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The Neonate
From birth through the first 28 days of life
Also called “the newborn period”
2/3 of all deaths that occur during the 1st year of life occur during this period; more than half occur
in the 1st 24 hours after birth---an indication of how hazardous this time is for an infant
How well a NB makes major adjustments depends on his or her:
o Genetic composition
o The competency of the recent intrauterine environment
o The care received during the neonatal period
PRINCIPLES IN IMMEDIATE NEW BORN CARE
1st day of life
1. initiation and maintenance of respiration (used bulb syringe initiate a/w)
2. establishment of extra uterine circulation
3. control of body temp
4. intake of adequate nourishment
5. establishment of waste elimination
6. prevention of infection
7. establishment of an infant parent relationship
8. dev’t care that balances rest and stimulation or mental dev’t
Immediate care of the newborn.
A-airway (most neonatal deaths with in 24 h caused by inability to initiate a/w, lung function begins after birth only)
B-body temperature
C-check/asses the newborn
D-determined identification
I. Establish and Maintain a Patent Airway / Effective Respiration
Nursing Interventions:
1. Wipe the mouth and nose secretions after delivery of the head
2. Suction secretions from the mouth and nose properly.
Catheter Suctioning
1.) Place head to side to facilitate drainage
2.) Suction mouth 1st before nose
-neonates are nasal breathers
3.) Period of time
-5-10 sec suctioning, gentle and quick
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Prolonged and deep suctioning can lead to hypoxia, laryngo spasm, brady cardia due to stimulation vagal nerve
4.) Evaluate for patency
-cover nostril and baby struggles there’s a need for additional suctioning
“If not effective, requires effective laryngoscopy to open a/w. After deep suctioning an endotracheal tube can be
inserted and oxygen can be administered by an (+) pressure bag and mask with 100% oxygen at 40-60b/m.”
Nsg alert:
No smoking
Always humidify to prevent drying of mucosa
Over dosage of oxygen can lead to scarring of retina leading to blindness ( retro lentalfibrolasia or retinopathy of
prematurity)
When mecomium stained (greenish) never administer oxygen with pressure ( O2 pressure will push mecomium
inside)
3. Stimulate the baby to cry if baby does not cry spontaneously or if baby’s cry is weak.
“A crying infant is a breathing infant. Effective cry means effective breathing”
Do not slap the buttocks but rub the soles of the feet
Do not stimulate the NB to cry unless the secretions have been suctioned to prevent
aspiration
The normal infant cry is loud & lusty. Observe for the ff. abnormal cry:
High-pitched cry : hypoglycemia, increased ICP
Weak cry: prematurity
Hoarse cry: laryngeal stridor
4. Oral mucus may cause the NB to choke, cough or gag during the first 12 to 18 hours of life.
Place the neonate in a position that would promote drainage of secretions
Trendelenburg (contraindicated to Increased ICP)
Side-Lying
5. Keep the nares patent. Remove mucus and other particles w/c can cause obstruction as newborns
are “obligatory nasal breathers” until they are about 2-3 weeks old.
6. Give O2 as needed. Oxygen should be given for 20-30 minutes when the neonate remains
cyanotic or tachycardic after initial suctioning and stimulation.
* asphyxiation → hypoxia → hypercapnia(↑ CO2) → acidosis → coma → death
• Observe precaution in giving oxygen
• Do not give more than 40% O2 as this may lead to retrolental fibroplasia (blood vessels of the eyes
become spastic leading to blindness)
• Use pulse oximeter and monitor O2 concentration every hour
7. If the heart rate falls below 60 bpm, cardiac massage may need to be carried out.
II. Maintain Appropriate Body Temperature
Temp Regulation
goal in temp regulation is to maintain it not less than 97.7% F (36.5 C)
maintenance of temp is crucial on preterm and SGA (small for gestational age) - babies prone
to hypothermia or cold stress
o Neonates have “physiologic resilience” wherein they tend to adopt or take temperature of
their own environment. (poikilothermic)
“cold stress (hypothermia) is more dangerous than hyperthermia”
Effects of cold stress
Cold stress metabolic acidosis CNS depression Coma Death
o Every NB is born slightly acidotic. Any new build-up of acid may lead to life-threatening
metabolic acidosis, which can be lethal even to normal newborn infants.
o The average NB temp.@ birth is around 37.2°C.
o NB lose heat easily because:
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Effects of Hypothermia
( Cold stress)
To Prevent Hypothermia
1. Dry and wrap baby
2. Mechanical pressure – radiant warmer
pre-heated first isolette (or square acrylic sided incubator)
3. Prevent an necessary exposure – cover baby
4. Cover baby with tin foil or plastic
5. Embrace the baby- kangaroo care
6. Delay initial bath until temp. has stabilized for at least 2 hours.
7. Maintain ambient temp. of nursery at 24°C or 75°F.
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8. Perform any extensive examination or procedure under radiant heat to prevent heat loss and expose only the part of the
body to be examined.
9. Note the presence of any cyanosis:
2 types of cyanosis: a.) central cyanosis
b.) peripheral cyanosis hands & feet are cyanotic, due to cold environment and poor circulation
Axillary temperature measurement. The thermometer should remain in place for 3 minutes. The nurse presses the
newborn’s arm tightly but gently against the thermometer and the newborn’s side, as illustrated
Ophthalmia neonatorum
Any conjunctivitis with discharge occuring during the first two weeks of life. It typically appears 2-5 days after
birth, although it may appear as early as the first day or as late as the 13th.
silver nitrate (used before) – 2 drops lower conjunctiva (not used now)
“Tetanus microorganism thrives in anaerobic environment so you actually prevent infection if cord is
exposed to air”.
A irway
B ody temperature
C heck/ assess the newborn
D etermine identification
Stimulate & dry infant
Assess ABCs
Encourage skin-to-skin contact
Assign APGAR scores
Give eye prophylaxis & Vit. K
Keep newborn, mother, & partner together whenever
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Physical Assessment
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 - coartation of aorta
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
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Seesaw respirations
Grunting
Nasal flaring
Retractions
Deep sighing
Tachypnea - respirations > 60
Persistent irregular breathing
Excessive mucus
Persistant fine crackles
Stridor
3.) increase BP and widening pulse pressure #3 & #4 are Cushings triad of
4.) Decreased RR, decreased PR ICP
5.) projective vomiting- sure sign of cerebral irritation
6.) high deviation – diplopia – sign of ICP older child
4-6 months- normal eye deviation
>6 months- lazy eyes
7.) High pitch shrill cry-late sign of ICP
Skin
o Skin reddish in color, smooth and puffy at birth
o At 24 - 36 hours of age, skin flaky, dry and pink in color
o Edema around eyes, feet, and genitals
o Venix Caseosa -whitish, cheese-like substance, covers the fetus while in utero and
lubricates the skin of the NB. The skin of the term or postterm nb has less vernix and is
frequently dry; peeling is common, esp. on the hands & feet
o Lanugo -moderate in full term; more in preterm; absent in postterm; shed after 2 weeks
in time of desquammation
o Turgor good with quick recoil Skin color
blue – cyanosis or hypoxia
o Hair silky and soft with individual strands White – edema
o Nipples present and in expected locations Grey – inf
Yellow – jaundice , carotene
o Cord with one vein and two arteries
o Cord clamp tight and cord drying
o Nails to end of fingers and often extend slightly beyond
Acrocyanosis
o Bluish discoloration of the hands and feet maybe present in the first 2 to 6 hours after birth
o This condition is caused by poor peripheral circulation, w/c results in vasomotor instability &
capillary stasis, esp. when the baby is exposed to cold.
Mongolian Spots
Mottling
Physiologic Jaundice
o Hyperbilirubinemia not associated with hemolytic disease or other pathology in the newborn.
Jaundice that appears in full term newborns 24 hours after birth and peaks at 72 hours.
Bilirubin may reach 6 to 10 mg/dl and resolve in 5 to 7 days.
o If jaundice occurs within 2 days – pathologic jaundice
o If jaundice occurs at 3rd-7th days of life – physiologic jaundice
o Jaundice is first detectable on the face (where skin overlies cartilage) and the mucus
membranes of the mouth and has a head-to-toe progression.
o *Evaluate it by blanching the tip of the nose, the forehead, the sternum, or the gum line. This
procedure must be done with appropriate lighting. Another are to assess is the sclera.
o Jaundice maybe related to breastfeeding, hematomas, immature liver function, bruises from
forceps, blood incompatibility, oxytocin induction or severe hemolysis process
Nsg Resp:
1. cover eyes – prevent retinal damage
2. cover genitals – prevent priapism –
painful continuous erection
3. change position regularly – even
exposed to light
4. increase fld intake – due prone to
dehydration
5. monitor I&O – weigh baby
6. monitor V/S – avoid use of oil or lotion
due- heat at phototherapy
= bronze baby syndrome-
transient S/E of phototherapy
Phototherapy
o Is the exposure of the NB to high intensity light.
o Maybe used alone or in conjunction w/ exchange transfusion to reduce serum bilirubin
levels.
o Decreases serum bilirubin levels by changing bilirubin from the non-water soluble form
to water-soluble by products that can be excreted.
Nursing Interventions:
1. Exposing as much of the NB’s skin as possible however genitals are covered & the nurse monitors the genitals
area for skin irritation
2. Eyes are covered with patches or eye shields and are removed at least once per shift to inspect the eyes
3. Monitor temp. closely & ↑ fluids to compensate water loss
4. NB is repositioned q 2° and stimulation is provided.
• NB will have loose green stools and green colored urine.
Exchange Transfusion
o Is the withdrawal and replacement of newborn’s blood with donor blood.
Milia
Milia which are exposed to sebaceous
glands, appear as raised white spots on
the face, esp. across the nose.
No treatment is necessary, bec they will
clear within first month.
Infants of African heritage have a similar
condition called transient neonatal
pustular melanosis.
Erythema toxicum
Harlequin Sign
o The color of the newborn's body appears to be half red and half pale. This condition is
transitory and usually occurs with lusty crying. Harlequin Coloring may be associated with to
an immature vasomotor reflex system.
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.
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3 types Hemangiomas
a.) Nevus Flammeus – port wine stain – macular purple or dark red lesions seen on face or thigh.
NEVER disappear. Can be removed surgically
b.) Strawberry hemangiomas – nevus vasculosus – dilated capillaries in the entire dermal or subdermal
area. Enlarges, disappears at 10 yo.
c.) 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.
HEAD
o Head circumference should be 2 cm greater than chest circumference
o Assess fontanelles and sutures - observe for signs of hydrocephalus and evaluate
neurologic status
o Craniosynostosis
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o Microcephaly
o macrocephaly
A, The asymmetry of gluteal and thigh fat folds seen in infant with left
developmental dysplasia of the hip.
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C, Dislocation is palpable as femoral head slips out of acetabulum. D, Ortolani's maneuver puts downward pressure on the hip and then
inward rotation. If the hip is dislocated, this maneuver forces the femoral
head over the acetabular rim with a noticeable “clunk.”
Clubfoot
Nursing Role
Be knowledgeable about normal newborn variations and responses that indicate further investigation
o Respiratory distress
o Central cyanosis
o Thermoregulation problems
o Dehydration
Teaching
During physical and behavioral assessment, identify family's need for teaching
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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””
BABINSKI reflex
Grasp reflex
Moro reflex
The Moro reflex is often called a startle reflex
because it usually occurs when a baby is startled
by a loud sound or movement. In response to the
sound, the baby throws back his/her head,
extends out the arms and legs, cries, then pulls the
arms and legs back in. A baby's own cry can
startle him/her and begin this reflex. This reflex
lasts about five to six months.
Step reflex -
This reflex is also called the
walking or dance reflex because a
baby appears to take steps or
dance when held upright with
his/her feet touching a solid
surface.
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Rooting Reflex
Suck reflex -
Rooting helps the baby become ready to
suck. When the roof of the baby's mouth is
touched, the baby will begin to suck. This
reflex does not begin until about the 32nd
week of pregnancy and is not fully developed
until about 36 weeks. Premature babies may
have a weak or immature sucking ability
because of this. Babies also have a hand-to-
mouth reflex that goes with rooting and
sucking and may suck on fingers or hands.
Female genitals
B, The clitoris is still visible.The labia C, The term newborn has well-developed, large
minora are now covered by the larger labia majora that cover both clitoris and labia
labia majora. Score 2. The gestational minora. Score 3.
age is 36 to 40 weeks
Neuromuscular Components
Scarf sign
BIRTHMARKS:
1. Mongolian spots – stale gray or bluish discoloration patches commonly seen across the sacrum or buttocks due to
accumulation of melanocytes. Disappear by 1 yr old
2. MIlla – plugged or unopened sebaceous gland . white pin point patches on nose, chin or cheek.
3. Lanugo – fine, downy hair – common preterm
4. Desquamation – peeling of newborn, extreme dryness that begin sole and palm.
5. Stork bites (Talengeictasi nevi) – pink patches nape of neck
hair will grow as child grows old
6. Erythema Toxicum – (flea bite rash)- 1st self limiting rash appear sporadically & unpredictably as to time & place.
7. Harlequin sign – dependent part is pink, independent part is blue
(side lying – bottom part is dependent pink)
8. Cutis Marmorato – transitory mottling of neonates skin when exposed to cold.
9. Hemangiomas – vascular tumors of the skin
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3 types Hemangiomas
a.) Nevus Flammeus – port wine stain – macular purple or dark red lesions seen on face or thigh. NEVER disappear. Can
be removed surgically
b.) Strawberry hemangiomas – nevus vasculosus – dilated capillaries in the entire dermal or subdermal area. Enlarges,
disappears at 10 yo.
c.) Cavernous hemangiomas – communication network of venules in SQ tissue that never disappear with age. - MOST
DANGERIOUS – intestinal hemorrhage
Skin color blue – cyanosis or hypoxia
White – edema
Grey – inf
Yellow – jaundice , carotene
Vernix Caseosa – white cheese like for lubrication, insulator