Download presentation
Presentation is loading. Please wait.
1
Chapter 18 Caring for the Normal Newborn
2
The Immediate Neonatal Assessment
Establish airway Suction Provide warmth Dry the infant Place on mother’s abdomen; heated blankets Place beneath radiant heater Cap
3
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
4
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
5
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
6
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:
7
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
8
Assessment of the Neonate: A Systems Approach
9
Integumentary System Inspect skin, scalp, nails, body hair
Color, texture, distribution, disruptions, eruptions, birthmarks Well-lit room Birth injuries
10
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 for Mongolian spots
11
Birthmarks Brown nevi—brown skin marks
Nevus flammeus—“port wine stain” Telangiectatic nevus—“stork bite” Nevus vasculosus—“strawberry mark” Refer to Figure for telangiectatic nevus
12
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
13
Head—Fontanels Estimate size Fullness without bulging—normal
Bulging and tense with large head circumference—increased intracranial pressure Sunken—dehydration Refer to figure for fontanels
14
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
15
Assessment Mouth Neck Facial features Epstein’s pearls Teeth
Ability to suck Hard and soft palate Neck Torticollis Facial features Refer to Figure for neonatal teeth Refer to Figure for Epstein’s pearls
16
Respiratory System Assessment
Symmetry in chest movement Breast tissue Nasal patency Respiration rate, pattern, and use of accessory muscles Auscultate lungs anterior and posterior
17
Respiratory Assessment
Skin color Capillary refill Signs of distress Retractions Nasal flaring Expiratory grunting
18
Cardiovascular System Assessment
Inspection and auscultation Point of maximum impulse Heart rate Capillary refill Peripheral pulses Auscultate all areas—murmurs Refer to Figures & 18-20
19
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
20
Conditions That Warrant Further Assessment
Abdominal distention Absence of bowel sounds Discharge from umbilical cord/site Abdominal mass Conditions That Warrant Further Assessment
21
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 for testicle assessment
22
Common Findings—Male Infants
Scrotal swelling Smegma Hypospadius Epispadius
23
Common Findings— Female Infants
Hymenal tags Vernix caseosa on labia Pseudomenstruation
24
Conditions That Warrant Further Assessment
Undescended testicles Micropenis Ambiguous genitalia Imperforate hymen Imperforate anus
25
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 for head lag Refer to Figure for hip assessment
26
Common Findings Torticollis Developmental dysplasia of the hip
Asymmetry of hip folds Barlow maneuver Ortolani maneuver Crepitus Unusual positions of foot
27
Conditions That May Warrant Further Assessment
Fractured clavicle Polydactyly Syndactyly Simian crease
28
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
29
Conditions That Warrant Further Assessment
Shoulder dystocia Erb’s palsy Cerebral palsy Spina bifida
30
Teaching About Newborn Care
Temperature assessment Bathing Nail Care and umbilical cord care Clothing Diapering Attachment
31
Newborn Care Circumcision Ensuring optimal nutrition
Discharge planning for the infant and family Child care Newborn metabolic screening tests
Similar presentations
