1. Nursing Care of the Newborn and Family
Chapter 24
Nursing Care of the Newborn
and Family
Copyright © 2016 by Elsevier Inc. All rights reserved.

2. Learning Objectives
Explain the purpose and components of the Apgar score.
Describe how to perform a physical assessment of a newborn.
Describe how to perform a gestational age assessment of a newborn.

3. Learning Objectives (Cont.)
Compare the characteristics of the preterm, late preterm, early term, and postterm neonate.
Provide nursing care to assist the newborn to transition to extrauterine life.
Explain the elements of a safe environment.

4. Learning Objectives (Cont.)
Discuss phototherapy and the guidelines for teaching parents about this treatment.
Explain the purposes and methods for circumcision, the postoperative care of the circumcised infant, and parent teaching regarding circumcision.
Describe the procedures for administering an intramuscular injection, performing a heelstick, collecting urine specimens, and venipuncture.

5. Learning Objectives (Cont.)
Evaluate pain in the newborn based on physiologic changes and behavioral observations.
Discuss pharmacologic and nonpharmacologic interventions to reduce neonatal pain.
Review anticipatory guidance nurses provide to parents before discharge.

6. Care Management: Birth Through the First 2 Hours
Assessment
Immediate care after birth
Initial physical assessment
Apgar scoring
Heart rate
Respiratory rate
Muscle tone
Reflex irritability
Generalized skin color

7. Apgar Score
Permits a rapid assessment of the need for resuscitation based on five signs that indicate the physiologic state of the neonate
Heart rate-based on auscultation of the stethoscope
Respiratory rate-based on observed movement of the chest wall
Muscle tone-based on degree of flexion and movement of the extremities
Reflex , on response to gentle slaps on the soles of the feet
Color-Described as pallid, cyanotic, or pink

8. Care Management: Birth Through the First 2 Hours (Cont.)
Physical assessment
General appearance
Vital signs
Baseline measurements of physical growth
Weight
Head circumference
Body length

9. Care Management: Birth Through the First 2 Hours (Cont.)
Neurologic assessment
Newborn reflexes
Gestational age assessment
Dubowitz Scale
New Ballard Scale

10. Gestational age assessment (Cont.)

11. Care Management: Birth Through the First 2 Hours (Cont.)
Gestational age assessment (Cont.)
Classification of newborns by gestational age and birth weight
Appropriate for gestational age (AGA)
Large for gestational age (LGA)
Small for gestational age (SGA)

12. Gestational age assessment (Cont.)

13. Care Management: Birth Through the First 2 Hours (Cont.)
Gestational age assessment (Cont.)
Classification by gestation
Preterm or premature—born before completion of 37 weeks of gestation, regardless of birth weight
Late preterm—34 0/7 through 36 6/7 weeks
Early term—37 0/7 through 38 6/7 weeks
Full term—39 0/7 through 40 6/7 weeks
Late term—41 0/7 through 41 6/7 weeks
Postterm—42 0/7 weeks and beyond
Postmature—born after completion of week 42 of gestation and showing the effects of progressive placental insufficiency

14. Neonatal Interventions
Airway maintenance
Side-lying position
Bulb syringe
Use of nasopharyngeal catheter with mechanical suction apparatus
Maintaining an adequate oxygen supply
Maintaining body temperature

15. Neonatal Interventions (Cont.)
Immediate interventions
Eye prophylaxis
To prevent ophthalmia neonatorum or neonatal conjunctivitis
Vitamin K administration
Promoting parent-infant interactions

16. Care Management: From 2 Hours After Birth Until Discharge
Common problems in newborns
Birth injuries
Retinal and subconjunctival hemorrhages
Soft-tissue injuries: erythema, ecchymoses, petechiae
Trauma secondary to dystocia
Accidental lacerations

17. Care Management: From 2 Hours After Birth Until Discharge (Cont.)
Common problems in newborns (Cont.)
Physiologic problems
Jaundice
Assessment and screening
Therapy for hyperbilirubinemia
Phototherapy
Types of phototherapy
Precautions
Exchange transfusion

18. Therapy for Hyperbilrubinemia
Prevention
Early feeding, which stimulates the passage of meconium
Goal of treatment of hyperbilirubinemia is to help reduce the newborn’s serum level of unconjugated bilirubin
Phototherapy
Unclothed infant is placed beneath a bank of light
Infant is turned every 2 hours to expose all body surfaces to the light

19. Exchange Transfusion
Usually reserved for infants at risk for kernicterus due to high bilirubin levels
Small amounts of cross-matched whole blood are transfused into the infant as equivalent amounts of the infant’s blood are withdrawn and discarded
Most often accomplished through an umbilical venous catheter
Potential complications of exchange transfusion include transfusion reaction, infection, metabolic instability and complications related to placement of the umbilical catheter

21. Care Management: From 2 Hours After Birth Until Discharge (Cont.)
Common problems in newborns (Cont.)
Hypoglycemia
Usually defined as blood glucose levels less than 45 mg/dl
Hypocalcemia
Serum calcium levels of less than 7.8 to 8 mg/dl in term infants and slightly lower (7 mg/dl) in preterm infants

22. Care Management: From 2 Hours After Birth Until Discharge (Cont.)
Laboratory and diagnostic tests
Universal newborn screening
Mandated by U.S. law
Early detection of genetic diseases that result in severe health problems if not treated early
Newborn hearing screening
Screening for critical congenital heart disease (CCHD)

23. Care Management: From 2 Hours After Birth Until Discharge (Cont.)
Collection of specimens
Heelstick
Venipuncture
Urine specimen
Interventions
Protective environment
Environmental factors
Infection control factors

24. Heel Stick
Newborn with foot wrapped for warmth to increase blood flow to extremity before heel stick
B. Heel stick sites (shaded areas) on infant’s foot for obtaining samples of capillary blood

25. Obtaining a Urine Specimen
Urine sample should be fresh and analyzed within 1 hour of collection
Female infants
Perineum is first stretched to flatten skin folds, and then the adhesive area on the bag is pressed firmly onto the skin all around the urinary meatus and vagina

26. Obtaining a Urine Specimen
Male infants
The penis and scrotum are tucked through the opening into the collection bag before removing the protective paper from the adhesive and pressing firmly onto the perineum, making sure the entire adhesive is firmly attached to skin and the edge of the opening do not pucker
Diaper is carefully replaced and the bag is check frequently

27. Care Management: From 2 Hours After Birth Until Discharge (Cont.)
Preventing infant abduction
Preventing newborn falls

28. Care Management: From 2 Hours After Birth Until Discharge (Cont.)

29. Care Management: From 2 Hours After Birth Until Discharge (Cont.)
Therapeutic and surgical procedures
Intramuscular injection
Immunizations
Circumcision
Policies and recommendations
Parental decision
Procedure
Yellen (Gomco) clamp
Mogen clamp
PlastiBell device

30. Circumcision PlastiBell also may be used for a circumcision
Applies constant direct pressure to prevent hemorrhage during the procedure and afterward protects against infection, keeps the site from sticking to the diaper, and prevents pain with urination

31. Care of the Newly Circumcised Infant
Bleeding is the most common complication of circumcision
Nurse checks the penis hourly for the next 12 hours to make sure no bleeding is occurring and voiding is normal
If bleeding occurs apply an absorbable gelatin sponge (Gelfoam) to stop the bleeding
Cleanse penis with warm water to remove urine and feces

32. Circumcision with Mogen (Yellen) Clamp
Prepuce drawn over cone
B. Mogen clamp is applied, hemostasis occurs, and then prepuce (over cone) is cut away

33. Circumcision Using Hollister PlastiBell
A. Suture around rim of PlastiBell controls bleeding B. Plastic rim and suture drop off in 7 to 10 days

34. Care Management: From 2 Hours After Birth Until Discharge (Cont.)

35. Care Management: From 2 Hours After Birth Until Discharge (Cont.)
Therapeutic and surgical procedures
Circumcision
Procedural pain management
Care of the newly circumcised infant

36. Neonatal Pain Neonatal responses to pain Behavioral responses
Most common sign is vocalization or cry
Physiologic/autonomic responses
Changes in heart rate
Blood pressure
Intracranial pressure
Vagal tone
Respiratory rate
Oxygen saturation

37. Neonatal Pain (Cont.) Assessment of neonatal pain
Neonatal Infant Pain Scale (NIPS)
Premature Infant Pain Profile (PIPP)
Neonatal Pain Agitation and Sedation Scale (NPASS)
CRIES—for use in the neonatal intensive care unit (NICU)

38. Neonatal Pain (Cont.) Management of neonatal pain
Nonpharmacologic management
Containment (swaddling)
Nonnutritive sucking
Oral glucose
Skin-to-skin contact
Breastfeeding

39. Neonatal Pain (Cont.) Management of neonatal pain
Pharmacologic management
Local and topical anesthesia
Nonopioid analgesia
Acetaminophen
Opioid analgesia
Morphine
Fentanyl

40. Care Management: From 2 Hours After Birth Until Discharge (Cont.)
Promoting parent-infant interactions
Assess attachment behaviors
Support and education for parents
Cultural considerations

41. Discharge Planning and Teaching
Temperature
Respirations
Use of bulb syringe
Feeding patterns
Elimination
Positioning and holding
Safe sleep positions
Sudden infant death syndrome (SIDS)

42. Discharge Planning and Teaching (Cont.)
Rashes
Diaper
Other (rash on the cheeks, erythema toxicum)
Clothing
Car seat safety
Nonnutritive sucking
Bathing
Cord care
Skin care

43. Care of the Newborn at Home
Plan of Care
Cord Care
Cord should be kept clean and dry
Fold the diaper below the cord to allow drying
Cord can be cleansed with water
Cord falls off in 10 to 14 days after birth

44. A nurse has provided instructions to a new mother regarding umbilical cord care. Which statement by the mother indicates a need for further instructions
1.“I should cleanse the cord three times a day.” 
2.“The cord will fall off in about 2 weeks.” 
3.“Alcohol may be used to clean the cord.” 
4.“I need to fold the diaper above the cord to prevent infection.” 

45. A mother calls the clinic and tells the nurse that her newborn’s umbilical cord looks moist and has a discharge coming from it. The nurse most appropriately tells the mother:
1.To increase the number of times that the cord is cleansed per day 
2.To monitor the cord for another 24 to 48 hours and to call the clinic if the discharge continues 
3.To bring the newborn to the clinic 
4.That this is a normal occurrence

46. Care of the Newborn at Home
Plan of care
Care of the Circumcised Male
Infant is circumcised the day of discharge
Observed to assure that excessive bleeding does not occur
Infants voids once before discharge
Petroleum jelly is applied to the penis each diaper change for the first 24 hours
Prevents the diaper from adhering to the penis
Diaper is applied loosely

47. Discharge Planning and Teaching (Cont.)

48. Discharge Planning and Teaching (Cont.)
Infant follow-up care
Immunizations
Cardiopulmonary resuscitation
Practical suggestions for first week at home
Interpretation of crying and use of quieting techniques
Recognizing signs of illness

49. Question
Prior to discharging a male infant who has just been circumcised, the nurse must evaluate that the parents understand the instructions for care at home. The nurse is reassured when the parents report which of the following?
They will check for bleeding with every diaper change.
The baby is expected to void at least four times in 24 hours.
Soap and water should be used to clean the penis.
They will notify the provider if a yellow exudate develops and covers the head of the penis.

50. Key Points
Assessment of the newborn requires data from the prenatal, intrapartal, and postnatal periods.
The immediate assessment of the newborn includes Apgar scoring and a general evaluation of physical status.
Knowledge of biologic and behavioral characteristics is essential for guiding assessment and interpreting data.

51. Key Points (Cont.)
Gestational age assessment provides important information for predicting risks and guiding care management.
Nursing care immediately after birth includes maintaining an open airway, preventing heat loss, and promoting parent-infant interaction.

52. Key Points (Cont.)
Providing a protective environment is a key responsibility of the nurse and includes such measures as careful identification procedures, support of physiologic functions, and ways to prevent infection.
The newborn has social and physical needs.
Newborns require careful assessment for physiologic and behavioral manifestations of pain.

53. Key Points (Cont.)
Nonpharmacologic and pharmacologic measures are used to reduce infant pain.
Before hospital discharge, nurses provide anticipatory guidance for parents regarding feeding and elimination patterns; positioning and holding; comfort measures; car seat safety; bathing, skin care, cord care, and nail care; and signs of illness.
All parents should have instruction in infant cardiopulmonary resuscitation (CPR).