N4441 Nursing of the Childbearing Family
Newborn
Prep Sheet Completed by N4441 Clinical Instructor
TerTerminology
Definitions (List reference – If using Ricci – only need to list page number)
Fontanels
Name for the intersections of the sutures between the cranial bones. The anterior fontanel is the diamond-shaped “soft spot” on top of a newborn’s head, measuring 4-6cm @ largest diameter, and remains open 12-18 mo. after birth, accommodating brain growth. The posterior fontanel is a smaller triangular-shaped space located above the occipital bone, measuring 0.5-1cm (fingertip size), and closes w/in 8-12 weeks after birth. Useful in determining the position of the fetal head in the birth canal, including amount of rotation (Ricci, 2017, p. 600). Both fontanels should be flat and soft to palpation. MEASURE BOTH and compare width & length with expected parameters above
(p. 600).
Molding
“The elongated shaping of the fetal head to accommodate passage through the birth canal…occurs with a vaginal birth from a vertex position…with prominence of the occiput and overriding sagittal suture line” Resolves w/o intervention w/in a week of birth (p. 600). Look up Figure 18.13 on same page for photo.
Apical Pulse
Obtained by placing a stethoscope over the 4th ICS on left side of baby’s chest and counting for a FULL minute. Normal NB HR = 120 – 160bpm w/ large fluctuations in rate between sleep and activity; sinus arrhythmia and murmurs can be normal finding. Murmurs will need to be re-assessed over several months to see if they resolve or persist (p. 588). HR usually assessed Q 30min. until stable for 2 hrs post birth, then Q4-8 hrs (p. 597).
Thermoregulation (how is this done)
Neutral thermal environment (NTE)
“…the process of maintaining the balance between heat loss and heat production” Newborns struggle to maintain body temperature because of the effects of conduction, convection, evaporation and radiation (p. 594). Baby’s metabolic rate will increase; muscular activity & peripheral vasoconstriction will increase during nonshivering thermogenesis (brown fat or adipose tissue oxidation in response to cold exposure). Baby assumes fetal position to “hold in heat and minimize exposed body surface area” (p. 594).
NTE is “an environment in which body temperature is maintained w/o an increase in metabolic rate or oxygen use” Either a radiant warmer or incubator is used to maintain newborn body temperature (p. 594).
Nursing Interventions to minimize effects of cold stress and maintain NTE are: Immediate drying of the newborn using pre-warmed blankets and applying a hat on the head, having parents hold baby skin-to-skin, promoting early breastfeeding, deferring bathing until baby is stable and then using radiant heat while bathing, transporting in a heated Isolette (p. 610).
Meconium
A newborn’s first stool which is green-black in color, tarry in consistency, and usually passed w/in 12-24 hrs. post birth. It is comprised of “amniotic fluid, shed mucosal cells, intestinal secretions, and blood.” Only the first stool passed is sterile (p. 611).
Jaundice
AKA “icterus” is the yellow hue seen in “the skin, sclera, and mucous membranes that results from increased [unconjugated] bilirubin blood levels” Occurs in > 50% of healthy newborns. Three classifications: 1) Bilirubin overproduction (Rh or ABO blood incompatibility), 2) Decreased bilirubin conjugation (physiologic jaundice), 3) Impaired bilirubin excretion (biliary obstruction, hepatitis, chromosomal abnormality and drugs) (p. 598).
Jaundice follows a “cephalocaudal progression” that is, from head to trunk and extremities; use digital pressure over a bony prominence to blanch the skin and detect jaundice (p. 905). Bilirubin levels are determined by taking blood using a heelstick; direct Coombs test is also performed from a heelstick sample (p. 906).
Bilirubin
“A yellow to orange bile pigment produced by the breakdown of red blood cells [in the liver]” Bilirubin is produced by the breakdown of ERYCs (normal in newborns) and released in unconjugated form that is fat soluble (indirect bilirubin). That is then processed into conjugated form which is water-soluble (direct bilirubin) and is excreted through feces and urine. Newborns produce more than 2X the rate of adults for the first days of life; the rate declines to adult levels w/in 10-14 days after birth (p.904). A Nomogram is used to determine if level is safe or not.
***I have included one in your clinical folder
Hyperbilirubinemia
A condition where the total serum bilirubin level is above 5mg/dL “resulting from unconjugated bilirubin being deposited in the skin and mucous membranes” which causes jaundice. African American babies experience lower rates of hyperbilirubinemia than do Asian or Caucasian infants (p. 903). Usually treated by phototherapy and labs to determine accurate blood levels (p. 903). At birth, the level should be < 5.
Acrocyanosis
NORMAL intermittent peripheral cyanosis; bluish color and coldness of the newborn’s hands and feet in most infants at birth that may persist 7 to 10 days (p. 598). **See Figure 18.11 on page 598 for photo.
Vernix Caseosa
“A thick white substance… formed by secretions from the fetus’s oil glands…that protects the baby’s skin; … it will be absorbed into the skin” (p. 599).
Cephalhematoma
“A localized effusion of blood beneath the periosteum of the skull…due to disruption of the vessels during birth” (prolonged labor, low forceps or vacuum extraction). Swelling does NOT cross suture lines. Usually appears 2-3 days after birth and resolves w/in weeks or months (p. 601). ***See Figure 18.14 on page 602.
Caput Succedaneum
“Localized edema on the scalp that occurs from the pressure of the birth process” Swelling DOES cross the suture lines; petechiae and ecchymosis often present. Usually resolves w/o tx in 3 days (p. 601). ***See Figure 18.14 on page 602.
Mongolian Spot
Blue or purple blotches on the lower back and buttocks of dark-skinned newborns of all races “caused by a concentration of pigmented cells and usually disappear w/in the first 4 years of life” (p. 599). Be SURE to DOCUMENT location and measurement as some ignorant parents have filed suit for suspected child abuse by care givers! Always cover your nursing practice with detailed description to protect yourself from liability in a lawsuit.
Milia
“Unopened sebaceous glands frequently found on a newborn’s nose…chin and forehead” Observed in 60% of newborns. Termed “Epstein’s pearls” when found inside the mouth or on the gums. Resolves on their own w/in 2-4 wks (p. 599). **See photo on page 599. AKA “Newborn Acne.”
Apgar Score (parameters assessed) What do scores mean?
A scoring system developed by Dr. Virginia Apgar in 1952, used to document a newborn’s physical adaptation to extrauterine life at 1 minute and 5 minutes after birth. FIVE parameters are scored from 0-2 points each (0=absent/poor response, 2=normal response): A = Appearance (color), P = Pulse (HR),
G = Grimace (reflex irritability), A = Activity (muscle tone), R = Respiratory effort.
Normal score = 8-10; 4-7 shows moderate difficulty; 0-3 indicate severe distress.
“When the newborn experiences physiologic depression, the Apgar score characteristics disappear in a predictable manner: first the pink coloration is lost, next the respiratory effort, and then the tone, followed by reflex irritability and finally heart rate” (p. 587).
Gestational Age (weeks + days)
Determined by using a pregnancy wheel (p. 372) to line up the “First day of LMP” arrow with the correct date OR the “Approximate date of delivery” arrow with the correct date. Then, determine the correct weeks and days of gestation by looking at the second circle inside the dates on the outer rim.
It is written as two numbers separated by a period: 34.5 GA = 34 weeks and 5 days gestational age.
Newborn physical & neurological maturity is determined using the New Ballard tool to score 12 items (6 physical characteristics and 6 neurological abilities) which produces an appropriate gestational age in weeks. Low scores are found in preterm babies; high scores in mature/postmature newborns (p. 587).
**See New Ballard Score form (p. 590); you will be completing one on your newborn pt. and your NICU pt.
LGA Large for Gestational Age (Percentage used to determine)
Weight > 90th percentile on standard growth charts –usually > 9 lb. (p. 590). *Be sure to circle on the Patient Focused Assessment Form if it applies!
SGA Small for Gestational Age (Percentage used to determine)
Weight < 10th percentile on standard growth charts—usually < 5.5 lb. in a term infant (p. 590). *Be sure to circle on the Patient Focused Assessment Form if it applies!
AGA Average for Gestational Age (Percentage used to determine)
Weight between 10th and 90th percentiles on standard growth charts (p. 590). *Be sure to circle on the Patient Focused Assessment Form if it applies!
IUGR (how is this different than SGA?)
Intrauterine growth restriction (IUGR) occurs in some SGA newborns when the rate of growth does not meet the expected growth pattern. It is the pathologic counterpart of SGA. An important distinction between the two classifications is that “not all who are SGA have IUGR. The converse also is true: not all newborns who have IUGR are SGA. Some SGA newborns are constitutionally small; that is, they are statistically small but otherwise healthy” (p. 835). Two categories: Symmetric and asymmetric.
Symmetric IUGR occurs 28 wks GA where infants’ head and long bones are spared compared to their abdomen and internal organs. Asymmetric has a better prognosis than symmetric IUGR because once born, the asymmetric infant’s growth is usually restored with optimal nutrition whereas the symmetric IUGR infant is at a distinct disadvantage with reduced organ sizes and overall weight. **”There is a strong association between stillbirth and fetal growth restriction” (p. 835).
Term
Newborns are typically classified by gestational age; “Term” refers to birth between 38.0 and 42.0 weeks gestation (p. 591). ***Note that many area hospitals are labeling infants born at 37 weeks as “term;” however, by definition, these babies are actually “late preterm” and should be identified as such. ”In 2006, a new classification was added, the late preterm newborn (near term)—one who is born between 34 weeks and 36 weeks, 6 days of gestation” (p. 857).
Phototherapy
AKA “Bili lights” involves “exposing the newborn to ultraviolet light, which converts unconjugated bilirubin into products that can be excreted through feces and urine” Most common tx for hyperbilirubinemia; has “virtually eliminated the need for exchange transfusion in newborns now” (p. 621).
Circumcision And what is taught to parents?
FEMALE: Female genital cutting (FGC) AKA female genital mutilation (FGM) or female circumcision is any surgical “injury of the external female genitalia for cultural or nontherapeutic reasons” 140 million women are victims of FGC, according to WHO and UNICEF! The practice predates Christianity & Islam (p. 613).
MALE: Surgical removal of all or part of the foreskin (prepuce) of the penis; traditionally for hygiene and medical reasons. It is the oldest known religious rite. Three methods: Gomco clamp, Mogen clamp & Plastibell device (most common). Controversial. Most common NB procedure: 61% American male babies are circumcised (pp. 613-614).
**If a Plastibell circumcision was performed, parents should be told that the plastic rim will remain “in place until healing occurs.” Once healed, the rim will loosen and fall off “in approximately 1 week” (pp. 613-614).
For Gomco or Mogen After the procedure, petroleum jelly-coated gauze is applied to the DIAPER “to keep the wound from sticking to the diaper.”
For all type: Other site care includes:
“Assess for bleeding every 30 minutes for at least 2 hours.
Document the first voiding to evaluate for urinary obstruction or edema
Squeeze soapy water over the area daily and then rinse with warm water. Pat dry.
Fasten the diaper loosely over the penis and avoiding placing the newborn on his abdomen to prevent friction
Inform parents not to pull [the Plastibell rim] off sooner
Inform parents to check daily for any foul-smelling drainage, bleeding, or unusual swelling” (p. 614).
Transient Tachypnea of the Newborn
TTN (respiratory rate above 60 bpm-p. 529) appears soon after birth—exhibits as retractions, expiratory grunting, or cyanosis which is relieved by low-dose O2 tx. Occurs when the liquid in the fetal lungs is removed slowly or incompletely; vaginal birth appears to be protective against TTN (p. 620).
Surfactant
“A surface tension-reducing lipoprotein found in the newborn’s lungs that prevents alveolar collapse at the end of expiration and loss of lung volume” It provides the lung stability for gas exchange (p. 620).
Surfactant deficiency has been linked with respiratory distress syndrome (RDS), a breathing disorder resulting from lung immaturity. 60% of preterm newborns < 28 weeks gestation are affected; 30% of preterms born @ 28-34 weeks exhibit RDS and only 5% of babies born after 34 weeks manifest it (p. 872).
SIDS
Sudden Infant Death Syndrome—one of the causes of early infant death in the U.S. “Despite the rapid decline in infant mortality for industrialized countries during the 20th century, the U.S. infant mortality rate has declined only marginally. Racial and ethnic disparities in infant mortality have persisted and increased, as have the percentages of preterm and low-birth-weight births” (p. 13).
**”African American and American Indian/Alaska Native infants have consistently had higher infant mortality rates than other ethnic groups” (according to the March of Dimes, 2011) (p. 13). “Emphasizing the importance of placing an infant on his or her back to sleep will reduce the incidence of SIDS” (p. 13).
“To prevent suffocation, all fluffy bedding, quilts, sheepskins, stuffed animals, and pillows should be removed from the crib. Parents should be informed that the practice of ‘co-sleeping’ (sharing a bed) is not safe. For example, infants who sleep in adult beds are up to 40 times more likely to suffocate than those who sleep in cribs” (according to the American Academy of Pediatricians, 2011), (p. 617). It is very important to include “recommendations for safe infant sleeping practices” when educating new parents!! (p. 617).
Medications
Dose
Route
Briefly State NB use
Nursing considerations and side effects
Vitamin K- Aquamephyton
0.5-1 mg
IM into vastus lateralis muscle
(Oral form is used in other parts of the world but not in the U.S.)
Promotes blood clotting by increasing the synthesis of prothrombin by the liver; prevents Vit. K deficiency bleeding (VKDB) of the newborn.
Because the newborn’s intestines are sterile, there are no bacteria to produce Vitamin K until microorganisms are introduced during the first feeding. Even then, it takes 7 days of life to produce enough Vit. K to prevent VKDB
*Wear gloves
*Administer w/in 1 to 2 hrs. after birth (Standard of care since early 1960’s when AAP first recommended it).
*Give @ 90-degree angle into middle 1/3 of vastus lateralis muscle.
*Use 25-guage, 5/8th inch needle
*Hold leg firmly and aspirate prior to injecting medication slowly.
*Assess for bleeding @ injection site. (Ricci, 2017, p. 593).
*Most hospitals apply a Band-Aid (Hesse, 2020).
Erythromycin Ophthalmic Ointment
0.5%
1-2 cm ribbon
Topical—
Apply into conjunctival sac of each eye
Provides bactericidal and bacteriostatic actions to prevent N. gonorrhea and C. trachomatis conjunctivitis.
Prevents ophthalmia neonatorum (can cause neonatal blindness)
*Install w/in 1 to 2 hrs. after birth; mandated by law in all 50 states
*Wear gloves: open eyes by placing thumb and finger above and below eye.
*Gently squeeze tube to apply a ribbon into the conjunctival sac from the inner canthus to the outer canthus of each eye.
*DO NOT touch the tip of the tube to the eye.
*Close the eye to make sure medication permeates; wipe off excess ointment after 1 min.
*Be alert for chemical conjunctivitis for 1-2 days (p. 593).
”Parents have the right to refuse this treatment, but if they received adequate teaching about the treatment and under- stand the importance, they usually will consent to it” (p. 593).
Hepatitis B Vaccine
5mcg Hepatitis B surface antigen (HBsAg) in 0.5mL
(Nursing 2017 Drug Handbook, p. 1635).
IM
Provides active immunity against Hepatitis B virus (HBV) when the immune system is not yet mature; prevents infant from becoming a chronic carrier of HBV (Ricci, 2017, p. 637).
*Wear gloves
*Must obtain signed parental consent
*First dose should be given in the hospital soon after birth (if mother is HBsAg-negative, immunization can be delayed up to 2 months).
* Infants born to HBsAg-positive mothers should receive single antigen HBV vaccine and Hepatitis B immunoglobulin (HBIG) in opposite thighs w/in 12 hrs. of birth.
*Document date, time, name and manufacturer, lot # and expiration date, site and route of administration, and name and title of the RN who gave the vaccine (Ricci, 2017, p. 637).
***”Without intervention, 70% to 90% of infants born to women who are positive for Hepatitis B will have chronic Hepatitis B by 6 months of age” (Ricci, 2017, p. 727).
*2nd dose of 5mcg IM should be administered after 30 days (Nursing 2017 Drug Handbook, p. 1635).
*Give 3rd dose of 5mcg IM 6 months after 1st dose Nursing 2017 Drug Handbook, p. 1635).
*Teach parents the importance of completing the 3-dose series of HBV to provide their infant with the maximum amount of ACTIVE immunity. **See IZ sched. (Ricci, p. 637).
Hepatitis Immune Globulin
0.5mL
IM
**Give in opposite anterolateral thigh from HBV injection
Provides some additional (passive) immunity from antibodies already formed by another person to HBsAg (Ricci, 2017, p. 593).
*Wear gloves
*Must obtain signed parental consent
*Administer w/in 12 hrs. of birth to infant born to HBsAg-positive mother as well as 0.5mg single-antigen HBV (Ricci, 2013, p. 594).
*”If mother’s HBsAg status is unknown, within 12 hours of birth administer Hep B vaccine for infants weighing > 2,000 grams, and Hep B vaccine plus HBIG for infants weighing 2,000 grams (no later than age 1 week) (Ricci, 2017, p. 594).
Narcan
0.01mg/kg
**Repeat dose Q 2 to 3 min. prn
IV, IM or Sub-Q
Reverses the effects of opioid induced CNS depression, including respiratory depression (Ricci 2017, p. 437).
*Antidote for opioid induced CNS depression
*Abrupt reversal of opioid-induced CNS depression may result in n/v, diaphoresis, tachycardia, CNS excitement and increased BP
*Respiratory rate should increase w/in 1-2 minutes
*Monitor respiratory depth & rate. Provide O2, ventilation, and other resuscitation measures prn.
*Don’t confuse naloxone with naltrexone! (Nursing 2017 Drug Handbook, p. 1019).
Sucrose
Pacifier is dipped into the solution
(Ricci, 2017, p. 614). (Use TB syringe (w/o needle)
(Hesse, 2020).
Oral
Used as non-pharmacologic pain relief for procedures such as circumcision (Ricci, 2017, p. 614). Many studies have been conducted showing evidence that the newborn’s pain threshold is increased, thereby providing relief of pain (Hesse, 2020).
*AKA non-nutritive sucking; pacifier is dipped in sucrose solution prior to a procedure for preterm newborns (p. 854).
*Other non-pharmacologic pain reducing techniques include swaddling and positioning to establish physical boundaries, warm blankets for wrapping to facilitate relaxation (p. 854).
*Other analgesic methods for circumcision are: EMLA cream, a dorsal penile nerve block with buffered lidocaine, acetaminophen, and swaddling (p. 614).
References
Comerford, K. C. (Ed.). (2017). Nursing 2017 drug handbook (37th ed.). China: Wolters Kluwer.
Ricci, S. S. (2017). Essentials of maternity, newborn, and women’s health Nursing (4th ed.). China: Wolters Kluwer Health/Lippincott
Williams & Wilkins.
Physical Assessment/System
Reference Expected normal findings (Site your reference, If using Ricci – only list page number) Use text to locate more information.
Normal/Expected Vital Signs
T 97.7-99.5F (36.5-37.5C)
P 120-160bpm (can increase to 180 during crying)
R 30-60 breaths/ min @ rest; increases w/ crying
B/P 50-75mmHg systolic
30-45mmHg diastolic (BP not routine for healthy newborn) (p. 547).
Weight: what # and what %? SGA, AGA or LGA? (Hesse, 2020).
Term average: 2,500-4,000grams = 5lbs8oz-8lbs14oz (pp. 545-546).
Length: what # and what %? SGA, AGA or LGA? (Hesse, 2020).
Term average: 44-55cm = 17-22in (p. 545).
Neurological-Psychological
Muscle Tone
Cry
Reflexes
Moro
Palmar Grasp
Plantar Grasp
Gag
Rooting
Sucking
Swallowing
Tonic Neck
Stepping
Babinski
Trunk Incurvation
Other?
Normal: Vigorous cry (sustained after stimulation), presence of reflexes (listed below), symmetry of movement with reflexes, movements may be jerky or have brief twitching (if unable to elicit reflexes take into consideration sleep/wake state, maternal medication in labor, etc.)
Abnormal: Weak, high pitched, hoarse, cry (may indicate neurological disorders)
List and define Reflexes:
Moro (aka Embrace reflex or Startle reflex):
Place baby on its back; lift arms w/o lifting baby off surface; release arms suddenly. Baby will throw arms outward and flex knees; thumb and fingers spread to form a C. Baby appears startled and then relaxes to resting position (p. 564. See photo on p. 566. Reflex disappears in 3-6 mos. (p. 566).
Palmar Grasp: Place a finger on newborn’s open palm; baby’s hand will close around your finger—attempting removal of finger causes baby’s grip to tighten. Grasp should be equal bilaterally (p. 566). See photo p. 568. Disappears in 3-4 mos. (p. 566).
Plantar Grasp: Place a finger @ base of newborn’s toes; toes typically curl down over your finger (p. 566). See photo top of p. 568. Disappears in 3-4 mos. (p. 566).
Gag Reflex: A protective reflex that is elicited when something irritating touches the back of the baby’s throat. Use a gloved finger or bulb syringe and slide it along the roof of the mouth until reflex is elicited. Persists into adulthood (p. 566).
Rooting: Stroke baby’s cheek with a gloved finger; baby should turn toward that side and begin to make sucking movements. Disappears in 4-6 mos. (p. 566). See photo on bottom of p. 567.
Sucking: Elicit by gently touching the newborn’s lips with a gloved finger or inserting a gloved finger into the mouth. Baby will typically open the mouth and begin sucking (p. 564). See photo on p. 566.
Swallowing: Usually follows the sucking reflex if any fluid is present in the mouth, such as the breast or bottle
Tonic Neck (aka Fencing reflex): Place baby on back and turn head to one side. The arm toward which the baby is facing should extend straight away from the body with the hand partially open, whereas the arm on the opposite side (away from the face) should flex with the fist clenched tightly. Reversing the direction to which the face is turned reverses the position (p. 565). See photo top of p. 567. Reflex disappears in 3-4 mos. (p. 566).
Stepping: Hold baby upright and inclined forward with soles of the feet touching a flat surface. Baby should make a stepping or walking motion by alternately flexing and extending the soles of the feet (p. 565). See photo top of p. 567. Disappears in 1-2 mos. (p. 566).
Babinski: Stroke the lateral sole of the newborn’s foot from the heel upward and across the ball of the foot. Baby’s toes should fan out. A diminished response is indicative of a neurologic problem and should be followed up. Disappears @ about 1 year of age (p. 566). See photo bottom of p. 567.
Trunk Incurvation (Galant reflex): Place baby in prone position or hold in ventral suspension; apply firm pressure and run a finger down either side of the spine. The pelvis should flex toward the stimulated side. Lack of response indicated missing T2-S1 innervation and needs to be explored further. Disappears in a few days to 4 wks. (p. 566). See photo middle of p. 568.
Anocutaneous reflex (anal wink): With a gloved finger, touch the perianal skin close to the anus; the external sphincter will constrict (wink) immediately, indicating S4-S5 innervation (p. 566).
Glabellar (blink reflex): tap on the forehead, bridge of the nose or cheek near the infant’s eyes; baby will blink for the first four or five taps as a protective measure. Persists into adulthood (p.566).
Tracking: A newborn will often turn to look at a penlight or a brightly colored object and track movement with the eyes.
Sneezing & coughing: Additional protective reflexes which are common in the newborn. Both persist into adulthood (p. 566).
HEENT
Head & Scalp
Shape
Fontanels
Sutures
Normal: Molding; caput succedaneum; slight pulsation of anterior fontanel 3-4 cm long by 2-3 cm wide, diamond shaped and closes by how many weeks?; head circumference 33-35 cm and 1 -2 cm larger than chest circumference. Be sure to measure HC and CC and compare the two to determine if the difference is normal or not, then document your findings (Hesse, 2020).
Abnormal: Cephalhematoma, hydrocephalus, microcephaly, buldging or sunken fontanels
Eyes
Normal; conjunctiva clear, occasional subconjunctival hemorrhage, chemical conjunctivitis, no tears until 2-4 weeks of age, able to focus on objects at distance of 7 1/2 in. and can follow moving object, clear cornea, some edema of eyelids, symmetry of shape, PERRLA. Blink Reflex
Abnormal: Asymmetry of shape, bacterial or viral conjunctivitis
Ears
Hearing Screen Completed? Results?
Normal: symmetry of shape, normal placement with insertion ear in line with outer canthus of eye, no lesions, able to hear (reacts to loud noise with Moro reflex)
Abnormal: asymmetry of shape, low set ears, malformed, no response to sound stimuli
Nose
Normal: bilateral patency of nares, sneezing, no discharge even placement in relationship to eyes and mouth
Abnormal: choanal atresia, mucosanguinous discharge of Syphilis, flaring of nares
Mouth & Throat
Normal: symmetry, Epstein’s pearls, geographic tongue, no teeth, mucous membranes of mouth smooth, pink, moist, not much saliva first 3 months of life, intact palates, tongue proportional to mouth, short neck, head moves freely.
Abnormal: cleft lip, large tongue, natal teeth, thrush, excessive saliva (esophageal atresia), web neck or excessive tissue
Cardiovascular
Heart Rate
Murmur
Pulses
Normal:: Rate 110-160 (rate is labile and follows the trends of respirations), text states may decrease to 80 during sleep (however, not typically seen in clinical agencies) if crying may go up to 180, systolic murmurs during 1st 24 hours, regular rhythm, umbilicus with 2 arteries and 1 vein (single artery may mean GI, GU, CNS, C V system anomalies)
Abnormal: tachycardia if rate exceeds 160 when not crying, bradycardia, murmurs after 1st 24 hours, irregular rhythm, less than 3 vessels in umbilical cord
Respiratory
Shape & appearance
Breath sounds
Respirations
Signs of Respiratory Distress
Nasal Flaring
Grunting
Retractions
Periodic Breathing vs Apnea
Normal: no depression or prominent sternum, symmetrical movement and shape, sighing, breath sounds bilaterally, may have some grunting, rales, and/or retractions 1st hour but really need to watch, rate should be 30-60/min but may be greater than 60/min 1st hour, periodic breathing in premature infant
Periodic Breathing vs Apnea: Periodic breathing is ” the cessation of breathing that lasts 5 to 10 seconds w/o changes in color or heart rate” (p. 530). Often observed in newborns in the first few days of life; requires close monitoring. Apnea (absence of breathing) lasting longer than 15 seconds with cyanosis and HR changes requires further evaluation (p. 530).
Abnormal: depressed or prominent sternum, asymmetrical movement and shape, diminished or absent breath sounds on one side, grunting, rales, and/or retractions after first hour, rising respiratory rate, apnea
Musculoskeletal
Range of Motion
Flexion
Clavicles
Spine
Extremities
Hip
Normal: Spontaneous movement, flexion of extremities, symmetrical through ROM but lack full extension, no gross abnormalities in extremities or spine, full abduction of flexed hips, short extremities, -term infant in central suspension should hold head 45 degrees with back straight. – check for this muscle tone. Palpate over clavicles to check for crepitus (indicates fx) (p. 561).
Abnormal: Flaccidity with extensions of extremities, decreased or absent spontaneous movement, asymmetry of tone, strength, movement, passive motion limitation due to brachial plexus injury, clavicular or humerus fracture, congenital hip dislocation, gross abnormality in extremities or spine
Gastrointestinal
Abdomen
Umbilical Cord/Number of vessels?
Bowel Sounds
Rectum
Normal stool cycle (consider breast vs. bottle-feeding) Appearance/frequency
Normal: Abdomen cylindrical with some protrusion, appears large in relation to pelvis, few vessels seen, synchronous movement with chest, no protrusion of umbilicus, soft bowel sounds heard shortly after birth, able to root, suck and swallow, patent anus
Abnormal: Abdomen distended, shiny, tight in appearance (with GI abnormalities), scaphoid appearance (with diaphragmatic hernia),
asynchronous movement with chest, imperforate anus
Genitourinary
Breast
Genitalia
Urinary
Normal: breast tissue 5 MM or more at term, breast engorgement on third day of life, for male: testes in scrotum or palpable in canal, urethral opening, for female: prominent labia minora, bloody mucoid discharge, voiding common at birth, should void within first 24 hours, urine pale with non-offensive odor.
Abnormal: supernumerary nipple, ambiguous genitals (penis needs to be at least 1.5 cm norm is 2.5 cm long), hypospadias, epispadius, testes in abdomen
**Record # of voids, color, clarity and amount on your shift
Integumentary
Color
Lesions
Skin Turgor
Texture
Temperature
Normal: pink or consistent with racial background, (state ethnicity) acrocyanosis, mottling when undressed, translucent umbilical stump. Mongolian spot, vernix caseosa, lanugo, milia, occasional petechiae, mild peeling, erythema toxicum
Abnormal: central cyanosis, pallor, jaundice, multiple petechiae, meconium stained, absence of vernix caseosa or lanugo, hemangiomas, massive peeling
**Gently pinch skin over abdomen and inner thigh between thumb and forefinger to check for turgor. After pinch is released, skin should return to original state immediately (Hesse, 2020).
What are signs of prematurity? BW CC, poor muscle tone, minimal subcutaneous fat, undescended testes, plentiful lanugo (soft, downy hair) esp. over face & back, poorly formed ear pinna w/ soft, pliable cartilage, fused eyelids, soft/spongy skull bones, matted scalp hair—wooly in appearance, absent to few creases on the soles and palms of feet & feet, minimal scrotal rugae in male infants; prominent labia & clitoris in female infants, thin, transparent skin w/ visible veins, breasts & nipples not clearly delineated, and abundant vernix caseosa (p. 790). See photos of preterm infants on p. 791.
What are signs of post maturity? Dry, cracked, peeling, wrinkled skin, absence of vernix caseosa & lanugo, long, thin extremities, creases that cover the entire soles of the feet, wide-eyed, alert expression, abundant hair on scalp, thin umbilical cord, meconium-stained skin & fingernails, long nails (p. 787).
Nutrition
Breast/Bottle Type? Amount in past 24 hours
Spitting/Vomiting
The American Academy of Pediatrics (2012) recommends exclusive breast-feeding for all full-term newborns for the first 6 months of life and as supplementation to food for at least the 1st year of life and beyond. Placing all stable newborns in uninterrupted skin-to-skin contact (kangaroo care) with their mother is good practice. Breastfeeding has many benefits for both baby and mother. The Baby-Friendly Hospital Initiative is a joint international program between WHO and UNICEF (started in 1991) that purports 10 Steps for a hospital to “provide an optimal environment for the promotion, protection, and support of breastfeeding” (p. 505).
“Bottle feeding should mirror breast-feeding as closely as possible.” Encourage caretaker to cuddle infant closely with infant’s head in a comfortable position and to communicate with the infant during feedings (p. 384). The AAP recommends iron supplementation for bottle-fed infants because all types of formula are low in iron. The AAP also recommends that all infants (breast and bottle-fed) receive a daily supplement of 400IU of vitamin D to prevent rickets and vitamin D deficiency (p. 581).
“Regardless of which method is chosen, the nurse needs to respect and support the couple’s decision”
(p. 581).
Spitting is common d/t infant’s immature stomach valves. Burp baby after every few ounces to assist in removing swallowed air from the stomach (p. 591).
Frequent vomiting (over a 6-hour period) or more than one episode of forceful vomiting must be reported to the healthcare provider (Clinical Companion, 2012, p. 339).
Fluid & Calorie Requirements
Breast
Frequency and length of feedings
Voids & Stools
Assessment of successful breastfeeding:
Alignment
Areola Grasp
Compression
Swallowing
Bottle
Calculate the fluid and calorie requirements for a 24-hr. period
for this infant (show formula used).
How many ccs per feeding are required for this age infant to meet these requirements?
Fluid Requirements: 100-150mL/kg daily (p. 581). Be sure to calculate both the minimum and maximum requirements for your infant based on your infant’s current weight!.
Calorie Requirements: 110-120cal/kg daily (p. 581). Be sure to calculate both the minimum and maximum requirements for your infant based on your infant’s weight!
Breastfeeding: state how many minutes per breast per feeding and how many successful feedings in past 24 hours as well as voids and stools. What are the signs of adequate nutritional intake for a breastfed infant? Is this infant “getting enough?” *****Don’t overlook these questions! (Hesse, 2020).
If bottle feeding, state formula type and show calculation for fluid and calorie requirements:
Text Reference: (Ricci, 2013, p. 581).
Age of infant:
How much intake (how may feedings and ccs per feeding) and output (voids and stools) has this infant had in the last 24 hours? Is this adequate nutritional intake for this infant?
References
Ricci, S. S. (2017). Essentials of maternity, newborn, and women’s health Nursing. (4th ed.). China: Wolters Kluwer Health/ Lippincott Williams
& Wilkins.
Clinical Companion (2012). Lippincott, Williams & Wilkins.
3 Newborn Complete/Revised 01/2021 Revised 7/15, 3/16, 5/16 bkh