Temperature

The most accurate way to determine body temperature is to measure it with a thermometer. The initial temperature of the neonate is generally taken via the axillary route. It is not usually taken rectally because this method could cause perforation of the mucosa. Tympanic thermometers are not as accurate in a newborn. Daily routine temperatures are taken in the axilla. Review the procedure for evaluation of vital signs in Chapter 3.

The neonate has an immature heat-regulating system. Thermoregulation of the neonate (regulation of heat) requires close monitoring. The newborn’s temperature falls immediately after birth to about 96° F (35.5° C). Within a few hours, it climbs slowly to a range of 98° F to 99° F (36.6° C to 37.2° C). The body temperature is influenced by the temperature of the room and the number of blankets covering the newborn. The nurse also needs to recognize the possibility of fever or sepsis (temperature could be low) in the newborn and alert the charge nurse or physician immediately.

One of the most critical needs of the infant is control of body temperature. This is especially true if the infant is at high risk. The neonate is at immediate risk for heat loss at the time of delivery. The newborn does not have the ability to produce or conserve heat that an older infant does. A newborn cannot shiver to generate heat. Through a process called nonshivering thermogenesis, brown fat is metabolized to increase metabolic rate and to generate heat. Brown fat is a fat store located in the axillae, between the scapulae, in the mediastinum, around the liver, and down the spine. If not corrected, cold stress can actually cause metabolic and physiologic problems in the neonate such as hypoglycemia (low blood sugar), hypoxia (low oxygenation), and metabolic acidosis.

Immediately after birth, the newborn is thoroughly dried (especially the hair) to eliminate evaporative heat loss and placed uncovered under radiant heat (Figure 5-2). The premature infant may be placed in the isolette (Figure 5-3). The infant’s temperature is maintained at a constant level with a heat-sensitive probe that is taped over a nonbony prominence on either the abdomen or back. This allows the infant to become a thermostat for the radiant warmer. The infant’s axillary temperature is also monitored. Overhead radiant warmers have the advantage of providing easier access to the child while maintaining a neutral environment. The nurse should also do the following:

If the newborn is placed on the mother’s chest, skin-to-skin contact should be maintained. A cap for the newborn prevents heat loss (Figure 5-4). The nurse remains with the mother and the newborn to ensure their safety, to monitor progress, and to ensure that the newborn stays warm. Table 5-2 discusses types of heat loss.

Another sign of the neonate’s system immaturity is acrocyanosis (acro, extremity; cyanosis, blue color) or peripheral blueness of the hands and feet. The hands and feet are also cooler than other parts of the body. The neonate has difficulty adapting to changes in temperature. Because heat perception is poor, the newborn must be monitored closely whenever an external heat source, such as a radiant warmer, is used. The newborn should also be wrapped in a blanket.

Heart Rate and Blood Pressure

An apical heart rate should be auscultated for 1 full minute (discussed in Chapter 3) in the newborn, and it can range between 120 and 160 beats per minute. This rate may increase if the infant is crying and decrease if the infant is sleeping. As a general rule, however, if the pulse is above 180 or drops below 100, the finding should be reported. Blood pressure in the newborn is usually low, and use of the correctly sized cuff is important. The average blood pressure at birth is 80/46 mm Hg.

Respirations

Respirations in the newborn may be irregular and should be counted for 1 full minute. Normal respirations are 40 to 60 breaths per minute and then drop to 30 to 50 breaths per minute after the first 24 hours after birth and are typically shallow and unlabored.

Reflexes

The nervous system directs most of the body’s activity. The neonate can move his or her arms and legs vigorously but cannot control them. The reflexes that a full-term baby is born with, such as blinking, sneezing, gagging, rooting, sucking, and grasping (Figure 5-9 and Table 5-3), help keep the child alive. The rooting reflex causes the infant to turn the head in the direction of anything that touches the cheek, such as in anticipation of food. The nurse should remember this when helping a mother breastfeed her infant. If the breast touches the infant’s cheek, the newborn turns toward it to find the nipple. The infant can also cry, swallow, and lift the head slightly when lying on the stomach. If startled, the newborn extends the extremities and then draws the legs up and folds the arms across the chest in an embrace position. The hands open, but the fingers often remain curved. This is normal and is called the Moro reflex (Figure 5-10). Its absence may indicate abnormalities of the nervous system.

The tonic neck reflex is a postural reflex that is sometimes assumed by babies while asleep (Figure 5-11). The head is turned to one side, with the arm and leg extended on the same side, whereas the opposite arm and leg are flexed in a “fencing” position. This reflex disappears around the 20th week of life. Prancing movements of the legs, seen when a newborn is held upright on the examining table, are termed the dancing reflex.

Vision

Although vision is the most poorly developed sense at birth, the neonate can see sizes, shapes, colors, and patterns and is able to fixate points of contrast. The infant shows preference for observing a human face and follows moving objects. Visual stimulation thus becomes an important ingredient in caring for the baby. Auditory toys and contrasted colors attract the neonate. Sensory overload, of course, should be avoided.

Most newborn infants appear cross-eyed because their eye muscle coordination is not fully developed. After birth and into the first few months of life, the infant’s eyes appear to be blue or gray; however, the permanent coloring becomes fixed by the first birthday.

Hearing

Hearing in newborns is thought to be keener than was once believed. Increased response to vocal stimulation, particularly higher-pitched female voices, can be documented. The ears and nose need no special attention, except for cleansing. This can be done during the bath with a soft cloth. Cotton-tipped applicator sticks are dangerous to use and may cause injury if inserted too far into the ear or if the newborn moves suddenly. They should never be used for ear wax removal.

Undetected hearing loss can cause a child to develop problems in speech, language, and cognitive development and can also lead to development of behavioral problems. Hearing loss is a common birth defect, occurring in up to 3 per 1000 newborn infants, and needs to be identified as soon as possible. In the past, parental observation and assessment by health care providers have not been reliable in identifying hearing loss in the first year of life. In 2000, the Joint Committee on Infant Hearing (JCIH) recommended universal screening of hearing loss before hospital discharge. The automated Auditory Brainstem Response (ABR) screening test as well as the Evoked Otoacoustic Emissions (OAE) screening test detect hearing loss in infants. The detection of hearing loss and early interventions aid the child in achieving academic and social success because they allow for the development of thinking and visual or spoken language skills.

Movements and Tremors

Movements of the neonate are random and uncoordinated. The newborn lacks the muscular control to hold the head up (Figure 5-12). The development of muscular control proceeds from head to foot and from the center of the body to the periphery (discussed in Chapter 4). The baby, therefore, holds up the head before sitting erect. In fact, the head and neck muscles are the first ones under control. The legs are small and short and may appear bowed. There should be no limitation of movement. Fingers clenched in a fist should be separated and observed.

Freedom of movement is observed as the baby stretches, sucks, and makes faces. The whole body moves vigorously when the newborn cries. Tremors of the lips and extremities during crying are normal. Constant tremors during sleep, which are accompanied by eye movements and are not related to any particular stimuli, may be pathologic. The morning assessment provides an excellent opportunity for the nurse to inspect and evaluate the newborn’s condition. When handled, the infant should not feel limp. General body proportions are noted. Bathing is also an excellent way to provide the neonate with stimulation.

Male Genitalia

The genitals are undeveloped at birth. The testes of the male child descend into the scrotum before birth. Occasionally, they remain in the abdomen or inguinal canal. This condition is called cryptorchidism (undescended testes). The prognosis is good with proper surgical treatment.

The penis is covered by a sleeve of skin called the foreskin or prepuce. After the foreskin separates from the glans, it can be pulled back away from the glans toward the abdomen. This is called foreskin retraction. This should never be forced because it can harm the penis and cause pain, bleeding, and tears in the skin. Most boys are able to retract their foreskins by age 5 years. Parents should be taught to wash all the male infant’s body parts and not to forcibly retract the foreskin. Parents may be surprised when their baby boy has an erection and should be taught that this is common and has no significance.

Circumcision is the surgical removal of the foreskin. The procedure has been subject to much controversy. Among the risks are infection and hemorrhage. Infants with congenital anomalies of the penis, such as hypospadias (occurs when the opening of the urethra is on the undersurface of the penis), should not be circumcised because the foreskin may be needed for surgery. Studies show that the risk for penile cancer and urinary tract infections are reduced in circumcised men compared with those who are uncircumcised; however, the incidence of such illness is so low that circumcision cannot be justified for prophylaxis (Hirji et al., 2005). There is also new research that indicates male circumcision has proven to be a primary prevention strategy against transmission of HIV (Uys, 2009/2010). A discussion of the pros and cons of this procedure should be included as part of the prenatal and postpartum education. The parents’ knowledge and understanding of the procedure of circumcision is necessary because a surgical consent form must be signed before this procedure can be performed.

When circumcision is desired, it is performed after 12 hours of age. This period of time allows the newborn to adjust from the stress of birth and for bonding to begin. The nurse needs to advocate for the use of pain medication for babies undergoing this procedure. Analgesics and/or anesthesia should be prescribed for pain control. For the circumcision procedure, the newborn is restrained on a circumcision board. The foreskin is freed with a probe, an incision is made the length of the foreskin, and a Plastibell, Gomco clamp, or Mogen clamp (rarely used) is used to control blood loss. Excess foreskin is removed with a scalpel or a scissor (Figure 5-13). After this procedure, it is important for the nurse to observe for bleeding, irritation, and voiding. Pain is always assessed as the fifth vital sign.

When a Plastibell is used, a string is tied over a fitted plastic ring beneath the foreskin. As the area heals, the plastic ring drops off in 7 to 10 days after the circumcision. Parents are instructed not to remove the plastic ring prematurely. No special dressing is required, and the newborn may be diapered as usual. Tub bathing may be done after the ring falls off and the circumcision is healed. A dark brown or black line encircling the plastic ring is normal and will disappear when the plastic ring drops off. Parents are instructed to consult their physician if there is increased swelling, the ring has not fallen off within 10 days, the ring has slipped onto the shaft of the penis, or for any other questions/concerns.

When a Mogen or Gomco clamp is used, a dressing with Vaseline (or another petroleum jelly) is used for 24 to 48 hours. Complete healing takes approximately 7 to 10 days.

Female Genitalia

The female genitals may be slightly swollen after birth. Blood-tinged mucus may be discharged from the vagina 3 to 5 days after birth, which is caused from withdrawal of hormones transmitted from the mother to the fetus. The nurse should clean the vulva from the urethra to the anus, with three strokes—right side, left side, and center. A clean cotton ball or clean (different) section of a washcloth is to be used for each stroke to prevent fecal matter from infecting the urinary tract. The importance and rationale of cleaning from front to back must be emphasized to parents.

Skin

The skin of newborn Caucasian babies is red to dark pink in color. The skin of African-American babies may be reddish brown. Infants of Latin descent may appear to have an olive or yellowish tint to the skin. The body is usually covered with fine hair called lanugo, which tends to disappear during the first weeks of life. Lanugo is more evident in premature infants (Figure 5-14). Vernix caseosa, a cheeselike substance that covers the skin of the neonate, is made up of cells and glandular secretions and is thought to protect the skin from infection. White pinpoint pimples caused by obstruction of sebaceous glands may be seen on the nose and chin. These are called milia and disappear within a few weeks. Mongolian spots, bluish discolorations of the skin, are common in babies of African-American, Latino, Native American, or Mediterranean descent. They are usually found over the sacral and gluteal areas (Figure 5-15). They disappear spontaneously during the first years of life. Be careful not to confuse Mongolian spots with bruises that can occur from child abuse. Pallor or generalized cyanosis is not normal and should be reported.

Some hospitals still identify newborn babies with footprints, although many hospitals now have more advanced identification techniques. Footprints may still be used because the skin is so constructed with ridges and grooves that each person has a unique pattern that never changes. Regardless of hospital policy on identification method, most parents appreciate a copy of the footprint for the baby scrapbook.

Tissue turgor refers to the condition of the skin and indicates how hydrated or dehydrated the newborn is. To test tissue turgor (elasticity), the nurse gently grasps and releases the skin on the chest. It should spring back into place immediately. When the skin remains distended, tissue turgor is termed poor.

Desquamation, or peeling of the skin, occurs during the first weeks of life. Skin on the nose, knees, elbows, and toes may break down because of friction from rubbing against the sheets. The area involved should be kept dry, and the newborn’s position should be changed frequently. The buttocks also need special attention. A wet diaper should be changed immediately to prevent irritation. The buttocks should be washed and dried well. Parents should be informed that this prevents diaper rash.