Steps

Rationale/Points of Emphasis

1 Apply identification (ID) bands with mother’s name and ID number as well as infant’s ID number to infant’s ankle and wrist before infant leaves the delivery room. Also apply band with infant’s number to the mother’s wrist. Placement of a similar wristband on the father or significant other should proceed following institutional guidelines. Apply infant security device to infant’s ankle per institutional policy, and explain the purpose of the device to family (see Chapters 82 and 118 ).

Identifies infant and associates infant with correct mother and father for later ID. Infant security device will stay on the infant’s ankle at all times until the nurse takes it off at the time of discharge. The infant security will track the location of the infant for abduction purposes.

2 Once infant is stable, gather identification and foot printing supplies.

Foot printing should be delayed until after infant is stabilized.

3 Press infant’s foot firmly to ink pad and then transfer footprint to ID form with firm gentle pressure. Clean ink from the child’s skin using ink removal towelette or soap and water.

Provides another means of infant ID. The footprints are given to the family upon discharge.

4 Always check mother’s ID band against infant’s ID band when bringing infant to mother.

Ensures that correct infant is given to mother. It is unrealistic to expect a newly delivered mother to recognize her newborn.

5 If the newborn must remain hospitalized after maternal discharge, ask the mother to continue to wear her ID band and an ID band matching that of her infant after discharge to ensure that proper identification strategies may be used when she visits her infant.

Allows for accurate mother and infant identification at each visit.

Steps

Rationale/Points of Emphasis

1 Warm the delivery room or nursery. Warm items that will be used in direct infant care, such as blankets, stethoscope, and isolette.

Premature infants are especially vulnerable to hypothermia because of the lack of brown fat stores.

Prevents newborn hypothermia that may result in increased metabolic needs, apnea, and bradycardia.

2 Perform hand hygiene; don protective apparel (gown and gloves) for care of infant immediately after delivery. Perform hand hygiene after each contact with the infant and before initiating new contact with infant.

Reduces transmission of microorganisms. Protects healthcare provider from exposure to blood and body fluids.

3 Place infant under warming source (on prewarmed warmer or isolette) after birth. Dry infant and remove wet linens. Provide warmed blankets and hat for warmth (see Chapter 76 )

Decreases evaporative heat loss and decreases loss from the head, which is an infant’s largest heat-losing body surface.

4 If possible, keep infant close to mother’s body with skin-to-skin contact.

Uses mother’s body temperature to warm infant and fosters early maternal-child bonding.

5 Cover infant’s head with hat and feet with booties for warmth.

Decreases loss of heat through infant’s head.

6 Bundle infant in warmed baby blanket.

Decreases exposure of infant’s skin to cooler room temperatures.

7 Remove gloves and perform hand hygiene.

Reduces transmission of microorganisms.

8 Transport infant in an isolette.

Prevents infant exposure to drafts.

9 If infant’s temperature remains unstable, evaluate for possible causes (e.g., hypoglycemia) and keep infant in controlled-temperature environment (isolette) while appropriate actions are taken and until infant’s temperature is stable (see Chapters 76 and 124 for further guidelines regarding thermoregulation).

If found, causes of temperature instability should be treated immediately. Infant should be kept in a warm environment.

caREminder

Instruct others to avoid opening the isolette unnecessarily.

10 Assess temperature hourly for the first 4 hours of life and then as indicated by infant’s acuity level and institutional policy.

Ensures that infant’s temperature stabilizes without excessive overheating and provides ongoing assessment of temperature stability.

Steps

Rationale/Points of Emphasis

1 Monitor infant’s color.

Central cyanosis is abnormal and may indicate a respiratory or cardiac problem. Notify healthcare prescriber. Peripheral cyanosis of the hands and feet may normally be present.

Infant’s skin color should be pink and nonmottled. A yellowish color may be indicative of hyperbilirubinemia.

2 Monitor infant’s quality of breathing and respiratory rate, counting respirations for a full minute. Use bulb syringe to gently suction airway and remove secretions, if needed. Monitor for signs of respiratory distress.

Infant should have a clear airway with spontaneous respirations. Respirations should be unlabored and without tachypnea, nasal flaring, grunting, retractions, rales, or rhonchi. The normal rate of respiration in the newborn is 30 to 60 breaths/minute.

3 Place stethoscope on infant’s chest at point of maximum impulse and count infant’s heart rate for a full minute, noting irregularities of rhythm and any murmurs.

Infant should have a strong regular heart rate, without murmurs. Many infants have “innocent murmurs”; that is, murmurs with no implication of a pathologic condition or process. All murmurs should be reported to the healthcare prescriber and further assessed to validate the characteristics of the murmur and the degree of further evaluation warranted. The normal heart rate of the newborn is 120 to 160 bpm.

4 Assess vital signs, including axillary temperature, apical pulse rate, and respirations hourly for the first 4 hours, then once every 4 hours for the next 24 hours, and then as ordered (see Chapters 119 , 120 , 122 , and 123 ). See Appendix A: Reference Ranges for Vital Sign Measurements for normal ranges.

Assesses stability of the infant through adjustment to the extrauterine environment.

caREminder

Axillary temperature should be obtained in the newborn to avoid possible damage to the rectal mucosa.

Steps

Rationale/Points of Emphasis

1 Obtain length, weight, and head and chest circumference of the newborn within 2 hours of birth, after stabilization of temperature (see Chapter 43 ).

Assesses birth weight, length, and head circumference.

2 Assess infant’s weight daily during initial hospital stay.

Assesses weight stability.

caREminder

An initial weight loss of 5% to 10% during the first few days of life is normal. The infant should be at or above birth weight by the 2-week well-child visit. If initial weight loss is greater than 10%, infant’s nutritional and hydration status must be reassessed.