Normal Newborn Adaptation and Assessment

Health Assessment Techniques for the Newborn

  • Normal values:

    • Temperature: 97.7-99.5 F

    • Pulse: 120-160 and regular

    • Respirations: 30-60 and irregular

    • BP: 65-95/30-60

    • Weight: 2500–4000 g (5 lb, 8 oz to 8 lb, 13 oz).

    • Weight loss: Up to 10% in early days.

      • High (LGA, maternal diabetes).

      • Low (SGA, preterm, multifetal pregnancy, medical conditions in mother that affected fetal growth).

      • Weight loss above 10% (dehydration, feeding problems).

    • Assess every 30 minutes after delivery for the first 2 hours

    • Always listen for 1 full minute to heart rate and respirations

Normal vs. Abnormal Assessment Findings

  • Vitals

    • Normal:

      • RR: 30-60

      • Heart rate: Apical (full minute) = 120-160

      • Temp: 97.7 to 99.5 F

      • Ranges according to age/weight

    • Abnormal:

      • Tachypnea

      • Tachycardia

      • Hypo/hyperthermia

      • Upper and lower extremities BP with significant difference

  • Head

    • Normal: Sutures with gaps, fontanels (posterior and anterior) flat, molding, caput succedaneum

    • Abnormal: Sutures over-riding, fontanels bulging or sunken in, bruising, cephalohematoma

  • Face

    • Normal: Eyes with strabismus, clear eyes, face symmetrical, nares patent

    • Abnormal: Drainage from eye, one nare not patent

  • Ears

    • Normal: Top of ear in line with eye

    • Abnormal: Low seat ears, pinholes in ears

  • Mouth/Palate

    • Normal: Intact, sucking reflex good

    • Abnormal: Tongue tied, teeth, cleft lip/palate

  • Chest

    • Normal: 2 nipples, capillary refill < 3 seconds, no crepitus in clavicles

    • Abnormal: Extra nipples, cap refill > 3 seconds, crepitus or deformity felt in clavicle

  • Abdomen

    • Normal: 3 blood vessels in cord, erythema toxicum, abdomen soft with BS X4

    • Abnormal: < 3 vessels in cord, distended abdomen

  • Extremities

    • Normal: Brachial and femoral pulses equal, 10 fingers and 10 toes, creases on palms, foot position straight

    • Abnormal: Pulses not equal, webbed fingers and toes, extra digits, one crease on palm (simian crease), foot turned in

  • Groin/Hip

    • Normal:

      • Boys: meatus on top of penis, testicles descended, rugae

      • Female: labia majora and minora cover clitoris

      • No hip click

    • Abnormal: Hypospadias, epispadias, hydrocele, not descended testicles

  • Back

    • Normal: No pilonidal dimple, no tuft of hair at base of spine, spine straight, gluteal folds even

    • Abnormal: Presence of pilonidal dimple or tuft of hair at base of spine, spine not straight, gluteal folds uneven

  • Color

    • Normal: Acrocyanosis

    • Abnormal: Blue in trunk/face/mucous membranes

Newborn Maturity Rating & Classification

  • Estimation of Gestational Age by Maturity Rating

    • Neuromuscular Maturity

      • Posture

      • Square window (wrist)

      • Arm recoil

      • Popliteal angle

      • Scarf sign

      • Heel to ear

    • Physical Maturity

      • Skin

      • Lanugo

      • Plantar surface

      • Breast

      • Eye/Ear

      • Genitals (male)

      • Genitals (female)

Other Assessments in Newborn

  • Reflexes: Check all reflexes: indication of neurological

  • Stool

  • Urine

  • Uric Acid Crystals

  • Circumcision

Review of Newborn Reflexes

  • Palmer grasp: 5 to 6 months

  • Rooting: 2 to 3 months McKinney

  • Stepping: 3 to 4 months McKinney

  • Tonic neck: 5 to 7 months

  • Moro: 3 to 4 months McKinney

  • Planter grasp: 8 to 9 months McKinney

  • Babinski: 8 to 9 months McKinney

Thermoregulation in Newborns

  • Normal temperature: 97.5-99.5 F

  • Hypothermia: Temp < 97.5 F

  • Hyperthermia: Temp > 99.5 F

  • Temperature instability is a sign of infection

  • How do babies stay warm naturally?

  • Why can babies lose heat so easily?

  • Radiant warmer at birth/warm delivery room

  • 4 ways the newborn can lose heat:

    • Evaporation: water converts to vapor (wet with amniotic fluid at birth or wet with bath)

    • Radiation: heat transfers to objects NOT in direct contact with body (wet clothing/diaper at end of crib)

    • Conduction: heat transfers to cooler objects THAT ARE in direct contact with body (cold hands/stethoscope/scale)

    • Convection: air current cools the body (baby next to fan, AC vent, window)

Preterm Thermoregulation

  • 34 week to 36.6 week gestation

  • Delivery room thermostat increased

  • Check that all equipment is ready

  • Turn warmer on to prewarm

  • During code, newborn placed from feet to nipples in plastic bag

  • Stable once preterm baby remains from 97.5 to 98.5

  • Use temperature probe sensor (Servo) on warmer and in isolette

  • Keep close watch on oxygen and glucose

  • The fetus will develop brown fat between 26-30 weeks gestation

Hypothermia vs Hyperthermia & Other complications

  • Hypothermia (cold stress) (below 97.5)

    • Symptoms: Tachypnea, crying, extremities pulled towards body—eventually: lethargy, weak cry, cool abdomen and extremities---shivering is RARE except in late stages

    • This causes an increased metabolic rate with increased oxygen needs---leads to metabolic acidosis, hypoxia and shock

    • Nursing Interventions: Warm slowly, Warm IV fluids, Hat on, Blankets, Sleep sack, Skin to skin

  • Hyperthermia (above 99.5)

    • Symptoms: Flushed, red skin, restless, irritable, extended posture, vasodilation

    • Baby will start using glucose stores for energy which can lead to hypoglycemia

    • Nursing Interventions: Cool slowly, Take off hat – recheck, Take off another item

  • Other complications you may see in the newborn

    • Hypoglycemia: at risk are babies born to mothers with diabetes mellitus, post-term babies, LGA, SGA, stressed birth, sick, asphyxia, cold stress

      • Symptoms: Treatment: see next slide

Hypoglycemia treatment

  • Dextrose (Glutose) 40% oral gel 1.25mL

  • Dose 0.5 mL/Kg x 2.74 kg buccal every 30 minutes if blood sugar is under 40 and after 24 hours blood sugar under 45.

  • If blood sugar is under 25, call the physician STAT Pt. 6 pounds 7 ounces with blood glucose of 36. Give 0.3 of 40% Dextrose gel on gloved finger, wipe cheek with gauze then place gel and rub into (buccal) cheek on each side X2, then have newborn breastfeed. Repeat blood sugar in 30 minutes if still low repeat gel, have newborn nurse and then repeat blood glucose in 30 minutes. If still low, call physician.

Newborn Jaundice

  • Jaundice = an elevated unconjugated or indirect bilirubin. It is seen in 60-70% of term infants and 80% of preterm infants.

  • Bilirubin = yellow pigment in lipids and fat of dermal and SQ tissues.

  • PATHOLOGIC JAUNDICE = occurs within first 24 hours- can be SERIOUS!!

    • Liver problems

    • ABO incompatibility

    • Rh iso-immunization

    • Hydrops fetalis

  • PHYSIOLOGIC JAUNDICE = more common, occurs after 24 hours

    • Immature liver

    • Delayed cord clamping

    • Fatty acid release

    • GI tract immaturity

    • Not eating/dehydration

  • KERNICTERUS ! = when bilirubin levels so high they cause injury to the CNS

Tests and Treatment of Jaundice:

  • Blood test (measure total serum bilirubin and direct bilirubin)

  • Transcutaneous bilirubin: a light on the forehead measures bilirubin

  • Treatment: depends on how severe

    • A baby must breastfeed/drink formula to stay hydrated and eliminate bilirubin in stool ( the more the baby eats, the more stool he/she will have, more bilirubin will be excreted)

    • Phototherapy: a bilirubin light that converts bilirubin into water soluble molecules that can be excreted

      • may be a blanket

      • may be an overhead light

      • may be a combination of both

Newborn Pain Assessment

  • Newborns do feel pain, in fact neurobiologist proved in 2015 that newborns, are “hypersensitive to pain due to immature inhibition mechanisms at birth.”

  • A study at Oxford used MRIs to compare the same pain stimuli with adults and infants proving “Babies experience pain similarly to adults.”

  • In fact, “18 of 20 brain regions were active in newborns and adults,” “with the same pain stimuli."

  • “Excessive, prolonged, painful events in neonates causes adverse physiological effects in all major organ systems which can be life threatening and have long-term effects.”

  • Pain Assessment Tools

    • NIPS (Neonatal Infant Pain Scale)

Discharge Teaching

  • Bulb Syringe

  • Breastfeeding

  • Bottle Feeding

  • Diaper change girls

  • Care of circumcised boys

  • Umbilical cord care

  • Positioning in crib

  • Holding /feeding/burping

  • Poor output

  • Jaundice

  • Visitors

  • Signs of infection

  • Safety

  • Bathing

  • Car seats

  • When should parents or guardians call the Nurse Practitioner/Physician's Assistant or Doctor?