Maternal and Child Health Nursing

Newborn Assessment

MATERNAL and CHILD HEALTH NURSING

NEWBORN ASSESSMENT

Lecturer: Mark Fredderick R. Abejo RN, MAN

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Newborn Assessment

Newborn Assessment Abejo

Maternal and Child Health Nursing
Newborn Assessment
Newborn Assessment and Nursing Care
 Temperature - range 36.5 to 37 axillary
 Common variations
o Crying may elevate temperature
Stabilizes in 8 to 10 hours after
delivery
o Temperature is not reliable indicator
of infection
A temperature less than 36.5
Temp: rectal- newborn – to rule out imperforate
Anus
- take it once only, 1 inch insertion
Imperforate anus
1. atretic – no anal opening
2. agenetialism – no genital
3. stenos – has opening
4. membranous – has opening
Earliest sign:
1. no mecomium
2. abd destention
3. foul odor breath
4. vomitous of fecal matter
5. can aspirate – resp problem
Mgt: Surgery with temporary colostomy
 Heart Rate
range 120 to 160 beats per minute
Common variations
 Heart rate range to 100 when sleeping
to 180 when crying
 Color pink with acrocyanosis
 Heart rate may be irregular with
crying
 Although murmurs may be due to
transitional circulation-all murmurs
should be followed-up and referred for
medical evaluation
 Deviation from range
 Faint sound
Cardiac rate: 120 – 160 bpm newborn
Apical pulse – left lower nipple
Radial pulse – normally absent. If present PDA
Femoral pulse – normal present. If absent COA
 Respiration
- range 30 to 60 breaths per minute
Common variations
 Bilateral bronchial breath sounds
Moist breath sounds may be present
shortly after birth
Signs of potential distress or deviations
from expected findings
 Asymmetrical chest movements
 Apnea >15 seconds
 Diminished breath sounds
 Seesaw respirations
 Grunting
 Nasal flaring
 Retractions
 Deep sighing
Newborn Assessment
 Tachypnea - respirations > 60
 Persistent irregular breathing
 Excessive mucus
 Persistant fine crackles
 Stridor
Breathing ( ventilating the lungs)
 check for breathlessness
 if breathless, give 2 breaths-
ambu bag
 1 yr old- mouth to mouth, pinch nose
 < 1 yr – mouth to nose
 force – different between baby &
child
 infant – puff
Circulation
 Check for pulslessness :carotid-
adult
 Brachial – infants
CPR – breathless/pulseless
 Compression – inf – 1 finger breath
below nipple line or 2 finger breaths
or thumb
 CPR inf 1:5
 Adults 2:30
 Blood Pressure - not done routinely
Factors to consider
Varies with change in activity level
Appropriate cuff size important for accurate
reading
65/41 mmHg
 General Measurements
 Head circumference - 33 to 35 cm
 Expected findings
 Head should be 2 to 3 cms larger than the
chest
 Abdominal circumference – 31-33 cm
 Weight range - 2500 - 4000 gms (5 lbs. 8oz.
- 8 lbs. 13 oz.)
 Length range - 46 to 54 cms (19 - 21 inches)
 Normal length- 19.5 – 21 inch or 47.5 –
53.75cm, average 50 cm
 Head circumference 33- 35 cm or 13 – 14 “
Hydrocephalus - >14”
Chest 31 – 33 cm or 12 – 13”
Abd 31 – 33 cm or 12 – 13”
Signs of increased ICP
1. abnormally large head
2. bulging and tense fontanel
3. increase BP and widening pulse pressure
4. Decreased RR, decreased PR
5. projective vomiting- sure sign of cerebral
irritation
6. high deviation – diplopia – sign of ICP older
child
a. 4-6 months- normal eye deviation
b. >6 months- lazy eyes
7. High pitch shrill cry-late sign of ICP
Abejo
Maternal and Child Health Nursing
Newborn Assessment

Head to Toe Newborn Assessment

CIRCULATORY UMBILICAL VEIN and DUCTUS VENOSUS constrict after cord id clamped
STATUS DUCTUS ARTERIOSUS constrict with establishment of respiratory function
FORAMEN OVALE closes functionally as respirations established, but anatomic or
permanent closure may take several months
HEART RATE averages 140 b.p.m.
BP 73/55 mmHg
PERIPHERAL CIRCULATION acrocyanosis within 24 hours
RBC high immediately after birth; falls after 1 st week
ABSENCE/ NORMAL FLORA INTESTINE Vitamin K

RESPIRATORY Adequate levels of surfactants (Lecithin and spingomyelin) ensure mature lung
STATUS function; prevent alveolar collapse and respiratory distress syndrome
RR = 30-80 breaths /minutes with short periods of apnea (< 15 seconds) = assess for
1 full minute change noted during sleep or activity

NOTE: Periodic apnea is common in preterm infants. Usually, gentle stimulation is

sufficient to get the infant to breathe

RENAL SYSTEM Urine present in the bladder at birth but NB may not void doe 1st 12-24 hours
Later pattern is 6-10 voidings/ day – indicative of sufficient fluid intake
Urine is pale and straw colored – initial voidings may leave brick-red spots on
diaper ( d/t passage of uric acid crystals in urine)
Infant unable to concentrate urine for the 1st 3 months

DIGESTIVE IMMATURE CARDIAC SPHINCTER – may allow reflux of food, burped,

SYSTEM REGURGITATE- placed NB right side after feeding
Newborn can’t move food from lips to pharynx. Insert nipple well to mouth
FEEDING PATTERS vary

- Newborns may nurse vigorously immediately afterbirth or may need as long as

several days to suck effectively
- Provide support and encouragement to new mothers during this time as infant
feeding is very emotional doe most mothers

NOTE: Distinguishing Neonatal Vomiting from Regurgitation

Vomiting is usually sour, looks like curdled milk due to HCL, with a sour odor, while
regurgitation has no sour odor or curdling of milk, or occurs during or immediately
after feeding.

IMPORTANT CONSIDERATIONS:
Breastfeeding can usually begin immediately after birth; bottle-fed newborns
may be offered few milliliters of sterile water or 5% dextrose 1 to 4 hours after
birth prior to a feeding with formula

An infant with gastrostomy tube should receive a pacifier during feeding

unless contraindicated to provide normal sucking activity and satisfy oral
needs.

At age4-6 months, an infant should begin to receive solid food foods one at a
time and 1 week apart.

FIRST STOOL is MECONIUM

- Black, tarry residue from lower intestine
- Usually passed within 12-24 hours after birth

If the amniotic fluid shows evidence of meconium staining, the physician most likely do
immediately after delivery is to suction the oropharynx immediately after the head is
delivered and before the chest is delivered.

TRANSITIONAL STOOLS thin, brownish green in color

After 3 days MILK STOOLS are usually passed
a. MILK STOOLS for BF infant – loose and golden yellow
b. MILK STOOLS for FORMULATED FED- formed and pale yellow

Newborn Assessment Abejo

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Newborn Assessment

HEPATIC Liver responsible for changing Hgb into conjugated bilirubin, which is further
changed into conjugated (water soluble) bilirubin that can be excreted
Excess unconjugated bilirubin can permeate the sclera and the skin, giving a jaundiced
or yellow appearance to these tissues

TEMPERATURE HEAT PRODUCTION in newborn accomplished by:

a. Metabolism of “ BROWN FAT”
- A special structure in NB is a source of heat
- Increased metabolic rate and activity
Axillary temperature: 96.8 to 99F
Newborn can’t shiver as an adult does to release heat

Newborns are unable to maintain a stable body temperature because they have an
immature vasomotor center, and unable to shiver to increase body heat.

NB’s body temperature drops quickly after birth – after stress occurs easily
Body stabilizes temperature in 8-10 hours if unstressed
Cold stress increases o2 consumption – may lead to metabolic acidosis and
respiratory distress

IMMUNOLOGIC NB develops own antibodies during 1st 3 months but at risk for infection during the
first 6 weeks
Ability to develop antibodies develops sequentially

Neonatal Physical Assessment

Birth weight=2500-400 grams (5 lbs. 8oz. – 8 lbs. 13 oz.)

Length= 45.7 – 55.9 cm. (18-22 inches)

HEAD Head circumference = 33-35 cm (2-3 cm. Greater than chest circumference)
Anterior fontanel (diamond shape) = closes 12-18 months
Posterior fontanel (triangle shape)= closes 2-3 months
NOTE: The posterior fontanel is located at the intersection of the sagittal and
lambdoid suture is the space between the pariental bones; the lambdoid suture
separates the two parietal bones and the occipital bone

Molding- asymmetry of head as a result of pressure in birth cana

Newborn Assessment Abejo

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Newborn Assessment

EYES Blue/ gray d/t scleral thinness; permanent color established w/in 3-12 mos.
Lacrimal glands immature at birth; tearless cry up to 2 months
Absence of tears is common because the neonate’s tear glands are not yet fully
developed
Transient strabismus
Doll’s eye reflex persist for about ten days

Red Reflex: A red circle on the pupils seen when an ophthalmoscope’s light is shining
onto the retina is a normal finding. This indicates that the light is shining onto the
retina.

CONVERGENT STRABISMUS (CROSS EYED)

It is common during infancy until age 6 months because of poor oculomotor
coordination

NOTE : Congenital Glaucoma

It is due to increased intraocular pressure caused by an abnormal outflow or
manufacturing of normal eye fluid.
Unequal size should be reported immediately.

NOSE Nose breathers for first few months of life

MOUTH Scant saliva with pink lips
Epstein’s Pearls - small shiny white specks on the neonate’s gums and hard palate
which are normal

EARS Incurving of pinna and cartilage deposition

NECK Short and weak with deep fold of skin

CHEST Characterized by cylindrical thorax and flexible ribs

NOTE:
appears circular since anteroposterior and lateral diameters are about equal
Respirations appear diaphragmatic
Nipples prominent and often edematous
Milky secretion (witch's milk) common ( effect of estrogen)

Newborn Assessment Abejo

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Newborn Assessment

ABDOMEN Cylindrical with some protrusion; scaphoid appearance indicates diaphragmatic hernia
Umbilical cord is white and gelatinous with two arteries and one vein and begins to dry
within 1-2 hours after delivery

NOTE: Umbilical cord

Three vessels, two arteries and one vein, in cord; if fewer than three vessels
are noted notify the physician
Small, thin cord may be associated with poor fetal growth
Assess for intact cord, and ensure that damp is cured
Cord should be clamped for at least the first 4 hours after birth; clamp can
be removed hen the cord is dried and occluded
Umbilical clamp can be removed after 24 hours

GENITALIA MALE: includes rugae on the scrotum and testes descended into the scrotum

Urinary meatus:
Hypospadias (ventral surface)
Epispadias (dorsal surface)

NOTE:
Meatus at tip of penis
Testes descended but may retract with cold
Assess for hernia or hydrocele
First voiding should occur within 24 hours

FEMALE: labia majora cover labia minora and clitoris

Pseudomenstruation possible (blood-tinged mucus) effect of estrogen

First voiding should occur within 24 hours

EXTREMITIES All neonates have bowlegged and flat feet

NOTE NORMAL FEATURES:

Major gluteal folds even
Creases on soles of feet
Assess for fractures (especially clavicle) or dislocations (hip)
Assess for hip dysplasia; when thighs are rotated outward, no clicks should be
heard

Some neonates may have abnormal extremities:

Polydactyl (more than 5 digits on extremity)
Syndactyl (two or more digits fused together)

Newborn Assessment Abejo

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Newborn Assessment

Polydactyl Syndactyl

SPINE Should be straight and flat

Anus should be patent without any fissure
Dimpling at the base is associated with spina bifida
A degree of hypotonicity or hypertonicity is indicative of central nervous system (CNS
damage)

SKIN Assessment for Jaundice

The #1 technique is to blanch the skin over the bony prominence such as the
forehead, chest or tip of the nose.

NOTE: Jaundice starts at the head first, spreads to the chest, then the abdomen, then the
arms and legs, followed by the hands and feet, which are the last to be jaundiced.
Jaundice in the first 24 hours after the birth is a cause for concern that requires
further assessment. Possible causes of early jaundice are blood incompatibility,
oxytocin induction, and severe hemolytic process.
Mongolian Spots
Gary, blue or black marks that are frequently found on the sacral area, buttocks, arms
shoulders or other areas.

Harlequins Sign
Occurs on one side of the body turns deep red color. It occurs when blood vessels on
one side constrict, while those on the other side of the body dilate.

Newborn Assessment Abejo

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Newborn Assessment

Erythema toxicum
 Is an eruption of lesions in the area surrounding a hair follicle that are firm, vary
in size from 1-3 mm, and consist of a white or pale yellow papule or pustule w/ an
erythematous base.
 It is often called “newborn rash” or “flea-bite” dermatitis
 The rash may appear suddenly, usually over the trunk and diaper area and is
frequently widespread.
 The lesions do not appear on the palms of the hands or soles of the feet.
 The peak incidence is 24-48 hours of life.
 Cause is unknown and no treatment necessary

Acrocyanosis versus Central Cyanosis

 Acrocyanosis involves the extremities of the neonate, for example bluish hands
and feet due to neonates being cold or poor perfusion of the blood to the
periphery of the body.
 Central cyanosis, which involves the lips, tongue and trunk indicating
HYPOXIA which needs further assessment by the nurse.

Milia are blocked sebaceous glands located on the chin and the nose of the infant.

VERNIX CASEOASA
Should not be removed by oil or hand lotion, because it is a protective layer of the
neonate after birth, and it disappears after birth. Never remove it with alcohol or
cotton balls, unless meconium skinned.

Newborn Assessment Abejo

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Newborn Assessment

BIRTH MARKS

Telangiectatic nevi (stork bites)

 Appear as pale pink or red spots and are frequently found on the eyelids, nose,
lower occipital bone and nape of the neck
 These lesions are common in NB w/ light complexions and are more noticeable
during periods of crying. These areas have no clinical significance and usually
fade by the 2nd birthday

Hemangioma is benign vascular tumor that may be present on the newborn

3 types Hemangiomas
1. Nevus Flammeus – port wine stain – macular purple or dark red lesions seen
on face or thigh. NEVER disappear. Can be removed surgically
2. Strawberry hemangiomas – nevus vasculosus – dilated capillaries in the
entire dermal or subdermal area. Enlarges, disappears at 10 yo.
3. Cavernous hemangiomas – communication network of venules in SQ tissue
that never disappear with age.

Nevus Flammeus (port-wine stain)

 A capillary angioma directly below the epidermis, is a non-elevated, sharply
demarcated, red-to-purple area of dense capillaries.
 Macular purple
 The size & shape vary, but it commonly appears on the face. It does not grow in
size, does not fade in time and does not blanch. The birthmark maybe concealed by
using an opaque cosmetic cream.
 If convulsions and other neurologic problem accompany the nevus flammeus,----
5th cranial nerve involvement.

Nevus vasculosus (strawberry mark)

 A capillary hemangioma, consists of newly formed and enlarged capillaries in the
dermal and subdermal layers.
 It is a raised,clearly delineated, dark-red, rough-surfaced birthmark commonly
found in the head region.
 Such marks usually grow starting the second or third week of life and may not
reach their fullest size for 1 to 3 months; disappears at the age of 1 yr. but as the
baby grows it enlarges.
 Providing appropriate information about the cause and course of birthmarks often
relieves the fears and anxieties of the family. Note any bruises, abrasions,or
birthmarks seen on admission to the nursery.

Newborn Assessment Abejo

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Newborn Assessment

GESTATIONAL ASSESSMENT

PARAMETER NURSING ‘TERM’ born between ‘PRETERM’ born before 37 weeks

ACTION 37-42 weeks gestation gestation
EAR Fold the pinna Pinna recoils (springs Pinna opens slowly or stays folded
(auricle) forward back) in very premature infants
BREAST TISSUE Measure it 3 mm Less than 3 mm
FEMALE GENITALIA Observe Labia majora cover Labia minora are more prominent;
labia minora vaginal opening can be seen
MALE GENITALIA Observe Scrotal sac very Fewer shallow rugae on the scrotum
wrinkled
HEEL CREASES Observe Extend 2/3 of the way Soles are smoother, creases extend
from the toes to the heel less than 2/3 of the way from the
toes to the heel

NEWBORN REFLEXES

 Immature central nervous system (CNS) of newborn is characterized by variety of reflexes

o Some reflexes are protective, some aid in feeding, others stimulate interaction
o Assess for CNS integration
 Protective reflexes are blinking, yawning, coughing, sneezing, drawing back from pain
 Rooting and sucking reflexes assist with feeding

“What reflexes should be present in a newborn? Reflexes are involuntary movements or actions. Some movements
are spontaneous, occurring as part of the baby's usual activity. Others are responses to certain actions. Reflexes
help identify normal brain and nerve activity. Some reflexes occur only in specific periods of development. The
following are some of the normal reflexes seen in newborn babies””

PALMAR GRASP  Newborn’s fingers curl around the examiner’s fingers and the newborn’s toes
REFLEX curl downward.
 The palmar grasp reflex is elicited by placing an object in the palm of a
neonate; the neonate's fingers close around it. This reflex disappears between
ages 6 and 9 months.
Palmar response lessens within 3-4 months
Palmar response lessens within 8 months

ROOTING  The rooting reflex is elicited by stroking the neonate's cheek or stroking near
REFLEX the corner of the neonate's mouth.
 The neonate turns the head in the direction of the stroking, looking for food.
 This reflex disappears by 6 weeks.

SUCKING  The sucking reflex is seen when the neonate's lips are touched
REFLEX  Lasts for about 6 months

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Newborn Assessment

MORO REFLEX  Symmetric & bilateral abduction & extension of arms and hands
 Thumb & forefinger form a C
 “EMBRACE” reflex
 Present at birth, complete response may occur up to 8 weeks
 A persistent response lasting more than 6 months may indicate the occurrence
of brain damage during pregnancy

A normal reflex in a young infant caused by a sudden loud noise. It results in drawing
up the legs, an embracing position of the arms, and usually a short cry.

BABINSKI’ SIGN  Beginning at the heel of the foot, gently stroke upward along the lateral aspect of
the sole; then the examiner moves the fingers along the ball of the foot
 The newborn’s toes hyperextend while the big toe dorsiflexes
 Absence of this reflex indicates the need for a neurological examination
 The Babinski reflex is elicited by stroking the neonate's foot, on the side of the
sole, from the heel toward the toes.
 A neonate will fan his toes, producing a positive Babinski sign, until about age 3
months

STEPPING OR  The newborn simulates walking, alternately flexing and extending the feet
WALKING  The reflex is usually present 3-4 months
REFLEX

TONIC NECK  While the newborn is falling asleep or sleeping, gently and quickly turn the head
REFLEX to one side
 As the newborn faces the left side, the left arm & leg extend outward while the
right arm & leg flex
 When the head is turned to the right side, the right arm & leg extend outward while
the left arm & leg flex
 Usually disappears within 3-4 months

Newborn Assessment Abejo

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Newborn Assessment

CRAWLING Place the newborn on the abdomen

The newborn begins making crawling movements with the arms and legs
The reflex usually disappears after about 6 weeks

BASIC TEACHING NEEDS OF NEW PARENTS

CORD CARE Cleanse the cord with alcohol and sometimes triple dye once a day
Keep the area clean and dry
Keep the newborn’s diaper below the cord to prevent irritation
Signs of infection: redness, drainage, swelling, odor
Notify physician for signs of infection
NOTE:
Note any bleeding or drainage from the cord
Triple dye may be applied for initial cord care because it minimizes
microorganisms and promotes drying; use a cotton-tipped applicator to paint
the dye, one time, on the cord on 1 inch of surrounding skin
Application of 70% isopropyl alcohol to the cord with each diaper change and
at least two r three times a day to minimize microorganisms and promote
drying.

NOTE: The skin is surrounded with alcohol which promotes drying and cleans the area.
The umbilical cord dries and falls off about 14 days. Peroxide and lanolin promote
moisture, which can inhibit drying and allow growth of bacteria. Water doesn’t
promote drying.

It is best to care for the neonate’s umbilical cord area by cleaning it with cotton
pledgets moistened with alcohol. The alcohol promotes drying and helps decrease the
risk of infection. An antibiotic ointment maybe used instead of alcohol, because there
are a lot of bacteria which is resistant against some bacteria. Other agents such as
wipes, sterile water and soap & water are not as effective as alcohol.

CIRCUMCISION Observe for bleeding, first urination

CARE Apply diaper loosely to prevent irritation
Notify physician for signs of infection
BONDING Encourage parent to talk to, hold, and sing to infant
Promotes skin-to-skin contact between parent and infant
Feedings are opportunities for parent-infant bonding
Notify physician for signs of infection

NOTE: Sense of Touch

The most highly developed sense at birth that is why, neonates responds well to
touch.

Newborn Assessment Abejo

Maternal and Child Health Nursing
Newborn Assessment

PRE TERM INFANT ( PREMATURE INFANT)

Definition PRE TERM INFANT

 A neonate born before 38 weeks age of gestation

Synonym Low birth weight

Contributing factors  Low socioeconomic level

 Poor nutritional status
 Lack of pre natal care
 Multiple pregnancy
 Prior previous early birth
 Race (non whites have a higher incidence of prematurity than
whites)
 Cigarette smoking
 The age of the mother ( the highest incidence is in mother’s
younger than age 20.)
 Order of birth ( early termination is highest in first pregnancies
and in those beyond the forth )
 Closely spaced pregnancies
 Abnormalities of the reproductive system such as intrauterine
septum
 Infections ( specially urinary tract infections)
 Obstetric complications such as premature rupture of membranes
or premature separation of the placenta
 Early induction of labor
 Elective cesarian birth

 Appears small and underdeveloped

Cardinal signs  The head is disproportionately large ( 3 cm or more greater than
chest size)
 Skin is thin with visible blood vessel and minimal subcutaneous
fat pads
 Vernix caseosa is absent
 Both anterior and posterior fontanelles are small

Abnormal laboratory values  Decreased RBC’s

 Decreased serum glucose
 Increased concentration of indirect bilirubin
 Decreased serum albumin
 NOTE: The normal range of urine output for a preterm
baby is 1 to 2ml/kg/day. The normal specific gravity for a
preterm baby is 1.020. The normal range for blood glucose
level in a preterm baby is 40 to 60 mg/dl.

Best procedure  Resuscitation

NOTE: resuscitation becomes important for infant who fails to
take first breath or difficulty maintaining adequate
respiratory movements on his own.

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Newborn Assessment

 Suctioning
NOTE: allows removing mucus and prevents aspiration of any
mucus and amniotic fluid present in the mouth and
nose of the newborn to establish clear airway.

 Intubations
NOTE: head of the infant in neutral position with towel under
shoulder.

Best position  Positioning the infant on the back with the head of the mattress
elevated approximately 15 degrees to allow abdominal contents to
fall away from the diaphragm affording optimal breathing space.

Best position for suctioning:

 Infant on the back and slide a folded towel or pad under shoulders
to rise, head is in neutral position.

Complications  Anemia of prematurity

 Hyperbilirubinemia/ kernicterus
 Persistent patent ductus arteriosus
 Periventricular / intraventricular hemorrhage
 Respiratory distress syndrome
 Retinopathy of prematurity
Retrolental fibroplasias are a complication that occurs if the
infant is overexposed to high oxygen levels.
 Necrotizing enterocolitis

Bedside equipment  Preterm size laryngoscope

 ET tube
 Suction catheter with synthetic surfactant
 Isolettes (incubator)

Drug study 1. Naloxone (Narcan)

Nature of the drug:
 Narcotic antagonist
Side effects:
 Hypertension, irritability, tachycardia

2. Surfactan ( Survanta)
Nature of the drug:
 Lung surfactant to improve lung compliance
Side effect:
 Transient bradycardia, rales

3. Vitamin K (Aquamephyton)
 Use for prophylaxis to treat hemorrhagic disease of the
newborn.
Side effects:
 Hyperbilirubinuria

4. Eye prophylaxis
(Erythromycin 0.5% Ilotycin, Tetracycline 1%
Silver Nitrate 1% ( not already used – causes chemical
conjunctivitis)
 Prophylactic measure to protect against Neisseria
gonorrhoeae and Chlamydia trachomatis
Side effects:
 Silver nitrate can cause chemical conjuctivitis

Nursing diagnosis 1. Impaired gas exchange related to immature pulmonary

functioning
2. Risk for fluid volume deficit related to insensible water loss at
birth and small stomach capacity

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Newborn Assessment

3. Risk for aspiration related to weak or absent gag reflex a nd/or

administration of tube feedings
4. Hypothermia related to lack of subcutaneous and brown fat
deposits, inadequate shiver response, immature
thermoregulation center, large body surface area in relation to
body weight, and/or lack of flexion of extremities toward the
body.
5. Risk for infection related to immature immune response, stasis of
respiratory secretions, and/ or aspiration
6. Imbalanced nutrition: less than body requirements related to
lack of energy to suck and/or weak or absent sucking reflex

Nursing intervention The nurse’s first priority in preparing a safe environment for a
preterm newborn with low Apgar scores is to prepare
respiratory resuscitation equipment. Airway maintenance is the
first priority.
Give the mother oxygen by mask during the birth to provide the
preterm infant with optimal oxygen saturation at birth ( 85-90%).
Keeping maternal analgesia and anesthesia to a minimum also
offers the infant the best chance of initiating effective respiration.
Bedside larngyoscope, endotracheal tube, suction catethers and
synthetic surfactant to be administered by the endotracheal tube.
Infant must be kept warm during resuscitation procedures so he
or she is not expending extra energy to increase the metabolic
rate to maintain body temperature.
Observe for changes in respirations, color and vital signs
Check efficacy of Isolette: maintain heat, humidity and oxygen
concentration, administer oxygen only if necessary
Maintain aseptic technique to prevent infection
Adhere to the techniques of gavage feeding for safety of infant
Observe weight-gain patterns
Determine blood gases frequently to prevent acidosis. Institute
phototherapy when hyperbilirubinemia occurs
Support parents by letting them verbalize and ask questions to
relieve anxiety.
Provide liberal visiting hours for parents, allow them to
participate in care.
Arrange follow-up before and after discharge by a visiting nurse.

Newborn Assessment Abejo

Maternal and Child Health Nursing
Newborn Assessment

POST TERM INFANT

Definition POST TERM INFANT

 A neonate born after 42 weeks age of gestation

 Low socioeconomic level

Contributing factors
 Poor nutritional status
 Lack of pre natal care
 Multiparous mother’s
 Cigarette smoking
 The age of the mother (the highest incidence is in mother’s younger
than age 20.)
 Mother’s with diabetes mellitus
 Congenital abnormalities such as omphalocele.
 Body is covered with lanugo
 Old man facies

Classic signs  Intrauterine weight loss, dehydrations and chronic hypoxia “old
man faces’
 Long & thin with cracked skin which is loose, wrinkled and
strained greenish yellow, with no vernix nor lanugo
 Long nails with firm skull
 Wide eyed alertness of one month old baby

Abnormal laboratory  Increased total no. of RBC’s

values  Increased hematocrit level
 Decreased serum glucose

Screening test  Sonogram

 Resuscitation
Best procedure NOTE: resuscitation becomes important for infant who fails to take
first breath or difficulty maintaining adequate respiratory
movements on his own.

 Suctioning
NOTE: allows removing mucus and prevents aspiration of any
mucus and amniotic fluid present in the mouth and nose of the
newborn.
To establish clear airway.

 Intubations
NOTE: head of the infant in neutral position with towel under
shoulder.

 Positioning the infant on the back with the head of the mattress
Best position elevated approximately 15 degrees to allow abdominal contents

Complications  Meconium aspiration syndrome

 Respiratory distress syndrome

NOTE: Post mature neonates have difficulty maintaining glucose

reserves. Other common problems include Meconium aspiration
syndrome, polycythemia, congenital anomalies, seizure activity and cold
stress.

NOTE: The infant who are exposed to high blood-glucose levels in

utero may experience rapid and profound hypoglycemia after birth
because of the cessation of a high in-utero glucose load. The small-for-
gestational-age infant has use up glycogen stores as a result of
intrauterine malnutrition and has blunted hepatic enzymatic response
with which to carry out gluconeogenesis.

Newborn Assessment Abejo

Maternal and Child Health Nursing
Newborn Assessment
Bedside equipment
Drug study
Nursing diagnoses
Nursing interventions
Newborn Assessment
NOTE: The patient with post-term pregnancy is at high risk for
decreased placental functioning, therefore increasing the risk of
inadequate oxygen circulation to the fetus
 ET tube
 Suction catheter
1. Vitamin K (Aquamephyton)
 Use for prophylaxis to treat hemorrhagic disease of the newborn
Side effects:
 Hyperbilirubinuria
2. Eye prophylaxis
(Erythromycin 0.5% Ilotycin, Tetracycline 1% Silver Nitrate 1%
 Prophylactic measure to protect against Neisseria gonorrhoeae and
Chlamydia trachomatis
Side effects:
 Silver nitrate can cause chemical conjuctivitis
1. Ineffective airway breathing
2. Risk for fluid volume deficit related to insensible water loss at birth
3. Ineffective infant feeding pattern
 Assess newborn’s respiratory rate, depth and rhythm. Auscultate
lung sound.
Note: Meconium stained syndrome of POST MATURE neonates
Aspiration of meconium is best prevented by suctioning the neonate’s
nasopharynx immediatelt after the head is delivered and before the
shoulders and chest are delivered. As long as the chest is
compressed in the vagina, the infant will not inhale and aspirate
meconium in the upper respiratory tract. Meconium aspiration
blocks the air flow to the alveoli, leading to potentially life
threatening respiratory complications.
 Suction every 2 hours or more often as necessary
 Position newborn on side or back with the neck slightly extended
 Administer O2, anticipate the need for CPAP or PEEP
 Continue to assess the newborn’s respiratory status closely.
 Encourage as much parental participation in the newborn’s care as
condition allows
 Administer IV fluids after birth to provide Glucose to prevent
hypoglycemia, monitor closely the infusion rate.
 Kept the infant under a radiant heat warmer to preserve energy
 Monitor baby’s weight, serum electrolytes and ensure adequate
fluid intake
 Measure urine output by weighing diapers
 Check for blood stools to evaluate for possible bleeding from
intestinal tract.
 Keep a restful environment.
 Anticipate the infants need to be breastfeed
 Demonstrate technique for feeding to mother, note proper
positioning of the infant, “latching on” technique, rate of delivery
of feeding and frequency of burping
 Provide a relaxed environment during feeding
 Adjust frequency and amount of feeding according to infants
response
 Alternate feeding procedure (nipple and gavage feeding) according
to infants ability.
 Monitor mother’s effort, provide feedback and assistance as needed
 Suggest mother to monitor infants weight periodically
Abejo