CMCA: NURSING CARE OF A FAMILY WITH A NEWBORN
The Neonatal Period Birth - 28 days
Nursing Process Overview for Health Promotion of
the Term Newborn
1. Assessment
2. Nursing Diagnosis
3. Outcome Identification and Planning
4. Implementation
5. Outcome Evaluation
ASSESSMENT
Review of mother’s pregnancy history, physical
examination of the infant, analysis of laboratory
report (Hct, Hgb, Bilirubin & Blood type: assessment
of parent-child interaction
NURSING DIAGNOSIS
 Ineffective airway clearance related to
mucus in the airway.
 Ineffective thermoregulation related to heat
loss from exposure in the birthing room.
 Imbalance nutrition, less than body
requirements, related to poor sucking
reflex.
 Health-seeking behaviors related to
newborn needs.
OUTCOME IDENTIFICATION AND PLANNING
Planning should take into account the newborn’s
needs during the transition period, a mother’s need
for adequate rest and parent’s need to become
acquainted with their new child.
IMPLEMENTATION
Role modelling by the nurse during the newborn
period is an effective way to help new parents grow
confident with their newborn. Parents will be
observing you closely. Conserving newborn warmth
and energy, to help prevent hypoglycemia and
respiratory distress, should be an important
consideration during all interventions
OUTCOME EVALUATION
Expected outcomes should reveal that a baby’s
primary caregiver is able to give beginning newborn
care with confidence. Infant establishes respirations
of 30-60 breaths per min. Infant maintains
temperature at 36.5 – 37.5 ℃ Mother
demonstrates competence in caring for newborn.
infant breastfeeds well with a strong sucking reflex
The Profile of a Newborn
“All newborns look alike” as they say. In actuality,
every child is born with individual physical and
personality characteristics that make him or her
unique right from the start.
VITAL STATISTICS
1. Weight
2. Length
3. Head Circumference
4. Chest Circumference
5. Abdominal Circumference
Be certain all healthcare providers who care for
newborns are aware of safety issue specific to
newborn care when taking the measurements, such
as not leaving a NB unattended on a bed or scale
and protecting against hypothermia.
 Plotting Weight in conjunction with height and
head circumference is also helpful because it
highlights disproportionate measurements that
indicates risk conditions.
 For example: A newborn’s head circumference
(HC) may be too large for his birth weight (BW)
and height causing the care giver to suspect for
possible hydrocephalus.
 Appropriate for Gestational Age (AGA infant) –
average weight
Physiologic weight loss of 5-10% of birth weight (6-
10 oz) during the first 10 days of life
Reasons for Physiologic Weight Loss
A. Newborns are no longer under the influence of
salt- and fluid-retaining maternal hormones.
B. Newborn voids & passes stool.
C. Minimal food intake (BF) because sucking is not
yet established and colostrum contains less
calories than mature milk.
D. Formula fed NB need time to establish effective
sucking
Compare the weight of the NB each day to be
certain an infant is not losing more than 10% of BW,
an abnormal loss of weight may be an indication of
an inborn error of metabolism. (adrenocortical
insufficiency)
VITAL SIGNS
 Temperature -37.2 degrees C at birth because
of warm and supportive uterus. Temperature
will fall almost immediately to below normal
because of:
1. Heat loss (4 mechanisms)
2. Newborn’s immature temperature-
regulating mechanisms.
Heat loss in the Newborn
1. Convection is the flow of heat from the
newborn’s body surface to cooler surrounding
air. Eliminating drafts from windows and air
conditioners will reduce this heat loss.
2. Radiation is the transfer of heat to a cooler
solid object not in contact with the baby such
as cold window or air conditioner
3. Conduction is the transfer of body heat to a
cooler solid object in contact with a baby. Ex:
Cold linen, weighing scale
4. Evaporation is loss of heat through conversion
of a liquid to a vapor. Ex: Newborns are wet
with amniotic fluid. Drying the infant especially
the face and hair effectively reduces
evaporation. Cover the hair with a cap.
 Newborns can conserve heat by constricting
blood vessels and moving blood away from the
CMCA: NURSING CARE OF A FAMILY WITH A NEWBORN
skin.
 Brown fat, a special tissue found in mature
newborns, helps to conserve or produce body
heat by increasing the metabolism as well as
regulating body temp. Other ways to increase
MR and produce heat is by crying and kicking.
Pulse
 FHT averages 110-160 bpm
 Immediately after Birth, as the newborn
struggles to initiate respirations, the heart rate CIRCULATION AFTER BRITH
may be as rapid as 180bpm. (apical heartbeat) Changes occur in:
 Within 1 hour after birth, as the newborn - Pulmonary circulation (lungs functional)
settles down to sleep, the heart rate stabilizes - Systemic circulation (placenta removed)
to an average of 120-140bpm.Always palpate Resulting in closure of:
the femoral pulses and document that they are - Foramen ovale
present because absence suggests possible - Ductus arteriosus
coarctation(narrowing) of the aorta, which their - Ductus venosus
is a cardiovascular abnormality(Lissauer, 2015).  The peripheral circulation of a newborn
Respiration remains sluggish for at least the first 24 hours
First few minutes as high as 90bpm which can cause cyanosis in the infant’s feet
of life and hands(acrocyanosis) and for a newborn’s
feet to feel cold to touch.
Over the next 30-60bpm Respiratory depth,
hour rate, and rhythm – irregular, BLOOD VALUES
short periods of apnea 80-110 ml/kg of body
Blood volume
(without cyanosis) sometimes wt (300ml)
called periodic respirations. 17-18 g/100 ml of
Respiratory rate observed most easily by Hemoglobin blood (11-12 g/ml
watching the movement of adult)
the abdomen because Hematocrit 45-50% (adult, 36-45%)
breathing primarily involves 6 million cells/mm3
RBC
the use of diaphragm and (adult 3.5-5.5)
abdominal muscles. 15,000 to 30,000
Coughing, are present at birth to help WBC cells/mm3 at birth (40t
sneezing and gag clear the airway if birth was stressful.
reflexes BLOOD COAGULATION
Blood Pressure  Vitamin K (Phytonadione, Aquamephyton,
 BP in NB – approximately 80/46mmHg at birth. Konakion)
 By the 10th day, it rises to about 100/50mmHg-  This intervention provides Vitamin K because he
infant year. newborn does not have the intestinal flora to
 BP measurement in newborns is somewhat produce this vitamin in the first week of life
inaccurate due to small size of their arms, it is after birth.
routinely measured unless a cardiac anomaly is  Vitamin K is given to prevent and treat
suspected. hemorrhagic disease in NB(HDN).
Physiologic Functions  Dosage: 0.5mg to 1.0 mg IM anterolateral
just as changes occur in vital signs after birth, so do thigh(Vastus lateralis)
changes in all major body systems. THE RESPIRATORY SYSTEM
CARDIOVASCULAR SYSTEM  With the infant’s first breath and exposure to
changes in the CVS are necessary after birth increased oxygen levels, there is an increased
because now, the lungs are responsible for blood flow to the lungs
oxygenating blood that was formerly oxygenated by  Umbilical cord clamping decreases oxygen
the placenta. As soon as the umbilical cord is concentration, increases carbon dioxide
clamped, which stimulates a neonate to take in concentration, and decreases the blood pH
oxygen through the lungs, fetal cardiovascular  This stimulates the fetal aortic and carotid
shunts begin to close chemoreceptors, activating the respiratory
centre
 A first breath is a major undertaking because it
CMCA: NURSING CARE OF A FAMILY WITH A NEWBORN
requires a tremendous amount of pressure for a
newborn to be able to inflate alveoli for the first
time.
 At birth, the baby's lungs are filled with fluid.
They are not inflated. The baby takes the first
breath within about 10 seconds after delivery.
This breath sounds like a gasp, as the newborn's
central nervous system reacts to the sudden
change in temperature and environment
 The cold stimulates skin nerve endings and the
newborn responds with rhythmic respirations.
 A baby born by cesarean birth does not have as
much lung fluid expelled at birth as one born
vaginally and so typically has more difficulty
establishing respiration because excessive fluid
blocks air exchange.
 Any newborn who had difficulty establishing
respirations at birth needs to be examined
closely for a cardiac murmur or any other
indication that he or she still has the patent
cardiac structures from fetal life, especially a
patent ductus arteriosus.(Benitz, 2015)
The Gastrointestinal System (COCA)
MECONIUM
sticky, tartlike, blackish green odorless stools
formed from mucus,vernix, lanugo, hormones and
carbohydrates that accumulates while in utero.
TRANSITIONAL stool–
on the 2nd or 3rdday of life stool changes in color
and consistency in response to the feeding pattern.
Appeared both loose and green; may resemble
diarrhea to the untrained eye.
URINARY SYSTEM
24 hour point is a general rule -
Newborns who do not void within this time need to
be assessed for the possibility of urethral stenosis
or absent kidneys or ureters
 Single voiding is only 15ml.
 Daily urinary output – 30-60ml total
 Week one – 300ml
 Male should void with enough force to produce
a small projected arc.
 Females should produce a steady stream, not
just continuous dribbling. Projecting urine
farther than normal may signal urethral
obstruction because it indicates urine is being
forced through a narrow channel
THE IMMUNE SYSTEM
 Newborns have limited immunologic protection
at birth because they are not able to produce
antibodies until 2 months(the reason most
immunizations are not administered until 2 mos
of age).
 Newborns are born with passive antibodies
(Immunoglobulin G) passed to them from their
mother that crossed the placenta. (Antibodies
against poliomyelitis, measles, diphtheria,
pertussis, chicken pox, rubella and tetanus)
 Hepatitis B vaccine is administered to promote
antibody formation against the
disease(CDC,2016)
THE NEUROMUSCULAR SYSTEM
 Term Newborns demonstrate neuromuscular
function by reflex actions present at birth and
serve the infant until neuromuscular
development is improved.
 Infant reflexes that don’t integrate successfully
can lead to developmental delay.
 Absence of reflex activity often indicates some
form of brain damage or CNS depression
 Newborns are born with built –in instincts like
the primitive reflexes.
 Retained primitive reflexes is a sign of Brain
imbalance that can lead to developmental
delays related to disorders like ADHD, sensory
processing disorder, autism, and learning
disabilities.
 Primitive reflexes are the first part of the brain
develop and should only remain for the first few
months of life.
TYPES OF PRIMITIVE REFLEXES
Moro/startle reflex
 acts as a baby’s primitive fight or flight reaction.
(8wks – 4th month).
 Most important reflex indicative of neurological
status.
 If retained beyond 4 months he may become
over sensitive and over reactive to sensory
stimulus.
 Best method to elicit this reflex: hold a
newborn in supine position and allow the head
to drop backward about I inch: Response: arms
and legs extends, then swings the arms into an
embrace position and pulls up the legs against
the abdomen.
Rooting reflex
 assists in the act of breastfeeding and is
activated by stroking a baby’s cheek, causing
her to turn and open her mouth. This reflex
serves to help newborn find food.
 Disappears at about 6th week of life.
Palmar reflex
 is the automatic flexing of fingers to grasp an
object placed in their palm. This reflex
disappears at about 6wks to 3 months and after
it fades, a baby begins to grasp meaningfully.
Tonic Neck Reflex or the Asymmetrical tonic neck
reflex (ATNR)
when the arm and leg on the side toward which the
head is turned extend, and the opposite arm and
leg contract. Also called the “boxer or fencing
reflex”. Function is not known but typically
CMCA: NURSING CARE OF A FAMILY WITH A NEWBORN
disappears between the 2nd to 3rd month of life
Deep Tendon Reflexes
 both patellar and a biceps reflex are intact in a
newborn. A normal NB can have hyperreflexia
and still be normal but absent reflexes
associated with low tone and weakness is
consistent with lower motor neuron disorder.
Landau Reflex
 when a newborn is supported in a prone
position by a hand, the newborn should
demonstrate some muscle tone. A newborn
may not be able to lift the head or arch the
back in this position but neither should the
infant sag into an inverted “U” position
 The latter response indicates extremely poor
muscle tone, which needs to be investigated.
Crawling reflex also known as symmetrical tonic
neck reflex (STNR)
is present briefly after birth and then reappears
around 6-9 months. This helps the body to divide in
half at the midline to assist in crawling- as the head
is brought towards the chest, arms bend and legs
extend. It should disappear by 11 mos.
Tonic Labyrinthine reflex (TLR)
 is the basis for head management and helps
prepare an infant for rolling over, creeping,
crawling, standing and walking.
 This reflex initiates when you tilt an infant’s
head backwards while placed on the back
causing legs to stiffen, straighten and toes to
point. Hands also becomes fisted and elbows
bend. It should integrate gradually as other
systems mature and disappear by 3 ½ old.
FEEDING REFLEXES
1. Rooting reflex
2. Sucking Reflex when a newborn’s lips are
touched, the baby makes a sucking motion to
find food. It disappears immediately if it is
never stimulated such as in a NB with
tracheoesophageal fistula who cannot take in
oral fluids. Diminish about 6 months
3. Swallowing reflex same as in the adult. Food
that reaches the posterior portion of the
tongue is automatically swallowed. Gag, cough,
and sneeze reflexes are also present in NB to
maintain clear airway.
4. Extrusion Reflex a newborn extrudes any
substance on the anterior portion of the tongue
in order to prevent swallowing of inedible
substances.
OTHER REFLEXES
 Babinski Reflex occurs when the sole of the
newborn’s foot is stroked in an inverted “J”
curve from the heel upward, a NB fans the toes
(+ Babinski sign). Remains until 3 months of
age.
 Plantar Grasp Reflex occurs when an object
touches the sole of the NB’s foot at the base of
the toes, the toes grasp in the same manner as
the fingers. Disppears at about 8-9 mos in
preparation for walking
 Walking/stepping reflex
o When sole of foot is pressed against the
couch, baby tries to walk
o Legs prance up & down as if baby is
walking or dancing
o Present at birth, disappears at approx
2-4 months
o With daily practice of reflex, infants
may walk alone at 10 months
Reflexes that tests for Spinal cord integrity
 Magnet Reflex if pressure is applied to the soles
of the feet of a NB lying in a supine position, he
or she pushes back against the pressure.
 Crossed Extension Reflex when the NB is lying
supine, if one leg is extended and the sole of
that foot is irritated by being rubbed with a
sharp object, such as a thumbnail, the infant
raises the other leg and extends it as if trying to
push away the hand irritating the first leg
 Trunk Incurvation Reflex or Spinal Galant Reflex
– when the paravertebral area is stroked, the
newborn flexes his or her trunk toward the
direction of the stimulation.
SENSES
 The senses of the newborns, probably are so
important for survival, are already fully
developed at birth.
Hearing
recognizes the voice of the mother and calm to
the sound since they have heard in utero. (25-
27wks AOG hearing is functional). As soon as the
AF drains or is absorbed from the middle ear by
way of the eustachian tube within hours after
birth, hearing becomes acute
Vision
– a pupillary reflex or ability to contract the pupil
is present from birth. The fetus has a blink or
squint reflex in response to bright light in utero
by 26wks AOG. Teach parents that NBs focus best
on black and white objects at a distance of 9-12in
Touch
–the sense of touch is also developed at birth.
Newborns quiet down at a soothing touch, cry at
painful stimuli, and show suckling and rooting
reflexes that are elicited by touch.
Taste
a newborn has the ability to discriminate taste
because taste buds are developed and
functioning even before birth. After birth, a baby
continues to show a preference for sweet over
bitter tastes.
CMCA: NURSING CARE OF A FAMILY WITH A NEWBORN
Smell
as soon as the nose is cleared of lung and
amniotic fluid, the sense of smell is present.
Newborns probably turn toward their mother’s
breasts partly out of recognition of the smell of
breastmilk and partly as a manifestation of the
rooting reflex.
DISCHARGE INSTRUCTIONS
Advise the mother to return or go to the hospital
immediately if:
- Jaundice
- Difficulty of feeding
- Convulsions
- Movement only when stimulated
- Fast or slow or difficult breathing
- Temp. > 37.5 C or < 35.5
- Check-up as preferred by AP & immunization
schedule.
- Newborn Screening (RA 9288 “Newborn Screening
Act of 2004”)
Congenital Metabolic Disorders (Newborn
Screening)
1. Congenital Hypothyroidism (CH)-lack or
absence of Thyroid hormone which is essential
for the physical and mental development of the
child (NB may suffer from growth and mental
retardation)
2. Congenital Adrenal Hyperplasia (CAH)- causes
severe salt loss, dehydration and abnormaly
high levels of male sex hormones in both boys
and girls (may die within 7-14 days)
3. Galactosemia (GAL)-unable to process
galactose. Excessive galactose in the body can
cause problems like liver damage, brain damage
and cataracts
4. Phenylketonuria (PKU) – NB cannot properly
use one of the building blocks of protein called
phenylalanine. Excessive in the blood causes
brain damage.
5. Glucose 6 Phosphatase Dehydrogenase
Deficiency (G6PD) – the body lacks enzyme
called G6PD, may ave hemolytic anemia
resulting from exposure to oxidatice substances
found in drugs, foods and chemicals
Key Points to remember:
1. Unang Yakap (EINC steps)
2. Mechanisms of heat loss
3. Apgar scoring assessment/Ballard’s scale
4. Newborn Vital statistics/Vital signs
5. Newborn therapeutics
6. Newborn Screening
7. NB identification/documentation (ID band, DR,
TOB, Gender, AS,VS, AVA, OutputU.O,BM)
THE APPEARANCE OF THE NEWBORN
SKIN General inspection of a
newborn’s skin includes color,
any birthmarks, and general
appearance.
COLOR Pink, cyanosis, jaundice, pallor
BIRTHMARKS Hemangiomas (vascular
tumors of the skin)
NUTRITIONAL NEEDS OF A NEWBORN
 Proper nutrition is essential for optimal growth
and development , especially in the first few
moths of life because brain growth proceeds at
such a rapid rate during this time.
 Feeding Newborn extends beyond physiologic
need of adequate nutrition, it also fulfills
important psychological needs that enhances
psychosocial development of the infant.
Nursing Process Overview for Promoting
Nutritional Health in a Newborn
 Assessment
 Nursing Diagnosis
 Outcome Identification and Planning
 Implementation
 Outcome Evaluation
ASSESSMENT
 Mother’s and her partner’s attitudes and
choices about infant feeding.
 Recognizing signs of hunger in their infants.
 Adequate intake by monitoring voiding and
stooling patterns
NURSING DIAGNOSIS
 Effective breastfeeding related to well-prepared
mother and a healthy newborn who is able to
latch properly and transfer milk effectively.
 Risk for ineffective breastfeeding related to a
poor latch, or ineffective transfer of milk.
 Imbalance nutrition, less than body
requirements, related to poor newborn
response, poor latch, or ineffective transfer of
milk.
 Risk for impaired parenting related to inability
to exclusively breastfeed the newborn if the
mother’s desire was to exclusively breastfeed
OUTCOME IDENTIFICATION AND PLANNING
 Human milk is the ideal food for newborns.
Patient education regarding infant feeding
begins during the prenatal period
 Expectant parents cannot make informed
choice if they are not aware of the nutritional
and health benefits of breastmilk. Parents who
choose formula feeding can practice behaviors,
such as skin to skin contact, to promote
bonding. They require instructions on formula
preparations, safe feeding techniques, and
appropriate volumes for newborn and infant
feeding
IMPLEMENTATION
 An intervention related to newborn nutrition is
CMCA: NURSING CARE OF A FAMILY WITH A NEWBORN
supporting a mother’s choice of a feeding
method and helping her feel confident in her
ability to feed her infant. Provide mothers with
information on breastfeeding support groups
at the time of discharge. Mothers may need to
see a lactation consultant for any breastfeeding
problems or challenges
OUTCOME EVALUATION
 This is an important final step to ensure a
newborn receives adequate nutrition because
unforeseen circumstances such as jaundice,
infant tongue-tie, or late preterm delivery may
require the mother to provide expressed
breastmilk until the problem is solved
Examples:
 Mother expresses satisfaction with her chosen
method of newborn feeding
 Newborn wakes for feedings every 2 to 3 hrs
after the first 24 hrs of life.
Nutritional allowances for Newborn
Calories
During growth spurts, more calories are needed
to supply additional energy
Protein
is necessary for the formation of a new cells to
provide for a rapid growth of new cells a well as
maintenance of existing cells.
Fat
Linoleic acid, an essential fatty acid, is necessary
for brain growth and skin integrity in infants
Carbohydrates
Lactose, the disaccharide found in human milk
and added to commercial formulas, appears to
be the most easily digested of the carbohydrates.
Improves calcium absorption and aids in nitrogen
retention.
Iron
some women who breastfeed and formula fed
NBs were advised to supplement iron to ensure
infant does not develop Iron-deficiency anemia.
Calcium
– is important to the newborn because the
skeleton grows so rapidly.
Fluid
it is important to maintain fluid intake in
newborns because their metabolic rate is so high
( and metabolism requires water). This
requirement can be supplied completely by
breastfeeding or formula feeding.
 Fruit juice is not recommended for infants
younger than 6 months because it supplies
no protein and if not pasteurized, can carry
infectious organisms (American Academy of
Pediatrics(AAP), 2012).
Minerals
A number of minerals are particularly important
to early growth.
Flouride
is essential for building sound teeth and for
preventing tooth decay.
Vitamins
the AAP recommends both breastfeeding and
formula fed infants to have 400 IU of Vitamin D.
 Human milk is the ideal food and the
preferred feeding method for newborns
because it provides antibodies as well as
nutrients. Encourage all mothers to
breastfeed by providing them with
knowledge, skill, and support to be
successful.
 Breastfeeding infants should be fed when
hunger cues are displayed: rooting, sucking
on fists, clenched fists: these cues may be
exhibited from 90 min to 3 hours after the
last feeding. Crying is the last sign of hunger.
 Night feedings will be necessary during the
first 6 to 8 weeks: the fat content of
breastmilk is high in the evening which may
help the infant to consume more calories and
therefore feel more satiated; infants who
consume more calories during the day may
be able to have longer stretches of sleep at
night.
 If a newborn will be formula fed, be certain
the parents understand how to prepare the
formula.
Here is an ACRONYM on the Benefits of
BREASTFEEDING
 B- est for baby, also best for mommy
 R-educes the incidence of allergies
 E-economical, no waste
 A-nti-bodies to protect baby against infection
 S-terile and pure
 T-emperature is always ideal
 F-resh milk never goes off
 E-asy to prepare and to digest
 E-radicates feeding difficulties
 D-evelops mother and child bonding
 I-mmediately available
 N-utritionally optimal
 G-astroenteritis greatly reduced
Tips of Breastfeeding:
1. With a clean washcloth or cotton swabs, wipe
your breasts clean before your baby feeds.
2. Sit comfortably in an upright position.
3. Support your baby's head
4. Guide your nipple towards his mouth. Baby's chin
should be against the breast and his tongue
underneath your nipple. Make sure that he's
sucking the whole areola (darkened area of the
nipple).
CMCA: NURSING CARE OF A FAMILY WITH A NEWBORN
5.When he's sucking subsides, switch him to other
breast until stops feeding. Next time he feeds, start
from the breast he nursed from last.
6.If your nipples get sore, never wash your nipples
with soap, give a minute for them to be exposed for
air dry
7. ALWAYS burp your baby every after feedings.
Discharge Planning for Newborn Nutrition
1. Teaching parents about either breastfeeding or
formula feeding is crucial. Connect the mother to
local breastfeeding support groups in the area.
2. Caution parents not to prop bottles because it
increases the risk of aspiration and otitis media and
deprives the infant of the pleasure of being held for
feedings.
3. Review adequate infant intake based on
recommended voiding and stooling pattern as
described.
4. Ensure the newborn has follow-up appointment
with a pediatric primary care provider.
5. Empower mother to learn to make decisions
regarding feeding and not to be reluctant to ask for
help when they need it