Chapter 24: Nursing Care of Newborns

Chapter 24: Nursing Care of Newborns

Newborn care consists of stabilization and/or resuscitation. This can include establishing a patent airway, maintaining adequate oxygenation, and thermoregulation for the maintenance of body temperature. A physical assessment (physical examination, measurements, and monitoring laboratory studies) is done every 8 hr or as needed.

Nursing interventions and family teaching (umbilical cord care, prophylactic measures, newborn screening, newborn feedings and bathing, and fostering baby-friendly activities) are integrated into a newborn’s plan of care.

QEBP

• Using the facility’s preferred pain assessment tool, conduct a pain assessment on the newborn with routine assessments and following painful procedures. Q

• Newborn hearing screening is required in most states. Newborns are screened so that hearing impairments can be detected and treated early. 

• Provide family education and promote family-newborn attachment. 

• The newborn should be warmed slowly over a period of 2 to 4 hr. Correct hypoxia by administering oxygen. Correct acidosis and hypoglycemia.

QPCC

• Decreased risk of penile cancer and cervical cancer in female partners (Circumcision)

QS

• Identification (using two identifiers) is applied to the newborn immediately after birth by the nurse. It is an important safety measure to prevent the newborn from being given to the wrong parents, switched, or abducted. 

• Newborns sleep approximately 16 to 19 hr/day with periods of wakefulness gradually increasing. Newborns are positioned supine, “safe sleep,” to decrease the incidence of sudden unexpected infant death (SUID).

Newborn Physical Assessment

Vital signs should be checked frequently per facility protocol.

Daily weight should be measured at the same time using the same scale.

Umbilical cord should be inspected for bleeding and secured to prevent hemorrhage.

Observe periods of reactivity within the first 6 to 8 hours after birth:

First period of reactivity (first 30 min)

• Newborn is alert, active, and makes sucking sounds.

• Heart rate rises to 160-180 bpm, then stabilizes at 100-120 bpm.

• Respiratory rate is elevated.

Period of relative inactivity (lasts 60 to 100 min)

• Newborn becomes quiet, rests, and sleeps.

• Heart rate and respirations slow down.

Second period of reactivity (2 to 8 hours after birth)

• Newborn reawakens, becomes active again.

• Gagging and choking on mucus may occur.

• Can last from 10 minutes to several hours.

Conduct a pain assessment using the facility’s preferred pain assessment tool.

First period of reactivity (first 30 min after birth) (1 of 3)

Newborn is alert, active, and makes sucking sounds.

Heart rate rises to 160-180 bpm, then stabilizes at 100-120 bpm.

Respiratory rate is elevated.

Period of relative inactivity (lasts 60 to 100 min after birth) (2 of 3)

Newborn becomes quiet, rests, and sleeps.

Heart rate and respirations slow down.

Second period of reactivity (2 to 8 hours after birth) (3 of 3)

Newborn reawakens, becomes active again.

Gagging and choking on mucus may occur.

Can last from 10 minutes to several hours.

Newborn Laboratory Tests

Routine Tests

• Hemoglobin (Hgb) and Hematocrit (Hct) if prescribed.

• Blood glucose for hypoglycemia per facility policy.

• Serum bilirubin before discharge.

Metabolic Screening

• Mandatory newborn genetic screening via heel stick

  • 24 hours after birth.

  • Must have had breast milk or formula for at least 24 hours for accurate results.

  • Repeat test in 1 to 2 weeks if discharged before 24 hours.

• Phenylketonuria (PKU) screening is required in all states.

• Additional tests may include galactosemia, cystic fibrosis, maple syrup urine disease, hypothyroidism, and sickle cell disease.

Blood Sample Collection

• Perform heel stick using sterile gloves.

• Warm the heel to improve circulation.

• Clean with antiseptic and dry before incision.

• Use spring-activated lancet for quick and painless incision.

• Use outer aspect of the heel, with lancet depth no more than 2.4 mm to prevent bone injury.

• Follow facility protocol for labeling and specimen collection.

• Apply pressure with dry gauze (not alcohol) until bleeding stops, then cover with a bandage.

• Provide comfort and reassurance after the procedure.

Newborn Circumcision

Surgical removal of the foreskin of the penis.

Parents decide based on health, hygiene, religion, culture, or social norms.

Timing:

• Within the first few days but may be delayed for medical or cultural reasons.

  • Not performed immediately due to low vitamin K levels (risk of bleeding).

Health Benefits:

• Improved hygiene.

• Lower risk of sexually transmitted infections (STIs) like HIV and HPV.

• Reduced risk of penile cancer and cervical cancer in female partners.

Newborn Circumcision Risks and Contraindications

Bleeding

Infection

Meatal stenosis (narrowing of the urinary opening)

Urethral fistula

Adhesions or dehiscence (skin separation)

Concealed penis

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Hypospadias or epispadias (abnormal urethral positioning)

Family history of bleeding disorders

Newborns who have not received vitamin K (higher bleeding risk)

Circumcision Gomco Clamp (Image)

Preprocedure Care for Newborn Circumcision

Check for:

• Bleeding disorders (family history of hemophilia or clotting disorders)

• Hypospadias or epispadias (abnormal urethral positioning)

• Ambiguous genitalia (unclear male or female characteristics)

• Signs of illness or infection

Nursing Actions

• Obtain signed informed consent from parents.

• Prepare supplies and administer prescribed medications.

• Assist during procedure:

  • Secure newborn on the restraining board and use a radiant heat source to prevent cold stress.

  • Keep a bulb syringe available for suctioning if needed.

  • Comfort the newborn as required.

  • Document procedure details, including:

    • Time and type of circumcision

    • Amount of bleeding

    • Voiding status post-procedure

Intraprocedure Care for Newborn Circumcision

Anesthesia

• Types used:

  • Ring block

  • Dorsal-penile nerve block

  • Topical anesthetic (eutectic mixture of local anesthetics)

  • Oral sucrose for pain relief

• Nonpharmacologic support:

  • Swaddling

  • Non-nutritive sucking

Equipment

1. Gomco (Yellen) or Mogen Clamp:

   • Clamp is applied to loosen the foreskin and provide a cutting surface for removal.

   • The clamp reduces blood loss.

   • Sterile petroleum gauze is used to prevent infection and control bleeding.

2. Plastibell Device:

   • A suture is tied around the foreskin at the coronal edge of the glans.

   • This cuts off circulation, leading the foreskin to fall off within 5 to 7 days.

   • No petroleum is used with the Plastibell method.

Circumcision Plastibell (Image)

Postprocedure Care for Newborn Circumcision

Nursing Assessment

• Monitor for bleeding:

  • Every 15 to 30 minutes for the first hour

  • Then check hourly for the next 4 to 6 hours

• Observe the first voiding

Nursing Actions

• Remove the newborn from the board and swaddle for comfort

• Monitor for bleeding and voiding

  • Apply light gauze pressure if oozing is present

• Apply diaper loosely to avoid pressure on the circumcised area

• Pain relief:

  • Liquid acetaminophen 10 to 15 mg/kg orally every 4 to 6 hours (max 30 to 45 mg/kg/day)

• Provide discharge instructions to parents regarding infection signs, pain relief, and when to seek medical help

Client Education

• Consent must be signed before the procedure

• Feeding instructions:

  • No bottle feeding for 2 to 3 hours before the procedure (aspiration risk)

  • Breastfeeding is allowed

• Diaper care:

  • Change diapers every 4 hours

  • Clean penis with warm water at each diaper change

  • For clamp procedures, apply petroleum jelly for at least 24 hours to prevent sticking

• Do not wrap the penis in tight gauze to avoid circulation issues

• No tub baths until fully healed, but warm water can be trickled over the penis

• Normal healing signs:

  • A yellowish mucus film may appear by day 2 (do not remove it)

• Avoid alcohol-based wipes

• Healing process:

  • Circumcision heals within a couple of weeks

• When to notify the provider:

  • Redness, swelling, strong odor, tenderness, lack of urination, excessive crying, or foul-smelling drainage

Complications and Nursing Management for Circumcision

Hemorrhage

• Monitor for bleeding

• Apply gentle pressure with a small gauze square

• Use Gelfoam powder or sponge to help stop bleeding

• If bleeding persists:

  • Notify the provider (may need vessel ligation)

  • Have a nurse continue applying pressure while another prepares suture material

Cold Stress / Hypoglycemia

• Monitor for heat loss leading to increased respirations and low body temperature

• Swaddle and feed the newborn immediately after the procedure

Respiratory Complications

Bradypnea: Respirations ≤ 30/min

Tachypnea: Respirations ≥ 60/min

Abnormal breath sounds: Expiratory grunting, crackles, wheezes

Respiratory distress: Nasal flaring, retractions, grunting, gasping, labored breathing

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Interventions

• Use bulb syringe for mouth first, then nostrils

• Cesarean newborns have more fluid in the lungs

• Use mechanical suction if bulb syringe is ineffective

• Teach family proper suctioning techniques:

  • Compress bulb before inserting into side of the mouth

  • Avoid center of mouth to prevent gag reflex

  • Suction mouth first, then nostrils

Newborn Identification

Apply two identifiers immediately after birth to prevent mix-ups or abduction

Plastic ID wristbands with locks (cut for removal) placed on ankle and wrist

Info includes:

• Newborn’s name, sex, birth date, time, health record number

• Footprints of newborn & thumbprints of parents

ID must match parent's band before newborn is given to them

Staff wear ID badges for authentication

No one without an ID badge can remove the newborn from the unit

Many facilities use electronic security systems to prevent unauthorized removal

Thermoregulation

Helps maintain the newborn's core body temperature with minimal oxygen and energy use.

Key Points:

• Newborns use brown fat metabolism to stay warm but have limited reserves.

• Cold stress can increase oxygen demands and deplete energy.

• Monitor for Hypothermia:

  • Axillary temperature below 36.5°C (97.7°F)

  • Cyanosis

  • Increased respiratory rate

• Aim to keep core temperature at 36.5 to 37°C (97.7 to 98.6°F)

Temperature Stabilization: Newborn’s temperature usually stabilizes at 37°C (98.6°F) within 12 hours after birth.

Brown fat metabolism

A specialized type of fat tissue that plays a crucial role in energy metabolism and thermogenesis (heat production).

Heat Loss Mechanisms

Conduction (Direct Contact Loss)

• Loss of heat to cooler surfaces through direct contact.

• Preventive Actions:

  • Preheat warmer and stethoscope

  • Place baby on parent's chest and cover with a warm blanket and cap.

Convection (Air Currents)

• Heat loss due to cool air around the newborn.

• Preventive Actions:

  • Avoid fans or air conditioning drafts

  • Swaddle newborn in a blanket and cover the head

  • Maintain room temperature between 22 to 26°C (72 to 78°F)

Evaporation (Liquid to Vapor Loss)

• Heat loss from evaporation of moisture on the skin.

• Preventive Actions:

  • Dry newborn thoroughly with a warm blanket after birth

  • Delay bath until temperature stabilizes

Radiation (Indirect Surface)

• Heat loss to nearby cold surfaces without direct contact.

• Preventive Actions:

  • Keep crib away from windows or air conditioners

Conduction (Direct Contact Loss)

Loss of heat to cooler surfaces through direct contact.

Preventive Actions:

• Preheat warmer and stethoscope

• Place baby on parent's chest and cover with a warm blanket and cap.

Convection (Air Currents)

Heat loss due to cool air around the newborn.

Preventive Actions:

• Avoid fans or air conditioning drafts

• Swaddle newborn in a blanket and cover the head

• Maintain room temperature between 22 to 26°C (72 to 78°F)

Evaporation (Liquid to Vapor Loss)

Heat loss from evaporation of moisture on the skin.

Preventive Actions:

• Dry newborn thoroughly with a warm blanket after birth

• Delay bath until temperature stabilizes

Radiation (Indirect Surface)

Heat loss to nearby cold surfaces without direct contact.

Preventive Actions:

• Keep crib away from windows or air conditioners

Newborn Care: Bathing, Feeding, and Sleep

Bathing

• Bathe only when temperature stabilizes at ≥ 36.5°C (97.7°F).

• Delay sponge bath until thermoregulation is stable.

• Wear gloves until the newborn’s first bath to prevent exposure to body secretions.

Feeding

• Start feeding immediately after birth.

• Breastfeeding: Begin as soon as possible (baby-friendly initiative).

• Formula Feeding: Start around 2 to 4 hours after birth.

  • Feed every 3 to 4 hours for bottle-fed infants, more frequently for breastfed infants.

  • Monitor and document feedings as per protocol.

Sleep

• Newborns sleep 16 to 19 hours per day with increasing wakefulness.

• Place newborn supine (on the back) to reduce Sudden Unexpected Infant Death (SUID) risk.

  • No bumper pads, loose linens, or toys in the bassinet.

  • Parents should sleep near but not share a bed with the newborn.

  • Educate parents about immunizations to prevent SUID.

Newborn Care: Infection Control & Family Education

Infection Control

• Prevent cross-contamination between newborns and staff.

• Use individual bassinets with diapers, T-shirts, and supplies.

• Hand hygiene: Scrub with antimicrobial soap before entering the nursery.

• Follow facility hygiene protocols between newborn care.

• Use gowns or uniforms to avoid direct contact.

Family Education

• Educate family during nursing care to encourage involvement.

• Guide parents in performing newborn care under supervision.

• Encourage holding the newborn for eye contact and bonding.

• Promote sibling interaction in newborn care.

Newborn Care: Umbilical Cord

Goal: Prevent infection and hemorrhage.

Nursing Actions:

• Clamp stays for 24-48 hours.

• Clean with water, using cleanser sparingly if needed.

• Assess stump for redness, swelling, or drainage during diaper changes.

• Fold diaper down to keep the cord dry.

• No submersion in water until the cord falls off (10-14 days).

Medications: Erythromycin Eye Prophylaxis

Prevents ophthalmia neonatorum (eye infection from gonorrhea/chlamydia).

Infections occur during birth from exposure to maternal bacteria.

Nursing Actions:

• Use single-dose unit to prevent cross-contamination.

• Apply a 1-2 cm ribbon to lower conjunctival sac, moving outward.

• May cause temporary conjunctivitis (redness, drainage, blurred vision for 24-48 hrs).

• Delay application for 1 hour to allow initial bonding and breastfeeding.

Vitamin K (Phytonadione)

Purpose: Prevent hemorrhagic disorders (newborns lack intestinal bacteria to produce Vitamin K).

Nursing Actions:

• Administer 0.5 - 1 mg IM into the vastus lateralis soon after birth.

Hepatitis B Immunization

Purpose: Protect against hepatitis B.

Nursing Actions:

• Given to all newborns (requires parental consent).

• Standard schedule: Birth, 1 month, 6 months.

• If mother is hepatitis B-positive

  • Give hepatitis B immunoglobulin (HBIG) + vaccine within 12 hrs of birth.

KICK LEFT, BE RIGHT

Important: Do NOT inject Vitamin K and Hepatitis B vaccine in the same thigh.

Cold Stress

Signs: Skin pallor, mottling, cyanotic trunk, tachypnea.

• Increased oxygen consumption → Can result in hypoxia.

• Increased glucose metabolism → Risk of hypoglycemia.

• Increased metabolic rate → Can cause metabolic acidosis.

• Peripheral vasoconstriction → Can lead to hypothermia anp;d bradycardia.

Nursing Actions:

• Monitor for signs of cold stress.

• Warm newborn slowly over 2-4 hours.

• Administer oxygen for hypoxia.

• Correct acidosis & hypoglycemia as needed.

Best Practices for Thermoregulation

Dry immediately after birth to prevent evaporative heat loss.

Use skin-to-skin contact to enhance thermal stability.

Maintain a warm environment to reduce convection and radiation losses.

Prewarm all surfaces before placing the baby to prevent conduction heat loss.

Monitor temperature frequently to detect cold stress early.

Educate parents about proper newborn thermoregulation at home.

Hypoglycemia

Cause: Sudden drop in blood sugar after birth.

Normal newborn tolerance: Blood glucose as low as 30 mg/dL.

At-risk newborns: Preterm, SGA/LGA, infants of diabetic mothers.

Intervention needed if: Blood glucose <40-45 mg/dL.

Nursing Actions:

• Monitor for jitteriness, tremors, weak/high-pitched cry, decreased tone, apnea, respiratory distress, seizures, or poor feeding.

• Initiate breastfeeding or formula in stable newborns.

• Monitor glucose and feed every 2-3 hours for at least 24 hours.

• Promote skin-to-skin contact for thermoregulation and blood sugar stabilization

Hemorrhage

Cause: Improper cord care or clamp placement.

Nursing Actions:

• Ensure cord clamp is tight.

• If blood seepage is noted, apply a second clamp.

• Notify provider if bleeding continues.