Chapter 18 Caring for the Normal Newborn

The Immediate Neonatal Assessment Establish airway Suction Provide warmth Dry the infant Place on mother’s abdomen; heated blankets Place beneath radiant heater Cap

The Immediate Neonatal Assessment Observe respiratory effort, color, muscle tone Stimulate neonate to breathe deeply and cry Assess heart rate, temperature Note obvious abnormalities Check and record number of umbilical cord vessels Refer to Table 18-1 for normal newborn parameters Generalized cyanosis Tachycardia (rapid heart rate > 160 bpm) Tachypnea (rapid respiratory rate > 70 bpm) Sternal or Rib retractions Expiratory grunting Flaring nostrils

Apgar Score—1, 5 minutes Assesses immediate adaptation Five categories—each scored 0 to 2 Respiratory effort Heart rate Muscle tone Reflex irritability Skin color

Immediate Nursing Care Mother–infant identification Infection/injury prevention Eye prophylaxis Vitamin K injection Hepatitis B vaccine (parental consent required) Assess blood glucose Hematocrit and hemoglobin

Question? The nurse administers vitamin K to the newborn for what reason? a. Most mothers have a diet deficient in vitamin K, which results in the infant being deficient. b. Vitamin K prevents the synthesis of prothrombin in the liver and must be given by injection. c. Bacteria that synthesize vitamin K are not present in the newborn’s intestinal tract. d. The supply of vitamin K is inadequate for at least 3 to 4 months, and the newborn must be supplemented. ANS: C Feedback A Incorrect: Vitamin K is provided because the newborn does not have the intestinal flora to produce this vitamin for the first week. The maternal diet has no bearing on the amount of vitamin K found in the newborn. B Incorrect: Vitamin K promotes the formation of clotting factors in the liver and is used for the prevention and treatment of hemorrhagic disease in the newborn. C Correct: This is an accurate statement. D Incorrect: Vitamin K is not produced in the intestinal tract of the newborn until after microorganisms are introduced. By day 8 normal newborns are able to produce their own vitamin K. DIF: Cognitive Level: Comprehension OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Implementation REF:

The Later Neonatal Assessment Body positioning Skin color Body size Level of reactivity Measurements and determination of gestational age Ballard Gestational Age by Maturity Rating Tool Refer to Figure 18-1 for body positioning Refer to Figures 18-2 & 18-3 for measurement Refer to Figure 18-4 for head circumference Refer to Figure 18-5 for chest circumference Refer to Figure 18-6 for abdominal circumference

Assessment of the Neonate: A Systems Approach

Integumentary System Inspect skin, scalp, nails, body hair Color, texture, distribution, disruptions, eruptions, birthmarks Well-lit room Birth injuries

Skin Assessment Smooth and soft Pustular melanosis Milia Postterm infants—tough, leathery skin Pustular melanosis Milia Erythema toxicum Pigmentation—Mongolian spots, café-au-lait marks Refer to Figure 18-9 for milia Refer to Figure 18-10 for Mongolian spots

Birthmarks Brown nevi—brown skin marks Nevus flammeus—“port wine stain” Telangiectatic nevus—“stork bite” Nevus vasculosus—“strawberry mark” Refer to Figure 18-11 for telangiectatic nevus

Assessment of the Infant’s Head Symmetry Eye shape, size, placement, and coordinated lid movement, red reflex, gross vision Ears: shape, size, placement, hearing Movement, color of the lips Chin—appropriate size

Head—Fontanels Estimate size Fullness without bulging—normal Bulging and tense with large head circumference—increased intracranial pressure Sunken—dehydration Refer to figure 18-14 for fontanels

Head Caput Succedaneum Cephalhematoma Diffuse edema, crosses suture lines, disappears in few days Cephalhematoma Subperiosteal hemorrhage Does not cross suture lines Persists for weeks Refer to Figure 18-15

Assessment Mouth Neck Facial features Epstein’s pearls Teeth Ability to suck Hard and soft palate Neck Torticollis Facial features Refer to Figure 18-16 for neonatal teeth Refer to Figure 18-17 for Epstein’s pearls

Respiratory System Assessment Symmetry in chest movement Breast tissue Nasal patency Respiration rate, pattern, and use of accessory muscles Auscultate lungs anterior and posterior

Respiratory Assessment Skin color Capillary refill Signs of distress Retractions Nasal flaring Expiratory grunting

Cardiovascular System Assessment Inspection and auscultation Point of maximum impulse Heart rate Capillary refill Peripheral pulses Auscultate all areas—murmurs Refer to Figures 18-19 & 18-20

Gastrointestinal System Assessment Abdominal inspection, including umbilical cord Auscultate bowel sounds, upper abdomen for gastric bubble, and heart sounds of the abdominal aorta Palpation Refer to Figure 18-21

Conditions That Warrant Further Assessment Abdominal distention Absence of bowel sounds Discharge from umbilical cord/site Abdominal mass Conditions That Warrant Further Assessment

Genitourinary System Assessment Hips abducted Palpate and inspect scrotum, testes, and penis Male—retract foreskin Palpate and inspect female genitalia Anus and anal wink reflex Refer to Figure 18-22 for testicle assessment

Common Findings—Male Infants Scrotal swelling Smegma Hypospadius Epispadius

Common Findings— Female Infants Hymenal tags Vernix caseosa on labia Pseudomenstruation

Conditions That Warrant Further Assessment Undescended testicles Micropenis Ambiguous genitalia Imperforate hymen Imperforate anus

Musculoskeletal System Assessment Observe infant’s movements in crib Inspect for differences in extremity length and size Assess muscle tone and symmetry Gentle passive ROM to assess joint rotation Assess head lag Skin folds on thighs Refer to figure 18-23 for head lag Refer to Figure 18-24 for hip assessment

Common Findings Torticollis Developmental dysplasia of the hip Asymmetry of hip folds Barlow maneuver Ortolani maneuver Crepitus Unusual positions of foot

Conditions That May Warrant Further Assessment Fractured clavicle Polydactyly Syndactyly Simian crease

Neurological System Assessment Reflexes Major—gag, Babinski, Moro, Galant Minor—palmar grasp, plantar grasp, rooting and sucking, head righting, stepping, tonic neck Refer to Table 18-2 for methods for assessing reflexes

Conditions That Warrant Further Assessment Shoulder dystocia Erb’s palsy Cerebral palsy Spina bifida

Teaching About Newborn Care Temperature assessment Bathing Nail Care and umbilical cord care Clothing Diapering Attachment

Newborn Care Circumcision Ensuring optimal nutrition Discharge planning for the infant and family Child care Newborn metabolic screening tests