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NEW BORN CARE

Objectives
 Describe the normal characteristics of a term newborn.
 Assess a newborn for normal growth and development.
 Formulate nursing diagnoses related to a newborn or the family of a newborn.
 Identify expected outcomes for a newborn and family during the first 4 weeks of life.
 Plan nursing care to augment normal development of a newborn, such as ways to aid parent-child
bonding
 Implement nursing care of a normal newborn, such as administering a first bath or instructing
parents on how to care for their newborn.
 Evaluate expected outcomes to determine effectiveness of nursing care and outcomes achievement.
 Use critical thinking to analyze ways that the care of a term newborn can be more family centered.
 Integrate knowledge of newborn growth & development and immediate care needs with the
nursing process to achieve quality maternal and child health nursing care.

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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They have immature temp.-regulating system


Of very little amount of subcutaneous fat to provide heat

They have a larger body surface area that results in more heat loss

They have little ability to conserve heat by changing posture and no ability to adjust its

own clothing
Methods of Heat Loss in Newborn
• Convection – the flow of heat from the NB’s body surface to cooler surrounding air; ex:
windows, air conditioners
• Conduction- the transfer of a body heat to a cooler solid object in contact with a baby; ex:
baby placed on a cold counter
• Radiation – the transfer of body heat to a cooler solid obj. not in contact with a baby; ex: cold
window or air con
• Evaporation – loss of heat through conversion of a liquid to a vapor; ex: after delivery,
newborns are wet, with amniotic fluid on their skin, tsb

Effects of Hypothermia
( Cold stress)

1.) Hypoglycemia- 45-55

mg/dl normal
50- borderline
2.) met acidosis-
catabolism of brown fats
(best insulator of newborns
body) will form ketones
3.) high risk for
kernicterus- bilirubin in
brain leading to cerebral
palsy
4.) additional fatigue to
allergy stressful heart

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

III. Perform Initial Assessment

 APGAR Scoring System
o Developed by Dr. Virginia Apgar in 1958
o It is a standardized method for evaluation of the newborn and serves as a baseline for future evaluations.
o It is taken twice: initially @ 1 minute, and then @ 5 minutes after birth
Special Considerations: 1st 1 min – determine general condition of baby
Next 5 min- determine baby’s capabilities to adjust extra uterinely
Next 15 min – dependent on the 5 min

APGAR Scoring System

0 1 2

Appearance Pale or Body pink, Pink all over

(Color) blue all over extremities blue
Pulse/♥ rate absent Below 100 Above 100
G rimace/Reflex No response grimace Sneezes,gags,
Irritability coughs,vigorous cry and foot
withdrawal
A ctivity / Muscle Limp, flaccid Some flexion of the extremities Active motion/
Tone well-flexed
R espiratory Effort absent Slow,irregular,weak cry Good, strong,lusty cry
APGAR result
0 – 3 = severely depressed, need CPR, admission NICU
4 – 6 = moderately depressed, needs add’l suctioning & O2
7 - 10 =good/ healthy

Silvermann & Anderson Scoring System

o Devised in 1956 and is a test used to evaluate or estimate the degrees of respiratory distress in newborns or the
respiratory status of premature infants.
o A NB is observed and then scored on each of five criteria ---0,1 or 2. The scores are then added. (the scores of this
system are interpreted as opposite of the Apgar)

The Silverman & Anderson Scoring System

0 1 2
Chest Movement Synchronized respirations Lag on inspiration Seesaw respirations
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Intercostal Retraction none Just visible Marked

Xiphoid Retraction none Just visible Marked

Nares Dilatation none minimal Marked
Expiratory Grunt none Audible by stethoscope Audible by unaided ear

Silvermann and Anderson Scoring Interpretation

 0 : no respiratory distress
 4-6 : moderate respiratory distress
 7-10 : severe respiratory distress

IV. Proper Identification of the Newborn

 Proper Id is made in the delivery room before mother and baby are seperated.
o Identification Band
o Footprints
o Others – fingerprints, crib card, bead bracelet
 Birth certificate
 A final identification check of the mother and infant must be performed before the infant can be allowed to leave
the hospital upon discharge to ensure that the hospital is discharging the right infant.
V. Preventing Infection

Credes Prophylaxis – Dr. Crede

 -prevent opthalmia neonatorum or gonorrheal conjunctivitis
- how transmitted – mom with gonorrhea
drug: erythromycin ophthalmic ointment- inner to outer

*It is part of the routine care of the NB to give prophylactic eye

treatment against gonorrheal conjunctivitis or ophthalmia neonatorum
within the first hour after delivery.
* Neisseria gonorrhea, the causative agent,maybe passed on to the
fetus when infected vaginal and cervical secretions enter the eyes as
the baby passes the vaginal canal during delivery. This practice was
introduced by Crede, German gynecologist in 1884. Silver Nitrate,
erythromycin and tetracycline ophthalmic ointments are the drugs
used for this purpose.

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)

Administering Erythromycin or Tetracycline Ophthalmic Ointment

 These ointments are the ones commonly used nowadays for eye prophylaxis because they do not cause eye irritation
and are more effective against Chlamydial conjunctivitis.
 Apply over lower lids of both eyes, then, manipulate eyelids to spread medication over the eyes.
 Wipe excess ointment after one minute Č sterile cotton ball moistened Č sterile water.

Principles of cleanliness at birth:

 Clean hands
 Clean perineum
 Nothing unclean to be introduced into the vagina
 Clean delivery surface
 Cleanliness in cutting the umbilical cord
 Cleanliness for cord care of the newborn baby
Handwashing
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 Before entering the nursery or caring for a baby

 In between newborn handling or after the care of each baby
 Before treating the cord
 After changing soiled diaper
 Before preparing milk formula.

VI. Preventing Hemorrhage

 As a preventive measure, 0.5mg (preterm) to 1 mg (full term) Vit. K or Aquamephyton is injected IM in the NB’s
vastus lateralis (lateral anterior thigh)muscle
 Vit-K – to prevent hemorrhage R/T physiologic hypoprothrombinemia
 Aquamephyton, phytomenadione or konakion
 .1 ml term IM, vastus lateral or lateral ant thigh
 .05 ml preterm baby
 Vit K – synthesized by normal flora of intestine
 Vit K – meds is synthetic due intestine is sterile

Procedure for vitamin K injection. Cleanse

area thoroughly with alcohol swab and
allow skin to dry. Bunch the tissue of the
upper outer thigh (vastus lateralis muscle)
and quickly insert a 25-gauge 5/8-inch
needle at a 90-degree angle to the thigh.
Aspirate, then slowly inject the solution to
distribute the medication evenly and
minimize the baby’s discomfort. Remove
the needle and gently massage the site with
an alcohol swab.

Care of the Cord

 The cord is clamped and cut approx. within 30 sec after birth. In the DR, the cord is clamped
twice about 8 inches from the abdomen and cut in between.
 When the NB, is brought to the nursery, another clamp is applied ½ to 1 in from the abdomen
and the cord is cut a second time.
 The cord and the area around it are cleansed w/ antiseptic solution.
 The manner of cord care depends on hospital protocol or the discretion of the birth attendant in
home delivery, what is impt. Is that principles are followed.
 Cord clamp is removed after 48 hours when the cord has dried. The cord stump usually dries
and falls off within 7-10 days leaving a granulating area that heals on the next 7-10 days.
 Leave cord exposed to air. Do not apply dressing or abdominal binder over it. The cord dries and
seperates more rapidly if it is exposed to air.
 Report any unusual signs & symptoms that indicate infection:
o Foul odor in the cord
o Presence of discharge
o Redness around the cord
o The cord remains wet and does not fall off within 7-10 days
o Newborn fever
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“Tetanus microorganism thrives in anaerobic environment so you actually prevent infection if cord is
exposed to air”.

Full bath – safely given when cord fall

3 cleans in community
o clean hand Dressing the Umbilical Cord – strict asepsis
o clean cord to prevent tetanus
o clean surface
betadine or povidone iodine – to clean cord Bathing
check AVA, then draw 3 vessel cord - oil bath – initial
- to cleanse baby & spread vernix caseosa
If 2 vessel cord- suspect kidney malformation Fx of vernix caseosa
- leave about 1” of cord 1. insulator
- if BT or IV infusion – leave 8” of cord best access - no nerve 2. bacterio- static
- check cord every 15 min for 1st 6 hrs – bleeding .> 30 cc of blood Babies of HIV + mom – immediately give full
bleeding of cord – Omphalagia – suspect hemophilia bath to lessen transmission of HIV
- 13 – 39% possibly of transmission of
Cord turns black on 3rd day & fall 7 – 10 days HIV
Faiture to fall after 2 weeks- Umbilical granulation
Mgt: silver nitrate or catheterization
- clean with normal saline solution not alcohol
- don’t use bigkis – air
- persistent moisture-urine, suspect patent uracus – fistula bet bladder and normal umbilicus
dx: nitrazine paper test – yellow – urine
mgt: surgery
Immediate Care of the Newborn

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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Newborn Assessment and Nursing Care

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

 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
o Head circumference - 33 to 35 cm
o Expected findings
o Head should be 2 to 3 cms larger than the chest
o Abdominal circumference – 31-33 cm
o Weight range - 2500 - 4000 gms (5 lbs. 8oz. - 8 lbs. 13 oz.)
o Length range - 46 to 54 cms (19 - 21 inches)
Anthropometic measurement
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
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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.

If the central circulation is adequate, the

blood supply should return quickly when
the skin is blanched with a finger. Blue
hands and nails are poor indicator of
oxygenation in NB. The nurse should
assess the face & mucus membranes for
pinkness reflecting adequate oxygenation

 Mongolian Spots

Patch of purple-black or blue-black

color distributed over coccygeal and
sacral regions of infants of African-
American or Asian descent. Not
malignant. Resolves in time. They
gradually fade during the first or
second year of life. They maybe
mistaken for bruises and should be
documented in the NB’s chart.
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 Mottling

lacy pattern of dilated blood vessels

under the skin
Occurs as a result of general
circulation fluctuations. It may last
several hours to several weeks or
may come and go periodically.
Mottling maybe related to chilling
or prolonged apnea.

 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

Care of Newborn in Jaundice

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 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

 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

 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.

 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.
 Birthmarks frequently worry parents. The mother maybe
especially anxious, fearing that she is to blame (“Is my
baby marked because of something I did?”) Guilt feelings
are common when parents have misconceptions about the
cause. Identify and explain them to the parents.
 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.

 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

 Face, Mouth, Eyes, and Ears

o Assess and record symmetry
o Assess for signs of Down syndrome.
o Low set ears
o Assess history for risk factors of hearing loss
o Test for Moro reflex- elicited by a loud noise or lifted slightly above the crib and then suddenly
lowered. In response, the NB straightens arms and hands outward while the knees flexed. Slowly
the arm returns to the chest as in embrace. The fingers spread, forming a C and the newborn may
cry. This lasts up to 6 months of age.
o Check for presence of gag, swallowing reflexes, coordinated with sucking reflex
o Check for clefts in either hard or soft palates
o Check for excessive drooling
o Check tongue for deviation, white cheesy coating
Eyes
o Assess for PERLA (pupils equal and reactive to light and accommodation)
o Assess cornea and blink reflex
o Note true eye color does not occur before 6 months
o May have blocked tear duct
 Heart and Lungs
 Assess and maintain airway
 Assess heart rate, rhythm - evaluate murmur: location, timing, and duration
o Examine appearance and size of chest
o Note if there is funnel chest, barrel chest, unequal chest expansion
 Assess breath sounds and respiratory efforts - evaluate color for pallor or cyanosis
 Breasts are flat with symmetric nipples - note lack of breast tissue or discharge
Abdomen
 Abdomen appears large in relation to pelvis
o Note increase or decrease in peristalsis
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o Note protrusion of umbilicus

 Measure umbilical hernia by palpating the opening and record
o Note any discharge or oozing from cord
o Note appearance and amount of vessels
 Auscultate and percuss abdomen
o Assess for signs of dehydration
o Assess femoral pulses
o Note bulges in inguinal area
o Percuss bladder 1 to 4 cm above symphysis
o Voids within 3 hours of birth or at time of birth
Genitals
o Pseudomenstruation: the discharge w/c can become tinged w/ blood and is caused by withdrawal of
maternal hormones
o Smegma: a white cheeselike substance is often present between labia. Removing it may traumatize
tender tissue
o Phimosis : tight foreskin or prepuce; w/c sometimes lead to early circumcision
o Cryptoorchidism: undescended testes ;if the testes did not go down
o Orchidopexy: repair of undescended testes before 2 y/o
o Penis: urethra should be at the tip of the penis
o Hypospadias : if the opening is at the ventral surface
o Epispadias: if the opening is at the dorsal surface
o Hydrocele – swelling due to accumulation of serous fluid in the tunica vaginalis of the testis or in the
spermatic cord
Anus
o Inspect anal area to verify that it is patent and has no fissure
o Digital exam by physician or nurse practitioner if needed
o Note passage of meconium
Extremities
o Tic dwarfism : very short arms
o Amelia : absence of arms
o Phocomelia : absence of long arm
o Polydactilism: more fingers; extra digits on either hands or feet
o Syndactilism: webbing; fusion of fingers or toes
o *Inspect the hands for normal palmar creases. A single palmar crease called SIMIAN line is frequently
present in Down’s syndrome
o Adactyl : no foot
o Down’s syndrome: inward rotation of little fingers
o Clubfoot/ talipes deformity – inward rotation of foot fingers.
o Erb-Duchenne paralysis (Erb’s palsy) : resulting from injury to the 5th and 6th cervical roots of the
brachial plexus; usually from a difficult birth; it occurs commonly when strong traction is exerted on
the head of the NB in an attempt to free a shoulder lodged behind the symphysis pubis in the presence
of shoulder dystocia.

A, The asymmetry of gluteal and thigh fat folds seen in infant with left
developmental dysplasia of the hip.
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B, Barlow's (dislocation) maneuver. Baby's thigh is grasped and

adducted (placed together) with gentle downward pressure.

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

o Nurse examines feet for evidence of talipes

deformity (clubfoot)
o Intrauterine positions can cause feet to appear
to turn inward - "positional" clubfoot
o To determine presence of clubfoot, nurse
moves foot to midline - if resists, it is true
clubfoot

B, To determine the presence of clubfoot, the nurse moves the foot to

the midline. Resistance indicates true 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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o Involve family early in care of infant

o Process establishes uniqueness and allays concern
 Teaching TALIPES – “clubfoot”
o Feeding cues a.) Equinos – plantar flexion – horsefoot
b.) Calcaneous – dorsiflexion – heal
o Alert state
lower that foot anterior posterior of
o Cord care foot flexed towards anterior leg
o Sleeping c.) Varus- foot turns in
Neurological Status d.) Valgus- foot turns out
 Assessment begins with period of observation Equino varus- most common
 Observe behaviors - note:
o State of alertness
o Resting posture
o Cry
o Quality of muscle tone
o Motor activity
o Jitteriness – feeling of extreme nervousness
o Differentiate causative factors
 Examine for symmetry and strength of movements
 Note head lag of less than 45 degrees
 Assess ability to hold head erect briefly

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

Babinski reflex - When the

sole of the foot is firmly
stroked, the big toe bends back
toward the top of the foot and
the other toes fan out. This is a
normal reflex up to about 2
years of age.

 Tonic neck reflex

Tonic neck reflex - When a baby's head is
turned to one side, the arm on that side
stretches out and the opposite arm bends
up at the elbow. This is often called the
"fencing" position. The tonic neck reflex
lasts about six to seven months.
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 Grasp reflex

Grasp reflex - Stroking the palm of a baby's

hand causes the baby to close his/her fingers in
a grasp. The grasp reflex lasts only a couple of
months and is stronger in premature babies.
Palmar & Plantar

 Palmar & Plantar 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

Root reflex - This reflex begins when the

corner of the baby's mouth is stroked or
touched. The baby will turn his/her head
and open his/her mouth to follow and
"root" in the direction of the stroking.
This helps the baby find the breast or
bottle to begin feeding.

 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.

ASSESSMENT OF PHYSICAL MATURITY CHARACTERISTICS OF NEWBORN

 Observable characteristics of newborn should be evaluated while not disturbing baby
 Gestational assessment tools examine the following physical characteristics
o Resting posture
o Skin
o Lanugo
o Sole (planar) creases
o Breast tissue
o Ear form and cartilage distribution
o Evaluation of genitals
Male genitals

A, Preterm newborn’s testes are not within the

scrotum. The scrotal surface has few rugae. score 2 B, Term newborn’s testes are generally fully descended. The entire
surface of the scrotum is covered by rugae. Score 3.
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Female genitals

A, Newborn has a prominent clitoris. The

labia majora are widely separated, and the
labia minora, viewed laterally, would
protrude beyond the labia majora. Score 1.
The gestational age is 30 to 35 weeks.

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

Square window sign

A, This angle is 90 degrees and suggests an immature

newborn of 28 to 32 weeks’ gestation. Score 0.

B, A 30- to 40-degree angle is commonly found

from 39 to 40 weeks’ gestation. Score 2-3.

C, A 0-degree angle can occur from 40 to 42 weeks. Score 4.

(C) Used with permission from V.Dubowitz, MD,
Hammersmith Hospital, London, England.
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Scarf sign

B, The elbow is at midline at

36 to 40 weeks’ gestation.
Score 2 C, Beyond 40 weeks’ gestation, the
elbow will not reach the midline.
A, No resistance is noted until after 30 weeks’ Score 4.
gestation. The elbow moves readily past the midline.
Score 1
BOARD EXAM REVIEW IN PEDIATRIC NURSING
Assessment of Gestational Age
-Ballards & Dobowitz
Findings Less 36 weeks (Preterm) 37 - 38 39 and up
Sole creases Anterior transverse crease Occasional creases 2/3 Covered with creases
only in
Breast nodules 2mm 4mm or 3.5 mm > 5 or 7mm
Scalp hair Fine & fuzzy Fine & fuzzy Coarse & silky
Ear lobe Pliable Some cartilage Thick cartilage
Testes and Scrotum testes in lower canal Some intermediate Testes pendulus
Scrotum – small few rugae Scrotum full extensive rugae

Signs of Preterm Babies

Born after 20 weeks, after 37 weeks
-frog leg or laxed positon
-hypotonic muscle tone- prone resp problem
-scarf sign – elbow passes midline pos.
- square window wrist – 90 degree angle of wrist
- heal to ear sign-
abundant lanugo-

Signs of Post term babies:

> 42 weeks
- classic sign – old man’s face
- desquamation – peeling of skin
- long brittle finger nails
- wide & alert eyes

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