Nursing Assessment Maternal history/labor data indicating potential problems with newborn

Apgar Scores Findings of brief physical examination performed in the delivery room

Ineffective airway clearance related to nasal and oral secretions from delivery

Ineffective thermoregulation related to environment and immature ability for adaptation

Risk for injury related to immature defenses of the newborn

1. When the head is delivered birth attendant immediately suction secretions Wipe mucus from face

and mouth and nose Aspirate/suction mouth

and nose bulb syringe Keep head slightly lower

than the body

2. Assess airway statusA. Assess for 5 Symptoms of respiratory distress

RetractionsTachypnea (rate: >60 cpm)Dusky color/circumoral cyanosisExpiratory gruntFlaring nares

B. Do not hyperextend neck at anytime (may close glottis)

Place infant in “sniff” position Neck slightly

extended as if sniffing air

Opens airway

3. Immediately dry infant under a radiant warmer or skin to skin contact with the motherKeep neonates

head covered

Infant temperature should be above 36.4°C.

Infants lose heat through evaporation, radiation, conduction and convection.

4. Obtain APGAR Scoring at 1 min and 5 min

Apgar test is a scoring system designed by Dr. Virginia Apgar,

an anesthesiologist, a systematic and measurable

method to access the newborn in the crucial minutes after birth. 

Purposes:evaluate the conditions of the baby

at birth, determine the need for

resuscitation, evaluate the effectiveness of

resuscitative efforts, identify neonates at risk for

morbidity and mortality.

Test 0 Points 1 Point 2 Points

Activity (Muscle Tone)

Absent Arms & legs extended

Active movement with flexed arms & legs

Pulse (Heart Rate) Absent Below 100 bpm

Above 100 bpm

Grimace (Response Stimulation or Reflex Irritability)

No Response

Facial grimace

Sneeze, cough, pulls away

Appearance (Skin Color)

Blue-gray, pale all over

Pink body and blue extremities

Normal over entire body – Completely pink

Respiration (Breathing)

Absent Slow, irregular

Good, crying

If there are problems with the infant: an additional score may be repeated at a 10-minute interval.

For a Cesarean section: the baby is additionally assessed at 15 minutes after delivery.

Scoring 7-9 = free from immediate distress; normal 4-6 = moderately depressed; may require

additional resuscitative measures 0-3 = severely depressed; necessitates

immediate medical attention

Note: APGAR score is strictly used to determine the newborn’s

immediate condition at birth and does not necessarily reflect the future health of

your baby.

Scores done at 1 minute to identify who needs immediate intervention.

Scores taken again at 5 minutes to assess recovery from depression or a subsequent turn for the worse.

Resuscitation takes precedence over determining score.

5. Do quick Gestational Age AssessmentA. Sole CreasesB. Breast tissue budC. Skin, vessels, and peelingD. GenitaliaE. Resting Posture

6. Cord Care A. Clamp

umbilical cord approximately 2.5 cm (1 inch) from abdominal wall w/ cord clamp

Examine clamp for closure, no oozing of blood from cord

B. Examine Cord for presence of 3 vessels and document2 arteries and 1 vein

7. Make sure cord blood is collected for analysis and sent to laboratory for checking of: RH Blood type Hematocrit Possible cord blood

gases

8. Document passage of meconium or urine after delivery

For presence of meconium before delvery, mechanical suctioning of naspharynx upon delivery of infant w/ an 8-10 French catheter is done

11.Administer a prophylactic vitamin K Prevent neonatal hemorrhage during first few

days of life before infant is able to produce vit. K Recommended route of administration:

intramuscular Dose:

1mg (of  Konakion MM®, 2mg/0.2ml) being given at birth. Preterm infants may receive 0.5mg.

Alternative Route: Oral Dose:

2mg orally at birth; Repeat dose (2mg) at 3-5 days and at 4-6 weeks of

age. Repeat dose if the infant vomits or regurgitates

within 1 hour

12. Bath once a baby's temperature has stabilized, the first bath can be given.

Measure weight, length, and head circumference helps determine if a baby's weight and

measurements are normal for the number of weeks of pregnancy.

Small or underweight babies, as well as very large babies, may need special attention and care.

Average range: 18-22 inches (46-56 cm)

Measured from crown to rump and rump to heel or from crown to heel at birth

Average range: 33 to 35 cm (13-14 inches)Normally, 2 cm larger than chest

circumference Place tape measure above

eyebrows and stretch around fullest part of occiput at posterior fontanele

Average range: 30-33 cm (12-13 inches) Normally, 2 cm smaller than head

circumference

Stretch tape measure around scapulae and over nipple line

Before a baby leaves the delivery area, identification bracelets with identical numbers are placed on the baby and mother.

Babies often have two, on the wrist and ankle.