The Newborn Infant



The Newborn Infant



Objectives



1. Define the vocabulary terms listed


2. Discuss the importance of airway maintenance in the neonate


3. Identify the range of average measurements in the newborn infant


4. Describe the importance of thermoregulation, particularly in the preterm infant


5. Discuss normal vital signs of the newborn


6. Differentiate AGA, SGA, and LGA infants


7. Differentiate low–birth weight, very low–birth weight, and extremely low–birth weight neonates


8. Describe the APGAR and the Ballard scoring systems


9. Briefly describe three normal reflexes of the neonate (including approximate age of disappearance) and the tests for their appearance


10. Discuss implications and treatment methodologies of jaundice in the newborn


11. List three causes of preterm birth


12. Describe the differences in care for the preterm infant with respiratory distress syndrome and apnea


13. Differentiate hypoglycemia and hypocalcemia


14. List three characteristics of the postterm infant


15. Describe the six neonatal states of the newborn


16. Discuss medications administered to the newborn


17. Discuss the purpose of metabolic screenings


18. Compare and contrast breastfeeding and formula feeding


19. Contrast the techniques of feeding the preterm and the full-term neonate


20. Describe precautions to prevent infection while caring for the newborn


21. Summarize teaching principles of bathing the newborn, providing cord care, and providing circumcision care


22. Discuss ways to help facilitate the maternal-infant bonding process for a preterm neonate


23. Describe discharge teaching needs of the parents




Introduction to the Newly Born Infant


imageevolve.elsevier.com/Price/pediatric/


Every parent wants a perfect baby. Reality is, however, that not all babies are born without defects. Birth defects can vary from minor to fatal. Chapter 1 discusses infant mortality. A birth defect is defined as “an abnormality of structure, function, or metabolism (body chemistry) present at birth that results in physical or mental disability or death. Several thousand different birth defects have been identified. Birth defects are the leading cause of death in the first year of life” (March of Dimes, 2006). Birth defects are the cause of death in one of every five infant deaths. The March of Dimes lists three major categories of birth defects: structural/metabolic, congenital infections, and other. Because these disorders include so many conditions, it has been necessary to limit the number discussed in this chapter and to discuss others in relevant areas of the textbook (see the Index for specific conditions).


In 1998, Congress passed the Birth Defects Prevention Act, which provides funding to the Centers for Disease Control and Prevention to collect and analyze data on birth defects, to support research, and to educate the public regarding birth defects. Defects present at birth often involve the skeletal system; limbs may be missing, malformed, or duplicated. Some abnormalities, such as congenital developmental dysplasia of the hip (DDH), are more subtle and require alertness on the part of health care providers to detect them. Inborn errors of metabolism include a number of inherited diseases that affect body chemistry. There may be an absence or a deficiency of a substance necessary for cell metabolism. This is usually an enzyme deficiency. Almost any organ of the body may be damaged. Examples of inborn errors of metabolism include cystic fibrosis and phenylketonuria. In disorders of the blood, there is a reduced or missing blood component or an inability of a component to function adequately. Sickle cell anemia, thalassemia, and hemophilia fall into this group. Chromosomal abnormalities number in the hundreds. Some involve mental retardation, and some are incompatible with life. The newborn infant with Turner syndrome or Klinefelter syndrome may be retarded in physical growth and sexual development. Perinatal damage also has many causes and can be seen in a variety of forms. The most common form is premature birth. Only a few birth defects can be attributed to a single cause; most are thought to result from a combination of environment and heredity.


Some prenatal tests (ultrasound, amniocentesis, and chorionic villus sampling [CVS]) may assist in the diagnosis of certain birth defects before birth. These tests may be helpful in detecting or ruling out a possible birth defect with families that are suspected of having a history of birth defects. Medical therapies, which can be used in the prenatal period, are being developed for some birth defects. Prenatal surgeries also have had some success repairing congenital diaphragmatic hernias and urinary tract blockages. As medical technology improves, new interventions may have positive results for additional defects.


With this understanding in mind, the remainder of the chapter will focus on the “normal” newborn, care of the newborn, and complications that can occur with prematurity. Additional chapters in the text will elaborate on the various systems and disorders that occur from birth through the teenage years.



Adaptations of the Neonate


When a baby is born, an orderly process of adaptation from fetal life to extrauterine life takes place. All the body systems undergo some change. Respirations are stimulated by chemical changes within the blood and by chilling. Sensory and physical stimuli also appear to play a role in respiratory function. Gentle physical contact is used to provide stimulation to begin breathing. Cold, pain, touch, movement, and light are other stimuli that affect the stimulation of respirations. With the first breath, which initiates the opening of the alveoli, the newborn enters the world of air exchange and begins an independent existence. In addition, this process begins cardiopulmonary interdependence (see Chapter 12). The ability of the neonate to metabolize food is hampered by immaturity of the digestive system, particularly by deficiencies in enzymes from the pancreas and the liver. Although the kidneys are developed structurally, their ability to concentrate urine and maintain fluid balance is limited. This is because of a decreased rate of glomerular flow and limited renal tubular reabsorption. Most neurologic functions are also primitive.



Initial Exam of the Newborn Infant


Airway


Regardless of the site of delivery (home, birthing room, taxicab), clearing the neonate’s airway is an immediate concern. A bulb syringe or suction may be used. Spontaneous breathing should begin within a few seconds. If there are no complications, the newborn is placed on a warming table where care can be given and the newborn’s general condition can be observed. The newborn is dried gently to remove excess blood from the face, scalp, and body. This also provides stimulation and decreases the risk of hypothermia. Mothers who are alert are given their child to hold and inspect.


If spontaneous breathing does not occur, resuscitative measures are taken. The need for resuscitation often can be anticipated from the history of the mother’s pregnancy, abnormal progression of labor, the size of the neonate, and the difficulty of delivery. Well-trained personnel and properly functioning equipment are imperative. Periodic review of techniques is also necessary. Resuscitation methods are directed toward clearing the airway, providing oxygen, and maintaining circulation. The administration of appropriate drugs, such as naloxone hydrochloride (Narcan), epinephrine, dextrose, or calcium gluconate, may also be warranted. Procedures range from the simple to the more complex. Measures such as tactile stimulation (rubbing the neonate’s back), assisted ventilation with bag and mask or endotracheal tube, and chest compressions may be necessary, if the newborn’s condition warrants this. The infant is then transferred to the nursery in a bassinet, isolette, or warmer. Assisted breathing via a mechanical ventilator may be necessary in the neonatal intensive care unit (NICU).



Umbilical Cord


The umbilical cord, which is attached to the placenta at birth, is cut and clamped by the attending physician. Before the clamp is applied, the cord is inspected to determine that two arteries and one vein are present. A single umbilical artery is often indicative of genitourinary anomalies. The findings are recorded.


Cord blood may be collected at the request of the parents. This is the blood that remains in the umbilical cord and placenta following birth. Cord blood is stored at a blood bank. This blood serves as an abundant source for stem cells, which are genetically distinctive to the newborn. These cells contribute to the development of all tissues, organs, and systems in the body. They can transform into other types of cells in the body and create new growth and development. They may be used one day to help treat problems such as heart disease, cancers, and stroke. Parents need to be aware there is a cost involved for this service.



The cord stump may be painted with a substance to help dry the cord and prevent infection. This dye may cause a temporary purplish discoloration. Parents should not try to rub or wash this off. The cord stump gradually shrinks, turns black, and falls off. This process usually takes 10 to 14 days. Until the umbilical wound is completely healed, the blood vessels of the cord and their extension into the abdomen are potential portals of entry for disease organisms. Redness, odor, or discharge from this area should be reported to the physician. The nurse observes the cord for bleeding, particularly during the first 24 hours.



Apgar Scoring


A system for recording the condition of the neonate and the need for resuscitation was devised by Dr. Virginia Apgar and is currently used in many delivery rooms. The first assessment is made 1 minute after delivery. This generally produces the lowest score. A second evaluation is made after 5 minutes. Table 5-1 shows how to determine the Apgar score. An infant with a score of 8 to 10 is in good condition and needs only routine suction and observation. Infants with a score of 4 to 7 require various forms of intervention and close observation. An infant with a score of 0 to 3 needs resuscitation and care in the NICU. Apgar scores, however, are not the sole indicator used to evaluate the long-term prognosis of a child.




imageMeasurements


The newborn is weighed and measured shortly after birth. The length of the average neonate is 19 to 21.5 in (48.25 to 54.5 cm). The weight varies from 6 to 9 lb (2700 to 4000 g). Girls generally weigh a little less than boys. In the first 3 to 5 days after birth, the newborn loses about 7% to 10% of the birth weight. This is from the loss of excess extracellular fluid and meconium and from limited food intake, especially in breastfed infants. The total weight loss for the newborn should not exceed 10%; this amount of weight loss is reflective of dehydration. By the tenth day of life, birth weight should be regained. Weight loss is expected, and parents should not be alarmed by it. For a more accurate assessment of weight, neonates are weighed naked on the same scale at the same time each day.


Head circumference is generally between 33 and 35 cm (13 to 15 in). This measurement may be somewhat less because of the molding process during a vaginal delivery (Figure 5-1). Within 2 to 3 days, it is usually the normal size. Chest circumference is normally 30.5 to 33 cm (12 to 13 in). Head circumference is generally about 2 to 3 cm (1 in) greater than the chest circumference.




Vital Signs



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.





Weight and Gestational Age


Gestational age refers to the actual time from conception to birth that the fetus remains in the uterus. A full-term infant is born between 38 and 42 weeks after conception. Infants born between 34 and 37 weeks are considered late preterm, while those born at less than 34 weeks are called preterm, and those born at more than 42 weeks are called postterm. Infants are considered appropriate for gestational age (AGA) if they are born between the 10th and 90th percentiles for weight. This infant has grown at a normal rate, regardless of the time of birth. If the infant is small for gestational age (SGA), below the 10th percentile, the infant has experienced intrauterine growth restriction or delay. In a similar fashion, those infants weighing above the 90th percentile on intrauterine growth curves are referred to as large for gestational age (LGA). Emphasis is placed on the gestational age and the level of maturation—preterm, term, and postterm (Figure 5-5). Current data also indicate that intrauterine growth rates are not the same for all babies and that individual factors must be considered.



Prematurity and low birth weight often occur together, and both of these factors are associated with increased neonatal morbidity and mortality. The less a baby weighs at birth, the greater are the risks to life during delivery and immediately thereafter. High-risk infants are also classified according to the following guidelines:




Maturity


Several differences are seen between a premature and a full-term infant. Muscle tone is decreased in the infant who is not full-term. The position that the infant maintains can also indicate low gestational age. When in a prone position, the full-term infant lies with the pelvis high and the knees drawn up under the abdomen. The premature infant that is placed in a prone position lies with the pelvis low and the knees at the side of the abdomen, with the hips flexed. In the supine position, the infant of 28 to 32 weeks’ gestational age lies in a froglike position with the lower limbs extended and the hips abducted. The full-term infant in a supine position lies with the limbs strongly flexed. Differences also exist in the hand movement of the infant across the chest to the opposite side of the neck. The reach of an infant of 28 weeks’ gestation can extend well past the acromion, whereas the hand of the full-term infant does not go beyond that point. If the hand is put behind the neck to the opposite side, the same difference between the ages is noted. This is called the scarf sign (Figure 5-6). The new Ballard scoring system is used to determine gestational age and consists of an evaluation of physical characteristics and neuromuscular tone (see Appendix C).




Characteristics of the Newborn Infant


imageHead


The newborn infant’s head is proportionately large in comparison with the rest of the body because the brain grows rapidly before birth. The head may be out of shape from molding, which occurs as the fetal head conforms to the size and shape of the mother’s pelvis. Another condition that can alter the shape of the newborn’s head is caput succedaneum, which is edema of the newborn’s scalp resulting from pressure against the cervix.


This condition usually clears within 24 to 48 hours. Occasionally, a hematoma (hemato, blood; oma, tumor) protrudes from beneath the scalp. The cephalhematoma takes longer to subside, but it usually clears by the time the infant is 2 to 4 weeks of age (Figure 5-7). Cephalhematoma can increase the risk of hyperbilirubinemia (the additional accumulation of blood increases the number of red blood cells, therefore there is an increased release of bilirubin; refer to section on jaundice).



Some neonates have a large amount of hair that eventually is replaced by new hair. The infant’s hair should be washed when the newborn is bathed and then can be brushed into place. Some infants develop cradle cap (seborrheic dermatitis), characterized by yellow, oily, crustlike scales on the scalp and forehead. Using mineral oil to soften the scales, massaging with a soft baby brush, and shampooing the area with a mild shampoo will help eliminate cradle cap.


Fontanels are junctures at the cranial bones that can be felt as soft spots on the cranium of the young infant. Two can be palpated on the neonate’s head. The fontanels may be smaller immediately after birth than several days later because of molding. The anterior fontanel is diamond-shaped and located at the junction of the two parietal and the two frontal bones. It usually closes by 12 to 18 months of age (Figure 5-8). The posterior fontanel is triangular and located between the occipital and the parietal bones. It is much smaller than the anterior fontanel and has usually ossified by the end of the second month. The pulsating of the anterior fontanel may be seen by the nurse. These areas are covered by a tough membrane, and there is little chance of their being injured with ordinary care.




Nervous System



imageReflexes

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.




Sensory System


The neonate can both taste and smell. In fact, the mother’s scent appears to stimulate the neonate to smell breast milk and to search for the nipple.




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.



Circulatory and Respiratory System


Before birth, a baby is completely dependent on the mother for all vital functions. The fetus needs oxygen and nourishment to grow. These are supplied through the bloodstream of the mother by way of the placenta and the umbilical cord. The fetus is relieved of the waste products of metabolism through the same route. The lungs are not inflated and are almost completely inactive. The circulatory system is adapted only to life within the uterus. Little blood flows through the pulmonary artery because of natural openings within the heart (foramen ovale) and vessels that close at or shortly after birth. When the umbilical cord is clamped and cut, the lungs take on the function of breathing in oxygen and removing carbon dioxide. The first breath taken helps expand the fluid-filled alveoli in the lungs. The physician assists the first respiration by holding the infant’s head down and removing mucus from the passages to the lungs. The newborn’s cry should be strong and healthy. The most critical period for the neonate is the first hour of life, when the drastic change from life within the uterus to life outside the uterus takes place.


The nurse refers to the child’s chart to review the Apgar score and to determine whether or not there were any particular difficulties during the birth process. The orders left by the doctor are reviewed. The nurse must observe the newborn very closely. Respiratory distress may be indicated by the rate and character of respirations, color (the nurse observes the newborn for signs of cyanosis), and overall general behavior. Any retractions should be reported immediately. (See Complications of the Preterm Infant Respiratory System later in this chapter for a discussion on retractions.) Mucus may be seen draining from the nose or mouth. Gentle suctioning with a bulb syringe may also be indicated. See Chapter 3 to review the use of a bulb syringe.



Musculoskeletal System


The bones of the newborn infant are soft because they are made up chiefly of cartilage, with only a small amount of calcium. The skeleton is flexible. The joints are elastic to accommodate passage through the birth canal. Because the bones of the child are easily molded by pressure, the position must be changed frequently. If the baby lies constantly in one position, the bones of the head can become flattened.



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.



Genitourinary System


The kidneys function normally at birth but are not fully developed. The glomeruli are small. Renal blood flow is only about one third of that in an adult. The ability to handle fluid load is reduced, as is the excretion of drugs. The renal tubules are short and have a limited capacity for reabsorbing important substances such as glucose, amino acids, phosphate, and bicarbonate. There is a decrease in the ability to concentrate urine and to cope with fluid imbalances. The infant should void within the first 24 to 48 hours after birth. The newborn may void in the delivery room, and it may not be observed. The nurse must keep an accurate record of the frequency of urination. Anuria (absence of voiding), changes in the color of urine, and any unusual findings should be brought to the attention of the physician. The newborn is not sent home unless voiding is observed.



imageMale 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.





Integumentary System



imageSkin

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.

Dec 22, 2016 | Posted by in NURSING | Comments Off on The Newborn Infant
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