin. response to decreased maintain acid-base
c. EVAPORATION—loss of heat temperatures; activated by mechanism; slower
excretion of electrolytes,
when water on infant’s skin is adrenaline.
d. FETAL POSITION—by assuming especially sodium and
converted to vapor.
a flexed position. hydrogen ions, results in
d. CONDUCTION—transfer of heat accumulation of these
when neonate comes into direct
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substances, which 2. Enlargement of mammary glands
predisposes the infant to (breast engorgement) in both
dehydration, acidosis, sexes—related to increased
and hyperkalemia. estrogen, luteal, and prolactin
• Excretion of large amount activity. Milky secretions may be
of uric acid during present (witch’s milk).
neonatal period— 3. Disturbances related to maternal
appears as brick dust endocrine pathology (eg, mother
stain on diaper. with diabetes or mother with
HEPATIC FUNCTION inadequate iodine intake).
Function limited because of lack of GI tract GI CHANGES
activity, deficiency in forming plasma - The neonate’s intestinal tract
proteins, and limited blood supply; is proportionately longer than
consequences include the following: the adult’s; however, elastic
1. Decreased ability to conjugate tissue and musculature are
bilirubin (rationale for physiologic not fully developed and
jaundice). neurologic control is variable
2. Decreased ability to regulate blood and inadequate.
glucose concentration (less glycogen 1. Most digestive enzymes are present,
stores) (rationale for neonatal with the exception of pancreatic
hypoglycemia). amylase and lipase. Protein and
3. Deficient production of prothrombin carbohydrates are easily absorbed, PHYSICAL ASSESSMENT FINDINGS
and other coagulation factors that but at absorption is poor. AND PHYSIOLOGIC FUNCTIONING
depend on vitamin K for synthesis 2. Limitations relate primarily to
APPEARANCE OF THE NEWBORN
(rationale for neonate’s anatomic structures and neutrality of
predisposition to hemorrhage). the gastric contents. POSTURE
ENDOCRINE FUNCTION 3. Limited production of pancreatic 1. Full-term neonate assumes
amylase leads to in adequate symmetric posture; face turned to
- Endocrine glands are better utilization of complex carbohydrates. side; flexed extremities; hands tightly
organized than other 4. Imperfect control of the cardiac and fisted with thumb covered by fingers.
systems: disturbances are pyloric sphincters and immaturity of 2. Asymmetric posture may be caused
most commonly related to neurologic control cause mild by fractures of clavicle or humerus or
maternally provided regurgitation or slight vomiting. by nerve injuries commonly of the
hormones. This can cause brachial plexus.
the following: 3. Infants born in breech position may
1. Vaginal discharge (or bleeding keep knees and legs straightened or
[pseudo menstruation]) in female in frog position, depending on the
infants. type of breech birth.
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LENGTH soles of feet, is common over a larger area; it can also be
- Average length of full-term because of immature peripheral seen in conjunctivae of eyes.
neonate is 20 inches (51 cm); circulation. This condition is
range, 18 to 22 inches (46 to exacerbated by cold
56 cm). temperatures.
WEIGHT b. Pallor—may indicate cold,
- Average weight of male stress, anemia, or cardiac failure.
neonates is 7½ lbs (3,400 g);
female neonates,7 lbs (3,200
g). Weight range of 80% of
full-term neonates is 6 lbs, 5
oz to 9 lbs, 2 oz (2,900 to
4,100 g)
SKIN
Examine under natural light for:
1. Hair distribution—term infant will c. Plethora—reddish (ruddy)
have some lanugo over back; most coloration may be caused by a
of the lanugo will have disappeared high level of RBCs to total blood
on extremities and other areas of the volume from intrauterine e. Meconium staining—staining of
body. intravascular transfusion(twins), skin, fingernails, and umbilical
cardiac disease, or diabetes in cord indicates passage of
the mother. meconium in utero (possibly
caused by fetal hypoxia in utero).

2. Turgor—term infant should have d. Jaundice—physiologic jaundice

good skin turgor (ie, after gently caused by immaturity of liver is
pinching small portion of skin and common beginning on day 2,
releasing it, the skin should return to peaking at 1 week, and
its original position). disappearing by the2nd week. It
3. Color first appears in skin over the face 4. DRYNESS/PEELING—marked
a. Cyanosis—acrocyanosis, bluish or upper body, then progresses scaling and desquamation are signs
color in palms of hands and of post maturity.
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5. VERNIX—in full-term infants, most
vernix is found in skin folds under
the arms and in the groin under the
scrotum (in males) and in the labia
(in females).
6. NAILS—should reach end of
fingertips and be well developed in
the full-term infant. There should be
no evidence of pits, ridges, aplasia,
or hypertrophy.
7. EDEMA—some edema may occur
over buttocks, back, and occiput if
the infant has been supine; pitting
edema may be caused by
erythroblastosis, heart failure, and
electrolyte imbalance.
8. ECCHYMOSIS—may appear over
the presenting part in a difficult
delivery; may also indicate infection
or a bleeding problem.
9. PETECHIAE—pinpoint hemorrhages
on skin caused by increased
intravascular pressure, infection, or
thrombocytopenia; regresses within
48hours.
10. ERYTHEMA TOXICUM (newborn
rash)—small white, yellow, or pink to
red papular rash that appears on
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trunk, face, and extremities;
regresses within 48hours.
11. HEMANGIOMAS—vascular lesions
present at birth; some may fade, but
others may be permanent.
a. STRAWBERRY (nevus
vasculosus)—bright red, raised,
lobulated tumor that occurs on
the head, neck, trunk, or
extremities; soft, palpable, with
sharp demarcated margins;
increases in size for
approximately 6months, then
regresses after several years.
b. CAVERNOUS—larger, more
mature vascular elements;
involves dermis and
subcutaneous tissues; soft,
palpable, with poorly defined
margins; increases in size the
first 6 to 12 months, then
involutes spontaneously
12. TELANGIECTATIC NEVI (stork
bites)—flat red or purple lesions
most commonly found on the back of
the neck, lower occiput, upper
eyelid, and bridge of the nose;
regress by age 2, although the ones
on the neck may persist through
adulthood.
13. MILIA—enlarged sebaceous glands
found on nose, chin, cheeks, brow,
and forehead; regress in several
days to a few weeks. They appear
as multiple yellow or pearly white
pap ules, approximately 1 mm in
diameter. When found in the mouth,
they are referred to as Epstein
pearls.
14. MONGOLIAN SPOTS—blue-green
or gray pigmentation on the lower
back, sacrum, and buttocks;
common in blacks (90%), Asians,
and infants of southern European
heritage; regress by age 4. May be
mistaken for signs of child abuse.
15. CAFÉ-AU-LAIT SPOTS—tan or light
brown macules or patches. When
less than 1¼ inches (3 cm) in length
and less than six in number, there is
nopathologic significance; if greater
than 1¼ inches or more than six in
number, may indicate cutaneous
neurofibromatosis.
16. Harlequin color change—when on
side, dependent half turns red, upper
half pale; caused by gravity and
vasomotor instability.
17. Abrasions or lacerations can result
from internal monitoring and
instruments used at birth.
18. Cutis marmorata—bluish mottling or
marbling of skin in response to
chilling, stress, or overstimulation.
19. Port-wine nevus (nevus flammeus)—
flat pink or reddish-purple lesion
consisting of dilated, congested
capillaries directly beneath the
epidermis; does not blanch.
HEAD
1. Examine head and face for
symmetry, paralysis, shape,
swelling, movement.
a. CAPUT SUCCEDANEUM—
swelling of soft tissues of the
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scalp because of pressure;
swelling crosses suture lines.
Associated with vacuum-assisted
birth.
b. CEPHALOHEMATOMA—
subperiosteal hemorrhage with
collection of blood between
periosteum and bone; swelling
does not cross suture lines. May
result from vacuum assisted birth
(use of the vacuum extractor).
c. MOLDING—overlapping of skull
bones, caused by compression
during labor and delivery
(disappears in a few days).
d. Examine symmetry of facial
movements.
e. FORCEPS MARKS—U-shaped
bruising usually on cheeks
following forceps delivery.
2. MEASURE HEAD
CIRCUMFERENCE—13 to 14
inches (33 to 36 cm), approximately
¾ inch (2 cm) larger than chest.
Measure just above the eyebrows
and over the occiput.
3. FONTANELLES—area where more
than two skull bones meet; covered
with strong band of connective
tissue; also called the soft spot.
a. ENLARGED OR BULGING—
may indicate increased
intracranial pressure (ICP).
b. SUNKEN—commonly indicates
dehydration.
c. SIZE—posterior may be
obliterated because of molding;
generally, closes in 2 to 3
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months. Anterior is palpable; formation does not usually begin
generally, closes in 12 to 18 until age 2 to 3 months.
months. e. JAUNDICE—may be seen in
4. SUTURES—junctions of adjoining sclera because of physiologic
skull bones. jaundice or, if severe, blood-
a. OVERRIDING—caused by group incompatibility.
molding during labor and f. PUPILS—equal in size and
delivery. should constrict equally in bright
b. SEPARATION—extensive light.
separation may be found in g. Infant can see and discriminate
malnourished infants and with patterns; limited by imperfect
increased ICP. oculomotor coordination and
FACE inability to accommodate for
1. EYES—examine the following: varying distances.
a. COLOR—sclera in most full-term h. RED REFLEX—red-orange color
infants is white; blue sclera is seen when light from an
indicative of osteogenesis ophthalmoscope is reflected from
imperfecta. Eye color usually the retina. No red reflex indicates
slate-gray, brown, or dark blue; cataracts.
final eye color is evident by 6 to
i. BRUSHFIELD’S SPOTS—white
12 months.
or yellow pinpoint areas on iris
b. HEMORRHAGIC AREAS—
that may indicate trisomy 21 or
subconjunctival hemorrhages even a normal variant.
may appear as are band from
j. Abnormal placement of eyes or
pressure during delivery; regress
small eye openings can signify a
within 2 weeks.
syndrome or chromosomal
c. EDEMA—edema of the eyelids
anomaly.
may be caused by pressure on
the head and face during labor k. STRABISMUS—cross-eyed
and delivery. appearance that is common;
d. CONJUNCTIVITIS OR nystagmus (constant, rapid,
DISCHARGE—may be caused involuntary movement of the
by instillation of silver nitrate (if eye) is also common and
still used) or infections from disappears by age 4 months.
organisms, such as 2 NOSE—examine the following:
staphylococcus, chlamydia a. PATENCY—necessary because
trachomatis, or gonococcus. Tear infants breathe through the nose,
not the mouth.
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b. NASAL FLARING—abnormal
and may indicate respiratory
distress. Check for appropriate
size and shape of the nose;
should be placed vertically
midline in face.
c. DISCHARGE—stuffiness
normal unless chronic nasal
discharge is present; may be
caused by possible infection.
d. SENSE OF SMELL—infants will
turn toward familiar odors and
away from noxious odors.
e. Septum should be midline; low
nasal bridge with broad base
may be associated with Down
syndrome.
f. Periodic sneezing is common.
3 Ears—examine the following:
a. Formation—large, flabby ears
that slant forward may indicate
abnormalities of the kidney or
other parts of the urinary tract.
b. Position in relation to the eye—
helix (top of ear) on the same
plane as eye; low-set ears may
indicate chromosomal or renal
abnormalities.
c. Cartilage—full-term infant has
sufficient cartilage to make the
ear feel firm.
d. Hearing—auditory canals may
be congested for a day or two
after birth; the infant should hear
well in a few days.
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e. Observe for skin tags;
preauricular sinus located in front
of the ear may be normal or may
be associated with genetic
disorders
4. MOUTH—examine the following:
a. SIZE—small mouth found in
is
trisomy 18 and 21; corners of
mouth turndown (fish mouth) in
fetal alcohol syndrome. Mucous
membranes should be pink.
b. PALATE—examine hard and soft
palate for closure.
c. Size of tongue in relation to
mouth—normally does not
extend much past the margin of
gums. Excessively large tongue
seen in congenital anomalies,
such as cretinism and trisomy
21.
d. TEETH—predacious teeth are
found on rare occasions; if they
interfere with feeding, they may
be removed.
e. EPSTEIN’S PEARLS—small
white nodules found on sides of
hard palate (commonly mistaken
for teeth); regress in a few
weeks.
f. FRENULUM LINGUAE—thin
ridge of tissue running from base
of tongue along undersurface to
tip of tongue, formerly believed
to cause tongue-tie; no treatment
necessary. True congenital
ankyloglossia (tongue-tie)is rare.
g. SUCKING BLISTERS (labial
tuberales)—thickened areas on
midline of upper lip that may be
filled with fluid or callous; no
treatment necessary.
h. INFECTIONS—thrush, caused
by Candida albicans, may
appear as white patches on
tongue and/or insides of cheeks
that do not wash away with
fluids; treated with nystatin
suspension.
NECK
Examine the following:
1. MOBILITY—infant can move head
from side to side; palpate for lymph
nodes; palpate clavicle for fractures,
especially after a difficult delivery.
2. TORTICOLLIS—appears as a
spasmodic, one-sided contraction of
neck muscles; generally, from
hematoma of sternocleidomastoid
muscle; usually no treatment
required.
3. Excessive skin folds may be
associated with congenital
abnormalities such as trisomy 21.
4. Stiffness and hyperextension may be
caused by trauma or infection
5. CLAVICLE—for intactness.
6. Observe for masses such as cystic
hygroma—soft and usually seen
laterally or over the clavicle.
CHEST
1. Circumference and symmetry—
average circumference is 12 to 13
inches (30 to 33 cm), approximately
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NCM7 21
¾ inch (2 cm) smaller than head
circumference.
2. Breast
a. ENGORGEMENT—may occur at
day 3 because of withdrawal of
maternal hormones, especially
estrogen; no treatment required.
Regresses in 2 weeks.
b. NIPPLES AND AREOLAE—less
formed and pronounced in pre
term infants.
RESPIRATORY SYSTEM
CARDIOVASCULAR SYSTEM
1. Rate—normally between 30 to 60
breaths/minute; influenced by
sleep−wake status, when last fed,
drugs taken by mother, and room
temperature.
2. Rhythm—respirations may be
shallow with irregular rhythm.
a. Respiratory movements are
symmetric and mainly
diaphragmatic because of weak
thoracic muscles. For example,
the lower thorax pulls in and the
abdomen bulges with each
respiration.
b. Periodic breathing—resumption
of respiration after 5- to 15-
secondperiod without respiration;
decreases with time; more
common in preterm infants.
Substernal retractions, if
accompanied by gasps or stridor,
are indicative of upper airway
obstruction.
BALANO 32 | Page Prepared by: Mary Grace Sescon-Penticostes, RN
c. Observe for abnormal respiratory
signs
3. BREATH SOUNDS—determined by
auscultation
a. Bronchial sounds are heard over
most of the chest.
b. Crackles may be heard
immediately after birth.
c. Expiratory grunting is indicative
of respiratory distress syndrome
(RDS).
1. RATE—normal between 110 and
160 bpm (80 to 110 normal with
deep sleep); influenced by
behavioral state, environmental
temperature, medication; take apical
count for 1 minute.
2. RHYTHM—common to find periods
of deceleration followed by periods
of acceleration.
3. HEART SOUNDS—second sound
higher in pitch and sharper than first;
third and fourth sounds rarely heard;
murmurs common, majority are
transitory and benign
4. PULSES—examine equality and
strength of brachial, radial, pedal,
and femoral pulses; lack of femoral
pulses indicative of inadequate aortic
blood flow.
5. CYANOSIS—examine for cyanosis.
Acrocyanosis of distal extremities is
common; record location of any
cyanosis, color changes with time,
and when crying.
6. BP—neonates who weigh more than
3 kg (6½ lbs) have systolic BP
between 65 and 95 mm Hg;
diastolic, between 30 and 60 mm
Hg. BP is usually higher in the lower
extremities than in the upper
extremities. BP assessment may not
be conducted routinely on healthy
neonates. Measurement of BP is
essential for infants who show signs
of distress, are premature, or are
suspected of having a cardiac
anomaly.
ABDOMEN
1. SHAPE—cylindrical, protrudes
slightly, moves synchronously with
chest in respiration.
2. Distention may be caused by bowel
obstruction, organ enlargement, or
infection.
3. Palpate abdomen for masses; gap
between rectus muscles is common;
palpate liver and spleen.
a. Liver has decreased ability to
conjugate bilirubin (rationale for
physiologic jaundice).
b. Liver has decreased production
of prothrombin and factors that
depend on vitamin K for
synthesis (rationale for neonate’s
predisposition to hemorrhage).
4. Auscultate abdomen in all four
quadrants for bowel sounds; usually
bowel sounds occur 1 hour after
delivery.
CARE OF MOTHER, CHILD, ADOLESCENT (WELL CLIENTS)
NCM7 21
5. KIDNEYS—palpate kidneys for size iii. Vaginal discharge—white 3. Examine hips for dislocation—with
and shape mucus discharge common; the infant in supine position, flex
a. Infant has decreased ability of pink-tinged mucus discharge knees and abduct hips to side and
kidney to concentrate urine, (pseudo menstruation) may down to table surface; clicking sound
excrete asolute load, maintain be present because of the indicates dislocation (Ortolani’s
water and electrolyte balance. drop in maternal hormones; sign).
b. Urine may contain uric acid no treatment necessary. 4. Asymmetrical gluteal folds also
crystals, which appear on diaper b. Male: indicate congenital hip dislocation.
as reddish blotches; uric acid i. Full-term—testes in scrotal 5. Examine feet for structural and
crystals may yield false-positive sac; scrotal sac appears positional deformities, that is,
result when the infant’ surine is markedly wrinkled due to clubfoot (talipes equinovarus) or
tested for protein. rugae. metatarsus adducts (inward turning
6. UMBILICAL CORD ii. Edema may be present in of the foot).
a. Normally contains two arteries, scrotal sac if the infant was NEUROLOGIC SYSTEM
one vein; single artery born in breech presentation; 1. Neurologic mechanisms are
sometimes associated with renal a frank collection of fluid in immature anatomically and
and other congenital the scrotal sac is a physiologically; as a result,
abnormalities. hydrocele—regresses in uncoordinated movements, labile
b. Signs of infection around approximately a month. temperature regulation, and lack of
insertion into abdominal wall— iii. Examine glans penis for control over musculature are
redness, discharge. urethral opening—normally characteristic of the infant.
c. Meconium staining—associated central; opening ventral 2. Examine muscle tone, head control,
with intrauterine compromise or (hypospadias); opening and reflexes.
postmaturity. dorsally (epispadias); 3. Two types of reflexes are present in
d. By 24 hours, becomes yellowish abnormally adherent foreskin the neonate:
brown; dries and falls off in {phimosis} a. Protective in nature (blink,
approx. 10 to14 days. c. Check for patent anus—infant cough, sneeze, gag)—remain
7. GENITALIA. should stool within 24 hours after
throughout life.
a. Female: delivery. If passed meconium in
b. Primitive in nature
i. Labia majora cover labia utero, patent anus has been
established. (rooting/sucking, Moro, startle,
minora and clitoris in full-term
MUSCULOSKELATAL SYSTEM tonic neck, stepping, and
female infants.
ii. Hymenal tag (tissue) may 1. Examine extremities for fractures, palmar/plantar grasp)—either
protrude from vagina— paralysis, range of motion, irregular disappear within months or
regresses within several position. become highly developed and
weeks. 2. Examine fingers and toes for number voluntary (sucking and grasping)
and separation: extra digits,
polydactyly; fused digits, syndactyly.
BALANO 33 | Page Prepared by: Mary Grace Sescon-Penticostes, RN