The Normal Newborn: Nursing Management

Immediate After Birth

  • Key Actions:

    • Anticipation, preparation, recognition, and intervention are crucial.

    • Newborn is either placed on mother’s abdomen or on a radiant warmer while being dried.

    • Stimulation: Initiate drying and stimulate the infant; important to keep warm for thermoregulation.

    • Implement skin-to-skin contact with the mother.

    • Airway Maintenance:

    • Ensure airway patency using a bulb syringe: suction mouth first, then nose.

    • APGAR Scoring:

    • Perform APGAR scoring as a quick assessment of the infant's condition.

    • NRP Guidelines: Follow Neonatal Resuscitation Program guidelines immediately after birth.

    • Identification Bands:

    • Must be placed on the baby (2 bands), mother, and significant other before newborn leaves the delivery room.

    • Complete a footprint sheet for identification.

Initial Newborn Assessments

  • Signs Indicating a Problem:

    • Nasal flaring

    • Chest retractions

    • Grunting on exhalation

    • Labored breathing

    • Generalized cyanosis

    • Flaccid body posture

    • Abnormal breath sounds

    • Abnormal respiratory rates

    • Abnormal heart rates

    • Abnormal newborn size

Early Care of the Normal Newborn

  • Cardiorespiratory Status:

    • Positioning the infant properly.

    • Suctioning secretions as necessary.

    • Close observation for any changes.

  • Administering Vitamin K:

    • Dosage: 1 mg (0.5 ml) IM in the vastus lateralis.

    • Rationale: Necessary because the newborn’s bowel is sterile and does not produce Vitamin K, which is required for clotting.

  • Eye Treatment:

    • Administer erythromycin ophthalmic ointment as a preventative measure against infection.

Apgar Scoring

  • Parameters:

    • A = Appearance (color)

    • P = Pulse (heart rate)

    • G = Grimace (reflex irritability)

    • A = Activity (muscle tone)

    • R = Respiratory (effort)

  • Rapid Assessment Use:

    • Completed at 1 minute and 5 minutes after birth.

    • Scoring Interpretation:

    • 0-3 = Severe distress

    • 4-6 = Moderate difficulty

    • 7-10 = Minimal or no difficulty

Apgar Scoring for Newborns

  • Assessment Techniques:

    • Heart Rate:

    • 0 points: Absent

    • 1 point: Slow (<100 bpm)

    • 2 points: >100 bpm

    • Respiratory Effort:

    • 0 points: Apneic

    • 1 point: Slow, irregular, shallow

    • 2 points: Regular respirations (30-60 breaths/min), strong, good cry

    • Muscle Tone:

    • 0 points: Limp, flaccid

    • 1 point: Some flexion, limited resistance to extension

    • 2 points: Tight flexion, good resistance to extension

    • Reflex Irritability:

    • 0 points: No response

    • 1 point: Grimace or frown when irritated

    • 2 points: Sneeze, cough, or vigorous cry

    • Skin Color:

    • 0 points: Cyanotic or pale

    • 1 point: Blue extremities (acrocyanosis)

    • 2 points: Completely appropriate color (pink on both trunk and extremities)

Gestational Age Scoring

  • Purpose:

    • Provides an estimation of gestational age and serves as a baseline for growth and development assessment.

    • Assess within the first 48 hours of life using the New Ballard Score.

Gestational Age Classification

  • Categories:

    • Preterm or Premature: Prior to 37 weeks’ gestation. 37-6/7

    • Term: 38 to 42 weeks’ gestation.

    • Postterm or Post-dates: After week 42 of gestation.

    • Postmature: After week 42 with signs of placental aging or insufficiency.

Size for Gestational Age

  • Categories:

    • Small for Gestational Age (SGA): Weight is <10th percentile.

    • Appropriate for Gestational Age (AGA): Weight is between the 10th and 90th percentile.

    • Large for Gestational Age (LGA): Weight is >90th percentile.

    • Low Birth Weight (LBW): 2500g or less at birth.

    • Intrauterine Growth Restriction (IUGR): Growth rate does not match expected norms.

Gestational Age Assessment

  • Physical Maturity Indicators:

    • Skin texture

    • Lanugo

    • Plantar creases

    • Breast tissue

    • Eyes and ears

    • Genital development

  • Neuromuscular Maturity Indicators:

    • Posture

    • Square window

    • Arm recoil

    • Popliteal angle

    • Scarf sign

    • Heel to ear

Continuing Care of the Normal Newborn

  • Thermoregulation:

    • Focus on preventing heat loss and restoring thermoregulation.

    • Interventions:

    • Keep infant dry and covered.

    • Avoid contact with cold surfaces and drafts.

    • Use swaddling and hats.

Expanded Assessments

  • Blood Glucose:

    • Assess all infants for risk factors and signs of hypoglycemia.

    • Perform a screening test for blood glucose; maintain safe levels per institutional policies.

  • Bilirubin:

    • Assess the risk for jaundice; ensure the infant is feeding well.

    • Provide education to parents about jaundice.

Ongoing Newborn Assessment and Care

  • Feeding Assistance: Monitor intake and output.

  • Bathing and Hygiene:

    • Bathing may be delayed; wear gloves.

    • Use plain water on the face and eyes; mild soap for the body.

    • Maintain focus on thermoregulation.

  • Elimination Care:

    • Monitor urine characteristics and stool patterns.

    • Provide care for the diaper area.

Safety and Infection Prevention

  • Cord Care: Monitor for infection and healing.

  • Circumcision Care: Provide appropriate care post-procedure.

  • Safety Protocols:

    • Educate on prevention of abduction and safe sleep practices.

    • Emphasize car safety procedures.

  • Infection Prevention:

    • Promote scrupulous hand washing and clean equipment usage.

  • Bonding: Encourage parental bonding and skin-to-skin contact.

Positioning the Infant

  • Safe Sleep Guidelines:

    • The American Academy of Pediatrics recommends placing infants supine for sleep to reduce SIDS risk.

    • Avoid overheating and promote pacifier use for infants over one month of age.

    • Infants should not sleep in adult beds or couches.

  • Plagiocephaly Prevention: Supervised tummy time each day is recommended to prevent flat spots on the head.

Circumcision Information

  • Reasons for Circumcision:

    • To prevent certain conditions, religious reasons, parental preference, and lack of knowledge about foreskin care.

  • Reasons Against Circumcision:

    • Belief that uncommon conditions do not warrant surgery and recognition of pain in infants.

Risks of Circumcision

  • Potential complications include:

    • Hemorrhage

    • Infection

    • Unsatisfactory cosmetic effect

    • Urinary retention

    • Urethral stenosis or fistula

    • Adhesions

    • Necrosis

    • Injury to the glans

    • Pain during and after surgery

Signs of Complications After Circumcision

  • Monitor for:

    • Bleeding beyond a few drops during the first diaper changes.

    • Failure to urinate.

    • Signs of infection: fever, low temperature, or purulent/foul-smelling drainage.

    • Displacement of PlastiBell device.

Screening Tests

  • Critical Congenital Heart Defects (CCHD): Perform pulse oximetry screening within the first 24 hours of life.

  • Hearing Loss Screening: Administer screening tests prior to discharge.

  • Metabolic Screening: To be done after 24 hours of age for conditions like:

    • Phenylketonuria (PKU)

    • Hypothyroidism

    • Galactosemia

    • Hemoglobinopathies

    • Other tests as specified by the State Department of Health.

  • Transcutaneous Bilirubin (TcB): Assess bilirubin levels non-invasively.

Discharge and Newborn Follow-up Care

  • Discharge Timing:

    • 24-48 hours after vaginal birth, 48-72 hours after cesarean section if vital signs are normal, feeding is adequate, and the infant has passed urine and stool with no bleeding from the circumcision site.

  • Follow-up Care Recommendations:

    • The American Academy of Pediatrics (AAP) suggests a follow-up visit within 48 hours.

    • Options include home visits, clinic visits, or telephone counseling for ongoing assessments.