Newborn Assessment & Nursing Care

absent HR

apgar score

0

slow HR <100 apgar score

1

>100 HR apgar score

2

apneic

apgar score

0

slow-irregular, shallow

apgar score

1

regular respirations (30-60 min) strong, good cry

apgar score

2

muscle tone: limp, flaccid

apgar score

0

muscle tone: some flexion of extremities

apgar score

1

muscle tone: active motion, tight flexion

apgar score

2

reflex irritability: none (no response)

apgar score

0

reflex irritability: grimace or frown when irritated

apgar score

1

reflex irritability: sneeze, cough, or vigorous cry

apgar score

2

cyanotic or pale

apgar score

0

appropriate body color, blue extremities

apgar score

1

completely appropriate color

apgar score

2

1 minute Apgar
❖ Crying vigorously
❖ Active flexion
❖ Pink face and lips,
blueish trunk and extremities

maybe 8

5 minute Apgar
❖ RR 56 breaths/min
❖ HR 126 bpm
❖ Active flexion
❖ Rooting reflex observed and sneezing
❖ Pink trunk and face, blue hand and feet

9

normal temp for newborn

97.7-99.5

normal HR for newborn

110-160

murmurs are normal for a newborn for how long

at delivery because of fetal circulation, resolved within first 24 hours

BP for a newborn systolic

50-75

BP for a newborn diastolic

30-45

immediate care for a newborn

maintain clear airway, (bulb)

thermoregulation,

meds,

initiation of first feeding,

parent-newborn attachment

neonatal distress s/s call provider

retractions,

nasal flaring,

grunting,

facial grimacing,

cyanosis,

abdominal distention,

vomiting,

jitteriness (glucose less than 40)

what does the Newborn Maturity Rating: Ballard Scale assess

neuromuscular and physical maturity to estimate gestational age

when you don’t know age of the baby or complications

Complete the Ballard Scale when

preterm, post term, no prenatal care, any complications, or if age is unknown

(determining gestational age)

physical maturity skin

texture and transparency (leathery, cracks, veins visible)

lanugo

presence and amount

plantar surfaces

creases over sole

breast

nodule and areolar area

eyes and ears

fusion of eyelids, ear stiffness, pinna recoil

male genitals

scrotum, testes, rugae

female genitals

clitoris, labia majora, labia minora

SGA - Small for gestational age weight less than the ____ percentile
(usually ____) - slide 14

10th

<5.5lb

AGA- Appropriate for gestational age between ___ and ____ percentile

10th

90th

Large for gestational age more than the ___ percentile
(usually >___...good rule of thumb is anything ____ grams or greater)

90th

9lbs

4000

neonatal transition

up to the first 6 hours of life

neonate

birth to 28 days

infant

under 1 year of age

until babies take their first breath, scream and cry, their lungs are filled with

fluid

a surface-tension reducing lipoprotein critical for alveolar stability

surfactant

Lung maturity more evident in __+ gestational age
infant

35

reflex breathing triggers

LOW BLOOD OXYGEN LEVELS
INCREASE BLOOD CARBON DIOXIDE
LOW BLOOD PH
TEMPERATURE CHANGES
DRYING

infants are ____ breathers

nose

normal RR for infants

30-60 breaths/min

apnea more than ___ seconds is abnormal

20

periodic breathing lasting ___ seconds

5-15

Umbilical vein to inferior vena cava

ductus venosus

right to left atrium

foramen ovale

Pulmonary artery to descending aorta

DUCTUS ARTERIOSUS

heat is produced by

shivering - limited muscle maturity

non-shivering - burning brown fat

non-shivering

brown fat

Problem maintaining normal temperature usually due to excessive
______ rather than impaired heat production*

heat loss

exposure to cool air currents

convection

exposure to cool objects near infant

radiation

- wet body surface (why we dry the baby at birth)

evaporation

- cold table surface, scale, cold

conduction

excessive heat loss resulting in compensatory mechanisms
(increased respirations and nonshivering thermogenesis) to
maintain core body temperature

cold stress

s/s of cold stress

lethargy,

hypotonia,

can lead to apnea and resp. distress

coordinating suck & swallow

rooting reflex

newborns have a lack of

enzymes and microflora

stomach capacity for newborns for day one of feeding

10-15 mL so small amount but feed more frequent

First _____ after birth, the newborn’s small stomach does not stretch to hold more, as it will within a ________

24 hours

day or two later

Should occur within first 24hr

Meconium stool (first stool), first pee

Transition from meconium, brown to ______

green

Breastfed babies ______ semi liquid yellow stools a day
per day by _______ day after milk production is established

6-10 small,

3rd or 4th

Formula-fed babies
_____ stools per day, more formed, yellow

1-2

Urination
● ___ wet diapers per day
● Should have first urination in first ______

6-8

24 hours

jitteriness and irritability is sign of

GHTN

gestational hypertension

for a vaginal birth fetal head molding/ridges on the bone should resolve

24 hours after birth

edema that will resolve in a couple of days on the scalp that CROSSES the suture line

caput succedaneum,

notify parents it will resolve in 3-4 days

blood on the scalp that does not resolve on its own, and it does NOT cross the suture line

cephalohematoma

What times do you do at apgar?

1 minute and 5 minutes

what does apgar stand for

appearance, pulse, grimace, activity, respirations

purpose of apgar in newborn assessment?

to measure overall health at birth

meds for baby for delivery

vitamin K IM for clotting,

erythromycin to prevent eye infections (antibiotic ophthalmic ointment),

hep b vaccine

when babies shiver and burn that fat to prevent cold what can drop?

blood glucose

Method commonly used to prevent neonatal heat loss in newborn babies?

skin to skin

Overheating also causes neonatal stress so a neutral thermal environment is crucial for stabilization, limited ability to sweat when overheated, _______________ during the golden first hour of life can help the infant thermoregulate

skin-to-skin or kangaroo care

Aid in digestion by encouraging initial feeding in __________, Rooting reflex, lack of enzymes and micro flora, Biggest benefit bf is boost to immune system and natural bioenzymes

first 30 minutes

Face/Eyes/Ears look for

symmetry

●Eye color established approx. _ months

3

●Eyelids edematous during

first few days of life

●Mouth-lips should be pink

           -saliva normally ____

           -Epstein’s Pearls

           -Thrush

scant

Ears-top of ears (pinna) should be ______ to the outer and inner canthus of the eye

if lower - tri 21

parallel

________ most immature sensory capability, only 8-10 inches in front of face, which is why mom’s nipples darken to be seen as a target to aim for when breastfeeding

Eyesight

jaundice starts where

how to check

face then spreads,

blanch to check

hormonal small white acne bumps usually on nose and cheeks

MILIA

don’t mess with it, document & move on

red marks on forehead, eyelids, nose, maybe back

●TELANGIECTATIC NEVI

  “stork bite”

newborn rash

ERYTHEMA TOXICUM

CONGENITAL DERMAL MELANOCYTOSIS

mongolian spot, melanin

cottage cheese looking like protectant for thermoregulation

VERNIX CASEOSA

abdomens should be _________, protrude slightly, and move with respirations

most common abnormal findings

cylindrical,

hernias most common abnormal findings

*Auscultate _________ before palpation

Bowel Sounds

is umbilical cord bleeding normal or abnormal?

abnormal

urethral opening forms on the underside of the penis rather than the tip

hypospadias, document

where one or both testes fail to move into the scrotum before birth

CRYPTORCHIDISM, document

a collection of fluid in the scrotum surrounding the testicle, often causing painless swelling.

hydrocele, document

normal, light vaginal bleeding in newborn baby girls, usually occurring 2–10 days after birth due to a sudden drop in maternal hormones (estrogen)

PSEUDOMENSTRUATION, just educate them & document

a normal, harmless, cheese-like mixture of dead skin cells, oils, and moisture that accumulates under the foreskin or around the clitoral hood

smegma