Assessment and Care of the Newborn and Family

Assessment and Care of the Newborn and Family

Shannon E. Perry

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A lthough most infants make the necessary biopsychosocial adjustments to extrauterine existence without undue difficulty, their well-being depends on the care they receive from others. This chapter describes the assessment and care of the infant immediately after birth until discharge, as well as important anticipatory guidance related to ongoing infant care. A discussion of pain in the neonate and its management is included.

Birth Through the First 2 Hours image

Nursing Care Management image

Care begins immediately after birth and focuses on assessing and stabilizing the newborn’s condition. The nurse has the primary responsibility for the infant during this period because the physician or midwife is involved with care of the mother. The nurse must be alert for any signs of distress and initiate appropriate interventions.

With the possibility of transmission of viruses such as hepatitis B virus (HBV) and human immunodeficiency virus (HIV) through maternal blood and blood-stained amniotic fluid, the newborn must be considered a potential contamination source until proved otherwise. As part of Standard Precautions, nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing.


Initial Assessment and Apgar Scoring

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).

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

Nursing Diagnoses

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

Possible nursing diagnoses for the parents are as follows:

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:

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

Nursing Care Plan

Normal Newborn

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

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 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


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.

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).

Maintaining an adequate oxygen supply.

Four conditions are essential for maintaining an adequate oxygen supply:

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

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.

Topical antibiotics such as tetracycline and erythromycin, silver nitrate, and a 2.5% povidone-iodine solution (currently unavailable in commercial form in the United States) are not effective in the treatment of chlamydial conjunctivitis. A 14-day course of oral erythromycin or an oral sulfonamide may be given for chlamydial conjunctivitis (AAP, 2006).

Vitamin K prophylaxis.

Administering vitamin K intramuscularly is routine in the newborn period in the United States. A single intramuscular injection of 0.5 to 1 mg of vitamin K is given soon after birth to prevent hemorrhagic disease of the newborn. Administration can be delayed until after the first breastfeeding in the birthing room (AAP & ACOG, 2012). Vitamin K is produced in the gastrointestinal tract by bacteria starting soon after microorganisms are introduced. By day 8, healthy newborns are able to produce their own vitamin K (Medication Guide).

Oct 8, 2016 | Posted by in NURSING | Comments Off on Assessment and Care of the Newborn and Family

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