• American Academy of Pediatrics Recommendations

• Newborns should be nursed when they show signs of hunger

• No supplements should be given unless there is a medical indication

• Exclusive breastfeeding is sufficient for approximately six months

• American Academy of Pediatrics Recommendations (continued)

• Gradual introduction of iron-rich solids should begin after six months

• Breastfeeding should continue for at least 12 months

• Nutrients in Breast Milk

• Protein

– Source of amino acids for growth

– Whey fraction more easily digested and promotes gastric emptying

• Fat

– Greatest concentration in hind milk

– Necessary for brain development

• Carbohydrates

– Enhance immunity and brain development

• Nutrients in Breast Milk (continued)

• Water and electrolytes

• Minerals

• Trace elements

• Fat-soluble and water-soluble vitamins

• Anatomy of the Breast

• Lactogenesis

• Estrogen and progesterone levels fall

• Prolactin triggers
milk production

• Oxytocin elicits the

let-down reflex
• Milk production depends
on supply and demand

– Feed often (every two to three hours)

– Avoid supplements

– Encourage night feedings

• Interferences with Lactation

• Poor nutrition, inadequate fluid intake

• Maternal anxiety

• Medical conditions

• Pendulous breasts

• Flat or inverted nipples

• Postoperative pain

• Deficient knowledge

• Promoting Successful Breastfeeding

• Maternal comfort and relaxation

• Positioning of mother and infant

• Correct latching on of the infant

• Removal of the infant from the breast

• Burping

• Promoting Successful Breastfeeding (continued)

• Timing

– Feed immediately after delivery if possible

– Offer both breasts at each feeding

– 15 minutes on each breast

– Offer the breast every two to three hours

• Positioning for Breastfeeding

• Techniques for Successful

Breastfeeding

• Benefits of Breastfeeding
• Maternal benefits

– Contraception

– Less anemia

– Weight loss

– Involution of the uterus

– Prevention against breast and ovarian cancer

• Benefits of Breastfeeding (continued)

• Infant benefits

– Bonding between mother/infant

– Optimal nutrition

– Prevention against infection

– Enhanced cognitive development

– Prevention against disease (diabetes, SIDS, asthma)

• Nursing Implications: Barriers to Successful Breastfeeding

• Maternal barriers

– Diet, medications, smoking, fatigue

– Prior breast surgery

– Nipple abnormalities

– Contraceptives

– Psychologic issues, modesty

• Infant barriers

– Prematurity

– Illness and disability

– Hypoglycemia

– Jaundice

• Assessment for
Insufficient Lactation

• Low urination pattern

• Low stooling frequency

• Minimal breast changes after delivery

• Irritable or sleepy infant

• Nursing less than seven times a day

• Weight loss of more than 10% of the birth weight

• Continued weight loss after day 10 of life

• Contraindications to Breastfeeding

• Maternal disease

– Hepatitis B, C

– HIV

• Maternal medications

• Infant

– Severe illness

– Inborn errors of metabolism

• Common Breastfeeding Problems

• Cracked or sore nipples

– Change positions

– Assess for proper latching on

– Apply breast milk after nursing

– Cabbage leaves, tea bags

• Mastitis

– Antibiotics

• Common Breastfeeding Problems (continued)

• Engorgement

– Feed frequently, avoid supplements

– Good support bra

– Apply warmth (towels, shower) before nursing

• Breast Pumps
• Resources for Breastfeeding Mothers

• Lactation consultants

• La Leche League

• International Lactation Consultant Association

• Formula Feeding

• Available in powder, concentrate,

ready-to-feed forms

– Ensure that parents know how to mix formula

– Ensure cleanliness in preparation

• Cow- or soy-based preparations

• Monitor for food allergy symptoms

– Rash, colic, diarrhea, bloody stool, respiratory symptoms

• Formula Feeding (continued)

• Solids usually introduced at about four months

– One new food at a time

– Wait at least three days between new foods

• NUR251
Nursing Theory & Science III

• NEWBORN

• Pulmonary System Transition

• Function of respiration switches from the placenta to the lungs

• Factors responsible for onset of breathing

– Hypercapnia

– Hypoxia

– Acidosis

– Environment (cold, light, noise)

• Fluid in the lungs must be cleared

• Pulmonary arterioles dilate, PVR level falls

• Cardiac System Transition

• Pressure in right side of the heart falls and pulmonary venous return to left atrium
increases

– Foramen ovale closes due to these changes

• Ductus arteriosis constricts and closes functionally by 96 hours

• Ductus venosis constricts and closes functionally by two to three days

• Thermoregulation

• Body heat lost easily due to large body surface area in relation to weight

• Limited neonatal fat stores

• Limited capacity for heat production

– Brown-fat metabolism is primary heat source

• Thermoregulation (continued)

• Normal axillary temperature is

97°F–99.5°F

– Hypothermia is <97.0

• Goal is to keep infant in a neutral thermal environment

• Nursing Interventions to
Prevent Hypothermia

• Dry infant, remove wet blankets

• Apply a hat and warm blankets

• Avoid placing infant on cold surfaces

• Avoid placing infants in drafts

• Nursing Interventions to
Prevent Hypothermia (continued)

• Use heat source when bathing infants

• Place under radiant warmer if temperature is unstable

• Metabolic Transition

• Infant’s source of nutrition from the placenta terminates at birth

• Blood sugar reaches its lowest point one to three hours after birth

• Glucose stabilizes by four to six hours after birth

• Range of 45–80 mg/dl is normal

• Gastrointestinal System

• At birth abdomen is flat and bowel sounds are absent

• Abdomen becomes rounded and soft with onset of respirations

• Bowel sounds usually audible within 15 minutes of birth

• First Period of Reactivity

• First minutes after birth

• Characteristics

– Alert, active, sucking activity, tachycardia, tachypnea, transient rales and

nasal flaring

• Implications for the family

– Infant alert and responsive

– Allow quiet time for family to be together

– Introduce breastfeeding

• Period of Decreased Activity

• Follows first period of reactivity

• Characteristics

– Less alert and active, sleep may occur, vital signs normalize

• Period of Decreased Activity (continued)

• Implications for the family

– Family may stay together or infant may be taken to nursery for assessment

– Opportunity for parents to have quiet time

– Mother may use this time to rest

• Second Period of Reactivity

• Infant awakens and shows increased responsiveness to the environment

• Characteristics

– Peristalsis increases and meconium may be passed, gagging, spitting up

• Implications for the family

 – Allow time together if mother is rested

– Parents may begin to have questions or need assistance with newborn care

• Asphyxia

• Arises from inadequate or absent respiration

– Impairment of oxygen/carbon dioxide exchange

– Hypoxemia, hypercarbia, respiratory acidosis

• Assessment findings

– Poor tone, gasping or absent respirations, bradycardia, cyanosis, low Apgar

score

• Asphyxia (continued)

• Management

– Tactile stimulation

– Positive pressure ventilation with 100% oxygen

• Meconium Staining

• Caused by distress, usually asphyxia

• Risk is that fetus/infant may aspirate

– Obstruction, chemical pneumonia may result

• Assessment findings

– Respiratory distress, hypoxemia

• Prevention

– Suctioning nose/mouth before delivery of the chest

– Appropriate suctioning post delivery

• Transient Tachypnea
of the Newborn

• Characteristics

– Grunting, retracting, tachypnea

• Risk factors

– Cesarean delivery, precipitous delivery

• Management
 – Oxygen therapy

– IV fluids

– Short-term ventilation

– Antibiotics if sepsis is suspected

• Hypoglycemia

• Plasma glucose level below 40 mg/dl

• Assessment findings

– Jitteriness, tremors, apnea, cyanosis, lethargy

• Risk factors

– SGA, preterm, perinatal stress, IDM, sepsis

• Hypoglycemia (continued)

• Management

– Early feeding of infants at risk

– Keep infant warm

– Glucose by nipple, gavage, or IV

– Recheck blood glucose 30 minutes after feeding

• Transition of the Premature Infant

• Pulmonary system

– Inadequate alveolar development, lack of surfactant

• May require ventilatory support

• Administration of surfactant

• Cardiac system

– Persistent ductus arteriosis (PDA)

• Indomethacin given to facilitate closure

• Resuscitation and Stabilization

in the Delivery Room

• Dry and provide warmth, tactile stimulation

• Clear airway
• Resuscitation for compromised infants

– Place under radiant warmer, stimulate

– Position to ensure a patent airway

– Suction using appropriate technique

– Evaluate respirations, heart rate, color

• Resuscitation and Stabilization

in the Delivery Room (continued)

• Resuscitation for compromised infants (continued)

– Administer oxygen if indicated

– Bag-mask ventilation if apneic

– Medications may be indicated if infant does not respond

• NUR251
Nursing Theory & Science III

• NEWBORN

• Assessment After Transition

• Temperature

– Normal axillary temperature 97°F–99.5°F

• Cardiovascular system

– Normal heart rate 120–150 bpm

– Observe color, pulse, murmurs

• Assessment After Transition (continued)

• Respiratory system

– Normal rate is 30–60/minute

– Nose-breather

– Observe for flaring, grunting, retracting

– Auscultate for rales

• General Nursing Care

• Eye prophylaxis

– Prevents gonorrhea and chlamydia

 – Erythromycin or tetracycline ointment

• Vitamin K prophylaxis (0.5–1.0 mg)

– IM into lateral thigh

– Prevents bleeding due to Vitamin K deficiency

• First bath

– Institute measures to prevent hypothermia

• General Assessment

• Position

– Flexion of upper and lower extremities

– Symmetrical movement

• Color

– Acrocyanosis

– Jaundice

• Body size

• Reactivity

• Identification

• Physical Examination

• Weight

2,500–4,300 g

• Length

45–54 cm

• Head circumference

33–38 cm

• Vital signs

• Gestational Age Assessment

• Neuromuscular maturity

– Posture

– Square window
 – Arm recoil

– Popliteal angle

– Scarf sign

– Heel-to-ear

• Physical maturity

– Skin

– Lanugo

– Plantar surface

– Breasts

– Eye and ear

– Genitalia

• Skin Assessment

• Normal findings: color pink

• Common variations

– Milia

– Erythema toxicum

– Mongolian spots

– Birthmarks

• Common problems

– Petechiae

– Blisters, lesions

– Plethara

– Abnormal hair distribution

• Head, Eyes, Nose, and Throat

Assessment

• Normal findings

– Symmetry in appearance, normal placement

– Anterior fontanel open

 • Common variations

– Molding

– Caput succedaneum

– Cephalhematoma

– Teeth

• Head, Eyes, Nose, and Throat

Assessment (continued)

Caput succedaneum

• Head, Eyes, Nose, and Throat Assessment (continued)

• Common problems

– Low-set ears

– Discolored sclera (yellow, bluish)

– Cleft lip, palate

– Absent red reflex

– Microcephaly, hydrocephaly

– Craniostenosis

– Features characteristic of FAS

• Respiratory System Assessment

• Normal findings

– Symmetrical expansion

• Common variations

– Accessory nipples

– Gynecomastia

• Common problems

– Retractions

– Tachypnea

– Rales

• Cardiovascular Assessment
• Normal findings

– Color pink

– Normal rate and rhythm

• Common variations

– Murmurs

– Acrocyanosis

• Cardiovascular Assessment (continued)

• Common problems

– Persistent murmurs

– Cyanosis

– Tachycardia, bradycardia

• Abdominal Assessment

• Normal findings

– Round, full, symmetrical, plus bowel sounds

– Two arteries, one vein in cord

• Common variations

– Hernia

• Abdominal Assessment (continued)

• Common problems

– Two-vessel cord

– Distension, absent bowel sounds

– Discharge/leakage from the cord

– Abdominal mass

• Genital and Anal Assessment

• Normal findings

– Patent anus

– Testes descended

– Stool and urine by 24 hours after birth

• Common variations

– Hydrocele

– Hymenal tag and vaginal discharge

• Genital and Anal Assessment (continued)

• Common problems

– Undescended testes

– Epispadius, hypospadius

– Imperforate anus

• Circumcision

• Risks

– Bleeding, infection, adhesions, pain

• Benefits

– Decreased incidence of UTIs

– Prevention against penile cancer

• Nursing care after circumcision

– Observe for bleeding

– Observe for voiding difficulties

• Musculoskeletal Assessment

• Normal findings

– Normal tone, flexion, symmetrical movement

• Common variations

– Hip click

– Club foot

• Musculoskeletal Assessment (continued)

• Common problems

– Fracture (clavicle most common)

– Hip dysplasia

– Syndactyly/polydactyly
 – Asymmetrical movement

– Simian crease

• Neurologic System

• Normal findings

– Normal reflexes (suck, rooting, grasp, Moro, Gallant, gag, Babinski’s)

• Common problems

– Brachial plexus injury (Erb’s palsy)

– Spina bifida

– Anencephaly

– Absent or abnormal reflexes

– Seizure activity

• Periodic Shift Assessment

• Vital signs

• Weight

• Feeding and elimination

• Hydration status

• Respiratory and cardiac function

• Hip movements

• Factors Placing the Infant at Risk

• Physical

– Birth injuries, congenital conditions, temperature control

• Psychological

– Interferences in interaction between parents, newborn

• Family

• Environment

• Illness and infection

• NUR251
Nursing Theory & Science III
• NEWBORN

• Intrauterine Growth Restriction

• Infants <10th percentile for weight at birth

• May be symmetric or asymmetric

• Factors may be fetal, maternal, or placental

• Complications

– Hypoxia, hypothermia, hypoglycemia, polycythemia, hyperbilirubinemia,

meconium aspiration

• Intrauterine Growth Restriction (continued)

• Nursing implications

– Prevent heat loss

– Monitor blood glucose, feed early

– Monitor for respiratory complications

– Management of hyperbilirubinemia

• Triplets Manifesting Different

Rates of Growth

• Large for Gestational Age Infant

• Infants >90th percentile for weight at birth

• Factors

– Maternal diabetes, parental obesity

• Complications

– Difficult delivery, birth trauma, hypoglycemia

• Nursing implications

– Assess for birth injury

– Monitor for hypoglycemia

• The Premature Infant

• Delivery prior to 37 weeks’ gestation

• Factors

– Multiple gestation, PROM, incompetent cervix

• The Premature Infant (continued)

• Assessment

– Gestational age assessment

– Neurologic assessment

– Physical characteristics

• Thin skin, soft cartilage, absent plantar creases

• Abundant lanugo and vernix

• Genitalia characteristic of prematurity

• Review of Systems and

Potential Complications

• Cardiovascular

– Patent ductus arteriosis

– Hypotension

• Central nervous system

– Intraventricular hemorrhage

– Posthemorrhagic hydrocephalus

• Hematologic system

– Anemia

– Polycythemia

• Hepatic system

– Hyperbilirubinemia

• Review of Systems (continued)

• Gastrointestinal system

– Dysmotility

– Necrotizing enterocolitis

– Gastroesophageal reflux

• Immune system

– Infection
• Integumentary system

– Epidermal stripping

– Absorption of chemical agents

• Review of Systems (continued)

• Ophthalmologic system

– Retinopathy of prematurity

• Renal system

– Oliguria

– Glycosuria

• Respiratory system

– Respiratory distress syndrome

– Bronchopulmonary dysplasia

– Apnea of prematurity

– Pneumonia

• Nutrition and Fluid Management

• Fluids

– Strict I&O, weigh diapers

• Electrolyte management

– Management of sodium
and potassium levels

• Glucose homeostasis

• Feeding

– Gavage or nipple method

– Types: formula or breast milk

• Developmental Care of the

Preterm Infant

• Light

• Sound

• Temperature
• Positioning and containment strategies

• Handling and touching

• Nonnutritive sucking

• NUR251
Nursing Theory & Science III

• NEWBORN

• Spina Bifida

• Etiology–failure of the spinal cord to close

• Assessment findings

– May be mild to severe

• Diagnosis possible before birth

– MSAFP screening and ultrasound

• Management

– Surgical closure of open defects

• Spina Bifida (continued)

• Nursing implications

– Cover defect, position to avoid pressure

– Administer antibiotics, monitor for infection

– Prevent stasis of urine

• Choanal Atresia

• Separation between nose and pharynx

• Assessment findings

– Respiratory distress

• Management

– Surgery

• Diaphragmatic Hernia

• Diaphragm fails to close and abdominal organs are displaced into the chest

• Prenatal diagnosis
 – Ultrasound

• Diaphragmatic Hernia (continued)

• Assessment findings

– Severe respiratory distress

– Scaphoid abdomen

– Absent breath sounds

• Management

– Surgical repair

• Congenital Heart Defects

• 100 different types

– Transposition of the great vessels and coarctation of the aorta most common
life- threatening

• Assessment findings

– Respiratory distress, cyanosis, murmurs, diminished femoral pulses

• Congenital Heart Defects (continued)

• Management

– Medical and/or surgical interventions

• Nursing interventions

– Careful monitoring, administer oxygen

– Minimize crying

– Gavage feeding

• Cleft Lip and Palate

• Failure of the maxillary and premaxillary processes to fuse

• Diagnosis

– Prenatal diagnosis possible with ultrasound, examination of the palate during

the initial assessment

• Cleft Lip and Palate (continued)

• Management

– Surgical repair
• Nursing interventions

– Feeding a major issue until the defect is repaired

• Various Gastrointestinal Anomalies

• Various Gastrointestinal Anomalies (continued)

• Genitourinary System Anomalies

• Hypospadius

– Urethral meatus on ventral surface of the penis

• Epispadius

– Urethral opening on the dorsal surface of the penis

• Exstrophy of the bladder

– Absent abdominal wall so bladder lies open on the lower abdomen

• Genitourinary System Anomalies (continued)

• Ambiguous genitalia

– External genitalia not defined as male or female

– May be caused by congenital adrenal hypoplasia

• Developmental Dysplasia
of the Hip

• Malformation of the hip

• Assessment findings

– Uneven gluteal folds (A.)

– Hip click with legs are abducted (B., C.)

• Management

– Hips flexed and abducted position

– Casting or surgery may be required

• Talipes Equinovarus (Club Foot)

• Portions of the foot and ankle are twisted out of normal position (A.)

• Management
 – Manipulation of
the foot (B.)

– Casting

– Surgery

• Trauma and Birth Injuries

• Fractures

– Clavicle, long bones, skull most common

– Risks

• Large infant, breech, difficult labor

– Assessment

• Impaired mobility

– Management

• Immobilization, traction, casting

• Trauma and Birth Injuries (continued)

• Facial Palsy

– Usually related to use of forceps

• Brachial Palsy

– Usually related to difficult delivery such as shoulder dystocia

– Assessment

• Impaired mobility of arm

– Paralysis may be temporary or permanent

• Infants of Diabetic Mothers

• Risk factors

– Congenital anomalies

– Macrosomia (>4,000 gm)

– Hypoglycemia

– Respiratory distress syndrome

• Infants of Diabetic Mothers (continued)

• Prevention of complications

– Normoglycemia during gestation and labor

– Deliver when lungs are mature

– Prepare for delivery of large infant

– Monitor for hypoglycemia

• Hyperbilirubinemia

• Excess bilirubin in the blood resulting in jaundice

• Can be caused by physiologic or pathologic processes

– Normal RBC breakdown

– Rh or ABO incompatibility

• Hyperbilirubinemia (continued)

• Complications

– Kernicterus

– Erythroblastosis fetalis

– Hydrops fetalis

• Assessment findings

– Jaundice, elevated bilirubin levels

• Management of Hyperbilirubinemia

• Encourage frequent feedings

• Exposure to sunlight

• Phototherapy

– Shield infant’s eyes

– Monitor body temperature

– Monitor weight

– Monitor fluid intake

– Weigh diapers

– Note frequency of stools

• Sepsis
• Risk factors

– Maternal infection (group B streptococcus most common)

– Long labor, prolonged rupture of the membranes

– Maternal fever, chorioamnionitis

– Fetal distress, aspiration

• Sepsis (continued)

• Assessment findings

– Unstable temperature, poor tone, poor sucking

• Management

– Antibiotics

– Supportive care