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Maternal and Child Health Nursing
Newborn Assessment




                                    MATERNAL and CHILD HEALTH NURSING

                                            NEWBORN ASSESSMENT

                                      Lecturer: Mark Fredderick R. Abejo RN, MAN
                      ______________________________________________________________________

                                              Newborn Assessment




Newborn Assessment                                                                             Abejo
Maternal and Child Health Nursing
Newborn Assessment


Newborn Assessment and Nursing Care                                   Tachypnea - respirations > 60
                                                                      Persistent irregular breathing
                                                                      Excessive mucus
   Temperature - range 36.5 to 37 axillary                           Persistant fine crackles
   Common variations                                                 Stridor
         o Crying may elevate temperature
               Stabilizes in 8 to 10 hours after                  Breathing ( ventilating the lungs)
              delivery                                             check for breathlessness
         o Temperature is not reliable indicator                         if breathless, give 2 breaths-
              of infection                                                   ambu bag
               A temperature less than 36.5                        1 yr old- mouth to mouth, pinch nose
Temp: rectal- newborn – to rule out imperforate                          < 1 yr – mouth to nose
              Anus                                                 force – different between baby &
          - take it once only, 1 inch insertion                       child
                                                                         infant – puff
Imperforate anus                                                  Circulation
   1. atretic – no anal opening                                     Check for pulslessness :carotid-
   2. agenetialism – no genital                                        adult
   3. stenos – has opening                                          Brachial – infants
   4. membranous – has opening                                    CPR – breathless/pulseless
        Earliest sign:                                              Compression – inf – 1 finger breath
                  1. no mecomium                                       below nipple line or 2 finger breaths
                  2. abd destention                                    or thumb
                  3. foul odor breath                               CPR inf 1:5
                  4. vomitous of fecal matter                       Adults 2:30
                  5. can aspirate – resp problem
       Mgt: Surgery with temporary colostomy              Blood Pressure - not done routinely
                                                               Factors to consider
    Heart Rate                                                Varies with change in activity level
          range 120 to 160 beats per minute                    Appropriate cuff size important for accurate
          Common variations                                    reading
           Heart rate range to 100 when sleeping              65/41 mmHg
              to 180 when crying
           Color pink with acrocyanosis                  General Measurements
           Heart rate may be irregular with                Head circumference - 33 to 35 cm
              crying                                        Expected findings
           Although murmurs may be due to                  Head should be 2 to 3 cms larger than the
              transitional circulation-all murmurs            chest
              should be followed-up and referred for        Abdominal circumference – 31-33 cm
              medical evaluation                            Weight range - 2500 - 4000 gms (5 lbs. 8oz.
           Deviation from range                              - 8 lbs. 13 oz.)
           Faint sound                                     Length range - 46 to 54 cms (19 - 21 inches)
                                                            Normal length- 19.5 – 21 inch or 47.5 –
Cardiac rate: 120 – 160 bpm newborn                           53.75cm, average 50 cm
Apical pulse – left lower nipple                            Head circumference 33- 35 cm or 13 – 14 “
Radial pulse – normally absent. If present PDA
Femoral pulse – normal present. If absent COA                   Hydrocephalus - >14”
                                                                Chest 31 – 33 cm or 12 – 13”
    Respiration                                                Abd 31 – 33 cm or 12 – 13”
          - range 30 to 60 breaths per minute
          Common variations
            Bilateral bronchial breath sounds         Signs of increased ICP
                 Moist breath sounds may be present        1. abnormally large head
                shortly after birth                        2. bulging and tense fontanel
          Signs of potential distress or deviations        3. increase BP and widening pulse pressure
          from expected findings                           4. Decreased RR, decreased PR
            Asymmetrical chest movements                  5. projective vomiting- sure sign of cerebral
            Apnea >15 seconds                                  irritation
            Diminished breath sounds                      6. high deviation – diplopia – sign of ICP older
            Seesaw respirations                                child
            Grunting                                                 a. 4-6 months- normal eye deviation
            Nasal flaring                                            b. >6 months- lazy eyes
            Retractions                                   7. High pitch shrill cry-late sign of ICP
            Deep sighing




Newborn Assessment                                                                                      Abejo
Maternal and Child Health Nursing
Newborn Assessment




                                           Head to Toe Newborn Assessment

CIRCULATORY                           UMBILICAL VEIN and DUCTUS VENOSUS constrict after cord id clamped
STATUS                                DUCTUS ARTERIOSUS constrict with establishment of respiratory function
                                      FORAMEN OVALE closes functionally as respirations established, but anatomic or
                                       permanent closure may take several months
                                      HEART RATE averages 140 b.p.m.
                                      BP 73/55 mmHg
                                      PERIPHERAL CIRCULATION acrocyanosis within 24 hours
                                      RBC high immediately after birth; falls after 1 st week
                                      ABSENCE/ NORMAL FLORA INTESTINE Vitamin K

RESPIRATORY                           Adequate levels of surfactants (Lecithin and spingomyelin) ensure mature lung
STATUS                                function; prevent alveolar collapse and respiratory distress syndrome
                                      RR = 30-80 breaths /minutes with short periods of apnea (< 15 seconds) = assess for
                                      1 full minute change noted during sleep or activity

                                      NOTE: Periodic apnea is common in preterm infants. Usually, gentle stimulation is
                                      sufficient to get the infant to breathe

RENAL SYSTEM                          Urine present in the bladder at birth but NB may not void doe 1st 12-24 hours
                                      Later pattern is 6-10 voidings/ day – indicative of sufficient fluid intake
                                      Urine is pale and straw colored – initial voidings may leave brick-red spots on
                                      diaper ( d/t passage of uric acid crystals in urine)
                                      Infant unable to concentrate urine for the 1st 3 months

DIGESTIVE                             IMMATURE CARDIAC SPHINCTER – may allow reflux of food, burped,
SYSTEM                                REGURGITATE- placed NB right side after feeding
                                      Newborn can’t move food from lips to pharynx. Insert nipple well to mouth
                                      FEEDING PATTERS vary

                                    - Newborns may nurse vigorously immediately afterbirth or may need as long as
                                       several days to suck effectively
                                    - Provide support and encouragement to new mothers during this time as infant
                                       feeding is very emotional doe most mothers

                               NOTE: Distinguishing Neonatal Vomiting from Regurgitation
                               Vomiting is usually sour, looks like curdled milk due to HCL, with a sour odor, while
                               regurgitation has no sour odor or curdling of milk, or occurs during or immediately
                               after feeding.

                                    IMPORTANT CONSIDERATIONS:
                                         Breastfeeding can usually begin immediately after birth; bottle-fed newborns
                                         may be offered few milliliters of sterile water or 5% dextrose 1 to 4 hours after
                                         birth prior to a feeding with formula

                                           An infant with gastrostomy tube should receive a pacifier during feeding
                                           unless contraindicated to provide normal sucking activity and satisfy oral
                                           needs.

                                           At age4-6 months, an infant should begin to receive solid food foods one at a
                                           time and 1 week apart.

                               FIRST STOOL is MECONIUM
                                  - Black, tarry residue from lower intestine
                                  - Usually passed within 12-24 hours after birth

                               If the amniotic fluid shows evidence of meconium staining, the physician most likely do
                               immediately after delivery is to suction the oropharynx immediately after the head is
                               delivered and before the chest is delivered.

                               TRANSITIONAL STOOLS thin, brownish green in color
                                After 3 days MILK STOOLS are usually passed
                                 a. MILK STOOLS for BF infant – loose and golden yellow
                                 b. MILK STOOLS for FORMULATED FED- formed and pale yellow



Newborn Assessment                                                                                                      Abejo
Maternal and Child Health Nursing
Newborn Assessment


HEPATIC                            Liver responsible for changing Hgb into conjugated bilirubin, which is further
                                    changed into conjugated (water soluble) bilirubin that can be excreted
                               Excess unconjugated bilirubin can permeate the sclera and the skin, giving a jaundiced
                               or yellow appearance to these tissues

TEMPERATURE                           HEAT PRODUCTION in newborn accomplished by:
                                      a. Metabolism of “ BROWN FAT”
                                         - A special structure in NB is a source of heat
                                         - Increased metabolic rate and activity
                                           Axillary temperature: 96.8 to 99F
                                           Newborn can’t shiver as an adult does to release heat

                               Newborns are unable to maintain a stable body temperature because they have an
                               immature vasomotor center, and unable to shiver to increase body heat.

                                             NB’s body temperature drops quickly after birth – after stress occurs easily
                                             Body stabilizes temperature in 8-10 hours if unstressed
                                             Cold stress increases o2 consumption – may lead to metabolic acidosis and
                                             respiratory distress

IMMUNOLOGIC                           NB develops own antibodies during 1st 3 months but at risk for infection during the
                                      first 6 weeks
                                      Ability to develop antibodies develops sequentially


                                              Neonatal Physical Assessment

          Birth weight=2500-400 grams (5 lbs. 8oz. – 8 lbs. 13 oz.)
          Length= 45.7 – 55.9 cm. (18-22 inches)

HEAD                                Head circumference = 33-35 cm (2-3 cm. Greater than chest circumference)
                                            Anterior fontanel (diamond shape) = closes 12-18 months
                                            Posterior fontanel (triangle shape)= closes 2-3 months
                                            NOTE: The posterior fontanel is located at the intersection of the sagittal and
                                            lambdoid suture is the space between the pariental bones; the lambdoid suture
                                            separates the two parietal bones and the occipital bone

                                    Molding- asymmetry of head as a result of pressure in birth cana




Newborn Assessment                                                                                                     Abejo
Maternal and Child Health Nursing
Newborn Assessment


EYES                                Blue/ gray d/t scleral thinness; permanent color established w/in 3-12 mos.
                                    Lacrimal glands immature at birth; tearless cry up to 2 months
                                    Absence of tears is common because the neonate’s tear glands are not yet fully
                                    developed
                                    Transient strabismus
                                    Doll’s eye reflex persist for about ten days


                                    Red Reflex: A red circle on the pupils seen when an ophthalmoscope’s light is shining
                                    onto the retina is a normal finding. This indicates that the light is shining onto the
                                    retina.

                                    CONVERGENT STRABISMUS (CROSS EYED)
                                    It is common during infancy until age 6 months because of poor oculomotor
                                    coordination




                                    NOTE : Congenital Glaucoma
                                    It is due to increased intraocular pressure caused by an abnormal outflow or
                                    manufacturing of normal eye fluid.
                                    Unequal size should be reported immediately.




NOSE                                Nose breathers for first few months of life
MOUTH                               Scant saliva with pink lips
                                    Epstein’s Pearls - small shiny white specks on the neonate’s gums and hard palate
                                    which are normal




EARS                                Incurving of pinna and cartilage deposition

NECK                                Short and weak with deep fold of skin

CHEST                               Characterized by cylindrical thorax and flexible ribs
                                    NOTE:
                                            appears circular since anteroposterior and lateral diameters are about equal
                                             Respirations appear diaphragmatic
                                             Nipples prominent and often edematous
                                             Milky secretion (witch's milk) common ( effect of estrogen)



Newborn Assessment                                                                                                     Abejo
Maternal and Child Health Nursing
Newborn Assessment


ABDOMEN                             Cylindrical with some protrusion; scaphoid appearance indicates diaphragmatic hernia
                                    Umbilical cord is white and gelatinous with two arteries and one vein and begins to dry
                                    within 1-2 hours after delivery

                                    NOTE: Umbilical cord
                                          Three vessels, two arteries and one vein, in cord; if fewer than three vessels
                                          are noted notify the physician
                                          Small, thin cord may be associated with poor fetal growth
                                          Assess for intact cord, and ensure that damp is cured
                                          Cord should be clamped for at least the first 4 hours after birth; clamp can
                                          be removed hen the cord is dried and occluded
                                          Umbilical clamp can be removed after 24 hours


GENITALIA                           MALE: includes rugae on the scrotum and testes descended into the scrotum

                                    Urinary meatus:
                                            Hypospadias (ventral surface)
                                            Epispadias (dorsal surface)




                                        NOTE:
                                                     Meatus at tip of penis
                                                     Testes descended but may retract with cold
                                                     Assess for hernia or hydrocele
                                                     First voiding should occur within 24 hours

                                    FEMALE: labia majora cover labia minora and clitoris

                                                 Pseudomenstruation possible (blood-tinged mucus) effect of estrogen
                                                 First voiding should occur within 24 hours

EXTREMITIES                         All neonates have bowlegged and flat feet

                                    NOTE NORMAL FEATURES:
                                      Major gluteal folds even
                                      Creases on soles of feet
                                      Assess for fractures (especially clavicle) or dislocations (hip)
                                      Assess for hip dysplasia; when thighs are rotated outward, no clicks should be
                                      heard

                                    Some neonates may have abnormal extremities:
                                           Polydactyl (more than 5 digits on extremity)
                                           Syndactyl (two or more digits fused together)




Newborn Assessment                                                                                                    Abejo
Maternal and Child Health Nursing
Newborn Assessment




                                                     Polydactyl                                  Syndactyl

SPINE                               Should be straight and flat
                                    Anus should be patent without any fissure
                                    Dimpling at the base is associated with spina bifida
                                    A degree of hypotonicity or hypertonicity is indicative of central nervous system (CNS
                                    damage)

SKIN                                Assessment for Jaundice

                                    The #1 technique is to blanch the skin over the bony prominence such as the
                                    forehead, chest or tip of the nose.

                                    NOTE: Jaundice starts at the head first, spreads to the chest, then the abdomen, then the
                                    arms and legs, followed by the hands and feet, which are the last to be jaundiced.
                                    Jaundice in the first 24 hours after the birth is a cause for concern that requires
                                    further assessment. Possible causes of early jaundice are blood incompatibility,
                                    oxytocin induction, and severe hemolytic process.
                                    Mongolian Spots
                                    Gary, blue or black marks that are frequently found on the sacral area, buttocks, arms
                                    shoulders or other areas.




                                    Harlequins Sign
                                    Occurs on one side of the body turns deep red color. It occurs when blood vessels on
                                    one side constrict, while those on the other side of the body dilate.




Newborn Assessment                                                                                                        Abejo
Maternal and Child Health Nursing
Newborn Assessment


                                    Erythema toxicum
                                          Is an eruption of lesions in the area surrounding a hair follicle that are firm, vary
                                           in size from 1-3 mm, and consist of a white or pale yellow papule or pustule w/ an
                                           erythematous base.
                                          It is often called “newborn rash” or “flea-bite” dermatitis
                                          The rash may appear suddenly, usually over the trunk and diaper area and is
                                           frequently widespread.
                                          The lesions do not appear on the palms of the hands or soles of the feet.
                                          The peak incidence is 24-48 hours of life.
                                          Cause is unknown and no treatment necessary




                                    Acrocyanosis versus Central Cyanosis
                                         Acrocyanosis involves the extremities of the neonate, for example bluish hands
                                           and feet due to neonates being cold or poor perfusion of the blood to the
                                           periphery of the body.
                                         Central cyanosis, which involves the lips, tongue and trunk indicating
                                           HYPOXIA which needs further assessment by the nurse.




                                    .

                                        Milia are blocked sebaceous glands located on the chin and the nose of the infant.




                                    VERNIX CASEOASA
                                    Should not be removed by oil or hand lotion, because it is a protective layer of the
                                    neonate after birth, and it disappears after birth. Never remove it with alcohol or
                                    cotton balls, unless meconium skinned.




Newborn Assessment                                                                                                           Abejo
Maternal and Child Health Nursing
Newborn Assessment


                                    BIRTH MARKS

                                    Telangiectatic nevi (stork bites)
                                     Appear as pale pink or red spots and are frequently found on the eyelids, nose,
                                        lower occipital bone and nape of the neck
                                     These lesions are common in NB w/ light complexions and are more noticeable
                                        during periods of crying. These areas have no clinical significance and usually
                                        fade by the 2nd birthday




                                    Hemangioma is benign vascular tumor that may be present on the newborn

                                    3 types Hemangiomas
                                         1. Nevus Flammeus – port wine stain – macular purple or dark red lesions seen
                                             on face or thigh. NEVER disappear. Can be removed surgically
                                         2. Strawberry hemangiomas – nevus vasculosus – dilated capillaries in the
                                             entire dermal or subdermal area. Enlarges, disappears at 10 yo.
                                         3. Cavernous hemangiomas – communication network of venules in SQ tissue
                                             that never disappear with age.




                                    Nevus Flammeus (port-wine stain)
                                       A capillary angioma directly below the epidermis, is a non-elevated, sharply
                                        demarcated, red-to-purple area of dense capillaries.
                                       Macular purple
                                       The size & shape vary, but it commonly appears on the face. It does not grow in
                                        size, does not fade in time and does not blanch. The birthmark maybe concealed by
                                        using an opaque cosmetic cream.
                                       If convulsions and other neurologic problem accompany the nevus flammeus,----
                                        5th cranial nerve involvement.

                                    Nevus vasculosus (strawberry mark)
                                     A capillary hemangioma, consists of newly formed and enlarged capillaries in the
                                       dermal and subdermal layers.
                                     It is a raised,clearly delineated, dark-red, rough-surfaced birthmark commonly
                                       found in the head region.
                                     Such marks usually grow starting the second or third week of life and may not
                                       reach their fullest size for 1 to 3 months; disappears at the age of 1 yr. but as the
                                       baby grows it enlarges.
                                     Providing appropriate information about the cause and course of birthmarks often
                                       relieves the fears and anxieties of the family. Note any bruises, abrasions,or
                                       birthmarks seen on admission to the nursery.




Newborn Assessment                                                                                                      Abejo
Maternal and Child Health Nursing
Newborn Assessment




                                            GESTATIONAL ASSESSMENT

PARAMETER                       NURSING                 ‘TERM’ born between         ‘PRETERM’ born before 37 weeks
                                ACTION                  37-42 weeks gestation       gestation
EAR                             Fold the pinna          Pinna recoils (springs      Pinna opens slowly or stays folded
                                (auricle) forward       back)                       in very premature infants
BREAST TISSUE                   Measure it              3 mm                        Less than 3 mm
FEMALE GENITALIA                Observe                 Labia majora cover          Labia minora are more prominent;
                                                        labia minora                vaginal opening can be seen
MALE GENITALIA                  Observe                 Scrotal sac very            Fewer shallow rugae on the scrotum
                                                        wrinkled
HEEL CREASES                    Observe                 Extend 2/3 of the way       Soles are smoother, creases extend
                                                        from the toes to the heel   less than 2/3 of the way from the
                                                                                    toes to the heel


                                                 NEWBORN REFLEXES

    Immature central nervous system (CNS) of newborn is characterized by variety of reflexes
         o Some reflexes are protective, some aid in feeding, others stimulate interaction
         o Assess for CNS integration
    Protective reflexes are blinking, yawning, coughing, sneezing, drawing back from pain
    Rooting and sucking reflexes assist with feeding

“What reflexes should be present in a newborn? Reflexes are involuntary movements or actions. Some movements
are spontaneous, occurring as part of the baby's usual activity. Others are responses to certain actions. Reflexes
help identify normal brain and nerve activity. Some reflexes occur only in specific periods of development. The
following are some of the normal reflexes seen in newborn babies””


PALMAR GRASP                           Newborn’s fingers curl around the examiner’s fingers and the newborn’s toes
REFLEX                                  curl downward.
                                       The palmar grasp reflex is elicited by placing an object in the palm of a
                                        neonate; the neonate's fingers close around it. This reflex disappears between
                                        ages 6 and 9 months.
                                             Palmar response lessens within 3-4 months
                                             Palmar response lessens within 8 months




ROOTING                                The rooting reflex is elicited by stroking the neonate's cheek or stroking near
REFLEX                                  the corner of the neonate's mouth.
                                       The neonate turns the head in the direction of the stroking, looking for food.
                                       This reflex disappears by 6 weeks.




SUCKING                                The sucking reflex is seen when the neonate's lips are touched
REFLEX                                 Lasts for about 6 months


Newborn Assessment                                                                                                        Abejo
Maternal and Child Health Nursing
Newborn Assessment


MORO REFLEX                            Symmetric & bilateral abduction & extension of arms and hands
                                       Thumb & forefinger form a C
                                       “EMBRACE” reflex
                                       Present at birth, complete response may occur up to 8 weeks
                                       A persistent response lasting more than 6 months may indicate the occurrence
                                        of brain damage during pregnancy

                            A normal reflex in a young infant caused by a sudden loud noise. It results in drawing
                           up the legs, an embracing position of the arms, and usually a short cry.




BABINSKI’ SIGN                 Beginning at the heel of the foot, gently stroke upward along the lateral aspect of
                                the sole; then the examiner moves the fingers along the ball of the foot
                               The newborn’s toes hyperextend while the big toe dorsiflexes
                               Absence of this reflex indicates the need for a neurological examination
                               The Babinski reflex is elicited by stroking the neonate's foot, on the side of the
                                sole, from the heel toward the toes.
                               A neonate will fan his toes, producing a positive Babinski sign, until about age 3
                                months




STEPPING OR                    The newborn simulates walking, alternately flexing and extending the feet
WALKING                        The reflex is usually present 3-4 months
REFLEX




TONIC NECK                     While the newborn is falling asleep or sleeping, gently and quickly turn the head
REFLEX                          to one side
                               As the newborn faces the left side, the left arm & leg extend outward while the
                                right arm & leg flex
                               When the head is turned to the right side, the right arm & leg extend outward while
                                the left arm & leg flex
                               Usually disappears within 3-4 months


Newborn Assessment                                                                                                     Abejo
Maternal and Child Health Nursing
Newborn Assessment




CRAWLING                   Place the newborn on the abdomen
                           The newborn begins making crawling movements with the arms and legs
                           The reflex usually disappears after about 6 weeks




                              BASIC TEACHING NEEDS OF NEW PARENTS

CORD CARE                     Cleanse the cord with alcohol and sometimes triple dye once a day
                              Keep the area clean and dry
                              Keep the newborn’s diaper below the cord to prevent irritation
                              Signs of infection: redness, drainage, swelling, odor
                              Notify physician for signs of infection
                           NOTE:
                                 Note any bleeding or drainage from the cord
                                 Triple dye may be applied for initial cord care because it minimizes
                                 microorganisms and promotes drying; use a cotton-tipped applicator to paint
                                 the dye, one time, on the cord on 1 inch of surrounding skin
                                 Application of 70% isopropyl alcohol to the cord with each diaper change and
                                 at least two r three times a day to minimize microorganisms and promote
                                 drying.

                           NOTE: The skin is surrounded with alcohol which promotes drying and cleans the area.
                           The umbilical cord dries and falls off about 14 days. Peroxide and lanolin promote
                           moisture, which can inhibit drying and allow growth of bacteria. Water doesn’t
                           promote drying.

                           It is best to care for the neonate’s umbilical cord area by cleaning it with cotton
                           pledgets moistened with alcohol. The alcohol promotes drying and helps decrease the
                           risk of infection. An antibiotic ointment maybe used instead of alcohol, because there
                           are a lot of bacteria which is resistant against some bacteria. Other agents such as
                           wipes, sterile water and soap & water are not as effective as alcohol.



CIRCUMCISION                        Observe for bleeding, first urination
CARE                                Apply diaper loosely to prevent irritation
                                    Notify physician for signs of infection
BONDING                             Encourage parent to talk to, hold, and sing to infant
                                    Promotes skin-to-skin contact between parent and infant
                                    Feedings are opportunities for parent-infant bonding
                                    Notify physician for signs of infection

                           NOTE: Sense of Touch
                              The most highly developed sense at birth that is why, neonates responds well to
                              touch.




Newborn Assessment                                                                                                  Abejo
Maternal and Child Health Nursing
Newborn Assessment


                                    PRE TERM INFANT ( PREMATURE INFANT)




Definition                              PRE TERM INFANT
                                            A neonate born before 38 weeks age of gestation

Synonym                                 Low birth weight


Contributing factors                           Low socioeconomic level
                                               Poor nutritional status
                                               Lack of pre natal care
                                               Multiple pregnancy
                                               Prior previous early birth
                                               Race (non whites have a higher incidence of prematurity than
                                                whites)
                                               Cigarette smoking
                                               The age of the mother ( the highest incidence is in mother’s
                                                younger than age 20.)
                                               Order of birth ( early termination is highest in first pregnancies
                                                and in those beyond the forth )
                                               Closely spaced pregnancies
                                               Abnormalities of the reproductive system such as intrauterine
                                                septum
                                               Infections ( specially urinary tract infections)
                                               Obstetric complications such as premature rupture of membranes
                                                or premature separation of the placenta
                                               Early induction of labor
                                               Elective cesarian birth

                                               Appears small and underdeveloped
Cardinal signs                                 The head is disproportionately large ( 3 cm or more greater than
                                                chest size)
                                               Skin is thin with visible blood vessel and minimal subcutaneous
                                                fat pads
                                               Vernix caseosa is absent
                                               Both anterior and posterior fontanelles are small

Abnormal laboratory values                     Decreased RBC’s
                                               Decreased serum glucose
                                               Increased concentration of indirect bilirubin
                                               Decreased serum albumin
                                               NOTE:        The normal range of urine output for a preterm
                                                baby is 1 to 2ml/kg/day. The normal specific gravity for a
                                                preterm baby is 1.020. The normal range for blood glucose
                                                level in a preterm baby is 40 to 60 mg/dl.

Best procedure                                 Resuscitation
                                                NOTE: resuscitation becomes important for infant who fails to
                                                       take first breath or difficulty maintaining adequate
                                                       respiratory movements on his own.



Newborn Assessment                                                                                              Abejo
Maternal and Child Health Nursing
Newborn Assessment


                                         Suctioning
                                          NOTE: allows removing mucus and prevents aspiration of any
                                                  mucus and amniotic fluid present in the mouth and
                                                  nose of the newborn to establish clear airway.

                                         Intubations
                                          NOTE: head of the infant in neutral position with towel under
                                                  shoulder.



Best position                            Positioning the infant on the back with the head of the mattress
                                          elevated approximately 15 degrees to allow abdominal contents to
                                          fall away from the diaphragm affording optimal breathing space.

                                     Best position for suctioning:
                                      Infant on the back and slide a folded towel or pad under shoulders
                                         to rise, head is in neutral position.


Complications                            Anemia of prematurity
                                         Hyperbilirubinemia/ kernicterus
                                         Persistent patent ductus arteriosus
                                         Periventricular / intraventricular hemorrhage
                                         Respiratory distress syndrome
                                         Retinopathy of prematurity
                                            Retrolental fibroplasias are a complication that occurs if the
                                            infant is overexposed to high oxygen levels.
                                         Necrotizing enterocolitis


Bedside equipment                        Preterm size laryngoscope
                                         ET tube
                                         Suction catheter with synthetic surfactant
                                         Isolettes (incubator)


Drug study                           1.   Naloxone (Narcan)
                                          Nature of the drug:
                                            Narcotic antagonist
                                               Side effects:
                                            Hypertension, irritability, tachycardia

                                     2.   Surfactan ( Survanta)
                                           Nature of the drug:
                                            Lung surfactant to improve lung compliance
                                               Side effect:
                                            Transient bradycardia, rales

                                     3.   Vitamin K (Aquamephyton)
                                            Use for prophylaxis to treat hemorrhagic disease of the
                                               newborn.
                                               Side effects:
                                            Hyperbilirubinuria

                                     4.   Eye prophylaxis
                                           (Erythromycin 0.5% Ilotycin, Tetracycline 1%
                                           Silver Nitrate 1% ( not already used – causes chemical
                                           conjunctivitis)
                                            Prophylactic measure to protect against Neisseria
                                                gonorrhoeae and Chlamydia trachomatis
                                                Side effects:
                                            Silver nitrate can cause chemical conjuctivitis

Nursing diagnosis                   1.    Impaired gas exchange related to immature pulmonary
                                          functioning
                                    2.    Risk for fluid volume deficit related to insensible water loss at
                                          birth and small stomach capacity

Newborn Assessment                                                                                            Abejo
Maternal and Child Health Nursing
Newborn Assessment


                                    3.   Risk for aspiration related to weak or absent gag reflex a nd/or
                                         administration of tube feedings
                                    4.   Hypothermia related to lack of subcutaneous and brown fat
                                         deposits, inadequate shiver response, immature
                                         thermoregulation center, large body surface area in relation to
                                         body weight, and/or lack of flexion of extremities toward the
                                         body.
                                    5.   Risk for infection related to immature immune response, stasis of
                                         respiratory secretions, and/ or aspiration
                                    6.   Imbalanced nutrition: less than body requirements related to
                                         lack of energy to suck and/or weak or absent sucking reflex

Nursing intervention                     The nurse’s first priority in preparing a safe environment for a
                                         preterm newborn with low Apgar scores is to prepare
                                         respiratory resuscitation equipment. Airway maintenance is the
                                         first priority.
                                         Give the mother oxygen by mask during the birth to provide the
                                         preterm infant with optimal oxygen saturation at birth ( 85-90%).
                                         Keeping maternal analgesia and anesthesia to a minimum also
                                         offers the infant the best chance of initiating effective respiration.
                                         Bedside larngyoscope, endotracheal tube, suction catethers and
                                         synthetic surfactant to be administered by the endotracheal tube.
                                         Infant must be kept warm during resuscitation procedures so he
                                         or she is not expending extra energy to increase the metabolic
                                         rate to maintain body temperature.
                                         Observe for changes in respirations, color and vital signs
                                         Check efficacy of Isolette: maintain heat, humidity and oxygen
                                         concentration, administer oxygen only if necessary
                                         Maintain aseptic technique to prevent infection
                                         Adhere to the techniques of gavage feeding for safety of infant
                                         Observe weight-gain patterns
                                         Determine blood gases frequently to prevent acidosis. Institute
                                         phototherapy when hyperbilirubinemia occurs
                                         Support parents by letting them verbalize and ask questions to
                                         relieve anxiety.
                                         Provide liberal visiting hours for parents, allow them to
                                         participate in care.
                                         Arrange follow-up before and after discharge by a visiting nurse.




Newborn Assessment                                                                                          Abejo
Maternal and Child Health Nursing
Newborn Assessment




                                                 POST TERM INFANT



    Definition                      POST TERM INFANT
                                        A neonate born after 42 weeks age of gestation

                                           Low socioeconomic level
    Contributing factors                   Poor nutritional status
                                           Lack of pre natal care
                                           Multiparous mother’s
                                           Cigarette smoking
                                           The age of the mother (the highest incidence is in mother’s younger
                                            than age 20.)
                                           Mother’s with diabetes mellitus
                                           Congenital abnormalities such as omphalocele.
                                           Body is covered with lanugo
                                           Old man facies

    Classic signs                          Intrauterine weight loss, dehydrations and chronic hypoxia “old
                                            man faces’
                                           Long & thin with cracked skin which is loose, wrinkled and
                                            strained greenish yellow, with no vernix nor lanugo
                                           Long nails with firm skull
                                           Wide eyed alertness of one month old baby

    Abnormal         laboratory            Increased total no. of RBC’s
    values                                 Increased hematocrit level
                                           Decreased serum glucose


    Screening test                         Sonogram

                                           Resuscitation
    Best procedure                          NOTE: resuscitation becomes important for infant who fails to take
                                             first breath or difficulty maintaining adequate respiratory
                                             movements on his own.

                                           Suctioning
                                            NOTE: allows removing mucus and prevents aspiration of any
                                               mucus and amniotic fluid present in the mouth and nose of the
                                               newborn.
                                               To establish clear airway.

                                           Intubations
                                             NOTE: head of the infant in neutral position with towel under
                                                shoulder.

                                           Positioning the infant on the back with the head of the mattress
    Best position                           elevated approximately 15 degrees to allow abdominal contents


    Complications                          Meconium aspiration syndrome
                                           Respiratory distress syndrome

                                       NOTE: Post mature neonates have difficulty maintaining glucose
                                      reserves. Other common problems include Meconium aspiration
                                      syndrome, polycythemia, congenital anomalies, seizure activity and cold
                                      stress.

                                        NOTE: The infant who are exposed to high blood-glucose levels in
                                        utero may experience rapid and profound hypoglycemia after birth
                                        because of the cessation of a high in-utero glucose load. The small-for-
                                        gestational-age infant has use up glycogen stores as a result of
                                        intrauterine malnutrition and has blunted hepatic enzymatic response
                                        with which to carry out gluconeogenesis.



Newborn Assessment                                                                                                 Abejo
Maternal and Child Health Nursing
Newborn Assessment




                                        NOTE: The patient with post-term pregnancy is at high risk for
                                        decreased placental functioning, therefore increasing the risk of
                                        inadequate oxygen circulation to the fetus


    Bedside equipment                       ET tube
                                            Suction catheter


    Drug study
                                     1. Vitamin K (Aquamephyton)
                                         Use for prophylaxis to treat hemorrhagic disease of the newborn
                                        Side effects:
                                         Hyperbilirubinuria

                                    2. Eye prophylaxis
                                       (Erythromycin 0.5% Ilotycin, Tetracycline 1% Silver Nitrate 1%
                                        Prophylactic measure to protect against Neisseria gonorrhoeae and
                                           Chlamydia trachomatis
                                       Side effects:
                                        Silver nitrate can cause chemical conjuctivitis

    Nursing diagnoses               1. Ineffective airway breathing
                                    2. Risk for fluid volume deficit related to insensible water loss at birth
                                    3. Ineffective infant feeding pattern

    Nursing interventions                    Assess newborn’s respiratory rate, depth and rhythm. Auscultate
                                              lung sound.
                                            Note: Meconium stained syndrome of POST MATURE neonates
                                            Aspiration of meconium is best prevented by suctioning the neonate’s
                                            nasopharynx immediatelt after the head is delivered and before the
                                            shoulders and chest are delivered. As long as the chest is
                                            compressed in the vagina, the infant will not inhale and aspirate
                                            meconium in the upper respiratory tract. Meconium aspiration
                                            blocks the air flow to the alveoli, leading to potentially life
                                            threatening respiratory complications.

                                            Suction every 2 hours or more often as necessary
                                            Position newborn on side or back with the neck slightly extended
                                            Administer O2, anticipate the need for CPAP or PEEP
                                            Continue to assess the newborn’s respiratory status closely.
                                            Encourage as much parental participation in the newborn’s care as
                                             condition allows
                                            Administer IV fluids after birth to provide Glucose to prevent
                                             hypoglycemia, monitor closely the infusion rate.
                                            Kept the infant under a radiant heat warmer to preserve energy
                                            Monitor baby’s weight, serum electrolytes and ensure adequate
                                             fluid intake
                                            Measure urine output by weighing diapers
                                            Check for blood stools to evaluate for possible bleeding from
                                             intestinal tract.
                                            Keep a restful environment.
                                            Anticipate the infants need to be breastfeed
                                            Demonstrate technique for feeding to mother, note proper
                                             positioning of the infant, “latching on” technique, rate of delivery
                                             of feeding and frequency of burping
                                            Provide a relaxed environment during feeding
                                            Adjust frequency and amount of feeding according to infants
                                             response
                                            Alternate feeding procedure (nipple and gavage feeding) according
                                             to infants ability.
                                            Monitor mother’s effort, provide feedback and assistance as needed
                                            Suggest mother to monitor infants weight periodically




Newborn Assessment                                                                                                  Abejo

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Newborn Assessment

  • 1. Maternal and Child Health Nursing Newborn Assessment MATERNAL and CHILD HEALTH NURSING NEWBORN ASSESSMENT Lecturer: Mark Fredderick R. Abejo RN, MAN ______________________________________________________________________ Newborn Assessment Newborn Assessment Abejo
  • 2. Maternal and Child Health Nursing Newborn Assessment Newborn Assessment and Nursing Care  Tachypnea - respirations > 60  Persistent irregular breathing  Excessive mucus  Temperature - range 36.5 to 37 axillary  Persistant fine crackles  Common variations  Stridor o Crying may elevate temperature Stabilizes in 8 to 10 hours after Breathing ( ventilating the lungs) delivery  check for breathlessness o Temperature is not reliable indicator  if breathless, give 2 breaths- of infection ambu bag A temperature less than 36.5  1 yr old- mouth to mouth, pinch nose Temp: rectal- newborn – to rule out imperforate  < 1 yr – mouth to nose Anus  force – different between baby & - take it once only, 1 inch insertion child  infant – puff Imperforate anus Circulation 1. atretic – no anal opening  Check for pulslessness :carotid- 2. agenetialism – no genital adult 3. stenos – has opening  Brachial – infants 4. membranous – has opening CPR – breathless/pulseless Earliest sign:  Compression – inf – 1 finger breath 1. no mecomium below nipple line or 2 finger breaths 2. abd destention or thumb 3. foul odor breath  CPR inf 1:5 4. vomitous of fecal matter  Adults 2:30 5. can aspirate – resp problem Mgt: Surgery with temporary colostomy  Blood Pressure - not done routinely Factors to consider  Heart Rate Varies with change in activity level range 120 to 160 beats per minute Appropriate cuff size important for accurate Common variations reading  Heart rate range to 100 when sleeping 65/41 mmHg to 180 when crying  Color pink with acrocyanosis  General Measurements  Heart rate may be irregular with  Head circumference - 33 to 35 cm crying  Expected findings  Although murmurs may be due to  Head should be 2 to 3 cms larger than the transitional circulation-all murmurs chest should be followed-up and referred for  Abdominal circumference – 31-33 cm medical evaluation  Weight range - 2500 - 4000 gms (5 lbs. 8oz.  Deviation from range - 8 lbs. 13 oz.)  Faint sound  Length range - 46 to 54 cms (19 - 21 inches)  Normal length- 19.5 – 21 inch or 47.5 – Cardiac rate: 120 – 160 bpm newborn 53.75cm, average 50 cm Apical pulse – left lower nipple  Head circumference 33- 35 cm or 13 – 14 “ Radial pulse – normally absent. If present PDA Femoral pulse – normal present. If absent COA Hydrocephalus - >14” Chest 31 – 33 cm or 12 – 13”  Respiration Abd 31 – 33 cm or 12 – 13” - range 30 to 60 breaths per minute Common variations  Bilateral bronchial breath sounds Signs of increased ICP Moist breath sounds may be present 1. abnormally large head shortly after birth 2. bulging and tense fontanel Signs of potential distress or deviations 3. increase BP and widening pulse pressure from expected findings 4. Decreased RR, decreased PR  Asymmetrical chest movements 5. projective vomiting- sure sign of cerebral  Apnea >15 seconds irritation  Diminished breath sounds 6. high deviation – diplopia – sign of ICP older  Seesaw respirations child  Grunting a. 4-6 months- normal eye deviation  Nasal flaring b. >6 months- lazy eyes  Retractions 7. High pitch shrill cry-late sign of ICP  Deep sighing Newborn Assessment Abejo
  • 3. Maternal and Child Health Nursing Newborn Assessment Head to Toe Newborn Assessment CIRCULATORY UMBILICAL VEIN and DUCTUS VENOSUS constrict after cord id clamped STATUS DUCTUS ARTERIOSUS constrict with establishment of respiratory function FORAMEN OVALE closes functionally as respirations established, but anatomic or permanent closure may take several months HEART RATE averages 140 b.p.m. BP 73/55 mmHg PERIPHERAL CIRCULATION acrocyanosis within 24 hours RBC high immediately after birth; falls after 1 st week ABSENCE/ NORMAL FLORA INTESTINE Vitamin K RESPIRATORY Adequate levels of surfactants (Lecithin and spingomyelin) ensure mature lung STATUS function; prevent alveolar collapse and respiratory distress syndrome RR = 30-80 breaths /minutes with short periods of apnea (< 15 seconds) = assess for 1 full minute change noted during sleep or activity NOTE: Periodic apnea is common in preterm infants. Usually, gentle stimulation is sufficient to get the infant to breathe RENAL SYSTEM Urine present in the bladder at birth but NB may not void doe 1st 12-24 hours Later pattern is 6-10 voidings/ day – indicative of sufficient fluid intake Urine is pale and straw colored – initial voidings may leave brick-red spots on diaper ( d/t passage of uric acid crystals in urine) Infant unable to concentrate urine for the 1st 3 months DIGESTIVE IMMATURE CARDIAC SPHINCTER – may allow reflux of food, burped, SYSTEM REGURGITATE- placed NB right side after feeding Newborn can’t move food from lips to pharynx. Insert nipple well to mouth FEEDING PATTERS vary - Newborns may nurse vigorously immediately afterbirth or may need as long as several days to suck effectively - Provide support and encouragement to new mothers during this time as infant feeding is very emotional doe most mothers NOTE: Distinguishing Neonatal Vomiting from Regurgitation Vomiting is usually sour, looks like curdled milk due to HCL, with a sour odor, while regurgitation has no sour odor or curdling of milk, or occurs during or immediately after feeding. IMPORTANT CONSIDERATIONS: Breastfeeding can usually begin immediately after birth; bottle-fed newborns may be offered few milliliters of sterile water or 5% dextrose 1 to 4 hours after birth prior to a feeding with formula An infant with gastrostomy tube should receive a pacifier during feeding unless contraindicated to provide normal sucking activity and satisfy oral needs. At age4-6 months, an infant should begin to receive solid food foods one at a time and 1 week apart. FIRST STOOL is MECONIUM - Black, tarry residue from lower intestine - Usually passed within 12-24 hours after birth If the amniotic fluid shows evidence of meconium staining, the physician most likely do immediately after delivery is to suction the oropharynx immediately after the head is delivered and before the chest is delivered. TRANSITIONAL STOOLS thin, brownish green in color After 3 days MILK STOOLS are usually passed a. MILK STOOLS for BF infant – loose and golden yellow b. MILK STOOLS for FORMULATED FED- formed and pale yellow Newborn Assessment Abejo
  • 4. Maternal and Child Health Nursing Newborn Assessment HEPATIC Liver responsible for changing Hgb into conjugated bilirubin, which is further changed into conjugated (water soluble) bilirubin that can be excreted Excess unconjugated bilirubin can permeate the sclera and the skin, giving a jaundiced or yellow appearance to these tissues TEMPERATURE HEAT PRODUCTION in newborn accomplished by: a. Metabolism of “ BROWN FAT” - A special structure in NB is a source of heat - Increased metabolic rate and activity Axillary temperature: 96.8 to 99F Newborn can’t shiver as an adult does to release heat Newborns are unable to maintain a stable body temperature because they have an immature vasomotor center, and unable to shiver to increase body heat. NB’s body temperature drops quickly after birth – after stress occurs easily Body stabilizes temperature in 8-10 hours if unstressed Cold stress increases o2 consumption – may lead to metabolic acidosis and respiratory distress IMMUNOLOGIC NB develops own antibodies during 1st 3 months but at risk for infection during the first 6 weeks Ability to develop antibodies develops sequentially Neonatal Physical Assessment Birth weight=2500-400 grams (5 lbs. 8oz. – 8 lbs. 13 oz.) Length= 45.7 – 55.9 cm. (18-22 inches) HEAD Head circumference = 33-35 cm (2-3 cm. Greater than chest circumference) Anterior fontanel (diamond shape) = closes 12-18 months Posterior fontanel (triangle shape)= closes 2-3 months NOTE: The posterior fontanel is located at the intersection of the sagittal and lambdoid suture is the space between the pariental bones; the lambdoid suture separates the two parietal bones and the occipital bone Molding- asymmetry of head as a result of pressure in birth cana Newborn Assessment Abejo
  • 5. Maternal and Child Health Nursing Newborn Assessment EYES Blue/ gray d/t scleral thinness; permanent color established w/in 3-12 mos. Lacrimal glands immature at birth; tearless cry up to 2 months Absence of tears is common because the neonate’s tear glands are not yet fully developed Transient strabismus Doll’s eye reflex persist for about ten days Red Reflex: A red circle on the pupils seen when an ophthalmoscope’s light is shining onto the retina is a normal finding. This indicates that the light is shining onto the retina. CONVERGENT STRABISMUS (CROSS EYED) It is common during infancy until age 6 months because of poor oculomotor coordination NOTE : Congenital Glaucoma It is due to increased intraocular pressure caused by an abnormal outflow or manufacturing of normal eye fluid. Unequal size should be reported immediately. NOSE Nose breathers for first few months of life MOUTH Scant saliva with pink lips Epstein’s Pearls - small shiny white specks on the neonate’s gums and hard palate which are normal EARS Incurving of pinna and cartilage deposition NECK Short and weak with deep fold of skin CHEST Characterized by cylindrical thorax and flexible ribs NOTE: appears circular since anteroposterior and lateral diameters are about equal Respirations appear diaphragmatic Nipples prominent and often edematous Milky secretion (witch's milk) common ( effect of estrogen) Newborn Assessment Abejo
  • 6. Maternal and Child Health Nursing Newborn Assessment ABDOMEN Cylindrical with some protrusion; scaphoid appearance indicates diaphragmatic hernia Umbilical cord is white and gelatinous with two arteries and one vein and begins to dry within 1-2 hours after delivery NOTE: Umbilical cord Three vessels, two arteries and one vein, in cord; if fewer than three vessels are noted notify the physician Small, thin cord may be associated with poor fetal growth Assess for intact cord, and ensure that damp is cured Cord should be clamped for at least the first 4 hours after birth; clamp can be removed hen the cord is dried and occluded Umbilical clamp can be removed after 24 hours GENITALIA MALE: includes rugae on the scrotum and testes descended into the scrotum Urinary meatus: Hypospadias (ventral surface) Epispadias (dorsal surface) NOTE: Meatus at tip of penis Testes descended but may retract with cold Assess for hernia or hydrocele First voiding should occur within 24 hours FEMALE: labia majora cover labia minora and clitoris Pseudomenstruation possible (blood-tinged mucus) effect of estrogen First voiding should occur within 24 hours EXTREMITIES All neonates have bowlegged and flat feet NOTE NORMAL FEATURES: Major gluteal folds even Creases on soles of feet Assess for fractures (especially clavicle) or dislocations (hip) Assess for hip dysplasia; when thighs are rotated outward, no clicks should be heard Some neonates may have abnormal extremities: Polydactyl (more than 5 digits on extremity) Syndactyl (two or more digits fused together) Newborn Assessment Abejo
  • 7. Maternal and Child Health Nursing Newborn Assessment Polydactyl Syndactyl SPINE Should be straight and flat Anus should be patent without any fissure Dimpling at the base is associated with spina bifida A degree of hypotonicity or hypertonicity is indicative of central nervous system (CNS damage) SKIN Assessment for Jaundice The #1 technique is to blanch the skin over the bony prominence such as the forehead, chest or tip of the nose. NOTE: Jaundice starts at the head first, spreads to the chest, then the abdomen, then the arms and legs, followed by the hands and feet, which are the last to be jaundiced. Jaundice in the first 24 hours after the birth is a cause for concern that requires further assessment. Possible causes of early jaundice are blood incompatibility, oxytocin induction, and severe hemolytic process. Mongolian Spots Gary, blue or black marks that are frequently found on the sacral area, buttocks, arms shoulders or other areas. Harlequins Sign Occurs on one side of the body turns deep red color. It occurs when blood vessels on one side constrict, while those on the other side of the body dilate. Newborn Assessment Abejo
  • 8. Maternal and Child Health Nursing Newborn Assessment Erythema toxicum  Is an eruption of lesions in the area surrounding a hair follicle that are firm, vary in size from 1-3 mm, and consist of a white or pale yellow papule or pustule w/ an erythematous base.  It is often called “newborn rash” or “flea-bite” dermatitis  The rash may appear suddenly, usually over the trunk and diaper area and is frequently widespread.  The lesions do not appear on the palms of the hands or soles of the feet.  The peak incidence is 24-48 hours of life.  Cause is unknown and no treatment necessary Acrocyanosis versus Central Cyanosis  Acrocyanosis involves the extremities of the neonate, for example bluish hands and feet due to neonates being cold or poor perfusion of the blood to the periphery of the body.  Central cyanosis, which involves the lips, tongue and trunk indicating HYPOXIA which needs further assessment by the nurse. . Milia are blocked sebaceous glands located on the chin and the nose of the infant. VERNIX CASEOASA Should not be removed by oil or hand lotion, because it is a protective layer of the neonate after birth, and it disappears after birth. Never remove it with alcohol or cotton balls, unless meconium skinned. Newborn Assessment Abejo
  • 9. Maternal and Child Health Nursing Newborn Assessment BIRTH MARKS Telangiectatic nevi (stork bites)  Appear as pale pink or red spots and are frequently found on the eyelids, nose, lower occipital bone and nape of the neck  These lesions are common in NB w/ light complexions and are more noticeable during periods of crying. These areas have no clinical significance and usually fade by the 2nd birthday Hemangioma is benign vascular tumor that may be present on the newborn 3 types Hemangiomas 1. Nevus Flammeus – port wine stain – macular purple or dark red lesions seen on face or thigh. NEVER disappear. Can be removed surgically 2. Strawberry hemangiomas – nevus vasculosus – dilated capillaries in the entire dermal or subdermal area. Enlarges, disappears at 10 yo. 3. Cavernous hemangiomas – communication network of venules in SQ tissue that never disappear with age. Nevus Flammeus (port-wine stain)  A capillary angioma directly below the epidermis, is a non-elevated, sharply demarcated, red-to-purple area of dense capillaries.  Macular purple  The size & shape vary, but it commonly appears on the face. It does not grow in size, does not fade in time and does not blanch. The birthmark maybe concealed by using an opaque cosmetic cream.  If convulsions and other neurologic problem accompany the nevus flammeus,---- 5th cranial nerve involvement. Nevus vasculosus (strawberry mark)  A capillary hemangioma, consists of newly formed and enlarged capillaries in the dermal and subdermal layers.  It is a raised,clearly delineated, dark-red, rough-surfaced birthmark commonly found in the head region.  Such marks usually grow starting the second or third week of life and may not reach their fullest size for 1 to 3 months; disappears at the age of 1 yr. but as the baby grows it enlarges.  Providing appropriate information about the cause and course of birthmarks often relieves the fears and anxieties of the family. Note any bruises, abrasions,or birthmarks seen on admission to the nursery. Newborn Assessment Abejo
  • 10. Maternal and Child Health Nursing Newborn Assessment GESTATIONAL ASSESSMENT PARAMETER NURSING ‘TERM’ born between ‘PRETERM’ born before 37 weeks ACTION 37-42 weeks gestation gestation EAR Fold the pinna Pinna recoils (springs Pinna opens slowly or stays folded (auricle) forward back) in very premature infants BREAST TISSUE Measure it 3 mm Less than 3 mm FEMALE GENITALIA Observe Labia majora cover Labia minora are more prominent; labia minora vaginal opening can be seen MALE GENITALIA Observe Scrotal sac very Fewer shallow rugae on the scrotum wrinkled HEEL CREASES Observe Extend 2/3 of the way Soles are smoother, creases extend from the toes to the heel less than 2/3 of the way from the toes to the heel NEWBORN REFLEXES  Immature central nervous system (CNS) of newborn is characterized by variety of reflexes o Some reflexes are protective, some aid in feeding, others stimulate interaction o Assess for CNS integration  Protective reflexes are blinking, yawning, coughing, sneezing, drawing back from pain  Rooting and sucking reflexes assist with feeding “What reflexes should be present in a newborn? Reflexes are involuntary movements or actions. Some movements are spontaneous, occurring as part of the baby's usual activity. Others are responses to certain actions. Reflexes help identify normal brain and nerve activity. Some reflexes occur only in specific periods of development. The following are some of the normal reflexes seen in newborn babies”” PALMAR GRASP  Newborn’s fingers curl around the examiner’s fingers and the newborn’s toes REFLEX curl downward.  The palmar grasp reflex is elicited by placing an object in the palm of a neonate; the neonate's fingers close around it. This reflex disappears between ages 6 and 9 months. Palmar response lessens within 3-4 months Palmar response lessens within 8 months ROOTING  The rooting reflex is elicited by stroking the neonate's cheek or stroking near REFLEX the corner of the neonate's mouth.  The neonate turns the head in the direction of the stroking, looking for food.  This reflex disappears by 6 weeks. SUCKING  The sucking reflex is seen when the neonate's lips are touched REFLEX  Lasts for about 6 months Newborn Assessment Abejo
  • 11. Maternal and Child Health Nursing Newborn Assessment MORO REFLEX  Symmetric & bilateral abduction & extension of arms and hands  Thumb & forefinger form a C  “EMBRACE” reflex  Present at birth, complete response may occur up to 8 weeks  A persistent response lasting more than 6 months may indicate the occurrence of brain damage during pregnancy A normal reflex in a young infant caused by a sudden loud noise. It results in drawing up the legs, an embracing position of the arms, and usually a short cry. BABINSKI’ SIGN  Beginning at the heel of the foot, gently stroke upward along the lateral aspect of the sole; then the examiner moves the fingers along the ball of the foot  The newborn’s toes hyperextend while the big toe dorsiflexes  Absence of this reflex indicates the need for a neurological examination  The Babinski reflex is elicited by stroking the neonate's foot, on the side of the sole, from the heel toward the toes.  A neonate will fan his toes, producing a positive Babinski sign, until about age 3 months STEPPING OR  The newborn simulates walking, alternately flexing and extending the feet WALKING  The reflex is usually present 3-4 months REFLEX TONIC NECK  While the newborn is falling asleep or sleeping, gently and quickly turn the head REFLEX to one side  As the newborn faces the left side, the left arm & leg extend outward while the right arm & leg flex  When the head is turned to the right side, the right arm & leg extend outward while the left arm & leg flex  Usually disappears within 3-4 months Newborn Assessment Abejo
  • 12. Maternal and Child Health Nursing Newborn Assessment CRAWLING Place the newborn on the abdomen The newborn begins making crawling movements with the arms and legs The reflex usually disappears after about 6 weeks BASIC TEACHING NEEDS OF NEW PARENTS CORD CARE Cleanse the cord with alcohol and sometimes triple dye once a day Keep the area clean and dry Keep the newborn’s diaper below the cord to prevent irritation Signs of infection: redness, drainage, swelling, odor Notify physician for signs of infection NOTE: Note any bleeding or drainage from the cord Triple dye may be applied for initial cord care because it minimizes microorganisms and promotes drying; use a cotton-tipped applicator to paint the dye, one time, on the cord on 1 inch of surrounding skin Application of 70% isopropyl alcohol to the cord with each diaper change and at least two r three times a day to minimize microorganisms and promote drying. NOTE: The skin is surrounded with alcohol which promotes drying and cleans the area. The umbilical cord dries and falls off about 14 days. Peroxide and lanolin promote moisture, which can inhibit drying and allow growth of bacteria. Water doesn’t promote drying. It is best to care for the neonate’s umbilical cord area by cleaning it with cotton pledgets moistened with alcohol. The alcohol promotes drying and helps decrease the risk of infection. An antibiotic ointment maybe used instead of alcohol, because there are a lot of bacteria which is resistant against some bacteria. Other agents such as wipes, sterile water and soap & water are not as effective as alcohol. CIRCUMCISION Observe for bleeding, first urination CARE Apply diaper loosely to prevent irritation Notify physician for signs of infection BONDING Encourage parent to talk to, hold, and sing to infant Promotes skin-to-skin contact between parent and infant Feedings are opportunities for parent-infant bonding Notify physician for signs of infection NOTE: Sense of Touch The most highly developed sense at birth that is why, neonates responds well to touch. Newborn Assessment Abejo
  • 13. Maternal and Child Health Nursing Newborn Assessment PRE TERM INFANT ( PREMATURE INFANT) Definition PRE TERM INFANT  A neonate born before 38 weeks age of gestation Synonym Low birth weight Contributing factors  Low socioeconomic level  Poor nutritional status  Lack of pre natal care  Multiple pregnancy  Prior previous early birth  Race (non whites have a higher incidence of prematurity than whites)  Cigarette smoking  The age of the mother ( the highest incidence is in mother’s younger than age 20.)  Order of birth ( early termination is highest in first pregnancies and in those beyond the forth )  Closely spaced pregnancies  Abnormalities of the reproductive system such as intrauterine septum  Infections ( specially urinary tract infections)  Obstetric complications such as premature rupture of membranes or premature separation of the placenta  Early induction of labor  Elective cesarian birth  Appears small and underdeveloped Cardinal signs  The head is disproportionately large ( 3 cm or more greater than chest size)  Skin is thin with visible blood vessel and minimal subcutaneous fat pads  Vernix caseosa is absent  Both anterior and posterior fontanelles are small Abnormal laboratory values  Decreased RBC’s  Decreased serum glucose  Increased concentration of indirect bilirubin  Decreased serum albumin  NOTE: The normal range of urine output for a preterm baby is 1 to 2ml/kg/day. The normal specific gravity for a preterm baby is 1.020. The normal range for blood glucose level in a preterm baby is 40 to 60 mg/dl. Best procedure  Resuscitation NOTE: resuscitation becomes important for infant who fails to take first breath or difficulty maintaining adequate respiratory movements on his own. Newborn Assessment Abejo
  • 14. Maternal and Child Health Nursing Newborn Assessment  Suctioning NOTE: allows removing mucus and prevents aspiration of any mucus and amniotic fluid present in the mouth and nose of the newborn to establish clear airway.  Intubations NOTE: head of the infant in neutral position with towel under shoulder. Best position  Positioning the infant on the back with the head of the mattress elevated approximately 15 degrees to allow abdominal contents to fall away from the diaphragm affording optimal breathing space. Best position for suctioning:  Infant on the back and slide a folded towel or pad under shoulders to rise, head is in neutral position. Complications  Anemia of prematurity  Hyperbilirubinemia/ kernicterus  Persistent patent ductus arteriosus  Periventricular / intraventricular hemorrhage  Respiratory distress syndrome  Retinopathy of prematurity Retrolental fibroplasias are a complication that occurs if the infant is overexposed to high oxygen levels.  Necrotizing enterocolitis Bedside equipment  Preterm size laryngoscope  ET tube  Suction catheter with synthetic surfactant  Isolettes (incubator) Drug study 1. Naloxone (Narcan) Nature of the drug:  Narcotic antagonist Side effects:  Hypertension, irritability, tachycardia 2. Surfactan ( Survanta) Nature of the drug:  Lung surfactant to improve lung compliance Side effect:  Transient bradycardia, rales 3. Vitamin K (Aquamephyton)  Use for prophylaxis to treat hemorrhagic disease of the newborn. Side effects:  Hyperbilirubinuria 4. Eye prophylaxis (Erythromycin 0.5% Ilotycin, Tetracycline 1% Silver Nitrate 1% ( not already used – causes chemical conjunctivitis)  Prophylactic measure to protect against Neisseria gonorrhoeae and Chlamydia trachomatis Side effects:  Silver nitrate can cause chemical conjuctivitis Nursing diagnosis 1. Impaired gas exchange related to immature pulmonary functioning 2. Risk for fluid volume deficit related to insensible water loss at birth and small stomach capacity Newborn Assessment Abejo
  • 15. Maternal and Child Health Nursing Newborn Assessment 3. Risk for aspiration related to weak or absent gag reflex a nd/or administration of tube feedings 4. Hypothermia related to lack of subcutaneous and brown fat deposits, inadequate shiver response, immature thermoregulation center, large body surface area in relation to body weight, and/or lack of flexion of extremities toward the body. 5. Risk for infection related to immature immune response, stasis of respiratory secretions, and/ or aspiration 6. Imbalanced nutrition: less than body requirements related to lack of energy to suck and/or weak or absent sucking reflex Nursing intervention The nurse’s first priority in preparing a safe environment for a preterm newborn with low Apgar scores is to prepare respiratory resuscitation equipment. Airway maintenance is the first priority. Give the mother oxygen by mask during the birth to provide the preterm infant with optimal oxygen saturation at birth ( 85-90%). Keeping maternal analgesia and anesthesia to a minimum also offers the infant the best chance of initiating effective respiration. Bedside larngyoscope, endotracheal tube, suction catethers and synthetic surfactant to be administered by the endotracheal tube. Infant must be kept warm during resuscitation procedures so he or she is not expending extra energy to increase the metabolic rate to maintain body temperature. Observe for changes in respirations, color and vital signs Check efficacy of Isolette: maintain heat, humidity and oxygen concentration, administer oxygen only if necessary Maintain aseptic technique to prevent infection Adhere to the techniques of gavage feeding for safety of infant Observe weight-gain patterns Determine blood gases frequently to prevent acidosis. Institute phototherapy when hyperbilirubinemia occurs Support parents by letting them verbalize and ask questions to relieve anxiety. Provide liberal visiting hours for parents, allow them to participate in care. Arrange follow-up before and after discharge by a visiting nurse. Newborn Assessment Abejo
  • 16. Maternal and Child Health Nursing Newborn Assessment POST TERM INFANT Definition POST TERM INFANT  A neonate born after 42 weeks age of gestation  Low socioeconomic level Contributing factors  Poor nutritional status  Lack of pre natal care  Multiparous mother’s  Cigarette smoking  The age of the mother (the highest incidence is in mother’s younger than age 20.)  Mother’s with diabetes mellitus  Congenital abnormalities such as omphalocele.  Body is covered with lanugo  Old man facies Classic signs  Intrauterine weight loss, dehydrations and chronic hypoxia “old man faces’  Long & thin with cracked skin which is loose, wrinkled and strained greenish yellow, with no vernix nor lanugo  Long nails with firm skull  Wide eyed alertness of one month old baby Abnormal laboratory  Increased total no. of RBC’s values  Increased hematocrit level  Decreased serum glucose Screening test  Sonogram  Resuscitation Best procedure NOTE: resuscitation becomes important for infant who fails to take first breath or difficulty maintaining adequate respiratory movements on his own.  Suctioning NOTE: allows removing mucus and prevents aspiration of any mucus and amniotic fluid present in the mouth and nose of the newborn. To establish clear airway.  Intubations NOTE: head of the infant in neutral position with towel under shoulder.  Positioning the infant on the back with the head of the mattress Best position elevated approximately 15 degrees to allow abdominal contents Complications  Meconium aspiration syndrome  Respiratory distress syndrome NOTE: Post mature neonates have difficulty maintaining glucose reserves. Other common problems include Meconium aspiration syndrome, polycythemia, congenital anomalies, seizure activity and cold stress. NOTE: The infant who are exposed to high blood-glucose levels in utero may experience rapid and profound hypoglycemia after birth because of the cessation of a high in-utero glucose load. The small-for- gestational-age infant has use up glycogen stores as a result of intrauterine malnutrition and has blunted hepatic enzymatic response with which to carry out gluconeogenesis. Newborn Assessment Abejo
  • 17. Maternal and Child Health Nursing Newborn Assessment NOTE: The patient with post-term pregnancy is at high risk for decreased placental functioning, therefore increasing the risk of inadequate oxygen circulation to the fetus Bedside equipment  ET tube  Suction catheter Drug study 1. Vitamin K (Aquamephyton)  Use for prophylaxis to treat hemorrhagic disease of the newborn Side effects:  Hyperbilirubinuria 2. Eye prophylaxis (Erythromycin 0.5% Ilotycin, Tetracycline 1% Silver Nitrate 1%  Prophylactic measure to protect against Neisseria gonorrhoeae and Chlamydia trachomatis Side effects:  Silver nitrate can cause chemical conjuctivitis Nursing diagnoses 1. Ineffective airway breathing 2. Risk for fluid volume deficit related to insensible water loss at birth 3. Ineffective infant feeding pattern Nursing interventions  Assess newborn’s respiratory rate, depth and rhythm. Auscultate lung sound. Note: Meconium stained syndrome of POST MATURE neonates Aspiration of meconium is best prevented by suctioning the neonate’s nasopharynx immediatelt after the head is delivered and before the shoulders and chest are delivered. As long as the chest is compressed in the vagina, the infant will not inhale and aspirate meconium in the upper respiratory tract. Meconium aspiration blocks the air flow to the alveoli, leading to potentially life threatening respiratory complications.  Suction every 2 hours or more often as necessary  Position newborn on side or back with the neck slightly extended  Administer O2, anticipate the need for CPAP or PEEP  Continue to assess the newborn’s respiratory status closely.  Encourage as much parental participation in the newborn’s care as condition allows  Administer IV fluids after birth to provide Glucose to prevent hypoglycemia, monitor closely the infusion rate.  Kept the infant under a radiant heat warmer to preserve energy  Monitor baby’s weight, serum electrolytes and ensure adequate fluid intake  Measure urine output by weighing diapers  Check for blood stools to evaluate for possible bleeding from intestinal tract.  Keep a restful environment.  Anticipate the infants need to be breastfeed  Demonstrate technique for feeding to mother, note proper positioning of the infant, “latching on” technique, rate of delivery of feeding and frequency of burping  Provide a relaxed environment during feeding  Adjust frequency and amount of feeding according to infants response  Alternate feeding procedure (nipple and gavage feeding) according to infants ability.  Monitor mother’s effort, provide feedback and assistance as needed  Suggest mother to monitor infants weight periodically Newborn Assessment Abejo