Nursing Care of the Newborn and Family

Chapter 23

Nursing Care of the Newborn and Family

Kathryn R. Alden

Although 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.

Care Management: Birth Through the First 2 Hours

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 nurse 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 wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing.

The foundation for providing comprehensive, family-centered newborn care is awareness of the mother’s preconception and prenatal history as well as intrapartal events. Recognition of risk factors (Box 23-1) enables the nurse to be more astute in observations and assessments and more likely to identify early signs of complications. This allows for earlier intervention and promotes positive outcomes.

Box 23-1

Assessment of Preconception, Prenatal, and Intrapartum Risk Factors

*TORCH is the collective name for toxoplasmosis, other infections (e.g., hepatitis), rubella virus, cytomegalovirus (CMV), and herpes simplex virus.

Adapted from Broussard AB and Hurst HM: Antepartum-intrapartum complications. In Verklan TM and Walden M (eds.): AWHONN core curriculum for neonatal intensive care nursing, ed 4, St Louis, 2010, Saunders.

Immediate Care After Birth

The primary goal of care in the first moments after birth is to assist the newly born infant to transition to extrauterine life by establishing effective respirations. If the infant is at term, is crying or breathing, and has good muscle tone, routine care can begin (Kattwinkel, Perlman, Aziz, et al., 2010). The infant is placed prone on the mother’s abdomen or chest, and the nurse assesses the airway. Slight extension of the neck helps keep the airway patent. Drying the infant with vigorous rubbing removes moisture to prevent evaporative heat loss and provides tactile stimulation to stimulate respiratory effort. The mother and her newborn are covered with a warm blanket (Niermeyer and Clarke, 2011).

If the neonate is apneic or has gasping respirations, positive-pressure ventilation is needed. The heart rate is quickly assessed by grasping the base of the cord or by auscultating the left chest with a stethoscope. Count for 6 seconds and multiply by 10 to calculate the heart rate. It should be greater than 100 beats/min. The newborn’s trunk and lips should be pink; acrocyanosis is a normal finding (see Fig. 22-4) (Niermeyer and Clarke, 2011).

If the newborn requires respiratory or circulatory support, the nurse and other members of the health care team (e.g., neonatologist, respiratory therapist) follow the American Heart Association guidelines for neonatal resuscitation (Kattwinkel, Perlman, Aziz, et al., 2010). The neonatal resuscitation algorithm directs the care (Fig. 23-1).

As soon as possible after birth, the nurse places identically numbered bands on the infant’s wrist and ankle, on the mother, and on the father or significant other. An electronic infant security tag or abduction system alarm should be placed on all newborns to aid in protecting against infant abduction. The infant is footprinted with ink or a scanning device within 2 hours of birth (Vincent, 2009). (See later discussion of infant abduction.)

Apgar Scoring and Initial Assessment

The initial assessment of the neonate is performed immediately after birth using the Apgar score (Table 23-1) and a brief physical examination (Table 23-2). A gestational age assessment is completed within the first hours of birth in a stable newborn (Fig. 23-2). A more comprehensive physical assessment is completed within 24 hours of birth (Table 23-3).

TABLE 23-3


Inspect newborn before disturbing for assessment
Refer to maternal chart for fetal presentation, position, and type of birth (vaginal, surgical), given that newborn readily assumes in utero position
Vertex: arms, legs in moderate flexion; fists clenched
Resistance to having extremities extended for examination or measurement, crying possible when attempted
Cessation of crying when allowed to resume curled-up fetal position (lateral)
Normal spontaneous movement bilaterally asynchronous (legs moving in bicycle fashion) but equal extension in all extremities
Frank breech: legs straighter and stiff, newborn assuming intrauterine position in repose for a few days
Prenatal pressure on limb or shoulder possibly causing temporary facial asymmetry or resistance to extension of extremities
Hypotonia, relaxed posture while awake (preterm or hypoxia in utero, maternal medications, neuromuscular disorder such as spinal muscular atrophy)
Hypertonia (chemical dependence, central nervous system [CNS] disorder)
Limitation of motion in any of extremities
Vital Signs
Check heart rate and pulses:      
Thorax (chest)      
 Inspection Visible pulsations in left midclavicular line, fifth intercostal space    
 Palpation Apical pulse, fourth intercostal space 120-160 beats/min when awake 80-100 beats/min (sleeping) to 180 beats/min (crying); possibly irregular for brief periods, especially after crying Tachycardia: persistent, ≥180 beats/min (respiratory distress syndrome [RDS]; pneumonia)
Bradycardia: persistent, ≤80 beats/min (congenital heart block, maternal lupus)

Quality: first sound (closure of mitral and tricuspid valves) and second sound (closure of aortic and pulmonic valves) sharp and clear Murmur, especially over base or at left sternal border in interspace 3 or 4 (foramen ovale anatomically closing at approximately 1 yr) Murmur (possibly functional)
Dysrhythmias: irregular rate

Heart on right side of chest (dextrocardia, often accompanied by reversal of intestines)
Peripheral pulses: femoral, brachial, popliteal, posterior tibial Peripheral pulses equal and strong   Weak or absent peripheral pulses (decreased cardiac output, thrombus, possible coarctation of aorta if weak on left and strong on right)
Obtain temperature:      
Axillary: method of choice
Temporal and intraauricular thermometers not effective in measuring newborn temperature
Axillary: 37° C (98.6° F)
Temperature stabilized by 8-10 hr of age
36.5°-37.5° C (97.7°-100° F)
Heat loss: from evaporation, conduction, convection, radiation
Subnormal (preterm birth, infection, low environmental temperature, inadequate clothing, dehydration)
Increased (infection, high environmental temperature, excessive clothing, proximity to heating unit or in direct sunshine, chemical dependence, diarrhea and dehydration)
Temperature not stabilized by 6-8 hr after birth (if mother received magnesium sulfate, newborn less able to conserve heat by vasoconstriction; maternal analgesics possibly reducing thermal stability in newborn)
Observe and monitor respiratory rate and effort:
Observe respirations when infant is at rest
Observe respiratory effort
Count respirations for full minute
Auscultate breath sounds
Listen for sounds audible without stethoscope
Tendency to be shallow and irregular in rate, rhythm, and depth when infant is awake
Crackles may be heard after birth
No adventitious sounds audible on inspiration and expiration
Breath sounds: bronchial; loud, clear
Short periodic breathing episodes and no evidence of respiratory distress or apnea (>20 sec); periodic breathing
First period (reactivity): 50-60/min
Second period: 50-70/min
Stabilization (1-2 days): 30-40/min
Crackles (fine)
Apneic episodes: >20 sec (preterm infant: rapid warming or cooling of infant; CNS or blood glucose instability)
Bradypnea: <25/min (maternal narcosis from analgesics or anesthetics, birth trauma)
Tachypnea: >60/min (RDS, transient tachypnea of the newborn, congenital diaphragmatic hernia)
Breath sounds:

Distress evidenced by nasal flaring, grunting, retractions, labored breathing
Stridor (upper airway occlusion)
Obtain blood pressure (BP) (usually not done in normal term infant)
Check oscillometric monitor BP cuff: BP cuff width affects readings, use appropriate-size cuff and palpate brachial, popliteal, or posterior tibial pulse (depending on measurement site) 60-80/40-50 mm Hg (approximate ranges)
At birth

At 2 weeks

Variation with change in activity level: awake, crying, sleeping Difference between upper and lower extremity pressures (coarctation of aorta)
Hypotension (sepsis, hypovolemia)
Hypertension (coarctation of aorta, renal involvement, thrombus)
Put cloth or paper protective liner in place and adjust scale to 0 g or pounds and ounces
Weigh at same time each day
Protect newborn from heat loss
Female: 3400 g (7.5 lb)
Male: 3500 g (7.7 lb)
Regaining of birth weight within first 2 weeks
2500-4000 g (5.5-8.8 lb)
Acceptable weight loss: 10% or less in first 3-5 days
Second baby weighing more than first (on average)
Weight ≤2500 g (preterm, small for gestational age, rubella syndrome)
Weight ≥4000 g (large for gestational age, maternal diabetes, heredity—normal for these parents)
Weight loss more than 10% to 15% (growth failure, dehydration); assess breastfeeding success

Measure length from top of head to heel; measuring is difficult in term infant because of presence of molding, incomplete extension of knees 50 cm (19.7 in) 45-55 cm (17.7-21.7 in) <45 cm (17.7 in) or >55 cm (21.7 in) (chromosomal abnormality, heredity—normal for these parents); some syndromes present shorter-than-average limb length (skeletal dysplasias, achondroplasia)

Head Circumference
Measure head at greatest diameter: occipitofrontal circumference
May need to remeasure on second or third day after resolution of molding and caput succedaneum
33-35 cm (13-13.8 in)
Circumference of head and chest approximately the same for first 1 or 2 days after birth; chest rarely measured on routine basis
32-36.8 cm (12.6-14.5 in) Microcephaly, head ≤32 cm: (maternal rubella, toxoplasmosis, cytomegalovirus, fused cranial sutures [craniosynostosis])
Hydrocephaly: sutures widely separated, circumference ≥4 cm more than chest circumference (infection)
Increased intracranial pressure (hemorrhage, space-occupying lesion)

Chest Circumference
Measure at nipple line 2-3 cm (0.8-1.2 in) less than head circumference; average 30-33 cm (11.8-13 in) ≤30 cm Prematurity

Check color:
Generally pink
Varies with ethnic origin, skin pigmentation beginning to deepen right after birth in basal layer of epidermis
Acrocyanosis common after birth
Harlequin sign
Telangiectases (“stork bites” or capillary hemangiomas) (see Fig. 22-6, A)
Erythema toxicum/neonatorum (“newborn rash”) (see Fig. 22-6, B)
Petechiae over presenting part
Ecchymoses from forceps in vertex births or over buttocks, genitalia, and legs in breech births
Dark red (preterm, polycythemia)
Gray (hypotension, poor perfusion)
Pallor (cardiovascular problem, CNS damage, blood dyscrasia, blood loss, twin-to-twin transfusion, infection)
Cyanosis (hypothermia, infection, hypoglycemia, cardiopulmonary diseases, neurologic or respiratory malformations)
Generalized petechiae (clotting factor deficiency, infection)
Generalized ecchymoses (hemorrhagic disease)
Observe for jaundice None at birth Physiologic jaundice in up to 60% of term infants in first week of life Jaundice within first 24 hr (increased hemolysis, Rh isoimmunization, ABO incompatibility)
Observe for birthmarks or bruises:
  Mongolian spot (see Fig. 22-5) in infants of African-American, Asian, and Native-American origin Hemangiomas
Nevus flammeus: port-wine stain
Nevus vasculosus: strawberry mark
Cavernous hemangioma
Check skin condition:
Edema confined to eyelid (result of eye prophylaxis)
Opacity: few large blood vessels visible indistinctly over abdomen
Possibly puffy
Slightly thick; superficial cracking, peeling, especially of hands, feet
No visible blood vessels, a few large vessels clearly visible over abdomen
Some fingernail scratches
Edema on hands, feet; pitting over tibia; periorbital (overhydration; hydrops)
Texture thin, smooth, or of medium thickness; rash or superficial peeling visible (preterm, postterm)
Numerous vessels very visible over abdomen (preterm)
Texture thick, parchment-like; cracking, peeling (postterm)
Skin tags, webbing
Papules, pustules, vesicles, ulcers, maceration (impetigo, candidiasis, herpes, diaper rash)
 Weigh infant routinely Dehydration: loss of weight best indicator Normal weight loss after birth: up to 10% of birth weight  
 Gently pinch skin between thumb and forefinger over abdomen and inner thigh to check for turgor After pinch released, skin returns to original state immediately   Loose, wrinkled skin (prematurity, postmaturity, dehydration: fold of skin persisting after release of pinch)
Tense, tight, shiny skin (edema, extreme cold, shock, infection)
Note presence of subcutaneous fat deposits (adipose pads) over cheeks, buttocks   Variation in amount of subcutaneous fat Lack of subcutaneous fat, prominence of clavicle or ribs (preterm, malnutrition)
Check for vernix caseosa:
Whitish, cheesy, odorless Usually more found in creases, folds Absent or minimal (postmature infant)
Abundant (preterm)
Green color (possible in utero release of meconium or presence of bilirubin)
Odor (possible intrauterine infection)
Assess lanugo:
Over shoulders, pinnas of ears, forehead Variation in amount Absent (postmature)
Abundant (preterm, especially if lanugo abundant, long, and thick over back)
Palpate skin (See “Skin”) Caput succedaneum, possibly showing some ecchymosis (see Fig. 22-10, A) Cephalhematoma (see Fig. 22-10, B)
Inspect shape, size Making up one fourth of body length
Molding (see Fig. 22-9)
Slight asymmetry from intrauterine position
Lack of molding (preterm, breech presentation, cesarean birth)
Severe molding (birth trauma)
Indentation (fracture from trauma)
Palpate, inspect, and note size and status of fontanels (open vs. closed) Anterior fontanel 5-cm diamond, increasing as molding resolves
Posterior fontanel triangle, smaller than anterior
Variation in fontanel size with degree of molding
Difficulty in feeling fontanels possible because of molding
Palpate sutures Palpable and separated sutures Possible overlap of sutures with molding Sutures:
Inspect pattern, distribution, amount of hair; feel texture Silky, single strands lying flat; growth pattern toward face and neck Variation in amount Fine, wooly (preterm)
Unusual swirls, patterns, or hairline; or coarse, brittle (endocrine or genetic disorders)
Check placement on face Eyes and space between eyes each one-third the distance from outer-to-outer canthus Epicanthal folds: characteristic in some ethnicities Epicanthal folds when present with other signs (chromosomal disorders such as Down, cri-du-chat syndromes)

Check for symmetry in size, shape Symmetric in size, shape    
Check eyelids for size, movement, blink Blink reflex Edema if eye prophylaxis drops or ointment instilled  
Assess for discharge None
No tears
Some discharge if silver nitrate used
Occasional presence of some tears
Discharge: purulent (infection)
Chemical conjunctivitis from eye medication is common—requires no treatment
Evaluate eyeballs for presence, size, shape Both present and of equal size, both round, firm Subconjunctival hemorrhage Agenesis or absence of one or both eyeballs
Lens opacity or absence of red reflex (congenital cataracts, possibly from rubella, retinoblastoma [cat’s eye reflex])
Lesions: coloboma, absence of part of iris (congenital)
Pink color of iris (albinism)
Jaundiced sclera (hyperbilirubinemia)
Check pupils Present, equal in size, reactive to light   Pupils: unequal, constricted, dilated, fixed (intracranial pressure, medications, tumor)
Evaluate eyeball movement Random, jerky, uneven, focus possible briefly, following to midline Transient strabismus or nystagmus until third or fourth month Persistent strabismus
Doll’s eyes (increased intracranial pressure)
Sunset (increased intracranial pressure)
Assess eyebrows: amount of hair, pattern Distinct (not connected in midline)   Connection in midline (Cornelia de Lange syndrome)
Observe shape, placement, patency, configuration Midline
Some mucus but no drainage
Preferential nose breather
Sneezing to clear nose
Slight deformity (flat or deviated to one side) from passage through birth canal Copious drainage (rarely congenital syphilis); blockage membranous or bone with cyanosis at rest and return of pink color with crying (choanal atresia)
Malformed (congenital syphilis, chromosomal disorder)
Flaring of nares (respiratory distress)
Observe size, placement on head, amount of cartilage, open auditory canal Correct placement line drawn through inner and outer canthi of eyes reaching to top notch of ears (at junction with scalp)
Well-formed, firm cartilage
Size: small, large, floppy
Darwin’s tubercle (nodule on posterior helix)
Lack of cartilage (preterm)
Low placement (chromosomal disorder, intellectual disability, kidney disorder)
Preauricular tag or sinus
Size: possibly overly prominent or protruding ears

Sep 16, 2016 | Posted by in NURSING | Comments Off on Nursing Care of the Newborn and Family
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