ASSESSMENT:

VITAL STATISTICS:
Weight : Between 2.5 -3.4 kg
- Use standard weighing scale
and plot in standard
neonatal graph; w/out linen, Continues to
increase in succeeding child in the family
6-10 oz loss of Birth wt due to diuresis (absence of
maternal hormones, starts to void and defecate)
 Weight stable on first day then begins to gain
weight
 BW regained after 10 days If BF, 7days if formula
fed
 Wt gain 2lbs/month for first 6 months
Length:F =53 cm; M=54 cm ; normal limit 46 cm (57.5 cm
rare)
Head circumference
 Mature=34-35 cm greater than this should investigate for
neurologic involvement
 Use tape measure drawn across the center of forehead and
around the most prominent portion of posterior
head(occiput)
Chest circumference
 Term: 2 cm less than head circumference
Measure at the level of nipple
VITAL SIGNS
 TEMPERATURE
 99 deg F (37.2 deg C) at birth; temp falls almost immediately due to heat loss
and immature temp-regulating mechanism; taken from the anal rectum

Heat is lost thru :

 CONVECTION:flow of heat from NB body to atmosphere

Nursing Care:Close windows, lower AC thermostat to reduce draft

 CONDUCTION: heat transfer to a cooler surface in contact with body

Nursing Care ; Cover surface with warmed blanket or towel

 RADIATION : heat transfer to cooler object not in contact with body
Nursing Care:Move infant away from cold surface
 EVAPORATION: conversion of liquid to vapor
Dry NB immediately after delivery, put bonnet/cap to head
and cover with dry, warm blanket, place under radiant
warmer or goosseneck lamp
Brown fat in the intrascapular area, thorax and perirenal
area controls temp in NB. Practice KANGAROO CARE

EINC Protocol
First few hours of life
Manual
Time-bound
Immediate drying
Skin-to-skin contact
Properly timed cord clamping
Non-separation of newborn from mother and
breastfeeding initiation
 Pulse- 180 bpm immediately after birth, then
stabilizes to 120-140 bpm after 1 hr
 Assessed from apical heartbeat for 1 full
minute
 Increase when crying and decreases when
sleeping
 Irregular due to immature cardiac regulatory
center in the medulla,
 With transient murmurs to due incomplete
closure of fetal shunts
 BLOOD PRESSURE
APPROX 80/46 mmHg at birth, rises to 100/50
after 10 days

> RESPIRATION-
 8O breaths/min after birth, then settles to 30-
60 at rest, irregular with short periods apnea
(periodic respirations)
 Assess by observing the abdomenal movement
(use of diaphragm and abdominal muscles)
 May cough or sneeze to clear airways

Apgar test -- is to determine quickly whether a newborn needs immediate
medical care; it was not designed to make long-term predictions on a child's
health.
 A score of 10 is uncommon due to the prevalence of transient cyanosis,
and is not substantially different from a score of 9.

A low score on the one-minute test

may show that the neonate requires
medical attention but is not
necessarily an indication that there
will be long-term problems,
particularly if there is an
improvement by the stage of the
five-minute test.
 If the Apgar score remains below 3
at later times such as 10, 15, or 30
minutes, there is a risk that the
child will suffer longer-term
neurological damage.
There is also a small but significant
increase of the risk of cerebral palsy.

.
 Unang Yakap: Essential Newborn Care (ENC)
Initiative to reduce infant and maternal mortality
 simple cost-effective newborn care
 an evidence-based intervention
 step -by-step
 time bound interventions
fills a gap
 Non-time bound
Immunization( hepa B)
Eye care
Vitamin K
Weighing

PREVENTION OF INFECTION AND INJURY

EYE PROPHYLAXIS(Crede’s )
- Prophylactis against gonorrheal conjunctivitis
(erythormycon ointment-applied from inner canthus
outward; Neosporin drops per eye over the conjunctiva,
nor the cornea)
- Practice single-tube use per infant

PREVENTION OF HEMORRHAGE
Inject .1 ml Vitamin K at the vastus lateralis to prevent hemorrhage
IMMUNIZATION
Hepatitis B vaccination and BCG may be given anythime afer birth intradermal route
NEWBORN SCREENING

Often referred to as PKU test- a

simple, inexpensive blood test
performed on babies in the first 48
hours after birth to look for serious
and often life-threatening disorders .
Nursing intervention: from a prick on
the heel.
 To check- disorders that can cause
mental retardation, severe illnesses or
premature death if not detected at
birth (phenylketonuria,
hypothyroidism, cystic fibrosis, Maple
syrup urine disease, sicle cell anemia,
galactosemia)
NUTRITION
Initial breastFeeding may be
given immediately
BF every 2 hours in the first few
days of life

ELIMINATION
Meconium –w/in 24hrs sticky,
tarlike, blackish-green, odorless
absence: imperforate anus, bowel
obstruction meconium ileus
Transitional stool-2nd to 3rd
day ; resemble diarrhea, 3 or 4
times daily; light yellow, sweet
smelling
  Neonatal reflexes or primitive reflexes

are the inborn behavioral patterns that develop during

uterine life. They should be fully present at birth and
are gradually inhibited by higher centers in the brain
during the first three to 12 months of postnatal life.
These reflexes, which are essential for a newborn's
survival immediately after birth:
 sucking, swallowing, blinking, urinating,
 hiccupping, and defecating.

These typical reflexes are not learned; they are

involuntary and necessary for survival.
 Newborn reflexes
A. Moro reflex in a four-day-old infant:
1) the reflex is initiated by pulling the infant up from the floor
and then releasing him;
2) 2) he spreads his arms;
3) 3) he pulls his arms in;
4) 4) he cries (10 seconds)
5. Primitive Reflexes – Moro reflex
The arms should fully abduct and extend, then return
towards the midline with the hand open and the thumb
and the index finger forming a “C” shape. An absent or
incomplete Moro is seen in upper motor neuron lesions.
An asymmetric Moro is most often seen with a brachial
plexus lesion. The brachial plexus palsy is
on the side of the poorly abducted arm.
Babinski's reflex occurs when the big toe moves toward the
top surface of the foot and the other toes fan out after the
sole of the foot has been firmly stroked.
Reflexes are predictable, uncontrollable responses to a
certain type of stimulation.
Babinski's reflex is one of the reflexes that occurs in infants.
It is normal in children up to 2 years old, but it disappears as
the child gets older and the nervous system becomes more
developed. It may disappear as early as 12 months.
The rooting reflex is present at birth;
 it assists in breastfeeding , disappearing at around four months of
age as it gradually comes under voluntary control. A newborn
newborn will turn his head toward anything that strokes his
cheek or mouth, searching for the object by moving his head in
steadily decreasing arcs until the object is found. After becoming
used to responding in this way (if breastfed, approximately three
weeks after birth), the infant will move directly to the object
without searching.
The sucking reflex is common to all mammals
and is present at birth.
 It is linked with the rooting reflex and
breastfeeding, and causes the child to
instinctively suck at anything that touches the
roof of their mouth and suddenly starts to suck
simulating the way they naturally eat.
There are two stages to the action:
 Expression: activated when the nipple is placed
between a child's lips and touches their palate.
They will instinctively press it between their
tongue and palate to draw out the milk.
Milking: The tongue moves from areola to
nipple, coaxing milk from the mother to be
swallowed by the child.
The tonic neck reflex,- also known as asymmetric tonic neck reflex or 'fencing
posture' is present at one month of age and disappears at around four
months. When the child's head is turned to the side, the arm on that side
will straighten and the opposite arm will bend (sometimes the motion will be
very subtle or slight).
If the infant is unable to move out of this position or the reflex continues to be
triggered past six months of age, the child may have a disorder of the upper
motor neuron. the tonic neck reflex is a precursor to the hand/eye
coordination of the infant. It also prepares the infant for voluntary reaching.
Grasp reflex- The palmar grasp reflex appears at birth and
persists until five or six months of age. When an object is
placed in the infant's hand and strokes their palm, the fingers
will close and they will grasp it. The grip is strong but
unpredictable; though it may be able to support the child's
weight, they may also release their grip suddenly and without
warning. The reverse motion can be induced by stroking the
back or side of the hand.
Plantar Reflex
The normal response to stroking the lateral aspect of the
plantar surface of the foot is extension of the great toe and
fanning of the other toes. If the stimulus is brought across
the ball of the foot then a grasp reflex will be elicited and the
toes will plantar flex. The up going toes or “Babinski sign” is
normal in the infant and may be present for the first year of
life because of the incomplete myelination of the
corticospinal tracts.
Galant reflex- also known as Galant’s infantile reflex, is present
at birth and fades between the ages of four to six months.
When the skin along the side of an infant's back is stroked, the
infant will swing towards the side that was stroked. If the reflex
persists past six months of age, it is a sign of pathology. The
reflex is named after the Russian neurologist Johann Susman
Galant
Primitive Reflexes - Stepping
The stepping or walking reflex is obtained by holding the
baby upright over the mat with the sole of the foot touching
the mat. This initiates a reciprocal flexion and extension of
the legs and it looks like the baby is walking.
Head Shape and Sutures
The head should be closely inspected as part of the
neurological examination. There can be molding of the
head, which is an expected finding in a newborn. Palpate
the sutures and outline the anterior and posterior
fontanelles.
Head Circumference
which sometimes is referred to as the OFC (occipital-frontal
circumference) the measurement is obtained by placing the
measuring tape around the most prominent aspect of the
frontal and occipital bones.
The head circumference measurement should be plotted on a
standardized head growth chart for the appropriate sex.
Extrusion reflex-a normal response in
infants to force the tongue outward
when it is touched or depressed. The
reflex begins to disappear by about 3 or
4 months of age. Constant protrusion of
a large tongue may be a sign of Down
syndrome.
Magnet reflex -If light pressure with e.g.
the thumb is applied to the sole of the
foot of a newborn lying in a supine
position, the baby pushes back against
the pressure. And when the parent
withdraws his thumb, he has the
sensation that his thumb is drawing the
limb out as by a magnet.
Landau reflex- a normal response of infants when held in a horizontal
prone position to maintain a convex arc with the head raised and the
legs slightly flexed. The reflex is displayed at about 3 months of age. It
is poor in those with floppy infant syndrome and exaggerated in
hypertonic and opisthotonic infants.
Reflexes - Deep Tendon Reflexes
Testing deep tendon reflexes is an important part of the
newborn neurological exam. Absence of deep tendon
reflexes is a much more important finding than
hyperreflexia in the newborn. A normal newborn can have
hyperreflexia and still be normal, if the tone is normal, but
absent reflexes associated with low tone and weakness is
consistent with a lower motor neuron disorder.
Behavior
5-day-old infant
 alert, quiet state,spontaneous movements, jerky or asymmetric. He seems
to be attentive to the environment.
 attempts to organize and comfort himself by sucking on his fists, which is a
favorable behavioral response.
 When a bright light is directed towards his eyes he has a definite response:
blinking and avoiding the light. With repeated stimulus there is habituation,
a diminished response to the stimulus.
 He responds to sound by quieting and even turning head and eyes toward
the sound. The above observations are the baby equivalent to the adult
mental status exam.
Tone - Resting Posture
For a term newborn the resting posture is flexion of the
extremities with the extremities closely adducted to the
trunk. After the first few days of life, the extremities are still
predominantly in the flexed position but they are not as
tightly adducted as they are in the first 48 hours of life.
Tone - Upper Extremity Tone
Assessing motor function of the upper extremities begins
with passive range of motion. This is done by rotating each
extremity at the shoulder, elbow and wrist and feeling the
resistance and the range of movement. Too little or too
much resistance reflects hypotonia or hypertonia. Further
testing helps to better define tone and any tone
abnormalities.
Tone - Arm Traction
Arm traction is done with the baby in the supine position.
The wrist is grasped and the arm is pulled until the shoulder
is slightly off the mat. There should be some flexion
maintained at the elbow. Full extension at the elbow is seen
in hypotonia.
Tone - Arm Recoil
Arm recoil tests tone and action of the biceps. The arms are
held in flexion against the chest for a few seconds, then are
quickly extended and released. The arms should spring back
to the flexed position. The hypotonic infant will have slow
incomplete recoil. Asymmetry to this response with lack of
recoil would be seen with Erb’s or brachial plexus palsy.
Tone - Scarf Sign
The tone of the shoulder girdle is assessed by taking the
baby’s hand and pulling the hand to the opposite shoulder
like a scarf. The hand should not go past the shoulder and
the elbow should not cross the midline of the chest.
Tone - Hand Position
A newborn baby’s hand is held in a fisted position with the
fingers flexed over the thumb. The hand should open
intermittently and should not always be held in a tight fisted
position. Rubbing the ulnar aspect of the hand or touching
the dorsum of the hand will often cause extension of the
fingers. Over the first 1 to 2 months of life, the baby’s hand
becomes more open. Persistence of a fisted hand is a sign of
an upper motor neuron lesion in an infant.
Tone - Lower Extremity Tone
Assessing motor function of the lower extremities begins
with passive range of motion. This is done by flexing the
hips, then abducting and adducting the hips. Next, flex and
extend the hips, the knees and ankles. Further testing helps
to better define the tone and any tone abnormalities.
 Tone - Leg Traction
Leg traction is done by holding the leg by the ankle. The leg is
pulled upward until the buttock starts to be lifted off the mat. The
knee should maintain a flexed angle. Full extension of the knee
with little resistance to pulling on the leg is a sign of hypotonia.
Tone - Leg Recoil
To test leg recoil, the legs are fully flexed on the abdomen for
a few seconds, then the legs are quickly extended and
released. The legs should spring back to the flexed position.
Legs that remain extended could be due to either hypotonia
or abnormal extensor tone.
Tone - Heel to Ear
Holding the baby’s foot in one hand, draw the leg towards
the ear to see how much resistance there is to the maneuver.
The foot should go to about the level of the chest or
shoulder, but not all the way to the ear. If the foot can be
drawn to the ear then there is hypotonia.
Tone - Neck Tone
The tone of the neck can be assessed by passively rotating
the head towards the shoulder. The chin should be able to
rotate to the shoulder but not beyond the shoulder. If the
chin goes beyond the shoulder then there is hypotonia of
the neck muscles, which is associated with poor head
control.
Tone - Head Lag
Starting in the supine position, the baby is pulled by the arms
to the sitting position. The head and the arms are observed
during the maneuver. The arms should remain partially
flexed at the elbow and the head may lag behind the trunk,
but should not be fully flexed backwards. When the baby is in
the sitting position, the head should be able to come to the
upright position for at least a few seconds before dropping
forward or backward.
Tone - Head Control
The strength and tone of the neck extensors can be tested by
having the baby in sitting position and neck flexed so the
baby’s chin is on the chest. The baby should be able to bring
the head to the upright position. The neck flexors can be tested
by having the head in extension while in the sitting position.
These tests are an extension of the test for head lag and are
done at the same time.
 INFANT MASSASE AND EARLY STIMULATION
-gentle massage or rubbing of the back and stomach can
soothe a crying infant;
reassures infant of someone special being there for
them; increases bonding
(Relaxation, Relief, Stimulation, Interaction); use plant-
based oil

SLEEP – REST
Average 16 hrs/day during first week or average 4 hrs at a
time; by 4 months 15hrs / day
Encourage baby to sleep on his back, no pillows, no stuff
toys on a firm mattress
Create day-night pattern for baby to follow
Sleeping on the stomach is associated with SIDS
PHYSIOLOGIC FUNCTION CHANGES

CARDIOVASCULAR – closure of DA (decrease pressure in

PA); closure of FO (increase pressure in the left side of
heart); acrocyanosis (sluggish circulation)
RESPIRATORY - Hi pressure necessary as first breath , little
moisture helpful to reduce surface tension (steam inhilation

URINARY –voids w/in 24 H (urethral stenosis, absent kidney

or ureters if no output), Males: projectile; Female: steady
stream; light colored, odorless (cannot concentrate urine);
15ml/voiding initially pinksih/dusky due to hi uric acid
crystals
IMMUNE SYSTEM- difficculty in forming antibodies until
2 mos(prone to infection)
NEUROMUSCULAR (Refer to exercise/activity above)
SENSES- generally fully developed; Hearing: starts in uteru,
acute at birth, difficulty locating the sound, respond with
generalized activity to sound(e.g. stops crying when hears bell),
calmed by soothing voice or startled by loud noise
VISION:focus on black and white at 9-12 in, pupillary reflex
present;
TOUCH: well developed, reacts to pain as well;
TASTE: taste buds fully developed
EYES: tearless cry til 3 mos, normal edema til 3rd day,
proportionate corneal size
 EARS: pinna bends easily but recoils after bendingtop portion
should be in line with outer canthus of eye (mental retardation if
lower)
 NOSE: appears large for the face
Caput succedaneum is a diffuse swelling of the scalp in a
newborn caused by pressure from the uterus or vaginal wall
during delivery, a head-first (vertex) delivery. A caput
succedaneum is caused by the mechanical trauma of the
initial portion of scalp pushing through a narrowed cervix.
The swelling may be on any portion of the scalp, may cross
the midline (as opposed to a cephalhematoma), and may be
discolored because of slight bleeding in the area. There may
also be molding of the head, which is common in
association with a caput succedaneum
 APPEARANCE: SKIN – color:ruddy,
cyanosis(acrocyanosis vs central
cyanosis),
mottling,Hyperbilirubinemia-leads to
jaundice(physiologic vs. Pathologic)
 Cephalhematoma vs caput
succedaneum; pallor (anemia)
 Harlequin Sign; BIRTHMARKS:
 hemangiomas; Mongolian Spot;

A birthmark is a benign irregularity on the

skin which is present at birth or appears
shortly after birth, usually in the first month.
They can occur anywhere on the skin.
Birthmarks are caused by overgrowth of blo
vessels, melanocytes, smooth muscle, fat
fibroblasts, or keratinocytes
Mongolian spots are flat, blue, or blue-gray skin
markings near the buttocks that appear at birth or
shortly
Vernix is to serve several purposes,
 moisturizing the infant's skin, and facilitating passage
through the birth canal .
 It serves to conserve heat and protect the delicate newborn
skin from environmental stress.
 have an antibacterial effect, though there is little to support
a chemical role of vernix in protecting the infant from
infection, it may form a physical barrier to the passage of
bacteria.
Milia are white points, formed because the skin cells and
sebaceous matter are trapped rather than naturally
exfoliated.
Milia can appear anywhere on the skin. Usually for the
intervention of the cyst (white point) it is used a lancet to
remove it
Lanugo grows on fetuses as a normal part of gestation,
usually shed and replaced by vellus hair at about 33 to 36
weeks of gestational age.
As the lanugo is shed from the skin, it is normal for the
developing fetus to consume the hair with the fluid, since it
drinks from the amniotic fluid and urinates it back into its
environment. Subsequently, the lanugo
It contributes to the newborn baby's meconium. The
presence of lanugo in newborns is a sign of premature birth
 MOUTH :opens evenly, large, prominent tongue, Epstein’s
pearls at palate, may have natal teeth
 NECK: short, soft, chubby, with creases/folds, head rotates
freely ; cannot support head
 CHEST: looks small til 2 yrs, engorged, witch’s milk, no
retraction
 ABDOMEn : slightlt protuberant, positive bowel souns in
hr after birth
 GENITALS : Male: edematous scrotum, testes present,
small penis (epispadias/hypospadias), prepuse slides
poorly Female:swollen vulva, some w/ mucus vaginal
secretion (pseudomenstruation)
Hypospadias is a congenital defect, primarily of males, in
which the urethra opens on the underside (ventrum) of the
penis. The corresponding defect in females is an opening of the
urethra into the vagina and is rare.
Epispadias (also called bladder exstrophy) is a congenital
defect of males in which the urethra opens on the upper
surface (dorsum) of the penis. The corresponding defect in
females is a fissure in the upper wall of the urethra and is
quite rare.
 BACK :Flat lumbar and sacral areas, no pinpoint
opening at base of spine nor dimpling, or sinus tract
in skin
 EXTREMITIES: arms & legs appear short, plump clench
fist, soft, smooth fingernails, moves symmetrically,
bowed legs, sole flat foot but crisscrossed (absense
immaturity)
Next topic:

FAMILY WITH INFANT