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(Refer to CP: The First Hour of Life.)
Activity/Rest
Wakeful state may be as little as 2\u20133 hr first several days.
Infant appears semicomatose while in deep sleep; grimacing or smiling is evident in rapid eye
movement (REM) sleep; averages 20 hr of sleep per day.
Circulation
Apical pulse averages 120\u2013160 bpm (115 bpm at 4\u20136 hr, rising to 120
bpm3k/images/1-c33809ec4f/000.jpg' style='left: 11.50em; clip: rect(0.07em 14.25em 0.13em
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NURSEREVIEW.ORG
THE NEONATE AT 2 HOURS TO 2 DAYS OF AGE
NEONATAL ASSESSMENT DATA BASE (FULL-TERM) at 12\u201324 hr after
birth); may fluctuate from 80\u2013100 bpm (sleeping) to 180 bpm (crying).
Peripheral pulses may be weak (bounding pulses suggest patent ductus arteriosus [PDA]);
brachial and radial pulses are more easily palpated than femoral pulses (absence of
femoral and dorsalis pedis pulses suggests coarctation of the aorta).
Heart murmur often present during transition periods.
Blood pressure (BP) ranges from 60\u201380 mm Hg (systolic)/40\u201345 mm Hg (diastolic),
average
resting pressure approximately 74/46 mm Hg; BP lowest at 3 hr of age.
Umbilical cord clamped securely with no oozing of blood noted; shows signs of drying within
1\u2013
2 hr of birth, shriveled and blackened by day 2 or 3.
Elimination
Abdomen soft without distension; active bowel sounds present several hours after birth
Urine colorless or pale yellow, with 6\u201310 wet diapers per 24 hr
Passage of meconium stool within 24\u201348 hr of birth
Food/Fluid
Mean weight 2500\u20134000 g (5 lb 8 oz to 8 lb 13 oz);<2500 g suggests small for gestational
age
(SGA) (e.g., prematurity, rubella syndrome, or multiple gestation), greater than 4000 g
suggests large for gestational age (LGA) (e.g., maternal diabetes; or may be associated
with heredity). (Refer to CPs: The Preterm Infant; Newborn: Deviations in Growth Patterns).
Weight loss 5%\u201310% initially.
Mouth: Scant saliva; Epstein\u2019s pearls (epithelial cysts) and sucking blisters are normal on

hard
palate/gum margins, precocious teeth may be present.
Neurosensory
Head circumference 32\u201337 cm; anterior and posterior fontanels are soft and flat.
Caput succedaneum and/or molding may persist for 3\u20134 days; overriding of cranial
sutures
may be noted, slightly obliterating anterior fontanel (2\u20133 cm in width) and posterior
fontanel (0.5\u20131.0 cm in width).
Eyes and eyelids may be edematous; subconjunctival or retinal hemorrhage may be noted;
chemical conjunctivitis lasting 1\u20132 days may develop following instillation of therapeutic
ophthalmic drops.
Strabismus and doll\u2019s eye phenomenon often present.
Top of ear aligns with inner and outer canthi of eye (low-set ears suggest genetic or kidney
abnormalities).
Neurological Examination: Presence of Moro, plantar, palmar grasp, and Babinski\u2019s
reflexes;
reflex responses are bilateral/equal (unilateral Moro reflex may indicate fractured clavicle
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or brachial plexus injury); transient crawling movements may be seen.

Absence of jitteriness, lethargy, hypotonia, and paresis.
Respiration
Transient tachypnea may be noted, especially following cesarean or breech birth.
Breathing Pattern: Diaphragmatic and abdominal breathing with synchronous movement of
chest and abdomen (inspiratory lag or alternating seesaw movements of the chest and
abdomen reflects respiratory distress); slight or occasional nasal flaring may be noted;
marked nasal flaring, expiratory grunting, or marked retraction of intercostal, substernal,
or subcostal muscles indicates respiratory distress; inspiratory crackles may persist for
first few hours after birth (rhonchi on inspiration or expiration may indicate aspiration).
Chest circumference approximately 30\u201335 cm (1\u20132 cm smaller than circumference of
head).
Safety
Skin Temperature: 96.8\u00b0F\u201397.7\u00b0F (36\u00b0C\u201336.5\u00b0C), rectal
97.8\u00b0F\u201399\u00b0F (36.6\u00b0C\u201337.2\u00b0C).
Skin Color: Acrocyanosis may be present for several days during transition period (general
ruddiness may indicate polycythemia); reddened or ecchymotic areas may appear over

cheeks or on lower jaw or parietal areas as a result of forceps application at delivery; facial
bruising may be noted following precipitous delivery.
Cephalhematoma may appear day after delivery, increasing in size by 2\u20133 days of age,
then be
reabsorbed slowly over 1\u20136 mo.
Extremities: Normal range of motion in all; mild degree of bowing or medial rotation of lower
extremities; good muscle tone.
Sexuality
Female Genitalia: Vaginal labia may be slightly reddened or edematous, vaginal/hymenal tag
may be noted; white mucous discharge (smegma) or slight bloody discharge
(pseudomenstruation) may be present.
Male Genitalia: Testes descended, scrotum covered with rugae, phimosis common (opening of
prepuce narrowed, preventing retraction of foreskin over the glans).
Teaching/Learning
Gestational age between 38 and 42 wk based on Dubowitz criteria
Diagnostic Studies
White Blood Cell (WBC) Count: 18,000/mm3, neutrophils increase to 23,000\u201324,000/mm3
the 1st day after birth (decline occurs in sepsis).
Hb: 15\u201320 g/dl (lower levels associated with anemia or excessive hemolysis).
Hct: 43%\u201361% (elevation to 65% or over indicates polycythemia; decreased levels reflect
anemia or prenatal/perinatal hemorrhage).
Guthrie Inhibition Assay: Tests for presence of phenylalanine metabolites, indicating
phenylketonuria (PKU).
Total Bilirubin: 6 mg/dl on 1st day of life, 8 mg/dl at 1\u20132 days, and 12 mg/dl at 3\u20135
days.
Dextrostix: Initial glucose drop during first 4\u20136 hr after birth averages 40\u201350 mg/dl,
raising to
60\u201370 mg/dl by day 3.
NURSING PRIORITIES
1. Facilitate adaptation to extrauterine life.
2. Maintain thermoneutrality.
3. Prevent complications.
4. Promote parent-infant attachment.
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5. Provide information and anticipatory guidance to parent(s).
DISCHARGE GOALS
1. Newborn adapting effectively to extrauterine life.
2. Free of complications.
3. Parent-infant attachment is initiated and progressing satisfactorily.
4. Parent(s) express confidence regarding infant care.
NURSING DIAGNOSIS:
BODY TEMPERATURE, risk for altered
Risk Factors May Include:
Extreme of age (inability to shiver, larger body surface
in relation to mass, limited amounts of insulating
subcutaneous fat, nonrenewable sources of brown fat
and few white fat stores, thin epidermis with close
proximity of blood vessels to the skin)
Possibly Evidenced By:
[Not applicable; presence of signs/symptoms
establishes anactual diagnosis]
DESIRED OUTCOMES/EVALUATION
Maintain temperature WNL.
CRITERIA\u2014NEONATE WILL:
Be free of signs of cold stress or hyperthermia.
ACTIONS/INTERVENTIONS
RATIONALE
Independent
Maintain ambient temperature within
In response to lower environmental temperature,
established thermoneutral zone (TNZ)
full-term infants increase their body temperature
considering neonate\u2019s weight, gestational age,
by crying or increasing motor activity, thereby
and usual clothing provided.
possibly consuming more energy (stored glucose)
and increasing their oxygen needs. Conversely,
failure to maintain the environmental temperature
within the upper limits of the TNZ may result in
increased oxygen consumption, dehydration,
hypotension, seizures, and apnea associated with
hyperthermia.
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Monitor neonates axillary, skin (abdominal), or

Temperature stabilization may not occur until 812
tympanic and environmental temperature at
hr following birth. Rates of oxygen consumption
least every 3060 min during stabilization period,
and metabolism are minimal when skin
or more frequently, per protocol.
temperature (a reliable indicator of energy exchanges
between infant and environment) is maintained
above 97.7F (36.5C). Skin temperature measured
over the abdomen (away from bony area) is an
earlier, more reliable indicator of cold stress, because
it drops in response to peripheral vasoconstriction.
Axillary temperature readings may be misleading,
because friction in the armpit, where brown fat stores
are located, can cause false elevations. Core body
temperature, as assessed by rectal temperatures, may
remain misleadingly high, especially in the coldstressed newborn, as a result of vasoconstriction and
metabolism of brown fat stores. Core temperature
may fall only after the newborn has exhausted
compensatory mechanisms and has markedly
increased oxygen consumption. Note: Rectal
perforation may occur with insertion of rectal
thermometer, and its occurrence is associated with
70% mortality.
Assess respiratory rate; note tachypnea (rate
Infant becomes tachypneic in response to
greater than 60/min).
increased oxygen needs associated with cold stress and attempts to eliminate excess carbon
dioxide to reduce respiratory acidosis.
Postpone initial bath until body temperature is
Helps prevent further heat losses caused by
stable and reaches 97.7F (36.5C).
evaporation. Larger appropriate-for-gestational age
(AGA) infants tend to maintain body temperature
more easily than the SGA infant.
Bathe neonate, working rapidly, exposing only a
Reduces possible heat loss through evaporation

portion of the body at a time, and drying each

and convection; helps conserve energy.
part immediately. Ensure that environment is free
of drafts.
Note secondary signs of cold stress (e.g.,
Hypothermia, which increases the utilization rate
irritability, pallor, mottling, respiratory distress,
of oxygen and glucose, is often accompanied by
tremors, jitteriness, lethargy, and cool skin).
hypoglycemia and respiratory distress. Cooling also
results in peripheral vasoconstriction, with a drop in
skin temperature observed as pallor or mottling.
Irritability and apnea may be associated with
hypoxia. Untreated or undetected cold stress may
progress to metabolic acidosis, associated with
anaerobic glycolysis; pulmonary vasoconstriction or
persistent fetal circulation; inhibition of lecithin
formation and increased severity of respiratory
distress; and release of fatty acids into bloodstream,
where they compete for bilirubin-binding sites on
albumin molecules.
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Maintain thermoneutral environment through

Prevents heat imbalance or losses. Gradual
use of automatically controlled or manually
warming of hypothermic infant helps avoid
adjustable heating equipment. Maintain
possible apneic spells, hypotension, seizures, or
controlled heat source at 98.6F (37C). Position
dehydration associated with too-rapid warming
crib or incubator away from heat sources such
and hyperthermia.

as sunlight, heaters, or bilirubin lights. Promote

gradual warming of infant as needed
(approximately 1.2F [1C] per hr). Adjust
clothing as indicated.
Assess for behavioral signs associated with
Heat dissipation occurs through peripheral
hyperthermia (e.g., increased restlessness,
vasodilation and through augmentation of cooling
perspiration that begins on head or face and
by evaporation and by increase in insensible water
proceeds to chest, apnea, seizure, and
loss. Apnea, seizures, and hypotension may be
hypotension activity).
related to peripheral vasodilation, which causes
increased evaporative water losses, cerebral ischemia,
and dehydration.
Note signs of dehydration (e.g., poor skin turgor,
Axillary temperature>99.5F (37.5C) is considered
delayed voiding, dry mucous membranes,
hyperthermic and suggests overheated infant.
elevated temperature, sunken fontanels).
Dehydration may develop in relation to a threefold to
fourfold increase in insensible water loss.
Initiate early oral feeding.
For every 1.8F (1C) increase in body temperature,
metabolism and fluid needs increase approximately
10%. Failure to replace fluid losses further
contributes to dehydrated state.
Assess infant for other disease processes, such as
Temperature instability or subnormal temperature
infection, if temperature deviates more than 1.8F
may indicate infection. (Refer to ND: Infection, risk
(1C) from one reading to next.
for.) In addition, CNS disorders and dehydration
may cause hyperthermia.
Collaborative
Make arrangements for transfer to NICU, if
If temperature remains low regardless of appropriate
indicated.
intervention related to thermoregulation, transfer of
neonate may be necessary for closer observation and
treatment.
Administer seizure-control medication (e.g.,
Acts directly on cerebrum to quiet excessive motor
phenobarbital), as needed.
activity, which can cause hyperthermia.
NURSING DIAGNOSIS:
GAS EXCHANGE, risk for impaired
Risk Factors May Include:
Prenatal/intrapartal stressors, excess production of
mucus, and fluctuations of body temperature
Possibly Evidenced By:
[Not applicable; presence of signs/symptoms

establishes anactual diagnosis]

DESIRED OUTCOMES/EVALUATION
Maintain patent airway with respiratory rate WNL
CRITERIANEONATE WILL:
(between 30 and 60/min).
Be free of signs of respiratory distress.
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ACTIONS/INTERVENTIONS
RATIONALE
Independent
Estimate gestational age using Dubowitz criteria.
Surfactant system develops as gestation progresses.
Once fetus reaches 35 weeks gestation, the presence
of phosphatidyl glycerol (a component of the
surfactant complex, which indicates fetal lung
maturity) markedly decreases the incidence of
respiratory distress syndrome (RDS). Infants of
diabetic mothers who have been exposed to
prolonged hyperinsulinemia in response to maternal
hyperglycemia may have depressed surfactant
production and greater respiratory distress even
though they are beyond 35 weeks gestation at birth.
Review prenatal and intrapartal events, noting
Such events contribute to the neonates inability to
risk factors that could have contributed to excess
clear airway of excess fluid, mucus, and aspirated
lung fluid or aspiration of amniotic fluid (e.g.,
material, and to the collection of excess fluid in
maternal diabetes, cesarean birth or breech delivery, lungs, resulting in type II RDS, which
usually
maternal bleeding, intrapartal asphyxia, maternal
resolves within 6 hr.
oversedation).

Assess respiratory rate and effort. Differentiate

Normal respiratory rate is 3060/min. Periodic
periodic breathing patterns from apneic episodes.
breathing that is of no physiological significance is
manifested by apneic periods lasting 515 sec
occurring during REM sleep and periods of motor
activity. It is easily converted to a normal breathing
pattern by increasing inspired oxygen through tactile
and sensory stimulation. Apneic episodes last longer
than 2030 sec, may be associated with changes in
heart rate and skin color, and require further
assessment and intervention.
Suction nasopharynx, as needed. Note color,
Ensures clearance of airway, which is critical to
amount, and character of regurgitated mucus.
neonate, who is an obligatory nose breather and may
not learn to open the mouth in response to nasal
obstruction until 34 wk of age. Regurgitation of
mucus associated with an episode of gagging often
occurs in the second period of reactivity (26 hr after
delivery).
Position newborn on side with rolled towel for
Facilitates drainage of mucus.
support at back.
Auscultate breath sounds and record equality
Breath sounds should be equal bilaterally.
and clarity. Note presence of crackles or rhonchi.
Inspiratory crackles may be present in the first few
hours following delivery until lung fluid is absorbed
from distal bronchioles. Persistent crackles may
indicate RDS or pneumonia. Rhonchi heard on
inspiration or expiration, caused by air moving
through passages that have been narrowed by
secretions or swelling, may indicate retained
secretions/aspiration.
Review delivery records for presence of
When thick meconium is present, deep suctioning
meconium at birth or meconium-stained
should take place before the initial breath is taken
amniotic fluid; determine whether appropriate
to avoid development of meconium-aspiration
suctioning of oropharynx was performed
pneumonia.
while infants head was still on perineum.
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Observe and record signs of respiratory distress

These signs represent compensatory mechanisms
(e.g., grunting, retraction of respiratory muscles,
to overcome hypoxia. Expiratory grunting occurs
nasal flaring, and tachypnea).
as an attempt to maintain alveolar expansion and to
retain air. Retraction of respiratory muscles increases
tidal volume, nasal flaring increases the diameter of
the nares, and tachypnea occurs in an attempt to
eliminate excess carbon dioxide.
Assess newborn for presence, location, and degree
Peripheral cyanosis (acrocyanosis) associated with
of cyanosis and its relationship to activity.
vasomotor instability, hypothermia, or local venous
or arterial obstruction may persist through the
transition period. Mild cyanosis and mottling may
occur in second period of reactivity in association
with fluctuations in cardiac and respiratory rates.
Cyanosis that worsens with crying suggests cardiac
problems (unresolved PDA or congenital anomalies)
rather than respiratory problems, in which cyanosis
is usually improved with crying.
Compare neonates skin temperature and ambient
Oxygen consumption is minimal when the
air temperature.
difference between skin temperature and ambient air
temperature is<2.7F (1.5C).
Monitor newborn for signs of hypothermia or
Hypothermia and hyperthermia increase
hyperthermia. (Refer to ND: Body Temperature,
metabolic rate and oxygen consumption, causing a
risk for altered.)
possible cycle of metabolic acidosis and hypoxia that
perpetuates fetal circulation, reduces surfactant
levels, and increases respiratory distress. A drop in
skin temperature to 96.6F (35.9C) increases oxygen
consumption by 10%. Too-rapid warming of neonate
may lead to hyperthermia, which increases oxygen
consumption by 6%.
Note symmetry of chest movement.
Asymmetry may indicate pneumothorax associated
with previous resuscitative measures.
Auscultate heart sounds; note presence of murmurs.

Transient cardiac murmurs (usually systolic) may

exist in the early newborn period because of
persistence or reopening of fetal structures in response
to hypoxia and crying. PDA often occurs with
hypoxia, pulmonary vasoconstriction, right-to-left
shunting, and congestive heart failure (CHF), or more
significantly with prenatal or birth asphyxia,
hyperviscosity, polycythemia, aspiration syndrome,
and hypoglycemia. Foramen ovale normally closes at
12 hr following delivery; ductus arteriosus closes at
34 days of age. Inadequate lung perfusion and
poorly ventilated lung tissue promote airway
constriction and respiratory compromise.
Collaborative
Administer supplemental oxygen, as indicated
Persistent uninterrupted oxygen depletion
by newborns condition.
increases hypoxic state, resulting in metabolic
acidosis secondary to anaerobic metabolism.
Record use and results of mechanical monitoring
Unmonitored use of oxygen therapy can result in
of supplemental oxygen.
oxygen toxicity. Transcutaneous (pulse oximetry)
monitoring helps prevent hypoxic states and
evaluates therapeutic effectiveness.
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Assess Hb and Hct levels. Note results of

The neonate whose Hb level is lower than normal
Kleihauer-Betke test.
has reduced oxygen-carrying capacity and possibly
severe hypoxia. Hb levels<15 g/dl may be caused by
blood loss, hemolysis, or decreased RBC production.
Clinical signs of cyanosis may not appear until Hb

levels are decreased by slightly more than 3 g/dl in

central arterial blood or 46 g/dl in capillary blood.
Kleihauer-Betke test identifies fetal bleeding in utero.
Monitor arterial blood gases (ABGs), if done.
Provides accurate measurement of acid-base balance
to clarify respiratory versus metabolic deficits.
Determine Rh factor and ABO blood group of
Identifies possible antigen-antibody reaction to Rh
newborn and mother; note results of Coombs test.
or ABO incompatibility, which contributes to
(Refer to CP: Newborn: Hyperbilirubinemia.)
lowered Hb levels and oxygen-carrying capacity.
Review chest x-ray.
May be necessary to diagnose pneumothorax.
NURSING DIAGNOSIS:
NUTRITION: altered, risk for less than body
requirements
Risk Factors May Include:
Increased metabolic rate, high caloric requirement,
fatigue, minimal nutritional stores
Possibly Evidenced By:
[Not applicable; presence of signs/symptoms
establishes anactual diagnosis]
DESIRED OUTCOMES/EVALUATION
Be free of signs of hypoglycemia, with blood
CRITERIANEONATE WILL:
glucose level WNL.
Display weight loss5%10% of birth weight by time of
discharge.
ACTIONS/INTERVENTIONS
RATIONALE
Independent
Review mothers prenatal history for possible
Full-term neonates who are especially susceptible to
stressors impacting on neonatal glucose stores,
hypoglycemia are those who are chronically
such as diabetes, PIH, or cardiac or renal
stressed in utero, are exposed to high glucose
disorders. Note results of tests related to fetal
levels in utero, are SGA or LGA, or are acutely ill.
growth and placental/fetal well-being.
The newborn has unique nutritional needs related to
a rapid metabolic rate, high caloric requirement,
potential loss of fluid and electrolytes caused by
increased insensible water losses through pulmonary
and cutaneous routes, and a potential for inadequate
or depleted glucose stores.
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