Immediate Care of the Newborn
– Assess and stabilize
– Evaluate if cardiac/respiratory help needed for baby to initiate breathing
S/S respiratory distress:
– grunting- noise on exhalation Retractions
– nasal flaring Cyanosis
– Lack of respiratory effort
– Respiratory- suction secretions from the airway.
– Cardiac: Always take apical pulse for 1 minute- 4th intercostals space a little left of the midclavicular line
– <100= bad. Normal= 120-160
– Dry and wrap in blanket-
– Newborns can’t shiver- problem regulating/ maintaining temperature.
– Heat loss and cold stress can cause hypoglycemia in newborn
– Apgar at 1 and 5 minutes
– Visual inspection:
– posture, muscle tone of extremities, state, color, gross abnormalities (congenital malformations)
– Take and record time of birth
|SIGN||Score 0||Score 1||Score 2|
|Heart Rate||Absent||Below 100 per minute||Above 100 per minute|
|Respiratory Effort||Absent||Weak, irregular, or gasping||Good, crying|
|Muscle Tone||Flaccid||Some flexion of arms and legs||Well flexed, or active movements of extremities|
|Reflex/Irritability||No response||Grimace or weak cry||Good cry|
|Color||Blue all over, or pale||Body pink, hands and feet blue||Pink all over|
If <5 resuscitative measures may be necessary.
- Temperature: 36.5 (97.7) to 37.2 (98.9)
- Pulse: 100-180 à Checked at 5th intercostals space- midclavicular line
- Respirations: 30-60/minute
Other nursing responsibilities in L & D
– Identify baby (ID band on child before leaving labor room) and footprints
– “Eyes and Thighs”- 2 medications need to be given: Put in Vastus Lateralis muscle
1- Vitamin K- 25 gauge 5/8 inch needle- given for clotting
2- Erythromycin Ophthalmic- put in eyes – for Chlamydia and gonorrhea in birth canal.
Benefits of skin to skin contact:
- Temperature regulation- babies who have skin to skin contact immediately after birth can better regulate their temp at 1 hour
- Decreased crying
- Enhanced breastfeeding
- Increased milk supply
Newborn Skin Issues
- Milia– little white ‘dots’ on nose, forehead and chin or mouth. Caused by blocked sebaceous glands. Will go away completely- totally benign
- Newborn Rash– will spontaneously go away by 3 weeks
- Vernix– is the waxy or “cheesy” white substance found coating the skin. It is very good for the newborn skin- rub it in- will absorb naturally. Don’t put products on it.
- Mongolian Spots– dark spots- collection of capillaries. Looks like a bruise. Completely benign. Most common on dark-skinned babies (black, Asian).
- Lanugo– fine hair most commonly found on preterm neonates. Tends to be most on back and chest. More premature=more lanugo.
- Acrocyanosis– cyanosis in hands and feet. Takes a few days to go away.
- Nevi– “stork bite”- will blanch when touched- will fade by 2 y/o. Collection of immature blood vessels.
- Strawberry Hemangioma- will be textured (rough, raised, bumpy). Will appear later- after birth and will fade by 9 y/o.
- Port-Wine Stain– Most often on head and neck. Will not change colors when touched. Tx most often laser surgery.
- Make sure fontanels aren’t sunken (dehydration) or bulging (increased ICP).
- Molding – reassure parents head will go back to ‘round’ shortly after birth. Sign to pay special attention to neuro exam.
Caput Succedaneum– swelling in a diffuse area
– edema – appears at birth, disappears in several days
– Vague, poorly defined outline -***Crosses suture lines***
Cephalhematoma– more significant
– blood between skull and periosteum – Appears several hours after birth, size increases
– Well defined outline – **Never crosses suture lines- will follow lines**
– Risk for jaundice, skull fracture, intracranial bleeds
Temp- 36.5- 37.2 C (97.7-98.9) normal- Take axillary- will stabilize in 8-12 hr.
Pulse- 120-160 (100-180 may be normal depending on activity level)
4th intercostal space, midclavicular line
Blood Pressure- 60-80/ 40-50
Evaporation: When wet surface on the baby is exposed to air – need to dry the infant after birth and after baths, especially the head.
Conduction: When the newborn comes into direct contact with something colder than them – Do not place them on a cold surface. Warm objects first that will touch the baby. Skin to skin contact prevents this loss.
Convection: Heat transfers to air around the infant such as AC or people walking around creating currents – Need to keep the newborn out of drafts, maintain a warm environment, warm oxygen before administering.
Radiation: Transferring of heat to cooler objects not in contact with the newborn – newborns lose their heat by being placed near a cold window. Place crib or play area away from windows.
***Test***Weight- Newborns lose 5-10% in the first 5 days- should regain birth weight by 2 weeks
if loose 7% this is a red flag that should be evaluated.
Renal- newborn should void within 24 hours
Urine output scant during first few days as baby adjusts to feedings
Once in 1st 24 hours, Twice in 2nd 24 hours, 3x in 3rd 24 hours
Increases on day 3-4 when milk comes in, then 6-8 voids/24 hours
Stools- Meconium at firstà progressive changes in appearance and pattern
Indication of adequate nutritional intake:
1st stool at 48 hours of age; 3 stools per 24 hours once milk comes in
Jaundice: Cephalocaudal pattern
Total Bilirubin- Conjugated (direct) – attached to albumin- can be excreted
Unconjugated (indirect) – causes problems- isn’t attached to protein (free floating)- could go into the brain.
Measured in lab with a heel stick
Physiologic Jaundice or Hyperbilirubinemia– onset after 24 hours of age
Peaks around day 4; subsides at 4-6 days
Benign in normal- healthy term newborn
Indirect bilirubin (normal) equal to or less than 12mg/dl by day 3
15-17 in preemie
Early (within 1 hour) and frequent feedings may help
Breastfeeding Jaundice– Early onset (within first few days) due to lack of adequate intake. Counsel mother to put baby to breast every 3 hours – even if sleeping. This stimulates stool to excrete excess bilirubin.
Breastmilk Jaundice– Late onset- Hyperbilirubinemia beyond 1st week- peaks at 2 weeks.
Pathologic Jaundice– Jaundice <24 hours. Usually caused by ABO incompatibility. Increases >0.5 mg/dl/hr. Peaks at >13 mg/dl/hr in term infant.
Associated with anemia and enlarged liver and spleen. If it persists past day 7- it can progress to kernicterus or bilirubin encephalophy (usually at bilirubin level >25). s/s= lethargy, hypotonic, poor suck.
Monitor Temp Eye patches
Turning q2 hours Monitor I & O
Shield Genitals (boys) Observe skin color
Risk factors for Hyperbilirubinemia:
ABO Incompatibility Preterm
Postterm Traumatic birth (bruising will cause RBC’s to lyse)
– Infant retains passive immunity for approx 3 months; longer if breastfeeding.
IgG- only immunoglobin that crosses placenta
IgM- 1st immunogloubin newborn makes
IgA- Secreted in colostrum – immunity to GI and respiratory infections if breastfed
Rooting and Sucking Stepping or Walking
Grasp – Palmar and plantar Moro
Babinski- on sole of foot, beginning at heel, stroke upward along side of sole then move finger across ball of foot- All toes hyperextend- with dorsiflexion of big toe.
Deep Sleep- Regular breathing
Light Sleep- REM, body movement, variable breathing
Drowsy- intermediate, state before waking
Quiet alert- optimal state of arousal- Easiest to interact- highly receptive
Active alert- high movement, fussy state
Crying- communication state
Behavioral Adaptation after birth
First period of reactivity: Transitions to extrauterine life. Very alert, irregular respiratory effort, irregular CV, etc. promote bonding, encourage breastfeeding.
Period of inactivity- Deep sleep- lasts 1 to 1 ½ hours. Can not breastfeed during this time.
Second Period of reactivity- alert, responsive. Lasts a few minutes to hours.
PKU- Causes Mental retardation- test done on day 2-3. Tx: diet low in Phenylamine.
Abnormal fontanel size- or bulging or sunken fontanel
Respiratory system signs:
Tachypnea (TTN- transient tachypnea of the newborn)- when newborn takes too long to transition to extrauterine life- will go away, but needs care until then.
Nasal Flaring Expiratory grunting
Retractions Rales and Rhonchi
Asynchronous breathing movements Cyanosis
Decreased/absent breath sounds Acidosis
Hypotension and shock Hypercapnia
Preterm – before 37 weeks
Immaturity in all systems
Risks: Excessive heat loss- thin skin, decreased subq fat, increased BSA
Vulnerability to hyperoxic injury (too high O2 level can damage retina causing blindness).
Immature lungs and diminished respiratory drive
Immature brain that is prone to bleeding
Vulnerability to infection
Necrotizing enterocolitis- part of intestine dies- most serious problem of preterm infant. s/s- not passing stool, increased vomiting, increasing abd. Distension, no bowel sounds.
Nursing: Monitor and control blood sugar
- Monitor for apnea, tachycardia, bradycardia, or O2 desaturations- intervene promptly.
- Monitor and control oxygenation and ventilation
- Consider delaying feeding if perinatal compromise is significant
- Increased suspicion for infection
- Control noise and light (cover isolette, decrease noise level)
Small For Gestational Age (SGA)- 2 types
Intrauterine growth retardation (IUGR)- wt. below 10th percentile
1- Symmetric- caused by an early insult to the fetus during pregnancy (ie: drug use, rubella)
Deficiency in cell numbers
Head circumference below 10th percentile
Small brain- child never catches up- mental retardation
2- Asymmetric- Caused by an insult late in the pregnancy
Atrophy in cells that are already formed by this time
Diminished cell size but cell numbers are normal
Large head (disproportionately)
Long body with little fat, looks emaciated
Postnatal growth and development rapid- can catch up if caught early.
Large for Gestational Age (LGA)- wt above 90th percentile or over 8lb14oz
Risk factors: Genetics, maternal weight gain, gestational diabetes
Potential for trauma (shoulder dystocia, clavicle fx, palsies, skull fx, facial nerve damage) if delievered vaginally-> may necessitate c-section.
Also at risk for hypoglycemia