NURSES NOTES

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NEWBORN CARE
NCM 107 - Care of Mother, Child and Adolescent (Well-Clients)
Second Semester, AY 2020-2021
The Care of Newborn at Birth
Essential Newborn Care: Protocol to New Life
ü Immediate and thorough drying of the newborn
ü Early skin to skin contact between mother and newborn
ü Properly-timed cord clamping and cutting
ü Non-separation of newborn and mother for early breastfe
eding

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The Care of Newborn at Birth
NEWBORN PROFILE
Every child is born with individual physical
amd personality characteritics that make hi
m or her unique from the start
(Silbert-Flagg & Pilliteri, 2018)

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Anthropometric Measurements
Vital Statistic Average Low or Arbitrary Low
Weight 2.6 to 3.5kgs. Less than 5.5 lbs.
Length 50cms (20in) (18-22in) 46cms (18in)
Head Circumference 33 to 35 cms
Chest Circumference
31-33cms or 2cms less than hea
d circumference
Abdominal
Circumference
31 to 33 cms
Anthropometric Measurements
WEIGHT

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Anthropometric Measurements
lEnGTH
Anthropometric Measurements
HEad
cIrcumfErEncE

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Anthropometric Measurements
cHEsT
cIrcumfErEncE
Anthropometric Measurements
abdomInal
cIrcumfErEncE

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VITAL SIGNS
Respiration
Pulse
Blood Pressure
Temperature

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Vital Sign Immediately At Birth After Birth
Temperature 36.5 to 37.2 Celsius
Pulse 180 beats/minute 120-140 beats/minute ave.
Respiration 80 breaths/minute 30-50 breaths/minute
Blood Pressure 80/46 mmHg 100/50 mmHg (by 10th day)
VITAL SIGNS
VITAL SIGNS
The temperature of newborns is about 99° F (37.2° C) at
birth because they have been confined in an internal body
organ. The temperature falls almost immediately to
below normal because of heat loss and immature
temperature regulating mechanisms.
Temperature

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VITAL SIGNS
Convection
Radiation
Conduction
Evaporation
Temperature
VITAL SIGNS
Newborns can conserve heat by
constricting blood vessels and
moving blood away from the skin.
Brown fat, a special tissue found in
mature newborns, apparently helps
to conserve or produce body heat by
increasing metabolism.
Temperature

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VITAL SIGNS Pulse
a newborn’s heart rate is always determined by
listening for an apical heartbeat for a full minute, rather
than assessing a pulse in an extremity.
*** Always palpate for femoral pulses because their absence suggests possible co
arctation (narrowing) of the aorta, a common cardiovascular abnormality.
VITAL SIGNS Respiration
Respiratory rate can be observed most easily by watching the
movement of a newborn’s abdomen, because breathing
primarily involves the use of the diaphragm and abdominal
muscles.
Respiratory depth, rate, and rhythm are likely to be irregular, and
short periods of apnea (without cyanosis) which last less than 15
seconds, sometimes called periodic respirations, are normal.

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VITAL SIGNS Blood Pressure
It is not routinely measured unless a
cardiac anomaly is suspected because measurement of blood
pressure in a newborn is somewhat inaccurate.
*** Hemodynamic monitoring is helpful when continuous assesment is necessary.
ASSESSMENT OF WELL-BEING
Apgar score
- standardized evaluation of the newborn’s condition.
- done at one minute after birth to determine the general
condition and then at 5 minutes to determine how
well the newborn is adjusting to extrauterine life.

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A P G A R
a
P
G
a
r
ppearance
ulse
rimace
ctivity
espiration
A P G A R

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Sign 0 1 2
Appearance: Color Pale, Blue all over Pinky body,
blue extremities
Pink all over
Pulse: Pulse Rate Absent Less than 100 More than 100
Grimace:
Reflex Irritability
No response to
stimulation
Grimace/feeble cry
when stimulated
Sneeze/Coughs/Pulls away
when stimulated; good
strong cry
Activity: Muscle Tone Limp, flaccid Some flexion of
extremities
Well-flexed extremities
Respiration: Breathing Absent Weak or irregular Good, strong cry
A P G A R
 Color—all infants appear cyanotic at birth and grow
pink with or shortly after the first breath
 Heart Rate—auscultation of the newborn’s heart
 Reflex irritability—response to a suction catheter or
having the soles of their feet slapped.
 Muscle tone—newborn hold the extremity tightly
flex. They should resist any effort to extend their
extremities
 Respiratory effort—a mature newborn usually cries
spontaneously at about 30 seconds after birth. At
one minute, the infant is maintaining regular
although rapid respirations.

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Acrocyanosis
A P G A R
Importance of APGAR:
1. Despite the advent of modern technology, the Apgar score r
emains the best tool for the identification of newly born infant
s in need for cardiopulmonary resuscitation.
2. Data suggest that serial APGAR ratings in infants with early
low scores detect clinically important recovery of lack thereof.

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A P G A R
Five minutes after delivery, a newborn baby has a pink face and
abdomen, cyanotic hands and feet, has a pulse of 140, promptly
squirms to stimulation of its feet, is spontaneously moving arms and
legs with good tone, and breathing vigorously. What is the 5 Minute APGAR s
core for this baby?
Sign 0 1 2
Appearance: Color Pale, Blue all over Pinky body,
blue extremities
Pink all over
Pulse: Pulse Rate Absent Less than 100 More than 100
Grimace:
Reflex Irritability
No response to
stimulation
Grimace/feeble cry
when stimulated
Sneeze/Coughs/Pulls away when stimulated;
good strong cry
Activity: Muscle Tone Limp, flaccid Some flexion of
extremities
Well-flexed extremities
Respiration: Breathing Absent Weak or irregular Good, strong cry
Respiratory Evaluation
Good respiratory function obviously has the highest priority in
newborn care, so assessment for it is ongoing at every newborn contact.
The Silverman and Andersen index, originally
devised in 1956 (Silverman & Andersen, 1956), can be used to estimate
degrees of respiratory distress in newborns.

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ASSESSMENT OF WELL-BEING
Assessment of Gestational Age
Specific findings on physical assessment provide clues to a newborn’s gestational age.
The new Ballard score is commonly used to determine gestational age.
ü Scores are given for 6 physical and 6 nerve and muscle development
(neuromuscular) signs of maturity. The scores for each may range from -1 to 5.
ü The scores are added together to determine the baby’s gestational age. The total s
core may range from -10 to 50.
ü Premature babies have low scores. Babies born late have high scores.

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BALLARD
BALLARD
To establish a baby’s
gestational age, the
total score obtained
(on both sections) is
compared with the ra
ting scale.

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To establish a baby’s gestational age, the total score
obtained (on both sections) is compared with the
rating scale.
BALLARD SCORING
CARE OF NEWBORN AT BIRTH
Birthing rooms provide an island for newborn care separate
from the supplies needed for the mother’s care.
Necessary equipment includes a radiant heat table or warmed bassinet; a
warm, soft blanket; and equipment for oxygen administration,
resuscitation, suction, eye care, identification, and weighing of
a newborn.

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Identification and Registration
Newborn identification is
an important nursing
responsibility.
ü Mother’s hospital number
ü Mother’s full name
ü Sex, date, and time of the infant’s birth
*** may vary per hospital protocol
Identification and Registration
The physician or nurse-midwife who
supervised the birth of an infant has
the responsibility to see that a birth
registration is filed.

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Birth Record Documentation
The infant’s chart is also a vital piece of documentation. It serves as a baseline indicating whet
her the infant was well at birth. Be certain a newborn chart contains the following information:
ü Time of birth
ü Time the infant breathed
ü Whether respirations were spontaneous or aided
ü Apgar score at 1 minute and at 5 minutes of life
ü Whether eye prophylaxis was given
ü Whether vitamin K was administered
ü General condition of the infant
ü Number of vessels in the umbilical cord
ü Whether cultures were taken (they are taken if at some point sterile birth technique was
broken or the mother has a history of vaginal or uterine infection)
ü Whether the infant voided and whether he or she passed a stool (this information is helpful
if, later on, the diagnosis of bowel obstruction or absence of a kidney is considered)
Newborn Care Procedures
• General Infection Pracautions
• Crede's Prophylaxis
• Vitamin K Injection
• Hepatitis B Vaccination
• Metabolic Screening Test (Newborn Screening)
• Initial Feeding
• Sleep positioning
• Bathing
• Diaper Area care

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References:
https://www.google.com/url?sa=i&url=https%3A%2F%2Ftwitter.com%2Fnursingahead%2Fstatus%2F96339140630700
4416&psig=AOvVaw3R41iGtZGWCTNm7k1Ef40K&ust=1616768283132000&source=images&cd=vfe&ved=0C
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Meldere, Ilze & Urtans, Valdis & Kruze, Dina & Petersons, Aigars & Abola, Zane. (2013). Neonatal Anthropometry: Me
asurement of the Abdominal Circumference in Newborns. Acta Chirurgica Latviensis. 13. 10.2478/chilat-2014-0010.
Shrestha SK. APGAR score in practice and its implications [Internet]. Epomedicine; 2020 Sep 2 [cited 2021 Mar 16]. Av
ailable from: https://epomedicine.com/medical-students/apgar-score-practice-implications/.
Gardner, S. (2020) Acrocyanosis. WebMD Medical Reference.https://www.webmd.com/skin-problems-and-treatments/acr
ocyanosis
Medzcool(2017, May 16). APGAR Score -Medzcool. YouTube.https://www.youtube.com/watch?v=98ikG8a9JKs&t=48s
Silbert-Flagg,J. & Pillitteri, A (2018).Maternal & Child Health Nursing:care of the childbearing and childrearing family,
Eighth Edition