Chapter
54
Newborn Care
Instructional Approaches
Approach: Immediate Needs of the Newborn
Review the immediate care of the newborn. Divide the students into groups and have each group demonstrate one of the areas of newborn care.
Discussion/Lecture
In Apgar scoring, heart rate, respiratory rate, muscle tone, reflex irritability, and color are assessed. Each of the five items is assessed at 1 minute and 5 minutes after birth. When the Apgar score is 8 or above, no interventions are needed. When the Apgar score is between 4 and 8, gentle rubbing of the infant’s back and administration of oxygen will usually increase the score. When the Apgar score is between 0 and 4, the infant requires resuscitation. The infant must be kept on one side with the head flat or slightly elevated, as a head-down position makes it more difficult to breathe.
Resuscitation is begun if there are no respirations initiated by the infant. Use a bulb syringe to suction mucus from the infant’s oropharynx, gently rub the infant’s back for stimulation, or provide oxygen. If these measures are not successful, the physician or registered nurse will provide more extensive resuscitation.
A neutral thermal environment is important. The infant must be dried to prevent heat loss by evaporation. A prewarmed radiant warmer is used when giving initial care. Skin-to-skin contact and a stocking cap on the infant’s dry head also help to prevent heat loss.
The infant must have proper identification. A set of four identification bands imprinted with the same number is used. The mother’s name, gender of infant, time of birth, and physician’s name are written on the band. Two bands are placed on the infant and one is placed on the mother. Footprints of the newborn infant and either a fingerprint or a thumbprint of the mother are collected. The baby’s identification bands must be checked and compared to the mother’s band each time the baby is brought into the mother’s room.
To promote parent/infant bonding, interaction between the parents and the infant should be promoted as soon as the infant is stable.
Prophylactic care includes an intramuscular injection of vitamin K, which is generally given to the newborn within the first hour after birth to prevent hemorrhagic disorders. A normal newborn is able to produce vitamin K by the eighth day. The first dose of Hepatitis B vaccine and Hepatitis B immune globulin should be given within 12 hours of birth. Erythromycin or tetracycline should be instilled in the newborn’s eyes to prevent gonorrheal or chlamydia infections.
Umbilical cord care is important. The cord and the skin around it should be assessed for redness, edema, and purulent drainage each time the diaper is changed. If bleeding from the cord is noted, check the clamp and apply a second clamp on the body side of the first clamp. Notify the physician if the bleeding does not stop. Clean the cord using hospital protocol.
Approach: Physical Characteristics of the Newborn
Assign student groups to research the physical characteristics of the newborn and have them present the information to the class. Each student group should verbalize the normal findings for each.
Discussion/Lecture
Most full-term infants weigh between 5 pounds, 8 ounces, and 8 pounds, 13 ounces. Newborns lose 5 to 10 percent of their body weight in the first 3 to 4 days and usually regain the weight by 10 days. Full-term infants’ length is approximately 19 to 21 inches. Crown to rump length is 12 to 14 inches, or approximately equal to the head circumference.
Vital signs of the infant include axillary temperature, which should be between 97.6 and 98.9. Crying may slightly increase body temperature. Apical heart rate is 120 to 140. Heart rate decreases while sleeping. Respirations are 30 to 60. Blood pressure ranges between 60 and 80 mm Hg systolic and 40 and 45 diastolic. By 10 days of age, the infant’s blood pressure is 100/50.
The infant’s general appearance should be noted. Full-term newborns have a flexed posture. Skin at birth is red, puffy, and smooth. Some vernix caseosa may thinly cover the newborn’s skin, with large amounts in the creases. Lanugo may be seen on the forehead and shoulders. Acrocyanosis may be present for several hours. Edema may be present around the newborn’s eyes, face, dorsa of hands, legs, feet, and labia or scrotum. The infant’s head circumference is between 13 and 14 inches. There are two fontanelles. The anterior is the largest, is diamond shaped, and closes by 18 months. The posterior fontanelle is triangular in shape and closes at about 2 months. The fontanelles should be firm and flat but may bulge when the baby cries. The infant’s eyes are either slate gray, blue, or brown. Permanent eye color is usually established by 3 months. Eyelids are edematous and there are no tears. Ear placement should be so the top of the ear is in line with the outer canthus of the eye. The infant’s neck is short, thick, and has several skin folds. Chest circumference is 12 to 13 inches. The infant’s abdomen is cylindrical in shape and the umbilical cord protrudes from the center. The female newborn’s labia are usually edematous. If the male infant’s testes are descended, the scrotum is large, pendulous, and edematous; if the testes are not descended, the scrotum is small. The scrotum is covered with rugae. The newborn should urinate within 24 hours. The spine should be intact with no masses, prominent curves, or openings. On the newborn’s feet, creases should be visible on the anterior two-thirds of the sole.
Approach: Common Variations in the Newborn
Discuss the common variations of the newborn. Have the students compare caput succedaneum and cephalhematoma using Table 54-1 in the text.
Discussion/Lecture
Jaundice occurring after the first 24 hours is related to the normal destruction of red blood cells. It usually peaks in 72 hours and disappears in a couple of weeks. Jaundice appearing within the first 24 hours is not normal; the physician should be called.
Ecchymosis and petechiae may be present after a difficult delivery.
Milia are white, pinhead-size, distended sebaceous glands on the infant’s cheeks, nose, chin, and trunk. They disappear in a few weeks and should not be squeezed.
Erythema toxicum neonatorum is a pink rash with firm, yellow-white papules or pustules found on the chest, abdomen, back, and buttocks. The rash appears 24 to 48 hours after birth and requires no treatment.
Telangiectatic nevi (stork bites) are birthmarks of dilated capillaries that blanch with pressure. They fade between 1 and 2 years of age.
Nevus flammeus (port wine stain) is a large, reddish-purple birthmark found on the infant’s face or neck that does not blanch with pressure. It is not raised and does not disappear without treatment.
Nevus vascularis (strawberry mark) is a birthmark of enlarged superficial blood vessels. The mark is elevated, red in color, and of variable size and shape. It usually disappears by school age.
Mongolian spots are deep blue areas of coloration seen mainly in the sacral area in infants of African, Asian, American Indian, Hispanic, and southern European descent. The spots appear to be bruises and can be mistaken for child abuse.
Approach: Common Variations in the Newborn Head
Describe the three common variations in the newborn head.
Discussion/Lecture
Molding is the shaping of the fetal head to adapt to the mother’s pelvis. This shaping is the result of the movement of the infant’s cranial bones during labor.
Caput succedaneum is edema of the newborn’s scalp, which may cross the suture lines. It is caused by compression against the cervix. No treatment is needed.
Cephalhematoma is a collection of blood that appears the first or second day of life, between the periosteum and the skull. It does not cross the suture lines and spontaneously resorbs in 3 to 6 weeks.
Student Learning Activities
1. Have students demonstrate the assessment of reflexes and verbalize the times when each reflex disappears. If possible, have a student volunteer to bring an infant from home to demonstrate the reflexes.
2. Have students demonstrate a gestational age assessment on a doll or an infant brought from home. Provide a screening tool and let students practice the charting required.
3. Assign two groups to develop a teaching plan for mothers who are going to bottle feed or breastfeed. Have students demonstrate the positions for feeding, burping, and latching on. Have them debate the advantages and disadvantages of both methods, using Table 54-2 in the text.
4. Have students work together in groups to design a teaching tool that includes bathing, cord care, and circumcision care.
5. Divide students into groups and have them research the major problems seen in the newborn. Have them present the information to the class. Medical–surgical management, assessments, and patient teaching should be included.
6. Classroom discussion tool: Have students review the case study and use the questions as a basis for discussion.
Resources
Krebs, T. (1998). Cord care: Is it necessary? Mother Baby Journal, (3), 5.
Letko, M. (1996). Understanding the Apgar score. Journal of Obstetric, Gynecologic, andNeonatal Nursing, 25(4), 299.
Penny-MacGillivray, T. (1996). A newborn’s first bath: When? Journal of Obstetric, Gynecologic, and Neonatal Nursing, 25(6), 481.
Tyrala, E. (1996). The infant of the diabetic mother. Obstetric and Gynecologic Clinicsof North America, 23(1), 221.
Verma, R. P. (1995). Respiratory distress syndrome of the newborn infant. ObstetricsGynecologic Survey, 50(7), 542.
Web Activities
1. Cord care and a new mom’s guide:
2. Neonatal nursing rounds:
3. Check the Internet for the most recent immunization schedule for children. Are there any changes from the previous year?
4. What resources are available on the Internet for parents with new infants?
Suggested Responses to the Case Study
Baby boy Hren, a full-term newborn, is 36 hours old. He has type B, Rh-positive blood and his mother has type O, Rh-positive blood. There is a small cephalhematoma on the right parietal bone. Routine assessment identified the appearance of jaundice when the skin was blanched on his forehead. His bilirubin level was 2 mg/dL on the cord blood and 4 mg/dL at 24 hours of age.
The following questions will guide your development of a nursing care plan for the case study.
1. What factors may be causing the jaundice?
Mother’s type O blood
Baby’s type B blood
ABO incompatibility
Cephalhematoma
Normal physiological destruction of excess red blood cells
2. What orders would you anticipate the physician would write?
Bilirubin level stat and every 12 hours till it decreases.
Institute phototherapy.
3. What are the critical levels of bilirubin?
Cord blood bilirubin should be 2 mg/dL.
Bilirubin of 10 to 12 mg/dL is generally when an exchange transfusion is instituted.
Kernicterus may occur at 20 mg/dL.
4. Phototherapy is begun using “bili” lights. What assessments and precautions must be taken when these lights are used?
Infant’s eyes must be covered when under light.
Only clothing is a diaper and the eye patches.
Turn infant every 2 hours to expose more skin area to lights.
Monitor infant’s temperature.
Monitor for signs of dehydration.
5. Identify two possible nursing diagnoses and a goal for each for baby boy Hren.
Nursing Diagnosis 1: Pain related to physical injury of heel sticks for bilirubin
Goal: Infant will decrease crying after each heel stick.
Nursing Diagnosis 2: Deficient Fluid volume, risk for, related to insensible water loss and frequent loose stools secondary to phototherapy
Goal: Infant’s intake will be at least 100 to 150 mL/kg/day.
6. Describe nursing interventions for meeting the goals.
Properly perform heel stick to avoid nerves and arteries.
Hold and comfort infant after heel stick procedure.
Encourage adequate feedings by mother.
Provide extra water intake.
7. How can the goals be evaluated?
The infant will comfort easily.
The infant’s fluid intake will be adequate; will have no signs of dehydration.
Answers to the Review Questions
1. The nurse is aware that survival of a newborn infant depends primarily on:
b. prompt expansion of the lungs and the establishment of gaseous exchange.
2. When assisting the establishment of respirations in a newborn, which of these actions should the nurse do first?
d. remove mucus from the mouth, throat, and nose.
3. The nurse dries a newborn infant as soon after birth as possible, primarily to help:
b. avoid excess heat loss from the infant’s body.
4. A new mother asks about the bluish area on her infant’s buttocks. The nurse’s response is based on knowledge that this discoloration:
a. is called mongolian spots.
5. The nurse is aware that the most generally accepted theory of the cause of physiologic jaundice is that it results from:
c. rapid destruction of excess red blood cells.