nursing care of the newborn newborns undergo many profound physiologic and psychological changes....
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Nursing Care of the Newborn
Newborns undergo many profound physiologic and psychological changes.
They are released from a warm, close, dark, liquid filled environment that met all needs, into a chilly, unbound, brightly lit, gravity based, outside world.
Within minutes respirations are initiated and circulatory accommodation are made.
Within 24 hours neurologic, renal, endocrine, GI, and metabolic functions must operate.
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Nursing Care of the Newborn
Newborn or neonatal period is the first 28 days of life.
2/3 of deaths occur in the 1st year
½ occur in the 1st 24 hours
Assessment
• Mother’s pregnancy history
• Physical exam of the newborn
• Lab reports
• Bonding
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Profile of the NewbornAll newborns are different.
Vital Statistics
Weight:
• Plot on neonatal graph (Appendix E)
• Average weight R/T gestational age– White female 7.5 lbs.– 3.4 kg.– White male 7.7 lbs.-3.5 kg.
• Other races-0.5 lbs less
• Limits-5.5 lbs to10 lbs (17 lbs largest)
• Newborn loses 5 to 10 % of birth weight ( 6 to 10 oz. during first few days.
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Profile of the Newborn• Loss due to salt and fluid retaining maternal
hormones. Voiding and stool, and diuresis.
• After wt. loss then 1 day of stable wt. then recaptures birth weight within:
– Breastfed 10 days
– Formula fed 7 days
• Will gain 2 lb/month (6 to 8 oz/week) for first 6 months.
Length:
• Female-53 cm.- 20.9 in.
• Male-54 cm. –21.3 in.
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Profile of the Newborn
• Limits 18 in. to 23 in.
Head Circumference:
• 34 to 35 cm. (13.5 to 14 in.)
• Limits-less than 33 cm. or greater than 37 cm.
• Measure with tape drawn across center of forehead and around the most prominent portion of the posterior head.
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Profile of the Newborn Chest Circumference:• About 2 cm. less than head circumference
(0.75 to 1 in.). • Measure at level of the nipples.Viral Signs:• Temp 99 F at birth• Newborns lose heat by:
– Convection– Conduction– Radiation– Evaporation
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Profile of the Newborn
• They have little subcutaneous fat for insulation. Shivering is rare.
• They have brown fat – helps to conserve or produce body heat by increasing metabolism.
• Quickly dry and wrap newborns and place under radiant heat source or place directly against mothers skin.
• Newborn with a bacterial infection will have a subnormal temperature.
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Profile of the Newborn
Pulse:
• Immediately after birth 180 bpm.
• Within 1 hour- 120 to 140 bpm.
• Irregular and transient murmurs due to immaturity of the cardiac regulatory center in the medulla and closure of the shunts.
• Sleeping – 90 to110 bpm.
• Always check apical for 1 full minute
• Check femoral pulse for coarctation.
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Profile of the Newborn
Respiration:
• 30 to 60 breaths / min.
• Rate, depth, and rhythm may be irregular with short periods of apnea (without cyanosis) called periodic respirations.
• Observe movement of the abdomen.
• Coughing and sneezing clear the airway.
• Newborns are nose breathers
• Short periods of crying are beneficial.
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Profile of the Newborn Blood Pressure:• 80/46 mm Hg at birth• 10th day 100/50 mm Hg• Cuff 2/3 the length of upper arm or thigh.Physiologic FunctionCardiovascular System:• Figure 23.3 p. 634• Peripheral circulation is sluggish for 1st 24
hours.• Common to see cyanosis of the feet and
hands (acrocyanosis) cold to touch.
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Profile of the NewbornBlood values:
Blood volume-300 mL
• Increased erythrocyte count-will decrease after 3 days. Breakdown of these cells cause an increase bilirubin >4 mg/100mL
• At 7 mg/ml tissue is jaundice. Physiological jaundice R/T brusing, cephalhematoma, dehydration, or intestinal obstruction.
• Treat at 10-12 phototherapy, fluids, >20 neuro kernicterus (permanent cell damage)
• Hgb 17-18
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Profile of the Newborn• Hct 45-50% (use warm cloth on heel to
increase sluggish circulation to get a more accurate value).
• WBC increased due to stress of birth.
Blood Coagulation:
• Prolonged coagulation or prothrombin time for 24 hours because of low vitamin K level.
• Infant intestine is sterile at birth.
• Administer Vitamin K (AquaMephyton) 1 hour after birth in lateral anterior thigh.
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Profile of the NewbornRespiratory:• First breath initiated by
– Cold receptors– Lowered PO2 (15 mm Hg)– Increased PCO2 (70 mm Hg)
• Surfactant allows the alveoli to inflate more easily.
• 1/3 of fluid is forced out of the lungs with the pressure of delivery.
• Within 10 min. a good residual volume is established.
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Profile of the Newborn
Gastrointestinal System:
• Sterile tract for 1st 24 hours
• Stomach holds 60 to 90 mL
• Decreased ability to digest fat and starch
• Regurgitation due to immature cardiac sphincter between stomach and esophagus.
• Lower glucose and protein serum levels due to immature liver.
• Stools – meconium 1st 24 hours. Sticky, tarlike, blackish green, odorless.
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Profile of the Newborn
• If no meconium in 24-48 hours possibility of ileus, imperforate anus, or bowel obstruction.
• Transitional stool- day 2-3 becomes green and loose.
• Day 4 breastfed will pass 3-4 light yellow stools per day.
• Bright green is due to increased bilirubin.
• Watery and loose or mucus may be a milk allergy.
• Gray clay stool – bile duct obstruction.
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Profile of the Newborn
Urinary System
• Voids within 24 hours
• Light color and odorless; kidneys do not concentrate urine well and no reabsorption.
• 6 voids /day 15 to 50 mL
• By 1st week total daily volume is 300 mL
Immune System:
• Unable to form antibodies the 1st 2 months.
• Has passive immunity from the mother
• Hepatitis B vaccine during 1st 12 hours.
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Profile of the Newborn
Neuromuscular System:
Reflex Maneuvers:
• Blink reflex
• Rooting
• Sucking
• Swallowing
• Extrusion
• Palmar Grasp
• Step-Walk in Place
• Placing
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Profile of the Newborn
• Plantar Grasp
• Tonic Neck
• Moro
• Babinski
• Magnet
• Crossed Extension
• Trunk Incurvation
• Landau
• Deep Tendon
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Profile of the Newborn
Senses:
• Hearing in utero
• Vision see immediately, blink, follow objects
• Touch well developed
• Taste likes glucose and avoids salt
• Smell breast milk
Adjustment to Extrauterine Life
• Table 23.1 p. 639
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Appearance of the NewbornSkin
Color:
• Ruddy due to increased concentration of RBC in blood vessels and decreased fat. Fades slightly over the 1st month.
• Cyanosis-lips, hands, feet
– Central cyanosis is a great concern
– Suction mouth before the nose because suctioning the nose may trigger a reflex gasp, possibly leading to aspiration.
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Appearance of the Newborn
• Hyperbilirubinemia leads to jaundice or yellowing of the skin.
• Occurs on day 2 or 3 in 50% of all newborns due to breakdown of fetal RBC.
• Indirect bilirubin > 7mg/100 mL
• Early feeding promotes intestinal movement and helps prevent bilirubin build up.
• Pallor due to anemia.
– Excessive blood loss when cord was cut.
– Inadequate flow of blood from cord into infant at birth.
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Appearance of the Newborn
– Fetal maternal transfusion
– Low iron stores
– Blood incompatibility
– Internal bleed in the baby
– CNS damage
• Harliquin Sign-newborn lying on side and it will appear red on the dependent side of the body and pale on the upper side, changing positions will make it fade.
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Appearance of the NewbornBirthmarks
Hemangiomas-vascular tumors of the skin.
• Nevus flammeus-port-wine stain
– Macular purple or dark red lesion
– Appears on face or thigh
– Those above the bridge of the nose fade
– Can be covered by cosmetics, remover surgically, or by laser therapy.
• Stork’s beak marks – at nape of neck, lighter pink patches. More frequent in females. Do not fade.
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Appearance of the Newborn
• Strawberry Hemangiomas:
– Elevated areas formed by immature capillaries and endothelial cells.
– Appear at birth or 2 week later.
– Due to high estrogen levels
– 50 to 75% may disappear by age 7
– Mark may grow in size.
– Surgery not recommended due to scarring
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Appearance of the NewbornCavernous Hemangiomas:
• Dilated vascular spaces
• Raised and resemble a strawberry hemangioma but does not disappear.
• Surgically removed.
Mongolian Spots:
• Collection of pigment cells (melanocytes) that appear slate-gray patches on sacrum or buttocks S/T arms and legs.
• Asian, Southern European, or African
• Disappear by school age.
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Appearance of the NewbornVernix Caseosa:
• White, cream cheese-like substance that serves as a skin lubricant.
Lanugo:
• Fine hair, covers newborn’s shoulders, back, and upper arms. Forehead and ears.
• By age 2 weeks it has disappeared.
Desquamation:
• Dry skin on palms of hands and soles of feet.
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Appearance of the Newborn
Milia:
• Pinpoint white papule found on cheek or across bridge of nose.
• Disappear by 2 to 4 week as sebaceous glands mature.
Erythema Toxicum (flea-bite rash):
• Rash, appears 1st to 4th day up to 2 weeks of age.
• Lacks pattern and will last only hours.
• Due to eosinophils reacting to environment.
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Appearance of the Newborn
Forceps Marks:
• May have a circular or linear contusion matching the rim of the blade on infants cheek.
• Disappears in 1 to 2 days
• Assess facial nerve while at rest and crying.
Skin Turgor:
• Feels elastic, smooth if well hydrated.
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Appearance of the Newborn
Head:
• Appears large, 1/4th total length, forehead large and prominent.
• Chin receding, quivers easily.
• Full-body of hair if well nourished
• Pinpoint ulcer where monitor was attached.
Fontanelles:
• Openings where skull bones join
• Anterior fontanelle
– Junction of parietal and frontal bones.
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Appearance of the Newborn• Diamond shaped-2 to 3 cm. width and 3 to
4 cm. length.
• Closes at 12 to 18 months
• Posterior fontanelle
• Triangle shaped-1 cm. length.
• Closed at 2 months.
Sutures:
• May override at birth.
Molding:
• Infant’s head (vertex) engages the cervix.
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Appearance of the Newborn
• After birth, appears prominent and asymmetric.
• Will restore to normal shape in a few days.
Caput Succedaneum:
• Edema of the scalp at the presenting part of the head.
• Crosses the suture line, will be absorbed and disappear by the 3rd day.
Cephalhematoma:
• Collection of blood between periosteum of
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Appearance of the Newbornthe skull bone and bone itself caused by rupture of periosteum capillary at birth.
• Occurs 24 hours after birth, severe swelling, black and blue, egg shape.
• Swelling stops at suture line.
• Takes weeks to be absorbed.
Craniotabes:
• Localized softening of the cranial bones.
• Indents easily with touch of the finger.
• Corrects after a few months.
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Appearance of the Newborn
Eyes:
• Usually tearless, lacrimal ducts mature at 3 months.
• Irises-gray or blue
• Sclera-blue due to thinness.
• Permanent eye color between 3 to 12 mo.
• Erythromycin ointment EES-for chlamydia and gonorrhea
• Subconjunctival hemorrhage-red spot on sclera or red ring around cornea. Absorbed in 2 to 3 weeks.
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Appearance of the Newborn• Edema around orbit or on eyelid. Will
remain for 2-3 day until kidneys remove the fluid.
Ears:• External not completely formed.• Top part in line with inner canthus of eye.• Test hearing by ringing a bell 6 in. from ear.Nose:• Appears large.• Assess by closing mouth and compress one
naris.
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Appearance of the Newborn
Mouth:
• Open evenly, tongue appears large.
• Palate intact, check for cysts.
• No teeth (1-2 natal teeth sometimes).
Neck:
• Short, chubby, skin folds, rotates freely.
• May try to raise head but lacks control.
Chest:
• Breast appear engorged, may secrete a thin, watery fluid (witch’s milk). 1 wk to subside
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Appearance of the Newborn• 2 in. less than head.
• Lungs have rhonchi due to mucus for first 24 to 48 hours. Alveoli open slowly.
Abdomen:
• Slightly protuberant
• Bowel sounds within 1 hour.
• Liver palpable 1 to 2 cm below right costal margin.
• Umbilical cord-white, gelatinous structure with red and blue streaks. Count veins and arteries.
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Appearance of the Newborn
• Inspect cord clamp, within 1 hour cord begins to dry and shrink and turns brown. Day 2 to 3 will turn black.
• Day 6 to 10 breaks free and new granulating area will heal in next week.
• Assess abdomen by stroking each quadrant and observe umbilicus to move or wink in that direction.
Anogenital Area:
• Check for patency.
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Appearance of the Newborn
Male Genitalia:
• Scrotum edematous and has rugae.
• Penis 2 cm., check prepuce (foreskin).
• Circumcision
Female Genitalia:
• Vulva swollen due to effect of maternal hormones.
• Mucus vaginal secretion, sometimes blood tinged.
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Appearance of the Newborn
Back:• Flat in lumbar and sacral areas.• Back rounded, arms and legs flexed on
abdomen and chest.Extremities:• Appear short, hands plump,clinched and
palmar crease.• Fingernails soft, smooth and long.• Muscle tone- unflex arm and immediately
returns flexed.• Fingertips cover proximal thigh.
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Appearance of the Newborn
• Legs bowed and short, feet turn inward.
• ROM
• Ortolani’s sign-clunk of femur head striking the shallow acetabulum.
• Barlow’s sign-hip slips in socket.
• Lying on abdomen newborns bring arms and legs underneath them and rise their stomach off the bed.
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Assessment of the Newborn
Apgar Scoring:
• 1 minute and 5 minutes after birth (Table 23.2 p. 650) Rated 0,1,or 2 then added together.
• Score of 4-6 = guarded, 7-10 = good.
• Heart rate-auscultate with stethoscope.
• Respiratory effort-cries spontaneously at 30 seconds after birth.
• Muscle tone-extremities tightly flexed.
• Reflex irritability-suctioning or sole of feet slapped.
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Assessment of the Newborn
• Color-cyanotic at birth, pink shortly after first breath.
Respiratory Evaluation
• Highest priority in newborn care.
Physical Examination
• Given immediately after birth, very quickly
Height and Weight
• Nude, also head, chest and abdominal circumferences.
• Weight daily at same time.
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Assessment of the Newborn
Laboratory Studies• Heel stick for H&H and hypoglycemia (<
40mg/100 mL)Gestational Age• Table 23-4 p. 654• Ballard’s assessment (figure 23.21 p. 655)Behavior Capacity• Physically active and emotionally prepared
to interact with people.• Brazelton Neonatal Behavioral Assessment
Scale
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Assessment of the Newborn
– Evaluates newborn’s behavioral capacity or ability to respond to stimuli.
Care of the Newborn at Birth
• Equipment-radiant heat table, warm soft blankets, O2, resuscitation, suction, eye care, identification, scales.
• Handle gently
Newborn ID and Registration
• ID
• Kidnapper profile- recently lost a pregnancy
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Care of the Newborn at Birth
or had an infant stillborn and who desires an infant very much.
• Familiar with hospital, pretends to be a volunteer or unlicensed health care worker and says she needs to take the baby out of the nursery.
ID Band (one arm and one leg)
• Plastic bracelet, number corresponds to the mother’s hospital number, mother’s full name, sex,date and time of infant’s birth.
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Care of the Newborn at Birth
• Has built in sensor unit that alarms if baby is transported beyond set boundaries.
• Foot prints are taken and placed on chart.
• Registration filed with the Bureau of Vital Statistics of the state of birth.
– Infant’s name, mother’s name, father’s name if mother chooses, birth date and place.
– Important because it provides eligibility for school, voting, social security benefits, passports.
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Care of the Newborn at Birth
Birth Record Documentation:
• Time of birth
• Time the infant breathed
• Whether respirations were spontaneous or aided
• Apgar at 1 and 5 minutes of life
• Whether eye prophylaxis was given
• Whether vitamin K was administered
• General condition of the infant
• Number of vessels in umbilical cord
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Care of the Newborn at Birth• Whether cultures were taken• Whether infant(1)voided and (2) passed
stool.Nursing InterventionsKeep Newborn Warm:• Reassess temp in 1 hour then q 4-8 hours.Promote Adequate Breathing Pattern and
Prevent Aspiration:• Suction with bulb syringeRecord First Cry:• Aided or unaided
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Care of the Newborn at BirthInspect and Care for Umbilical Cord
• Hazeltine or Kane clamp
• Count vessels
• Apply triple dye
• Coed falls off 7 to 10th day. Do sponge bath.
• Apply alcohol to cord site.
Administer Eye Care
• Erythromycin ointment
General Infection Precautions
• Wash up to elbows between babies, gown
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Care of the Newborn at Birth
• Personnel with infections excluded until clear.
• Isolate with contagious illness.
Postpartal Period
Initial Feeding:
• May breastfed immediately
• Formula fed in 2-4 hours
• On demand schedule may be q 2 hours
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Care of the Newborn in Postpartal
• First bath within 1 hour
• Supervise parents with 1st bath, cleanest to most soiled. No soap on face.
• Football hold
Sleeping Position
• On back due to SIDS
Diaper Area Care
• Wash with clear water and dry.
• A&D may be applied to buttocks
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Care of the Newborn in Postpartal
Metabolic Screening Tests
• PKU-phenylketonuria-disease of defective protein metabolism
• Hypothyroidism
• 3 drops from heel stick on special filter paper.
Hepatitis B Vaccination
• Within 12 hours after birth, second dose due in 1 month and 3rd due at 6 months.
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Care of the Newborn in Postpartal
Vitamin K Administration
• Newborn’s are at risk for bleeding disorders
• Single dose 0.5 to 1.0 mg IM of vitamin K is administered within 1 hour after birth.
Circumcision
• Surgical removal of penis foreskin
• 1st or 2nd day of life
• Check q 15 min for 1 hour for bleeding, document voiding after the procedure.
• Petrolatum for 3 days.
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Readiness To Care For Newborn
Assess how prepared each family is to care for the newborn.
Infants wake up during the night for 1 or more feedings for about the 1st 4 months.
Numerous questions to ask to assess for an adequate and safe home.
Daily care:
• Some consistency
• Satisfy the infant
• Sense of well-being and contentment
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Readiness To Care For Newborn
Sleep Patterns
• Sleeps 16 of 24 hours in 1st week at 4 hour intervals
• By 4 months 15 hours of 24 and through the night.
Crying
• 2 hours of every 24 for 1st 7 weeks. Peaks at 6 to 7 weeks then tapers off.
• Most typical wakeful time is between 6pm to 11 pm.
• Pacifier is up to parents.
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Readiness To Care For Newborn
• Cleanliness is a concern
Parental Concerns Related to Breathing
• Stuffy nose or making snorting noises in sleep, have mucus for 2 weeks
• Breath irregularly
Continued Heath Maintenance for Newborn
• Appointment with PCP in 2 to 6 weeks
• Parents need to judge the infants state of health, appearance, eating, activity, disposition.
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Readiness To Care For Newborn
Car Safety
• Meets federal guidelines
• Health Dept or Red Cross has info.
• Place in back seat may use a blanket to support the head. Facing the back.