Newborn

Nursery Guide

2017­2018
University of Arkansas 
College of Medicine
Department of Pediatrics
NURSERY SERVICE
Duties
 Please arrive in the nursery by 7:00am and stay in the nursery area when not in
conferences or attending deliveries.
 Read all Blackboard topics and watch videos prior to beginning the rotation.
 You should be following at least 3-4 babies by the end of the week. You should
follow both well and NICU babies.
 Attend nursery rounds and present your babies to the team.
 Attend all scheduled conferences and lectures.
 One student will attend each delivery.
 Assist the residents with new admissions. You may need to speak with the
obstetrician and review the mother’s chart to get an accurate prenatal and
perinatal history. You may help the resident complete growth charts and a
Dubowitz/Ballard gestational age assessment on each new baby.
 During your week on the nursery you should take one weeknight call from 4-
10pm (Monday through Thursday) and one weekend call, being either from 4-
10pm on Friday night or 12-5pm on Saturday or Sunday. *Students should make
an effort to take call on different days when possible.*
 On weekends when you are not on call you are expected to come in each day and
do the duties as you would on Monday-Friday. Once your work is done, rounds
are completed, and you have signed off with the residents, you may leave, usually
but not always by noon.

Other important information

 Medical students are expected to wear ceil blue scrubs while in the nursery.
Scrubs are the responsibility of the student and are not provided.
 Due to infection controls concerns, rings, watches, and long sleeves (“Bare Below
the Elbows”) should not be worn in the nursery. A 2-minute scrub of your hands
and forearms should be done when you arrive in the nursery each day. Wash your
hands with soap and water or hand sanitizer before and after examining each baby
and upon entering/leaving every patient room during rounds. Wear gloves as a
part of universal precautions until a newborn has been bathed (Usually around 10
hours of age).
 Healthy babies should be placed skin-to-skin with the mom and left so for at least
one hour after delivery (“The Golden Hour”). Exams, measurements, etc. may be
performed after the first hour.
 Do not interrupt breastfeeding to perform an exam. You may come back after the
baby is done feeding.
 Babies in isolettes should be examined through the port holes if possible, so they
don’t get cold. If the baby is in an isolette, leave the baby in the same position
when you leave so the temperature probe will work.
 Babies in cribs should be swaddled in a thin blanket or sleep sack after your
examination. Healthy babies should be placed on their back since this position has
been shown to decrease the incidence of Sudden Infant Death Syndrome. Cribs
should be free of any soft objects such as clothes, loose blankets, and toys.
Information needed for History and Physical

A. Information concerning Infant

 Name (baby boy Jones, baby girl Smith, etc.) **The baby will be under mom’s
last name while in the hospital, last names will often change at discharge**
 Birth weight
 Gestational age (estimated from last menstrual period or early ultrasound, and by
Dubowitz Exam)
 Sex
 Classification (SGA, LGA, AGA): weight compared to gestational age
 APGAR scores
B. Information concerning Mother
 Age
 Childbearing Status
 Number of pregnancies: gravida 3 = 3 pregnancies (Abbreviated G3)
 Number of viable newborns: para 2 = 2 viable newborns (Abbreviated P2)
 Number of abortions (miscarriages or elective terminations): abortus 1 =
one non-viable fetus (Abbreviated Ab1)
C. Information concerning Pregnancy (you may need to obtain history directly
from mother and prenatal chart):
 Procedures done during pregnancy (i.e., ultrasound, amniocentesis, etc.)
 Complications of current pregnancy (i.e., thyroid disease, hypertension, diabetes
mellitus, infections, illicit drug or alcohol use/abuse, tobacco use, vaginal
bleeding, eclampsia/pre-eclampsia, anemia, inadequate maternal weight gain, etc.)
 Complications of previous pregnancies (as above, plus any known genetic syndromes)
 Any other maternal health problems
 Note if there was poor or limited prenatal care (drug screening may be performed on
the baby)
 Mother’s history and physical information written by OB
D. Information concerning Labor & Delivery (see mother’s chart)
 Type of delivery (i.e., vaginal, C-section, vertex, breech, spontaneous, induced, forceps,
vacuum extraction, etc.)
 Type of anesthesia (i.e., local, epidural, spinal, IV, general)
 Medications (especially note narcotics, antibiotics, and magnesium)
 Complications (i.e., prolonged rupture of membranes, fetal distress, nuchal cord,
prolapsed cord, resuscitation, etc.
E. Physical examination (this information may be found on the bedside chart)
 Vital signs
 Weight
 Length
 Head circumference
 Dubowitz form
F. Laboratory
Mom:
 Blood type and antibody screen
 Syphilis screen
 HIV
 Hepatitis B
 Rubella status (immune or non-immune)
 Group B strep (if positive, determine how many doses of penicillin she
received)
 Gonorrhea and Chlamydia
 Others: Quad screen, NIPT, etc.

Baby:
 Determine the Maternal Blood Type (MBT). If MBT is Type O or Rh negative,
the infant’s blood type (IBT) must also be obtained along with a direct coombs
test (DAT).
 Initial glucose (Normal ≥45)
 A hematocrit (normal 40-60) is sent on infants at risk for anemia or
polycythemia (preterm, multiple gestation, small or large for gestational age,
infant of a diabetic mother, maternal hypertensive disorder)

G. Assessment and Plan

Assessment
 Term newborn (or preterm/post-term) and weeks gestation (EX: 39 weeks 0
days gestation)
 Hours old (if less than 72 hours old) or days old (if >72 hours old)
 Post conceptual age or PCA (EX: if 39 weeks 0 days at birth, will be 39 weeks 1
day PCA the next day) *Gestational age (age at birth) will not change,
PCA will change each day*
 Appropriate, Small, or Large for Gestational Age (AGA, SGA, LGA)
 Other assessments: i.e., Meconium-stained fluid, maternal chorioamnionitis,
infant of diabetic mother, etc.

Plan
 Routine newborn care/Couplet Care/NICU
 Feeding method (Breast, Bottle, NPO)
 Labs or other interventions needed
 Plans for infants in the NICU should be developed by systems
(Cardiovascular, Respiratory, FEN, etc)
Progress Notes
Please discuss with your attending whether you should write a progress note in EPIC. Even
if a formal note is not written, you are responsible for knowing the following information on
your patients.
Date and Time
Day of life (In the first 3 days of life state the child’s age in hours)
(S) Include comments or problems since previous progress notes. Include concerns
of parents, nurses, on-call physicians. Review orders for any changes made in
patient’s care.

(O) Vital signs, weight, changes in weight

Intake: include total intake broken down into PO/NG/IV. Calculate the intake
ml/kg/day (using birth weight until birth weight is surpassed) and calculate
kcal/kg/day when able. Document the type of fluid or formula and whether po or
OG/NG. Document how well patient takes po feeds.
*For well babies, the number of bottle feeds (and volume) or breast feeds (and
time) should be recorded.
Output: list number of stools or urination. Calculate ml/kg/hr if applicable.
Document 02 and route of deliver (CPAP, NC, etc.)
Physical exam: Be sure to include if in open crib or isolette.
Lab and/or radiologic exam: Include results of all lab or studies that were
performed or mentioned in the plan of the previous day.

(A) Include a concise summary of the status of each infant (by problem). If there are
no problems, the assessment is simply, “term newborn/appropriate for gestational
age”.

(P) Formulate diagnostic and/or therapeutic plans for the management of each clinical
problem. If discharge approaching, document plans toward discharge. AGAIN,
include the phase, “I have discussed all findings with Dr. Attending who agrees
with this plan”.
 CALCULATING FLUID AND KCAL INTAKE
 CALCULATING TOTAL DAILY FLUID INTAKE
**Total fluid intake in mL = mL/kg/day
Wt (kg)

**to include IV fluids and enteral feeds via NG/OG/PO, etc.

Example:
IV fluids for Baby Smith = 8mL/hr = 192 mL/day
PO feeds for Baby Smith = 28mLQ3hrPO = 224 mL/day
Total fluids for Baby Smith = 192 + 224 = 416 mL/day
Divide this by Baby Smith’s wt (3.2 kg) to get mL/kg/day:
416 mL/day = 130 mL/kg/day
3.2kg

 CALCULATING TOTAL DAILY KCAL INTAKE

 Total intake in mL = Total # oz
30 mL/oz*

 Total #oz x 20 kcal** = Total Kcals

oz
 Total kcals = kcals/kg/day

Example:
Baby Smith’s total intake was 416 mL/day:
416 mL = 13.9 oz
30mL/oz
13.9 oz x 20 kcal = 278 kcals
oz
278 kcals = 87 kcal/kg/day
3.2 kg

(*30mL formula = 1 oz)

(**Standard Infant formula and breast milk contain 20 kcal/oz; although they can be fortified to 22,
24, 26 kcal/oz.)