The initial assessment of the neonate is performed immediately after birth using the Apgar score (Table 17-1) and a brief physical examination (Box 17-1). A gestational age assessment is completed within the first hours of birth in a stable newborn. A more comprehensive physical assessment is completed within 24 hours of birth (see Table 16-4).

BOX 17-1 Initial Physical Assessment by Body System

Central nervous system	[ ] Moves extremities, muscle tone good
	[ ] Symmetric features, movement
	[ ] Suck, rooting, Moro response, grasp reflexes good
	[ ] Anterior fontanel soft and flat
Cardiovascular system	[ ] Heart rate strong and regular
	[ ] No murmurs heard
	[ ] Pulses strong and equal bilaterally
Respiratory system	[ ] Lungs clear to auscultation bilaterally
	[ ] No retractions or nasal flaring
	[ ] Respiratory rate, 30-60 breaths/min
	[ ] Chest expansion symmetric
	[ ] No upper airway congestion
Genitourinary system	[ ] Male: urethral opening at tip of penis; testes descended bilaterally
Genitourinary system	[ ] Female: vaginal opening apparent
Gastrointestinal system	[ ] Abdomen soft, no distention
	[ ] Cord attached and clamped
	[ ] Anus appears patent
Ear, nose, throat	[ ] Eyes clear
	[ ] Palates intact
	[ ] Nares patent
Skin	Color [ ] pink [ ] acrocyanotic
	[ ] No lesions or abrasions
	[ ] No peeling
	[ ] Birthmarks
	[ ] Caput and molding
	[ ] Vacuum “cap”
	[ ] Forceps marks
	[ ] Other

Comments:

___________________________________________________

TABLE 17-1

Apgar Score

	SCORE
SIGN	0	1	2
Heart rate	Absent	Slow (<100)	>100
Respiratory rate	Absent	Slow, weak cry	Good cry
Muscle tone	Flaccid	Some flexion of extremities	Well flexed
Reflex irritability	No response	Grimace	Cry
Color	Blue, pale	Body pink, extremities blue	Completely pink

Apgar score

The Apgar score permits a rapid assessment of the newborn’s transition to extrauterine existence based on five signs that indicate the physiologic state of the neonate: (1) heart rate, based on auscultation with a stethoscope or palpation of the umbilical cord; (2) respiratory rate, based on observed movement of respiratory efforts; (3) muscle tone, based on degree of flexion and movement of the extremities; (4) reflex irritability, based on response to bulb syringe or catheter inserted in the nasopharynx; and (5) generalized skin color, described as pallid, cyanotic, or pink (see Table 17-1). Evaluations are made at 1 and 5 minutes after birth and can be completed by the nurse or birth attendant. Scores of 0 to 3 indicate severe distress, scores of 4 to 6 indicate moderate difficulty, and scores of 7 to 10 indicate that the infant is having minimal or no difficulty adjusting to extrauterine life. Apgar scores do not predict future neurologic outcome but are useful for describing the newborn’s transition to extrauterine environment (Box 17-2). If resuscitation is required, it should be initiated before the 1-minute Apgar score (American Academy of Pediatrics [AAP] and American College of Obstetricians and Gynecologists [ACOG], 2007).

BOX 17-2

Significance of the Apgar Score

The Apgar score was developed to provide a systematic method of assessing an infant’s condition at birth. Researchers have tried to correlate Apgar scores with various outcomes such as development, intelligence, and neurologic development. In some instances, researchers have attempted to attribute causality to the Apgar score, that is, to suggest that the low Apgar score caused or predicted later problems. This use of the Apgar score is inappropriate. Instead the score should be used to ensure that infants are systematically observed at birth to ascertain the need for immediate care. Either a physician or a nurse may assign the score; however, to avoid the real or perceived appearance of bias, the person assisting with the birth should not assign the score. Lack of consistency in the assigned scores limits studies of the Apgar’s long-term predictive value. Prospective parents and the public need education on the significance of the Apgar score, as well as its limits. Because infants often do not receive the maximal score of 10, parents need to know that scores of 7 to 10 are within normal limits. Attorneys involved in litigation related to injury of an infant at birth or negative outcomes, either short term or long term, also need education about the Apgar score, its significance, and its limits. This useful tool needs to be used appropriately; health care providers, parents, and the public may need education to ensure appropriate use of the score.

Source: Montgomery, K. (2000). Apgar scores: Examining the long-term significance. Journal of Perinatal Education, 9(3), 5-9.

Initial physical assessment

The initial physical assessment includes a brief review of systems (see Box 17-1):

1. External: Note skin color, general activity, position; assess nasal patency by closing one nostril at a time while observing respirations; skin: peeling, or lack of subcutaneous fat (preterm or postterm); temperature; note meconium staining of cord, skin, fingernails, or amniotic fluid (staining may indicate fetal release of meconium); note length of nails and development of creases on soles of feet.

2. Chest: Auscultate apical heart for rate and rhythm, heart tones, and presence of abnormal sounds; assess rate and character of respirations and presence of crackles or other adventitious sounds; note equality of breath sounds by auscultation and observation.

3. Abdomen: Verify characteristics of the abdomen (rounded, flat, concave) and absence of anomalies; auscultate bowel sounds; note number of vessels in the cord and general status of the cord (e.g., thin, emaciated; thick, tortuous; presence of hematoma).

4. Neurologic: Check muscle tone, and assess Moro and suck reflexes; palpate anterior fontanel; note by palpation the presence and size of the fontanels and sutures; note bulging or depression of the anterior fontanel.

5. Genitourinary: Note external sex characteristics and any abnormality of genitalia; check anal patency (presence of meconium); note passage of urine.

6. Other observations: Note gross structural malformations obvious at birth that may require immediate medical attention (e.g., omphalocele, meningocele).

The nurse responsible for the care of the newborn immediately after birth verifies that respirations have been established, dries the infant thoroughly, assesses temperature, and places identical identification bracelets on the infant and the mother. In some settings the father or partner also wears an identification bracelet. In many settings, immediately after birth the infant is placed on the mother’s abdomen to allow skin-to-skin contact. This action contributes to stabilizing and maintaining the newborn’s body temperature and promotes parental bonding. In other settings, the neonate may be wrapped in a warm blanket and placed in the mother’s arms, given to the partner to hold, or kept partially undressed under a radiant warmer. The infant may be admitted to a nursery or may remain with the parents throughout the hospital stay.

The initial examination of the newborn can occur while the nurse is drying and wrapping the infant, or observations can be made while the infant is lying on the mother’s abdomen or in her arms immediately after birth. Efforts should be directed toward minimizing interference in the initial parent-infant acquaintance process. If the infant is breathing effectively, is pink in color, and has no apparent life-threatening anomalies or risk factors requiring immediate attention (e.g., infant of a diabetic mother), further examination can be delayed until after the parents have had an opportunity to interact with the infant. Routine procedures and the admission process can be carried out in the mother’s room or in a separate nursery.

The nursing process in the immediate care of the newborn and family is outlined in the Nursing Process box.

Nursing Process

Care of the Newborn and Family

Assessment

A brief initial assessment is performed to detect problems that can interfere with effective newborn transition. After the infant is stabilized and mother-infant contact has occurred, a gestational assessment and a complete examination can be performed (see Box 17-1, Fig. 17-1, and Table 16-4).

Assessment should include a psychosocial assessment focusing on parent-infant attachment, adjustment to the parental role, sibling adjustment, social support, and education needs, as well as the mother’s and the baby’s physical adaptation (see Chapter 15).

Nursing Diagnoses

Nursing diagnoses for the newborn are established after analyzing the findings of the physical assessment and may include the following:

• Ineffective airway clearance related to:

• Airway obstruction with mucus, blood, and amniotic fluid

• Inability to clear mucus by cough or expectoration

• Impaired gas exchange related to:

• Airway obstruction

• Ineffective breathing pattern

• Risk for imbalanced body temperature related to:

• Imbalance between body heat loss and heat production

• Pain related to:

• Heel stick, circumcision, venipuncture

Possible nursing diagnoses for the parents are as follows:

• Readiness for enhanced parenting related to:

• Knowledge of newborn’s social capabilities and dependency needs

• Knowledge of newborn’s biologic characteristics

• Readiness for enhanced family coping related to:

• Positive attitude and realistic expectations for newborn and adapting to parenthood

• Nurturing behaviors with newborn

• Verbalizing positive factors in lifestyle change

• Risk for impaired parent-infant attachment related to:

• Difficult labor and birth

• Postpartum complications

• Neonatal complications or anomalies

• Situational low self-esteem related to:

• Misinterpretation of newborn’s behavioral cues

Expected Outcomes of Care

Expected outcomes can apply to both the infant and the caregiver. Expected outcomes for the newborn during the immediate recovery period include that the infant will achieve the following:

• Maintain an effective breathing pattern

• Maintain effective thermoregulation

• Remain free from infection

• Receive necessary nutrition for growth

• Establish adequate elimination patterns

• Experience minimal pain

• Remain injury free

Expected outcomes for the parents include that they will accomplish the following:

• Attain knowledge, skill, and confidence relevant to infant care activities.

• State understanding of biologic and behavioral characteristics of the newborn.

• Identify deviations from normal that should be brought to the attention of the primary health care provider.

• Have opportunities to intensify their relationship with the infant.

• Begin to integrate the infant into the family.

Plan of care and interventions

Several intervention strategies for the newborn infant and family are discussed on pp. 482-488.

Evaluation

Evaluation is based on the expected outcomes of care. The plan is revised as needed based on the evaluation findings.

Nursing Care Plan

Normal Newborn

Nursing Diagnosis Risk for ineffective airway clearance related to excess mucus production or improper positioning

Expected Outcomes Neonate’s airway remains patent; breath sounds are clear, and no respiratory distress is evident.

Nursing Interventions/Rationales

• Teach the parents that gagging, coughing, and sneezing are normal neonatal responses that assist the neonate in clearing the airways.

• Teach the parents feeding techniques that prevent overfeeding and distention of the abdomen and to burp the neonate frequently to prevent regurgitation and aspiration.

• Position the neonate on the back when sleeping to prevent suffocation.

• Suction the mouth and nasopharynx with a bulb syringe as needed; clean the nares of crusted secretions to clear the airway and prevent aspiration and airway obstruction.

Nursing Diagnosis Risk for imbalanced body temperature related to larger body surfaces relative to mass

Expected Outcome Neonate temperature remains in range of 36.5° to 37.5° C.

Nursing Interventions/Rationales

• Maintain a neutral thermal environment to identify any changes in the neonate’s temperature that may be related to other causes.

• Monitor the neonate’s axillary temperature frequently to identify any changes promptly and ensure early interventions.

• Bathe the neonate efficiently when temperature is stable, using warm water, drying carefully, and avoiding exposing neonate to drafts to avoid heat losses from evaporation and convection.

• Report any alterations in temperature findings promptly to assess and treat for possible infection.

Nursing Diagnosis Risk for infection related to immature immunologic defenses and environmental exposure

Expected Outcome The neonate will be free from signs of infection.

Nursing Interventions/Rationales

• Review the maternal record for evidence of any risk factors to ascertain whether the neonate may be predisposed to infection.

• Monitor vital signs to identify early possible evidence of infection, especially temperature instability.

• Have all care providers, including parents, practice good handwashing techniques before handling the newborn to prevent the spread of infection.

• Provide the prescribed eye prophylaxis to prevent infection.

• Keep the genital area clean and dry using proper cleansing techniques to prevent skin irritation, cross-contamination, and infection.

• Keep the umbilical stump clean and dry, and keep it exposed to the air to allow to dry and minimize the chance of infection.

• If the infant is circumcised, keep the site clean, and apply the diaper loosely to prevent trauma and infection.

• Teach the parents to keep the neonate away from crowds and environmental irritants to reduce potential sources of infection.

Nursing Diagnosis Risk for injury related to sole dependence on caregiver

Expected Outcome Neonate remains free of injury.

Nursing Interventions/Rationales

• Monitor the environment for hazards such as sharp objects, long fingernails of the caretaker and neonate, and jewelry of the caretaker that may be sharp to prevent injury.

• Handle the neonate gently and support the head, ensure the use of a car seat by parents, teach parents to avoid placing the neonate on a high surface unsupervised and to supervise pet and sibling interactions to prevent injury.

• Assess the neonate frequently for any evidence of jaundice to identify rising bilirubin levels, treat promptly, and prevent kernicterus.

Nursing Diagnosis Readiness for enhanced family coping related to anticipatory guidance regarding responses to the neonate’s crying

Expected Outcome Parents will verbalize their understanding of the methods of coping with the neonate’s crying, and describe increased success in interpreting the neonate’s cries.

Nursing Interventions/Rationales

• Alert the parents to crying as the neonate’s form of communication and that cries can be differentiated to indicate hunger, wetness, pain, and loneliness to provide reassurance that crying is not indicative of the neonate’s rejection of parents and that parents will learn to interpret the different cries of their child.

• Differentiate self-consoling behaviors from fussing or crying to give parents concrete examples of interventions.

• Discuss methods of consoling a neonate who has been crying, such as checking and changing diapers, talking softly to the neonate, holding the neonate’s arms close to the body, swaddling, picking the neonate up, rocking, using a pacifier, feeding, or burping to provide anticipatory guidance.

Nursing Care Plan: The Normal Newborn and Family

Interventions

Changes can occur rapidly in newborns immediately after birth. Assessment must be followed quickly by the implementation of appropriate care.

Airway maintenance

Generally, the healthy term infant born vaginally has little difficulty clearing the airway. Most secretions are moved by gravity and brought by the cough reflex to the oropharynx to be drained or swallowed. The infant is often maintained in a side-lying position (head stabilized, not in the Trendelenburg position) with a rolled blanket at the back to facilitate drainage.

If the infant has excess mucus in the respiratory tract, the mouth and nasal passages can be gently suctioned with a bulb syringe (Fig. 17-1). Routine chest percussion and suctioning of healthy term or late preterm infants is avoided; evidence is insufficient to support anything other than gentle nasopharyngeal and oropharyngeal suctioning to clear secretions (Hagedorn, 2006). The infant who is choking on secretions should be supported with the head to the side. The mouth is suctioned first to prevent the infant from inhaling pharyngeal secretions by gasping as the nares are touched. The bulb is compressed and inserted into one side of the mouth. The center of the mouth is avoided because the gag reflex could be stimulated. The nasal passages are suctioned one nostril at a time. The nurse should listen to the infant’s respirations and lung sounds with a stethoscope to determine whether crackles, rhonchi, or inspiratory stridor are present. Fine crackles may be auscultated for several hours after birth. If the bulb syringe does not clear mucus interfering with respiratory effort, mechanical suction can be used.

Fig. 17-1 Bulb syringe. Bulb must be compressed before insertion. (Courtesy Cheryl Briggs, RN, Annapolis, MD.)

Procedure

Suctioning with a Bulb Syringe

• The bulb syringe should always be kept in the infant’s crib.

• The mouth is suctioned first to prevent the infant from inhaling pharyngeal secretions by gasping as the nares are touched.

• The bulb is compressed (see Fig. 17-1) and inserted into one side of the mouth. The center of the infant’s mouth is avoided because the gag reflex could be stimulated.

• The nasal passages are suctioned one nostril at a time.

• When the infant’s cry does not sound as though it is through mucus or a bubble, suctioning can be stopped.

• The parents should be given demonstrations on how to use the bulb syringe and asked to perform a return demonstration.

The bulb syringe should always be kept in the infant’s crib. The parents should be given a demonstration of how to use the bulb syringe and asked to perform a return demonstration.

If the newborn has an obstruction that is not cleared with suctioning, further investigation must occur to determine if a mechanical defect (e.g., tracheoesophageal fistula, choanal atresia [see Chapter 24]) is causing the obstruction.

Deeper suctioning may be needed to remove mucus from the newborn’s nasopharynx or posterior oropharynx. However, this type of suctioning should be performed only after an assessment of the risks involved. Proper tube insertion and suctioning for 5 seconds or less per tube insertion helps prevent vagal stimulation and hypoxia. If wall suction is used, the pressure should be adjusted to less than 80 mm Hg. After the catheter is properly placed, suction is created by intermittently placing one’s thumb over the control as the catheter is carefully rotated and gently withdrawn. This procedure may need to be repeated until the infant has a clear airway (see Procedure box).

Procedure

Suctioning with a Nasopharyngeal Catheter with Mechanical Suction Apparatus

To remove excessive or tenacious mucus from the infant’s nasopharynx:

• If wall suction is used, adjust the pressure to under 80 mm Hg. Proper tube insertion and suctioning for 5 seconds per tube insertion help prevent laryngospasms and oxygen depletion.

• Lubricate the catheter in sterile water and then insert either orally along the base of the tongue or up and back into the nares.

• After the catheter is properly placed, create suction by intermittently placing your thumb over the control as the catheter is carefully rotated and gently withdrawn.

• Repeat the procedure until the infant’s cry sounds clear and air entry into the lungs is heard by stethoscope.

Maintaining an adequate oxygen supply.

Four conditions are essential for maintaining an adequate oxygen supply:

• A clear airway

• Effective establishment of respirations

• Adequate circulation, adequate perfusion, and effective cardiac function

• Adequate thermoregulation (Exposure to cold stress increases oxygen and glucose needs.)

Signs of potential complications related to abnormal breathing are listed in the Signs of Potential Complications box.

Signs of Potential Complications

Abnormal Newborn Breathing

• Bradypnea (≤25 respirations/min)

• Tachypnea (≥60 respirations/min)

• Abnormal breath sounds: crackles, rhonchi, wheezes, expiratory grunt

• Respiratory distress: nasal flaring, retractions, chin tug

• Skin color: cyanosis, mottling

• Pulse oximetry value: <95%

Maintaining body temperature

Effective neonatal care includes maintenance of an optimal thermal environment (see Chapter 16). Cold stress increases the need for oxygen and may deplete glucose stores. The infant may react to exposure to cold by increasing the respiratory rate and may become cyanotic. Ways to stabilize the newborn’s body temperature include placing the infant directly on the mother’s abdomen and covering with a warm blanket (skin-to-skin contact), drying and wrapping the newborn in warmed blankets immediately after birth, keeping the head well covered, and keeping the ambient temperature of the nursery at 22° to 26° C (AAP & ACOG, 2012). Allowing vernix caseosa to remain on the infant’s skin has not been associated with a decrease in axillary temperature in the first hour after birth (Visscher et al., 2005).

If the infant does not remain with the mother during the first 1 to 2 hours after birth, the nurse places the thoroughly dried infant under a radiant warmer or in a warm incubator until the body temperature stabilizes. The infant’s skin temperature is used as the point of control in a warmer with a servo-controlled mechanism. The control panel is usually maintained between 36° and 37° C. This setting should maintain the healthy term newborn’s skin temperature at approximately 36.5° to 37° C. A thermistor probe (automatic sensor) is usually placed on the upper quadrant of the abdomen immediately below the right or left costal margin (never over a bone). A reflector adhesive patch may be used over the probe to provide adequate warming. This probe will ensure detection of minor temperature changes resulting from external environmental factors or neonatal factors (peripheral vasoconstriction, vasodilation, or increased metabolism) before a dramatic change in core body temperature develops. The servo-controller adjusts the temperature of the warmer to maintain the infant’s skin temperature within the preset range. The sensor needs to be checked periodically to make sure it is securely attached to the infant’s skin. The axillary temperature of the newborn is checked every hour (or more often as needed) until the newborn’s temperature stabilizes. The length of time to stabilize and maintain body temperature varies; each newborn should therefore be allowed to achieve thermal regulation as necessary, and care should be individualized.

During all procedures, heat loss must be avoided or minimized for the newborn; therefore examinations and activities are performed with the newborn under a heat panel. The initial bath is postponed until the newborn’s skin temperature is stable and can adjust to heat loss from a bath. The exact and optimal timing of the bath for each newborn remains unknown.

Even a healthy term infant can become hypothermic. Birth in a car on the way to the hospital, a cold birthing room, or inadequate drying and wrapping immediately after birth may cause the newborn’s temperature to fall below the normal range (hypothermia). Warming the hypothermic infant is accomplished with care. Rapid warming may cause apneic spells and acidosis in an infant. Therefore the warming process is monitored to progress slowly over a period of 2 to 4 hours.

Immediate interventions

One of the nurse’s responsibilities is to perform certain interventions soon after birth to provide for the safety of the newborn. Such interventions can be delayed for an hour or two so that uninterrupted maternal-infant bonding can occur.

Eye prophylaxis.

The instillation of a prophylactic agent in the eyes of all neonates (Fig. 17-2) is mandatory in the United States. This is a precautionary measure against ophthalmia neonatorum, which is an inflammation of the eyes resulting from gonorrheal or chlamydial infection contracted by the newborn during passage through the mother’s birth canal. In the United States, if parents object to this treatment, they may be asked to sign an informed refusal form, and their refusal will be noted in the neonate’s record. The agent used for prophylaxis varies according to hospital protocols, but usual agents include forms of erythromycin, tetracycline, or silver nitrate (Medication Guide). Canadian hospitals have not recommended the use of silver nitrate since 1986. Its use in the United States is minimal because silver nitrate does not protect against chlamydial infection and can cause chemical conjunctivitis. Instillation of eye prophylaxis may be delayed until an hour or so (up to 2 hours in Canada) after birth so that eye contact and parent-infant attachment and bonding are facilitated.