Chapter 24 discharge, early home visit and

Nursing Care of a Newborn well baby visit

and Family Teach the client about
Key Terms assessment
Acrocyanosis
jaundice
physiologic jaundice Nursing Diagnosis
Caput succedaneum Ineffective airway clearance r/t
kangaroo care mucus in airway
radiation Ineffective thermoregulation r/t
Kernicterus heat loss from exposure in
pseudomenstration birthing room
strawberry hemangioma Imbalance nutrition, less than
Central cyanosis body requirements r/t poor
lanugo sucking reflex
thrush Readiness for enhanced family
Cephal-hematoma coping r/t birth of planned
meconium infant
transitional stools Health seeking behaviors r/t
Conduction newborns needs
milia Parental fear r/t
vernix caseosa Outcome Identification
Convection
mongolian spots Implementation
subconjunctival hemorrhage
Erythema toxicum role modeling
natal teeth conserving warmth and
Evaporation energy to prevent
neonatal period hypoglycemia and respiratory
Hemangioma distress should be an
neonate important consideration to
accompany all intervention
Nursing Process: Health Promotion
of the Term Newborn
Assessment
Nursing diagnosis
Outcome identification and
planning
Implementation Evaluation
Outcome evaluation Parents should be able to give
Assessment beginning newborn care with
review of the mothers confidence.
pregnancy history parents make for continued
Birthing history health supervision
Analgesia and anesthesia infant establishes respirations
physical examination of the of 30 to 60 per minutes
infant Infant breast-feeds for a
analysis of laboratory reports minimum of 10 minutes
assessment of parent-child
bonding

Timing of assessment
Begins at birth, at every
contact (every 4 hours) , before

Vital signs
Temperature
Profile of a Newborn
Vital statistics
Weight
Length
Head circumference
Chest circumference
Weight
Varies depending on the racial,
nutritional , intrauterine and
genetic factors
second-born children usually
weigh more than first born.
Male: 3.5 kg (7.7 lbs);
Female : 3.4 kg ( 7.5 lbs)
>4.7 kg , suspect maternal
diabetes
A newborn loses 5%-10% (6-
10 oz) of birthweight during the
first few days after birth.
Causes: withdrawal of
hormones, diuresis (75- 90%
of newborns weight is fluid)
Newborn begins to gain
about 2lb/month (6-8
onz/week) for the first six
months
Facts
Length
Male 54 cm (21.3 in);
female 53 (20.9 in)
Lower limit : 46 cm (18
in)
Head circumference
34-35 cm (13.5 to 14 in)
> 37 cm or < 33 should
be investigated
Chest Circumference
2 cm less than the head
circumference
Profile of a Newborn
37.2 C (99F)
Falls below normal due to
immature temperature
regulation and heat los
Convection
Conduction
Radiation
Evaporation
Methods of Heat loss
Convection the flow of heat
from the newborns body
surface to cooler surrounding
air.
Conduction transfer of heat
to a cooler solid object in
contact with a baby.
Radiation transfer of body
heat to a cooler solid object
not in contact with the baby,
such as cold window and
airconditioner
Evaporation loss of heat
through conversion of a liquid
to a vapor.
Methods of
Heat loss
The head is the largest surface
area in a newborn, can be
responsible for a great amount
of heat loss.
Insulation is ineffective due to
little subcutaneous fat
 Shivering is rarely seen in
newborn
Brown fat helps to conserve /
produce heat by increasing
metabolism
response to cold tend to kick
and cry to increase metabolic
rate and produce heat,
however, also increases their
need for oxygen and increases
RR.
Kangaroo care placing a
newborn against the mothers
skin and then covering the
newborn also helps to transfer
heat from the mother to the
newborn.
NB with bacterial infection may
ha subnormal temperature
Decreased adipose tissue,
thinner skin, blood vessels
closer to the skin results in
increased heat loss.
Infant develops mechanisms to
counterbalance heat loss.
Vasoconstriction - blood
directed away from skin
surfaces.
Insulation - from
subcutaneous adipose
tissue.
Heat production by
nonshivering
thermogenesis (brown
fat metabolism) elicited
by the sympathetic
nervous system's
response to decreased
temperatures; activated
by adrenaline.
Fetal position by assuming a
flexed position
Kangaroo
Care
Profile of a Newborn
Vital signs
Pulse
FHT - 120-160 bpm; after
birth may be 180 bpm
After 1 hour 120-140 bpm
irregular due to
immature regulatory
center
transient murmur due
to incomplete closure of
shunts
sleep 90-110
Listen for apical heart
rate for 1 minute
absence of femoral
pulses suggest
coarctation of the aorta
Respiration
- As high as 80 during the first
minute
- Average 30-60 cpm (at rest)
- Respiratory rate, depth and
rhythm are likely to be irregular
and short periods of apnea (no
cyanosis)
- Periodic respiration
Respiratory Changes
Factors Initiating
Respiration
Mechanical - pressure
changes from intrauterine life
to extrauterine life produce
stimulation to initiate
respirations.
Chemical - changes in the
blood, as a result of transitory
asphyxia, include:
Lowered oxygen level.
Increased carbon
dioxide level.
Lowered pH if asphyxia
is prolonged, depression
of the respiratory center
(rather than
stimulation) occurs, and
resuscitation is
necessary.
Sensory - light (visual), sound
(auditory), olfactory, and tactile
stimulation, beginning in utero
with uterine contraction and
when the infant is touched and
 dried, contribute to the
initiation of respiration.
Thermal- a drop in
environmental temperature
from 98.6 F (37 C) to 70 F
to 75 F (21 to 23.9 C).
First breath maximum effort is
required to expand the lungs
and to fill the collapsed alveoli.
Surface tension in the
respiratory tract and
resistance in lung
tissue, thorax,
diaphragm, and
respiratory muscles
must be overcome.
First active inspiration comes
from a strong contraction of the
diaphragm,
Character of Normal
Respirations
First period of reactivity-
occurs immediately after birth.
Vigorous, diffuse, purposeless
movements alternate with
periods of relative
immobility/inactivity.
Respirations are rapid, as
frequent as 80 breaths/minute,
accompanied by tachycardia,
140 to 180 breaths/minute.
Period of Relaxation - occurs
and the infant usually sleeps;
he or she then awakes to a
second period of activity. Oral
mucus may be a major problem
during this period.
Respirations are reduced to 35
to 50 breaths/minute and
become quiet and shallow;
respiration is carried out by the
diaphragm and abdominal
muscles.
Period of dyspnea and cyanosis
may occur suddenly in an infant
who is breathing normally; this
may indicate an anomaly or a
pathologic condition.
Apnea is normal in the neonatal
period and lasts 10 to 15
seconds.
- Obligate nose breathers
- Short periods of crying
increases the deep of
respiration, aerating the deep
portions of the lungs.
Blood pressure
80/46 mmHg
By 10th day 100/50
NURSING ALERT
A systolic blood pressure in the
upper extremities that is 20
mm Hg greater than in the
lower extremities strongly
suggests coarctation of the
aorta.
Profile of a Newborn
Physiologic function
Cardiovascular system
Blood values
Blood coagulation
Blood flow to the heart
Cardiovascular
function
Fetal Circulation
The placenta accepts the bluest
blood (blood without oxygen)
from the fetus through blood
vessels that leave the fetus
through the umbilical cord
(umbilical arteries, there are
two of them).
When blood goes through the
placenta it picks up oxygen and
becomes red. The red blood
then returns to the fetus via
the third vessel in the umbilical
cord (umbilical vein).
The red blood that enters the
fetus passes through the fetal
liver and enters the right side
of the heart.
The red blood goes through one
of the two extra connections in
the fetal heart that will close
 after the baby is born.
The hole between the top two
heart chambers (right and left
atrium) is called a patent
foramen ovale (PFO). This hole
allows the reddest blood to go
from the right atrium to left
atrium and then to the left
ventricle and out the aorta. As
a result the blood with the most
oxygen gets to the brain.
Blood coming back from the
fetuss body also enters the
right atrium, but the fetus is
able to send this blue blood
from the right atrium to the
right ventricle (the chamber
that normally pumps blood to
the lungs). Most of the blood
that leaves the right ventricle in
the fetus bypasses the lungs
through the second of the two
extra fetal connections known
as the ductus arteriosus.
The ductus arteriosus sends the
bluer blood to the organs in the
lower half of the fetal body.
This also allows for the bluest
blood to leave the fetus
through the umbilical arteries
and get back to the placenta to
pick up oxygen.
Since the patent foramen ovale
and ductus arteriosus are
normal findings in the fetus, it
is impossible to predict whether
or not these connections will
close normally after birth in a
normal fetal heart. These two
bypass pathways in the fetal
circulation make it possible for
most fetuses to survive
pregnancy even when there are
complex heart problems and
not be affected until after birth
when these pathways begin to
close.
Drying and clamping of
umbilical cord
Stimulation of cold receptor
Fetal heart structures
Foramen ovale closes with
decrease pulmonary vascular
resistance
Increases pressure to left side
of heart
Ductus arteriosus closes due to
increase of O2 to lungs
Ductus venosus close and liver
begins to fx
Blood values
blood volume:80-100 ml per
kg body weight (300 ml)
High erythrocyte count: 6
million cells per cubic ml,
begins to deteriorate after few
days
Hematocrit: 45%-50%
Indirect bilirubin levels is 1-4
mg/ 100 ml
Wbc: 15000 to 30 000
cells/cubic mm (nonpathogenic
as a result of trauma to birth)
Blood Coagulation
Lower level of vitamin k
Prolonged coagulation or
prothrombin time
Blood Elements
Values for blood components in
the neonate:
Hemoglobin, 16 to 22 g.
Reticulocytes, 2.5 to 6.5%.
Leukocytes, 15,000 to
20,000/l.
Blood Coagulation
Coagulability is temporarily
diminished because of lack of
bacteria in the intestinal tract
that contributes to the
synthesis of vitamin K.
Coagulation time is 3 to 4
minutes.
Bleeding time is 2 to 4 minutes.
 Prothrombin 50%, decreasing
to 20% to 30%.
Circulatory Changes
Anatomic Changes
Blood Volume
Blood volume is 80 to 100
mL/kg at birth. Factors that
influence blood volume:
Maternal blood volume
(affected by maternal diseases
and iron intake).
Placental function.
Uterine contractions during
labor.
Amount of blood loss
associated with delivery.
Placental transfusion at birth
increase in blood volume of
60% if cord is clamped and cut
after pulsation ceases.
Vitamin k synthesis
Aid of intestinal flora
Formation of factor II
(prothrombin)
Factor VII (proconvertin)
Factor IX ( plasma thromboplastic
component)
Factor X ( Stuart-Prower factor )
Vitamin K (aquaMEPHYTON) IM
lateral anterior thigh is
administered
Profile of a Newborn
Physiologic function
Respiratory system
Gastrointestinal system
Stools
Urinary system
Immune system
Profile of newborn
Respiratory
First breath is initiated by 2
factors:
Lowered PO2 (80 mmHg to 15
mmHg)
Increased PCO2 (up to 70 mmhg)
-all newborns have some fluid in
the lungs from intrauterine life.
About a third of this fluid is forced
out of the lungs by pressure of
vaginal birth and by absorption of
blood vessels and lymphatics.
- Immature newborns and whose
alveoli collapse each time they
exhale have difficulty
establishing effective
respiration
-if alveoli do not open well, a
newborns cardiac system becomes
compromised
-closure of foramen ovale and
ductus arteriosus depends on the
free blood flow through pulmonary
artery and good oxygenation of
blood.
Gastrointestinal
sterile at birth
-bacteria may be cultured 5
hours after birth
Accumulation of bacteria is
important for the synthesis of
vitamin K
Milk has low vitamin k content
Stomach holds 60 to 90 ml
Limited ability to digest fat and
starch (deficient lipase and
amylase)
Regurgitates easily because of
immature cardiac sphincter
Pic newborn skin to skin
contact
Vitamin K administration
Gastrointestinal
Stools
-meconium, a sticky , tarlike ,
blackish-green, oderless material
formed from mucus, vernix ,
lanugo , hormones,and
carbohydrates that accumulated
during intrauterine life.
-inability to pass meconium within
24hrs may suggest meconium
ileus, imperforate anus, bowel
obstruction
Transitional stools second or
third day ; changes in color and
consistency, becoming from green
and loose.
Breastfeed baby- 3-4 yellow
stools / day
Bottlefeed 2-3 bright yellow
stools/day
Stools
Phototherapy - increased
bilirubin excretion bright
green stools
Bile duct obstruction clay-
colored (gray)
Anal fissure blood-flecked
Intestinal bleeding black-tarry
Milk allergy mucus is mixed
with stools/ watery and loose
Urinary
- A single voiding in a newborn is
only about 15 ml and may be
easily missed in a thick diaper.
- Specific gravity ranges from
1.008 to 1.010. The daily
urinary output for the first 1 or
2 days is about 30 to 60 ml
total.
Hepatic Function
Function limited because of lack
of GI tract activity and limited
blood supply; consequences
include the following:
Decreased ability to conjugate
bilirubin (rationale for
physiologic jaundice).
Decreased ability to regulate
blood glucose concentration
(rationale for neonatal
hypoglycemia).
Deficient production of
prothrombin and other
coagulation factors that depend
on vitamin K for synthesis
(rationale for neonate's
predisposition to hemorrhage).
Renal Function
Low arterial blood pressure and
increased renal vascular
resistance lead to the following
effects:
Decreased ability to
concentrate urine because of
low tubular resorption rate and
low levels of antidiuretic
hormone.
Limited ability to maintain
water balance by excretion of
excess water or retention of
needed water.
Decreased ability to maintain
acid-base mechanism; slower
excretion of electrolytes,
especially sodium and the
hydrogen ions, results in
accumulation of these
substances, which predisposes
the infant to dehydration,
acidosis, and hyperkalemia.
Excretion of large amount of
uric acid during neonatal period
appears as brick dust stain on
diaper.
Endocrine Function
Endocrine glands are better
organized than other systems:
disturbances are most
commonly related to maternally
provided hormones. This can
cause the following:
Vaginal discharge (or
bleeding
[pseudomenstruation]) in
female infants.
Enlargement of mammary
glands (breast engorgement) in
both sexes related to increased
estrogen, luteal, and prolactin
activity. Milky secretions may
be present (witch's milk).
Disturbances related to
maternal endocrine pathology
(eg, mother with diabetes or
mother with inadequate iodine
intake).
Immune system
Passive antibodies (immune
globulin G) from the mother
through the placenta.
Due to the difficulty forming
antibodies against invading
antigens until they are about 2
months of age, the newborn is
prone to infection.
Neurologic Changes
Neurologic mechanisms are
immature; they are not fully
developed anatomically or
physiologically. As a result,
uncoordinated movements,
labile temperature regulation,
and poor control over
musculature are characteristic
of the infant. Reflexes are
important indicators of infant
neural development.
Neuromuscular System
Blink reflex rapid eyelid
closure to protect the eye
Rooting reflex if the check
is brushed or stroked near
the corner of the mouth, a
newborn infant will turn the
head in that direction.
-to help newborn find food
-disappears at about 6 weeks
of life (eye focus)
Sucking when the babys lips
are touched , the baby
makes a sucking motion
-begins to diminish at
about 6 months
Rooting reflex
Neuromuscular
Swallowing Reflex food
that reaches the posterior
portion of the tongue is
automatically swallowed.
Extrusion newborn extrudes
any substance that is placed on
the anterior portion of the
tongue
protective reflex
prevents the swallowing
of inedible substances
disappears at about 4
months of age
Palmar Grasp grasping
objects placed in their palm
by closing their fingers on it
-disappears at about 6 weeks
to 3 months
Extrusion
Palmar grasp
Neuromuscular
Step (walk)-in-place Reflex
newborns are held in vertical
position with their feet touching
a hard surface will take a few
quick, alternating steps.
-Disappears by 3 months
Plantar grasp reflex when
an object touches the sole of a
newborns foot at the base of
the toes, the toes grasp in the
same manners as fingers do.
Disappears at about 8-9
months
Tonic-neck reflex (boxer/
fencing reflex) when
newborn lie on their backs,
their head usually turn to one
side or the other. The arm and
the leg on the side toward
which the head turns extended,
and the opposite arm and leg
contract.
-disappears between 2-
3rd month
Tonic neck
Stepping reflex
Plantar grasp
Neuromuscular
Moro reflex (startle)- can be
initiated by startlinga newborn
with a loud noise or by jarring
the basinet.
The most accurate is to
hpld newborns in a
supine position and llow
their heads to drop
backwards about 1 inch.
Response: abduction
and extension of their
arms and legs. Finally
they swing their arms
into an embrace
position and pull up
 their legs against their
abdomen (adduction)
Strong at first 8 weeks
and fades at 4-5th
month
Significance : muscle
tone
Babinski
Babinski reflex when the
side of the sole of the foot is
stroked in an inverted J curve
from the heel upward , a
newborn fans the the toes
(positive babinski sign)
Remains positive until
at least 3 months
Magnet reflex if
pressure is applied to
the soles of the feet a
newborn lying in a
supine position, he/she
pushes back against the
pressure.
Neuromuscular
Crossed extension reflex if
one leg of a newborn lying
supine is extended and the sole
of that foot is irritated by being
rubbed with a sharp object, the
infant raises the other leg and
extends it , as if trying to push
away the hand irritating the
first leg.
Trunk Incurvation reflex
when newborns lie in a prone
position and are touched along
the paravertebral area by a
probing finger, they flex their
trunk and swing their pelvis
toward the touch.
- Lifting head from surface;
crawling motion with legs
Trunk incurvation
Neuromuscular
Landau a newborn who is
held in a prone position with a
hand underneath , supporting
the trunk, should demonstrate
some muscle tone
Deep tendon reflexes
Patellar tap the
patellar tendon with the
tip of the finger (L2 to
L4)
Biceps place the
thumb of your left hand
on the tendon of the
biceps on the inner
surface of the elbow
(test spinal nerve C5
and C6)
Landau
Profile of a Newborn
Physiologic function
Neuromuscular function
Blink reflex
Rooting reflex
Sucking reflex
Swallowing reflex
Profile of a Newborn
Neuromuscular function
Extrusion reflex
Palmar grasp reflex
Step-in-place reflex
Placing reflex
Plantar grasp reflex
Profile of a Newborn
Neuromuscular function
Tonic neck reflex
Moro reflex
Babinski reflex
Magnet reflex
Crossed extension
reflex
Profile of a Newborn
Neuromuscular function
Trunk incurvation reflex
Landau reflex
Deep tendon reflex
Profile of a Newborn
Senses
Hearing
Vision
Touch
Taste
 Smell
THE SENSES
The senses in newborns appear
to be much better develop than
previously believed.
Hearing A fetus is able to
hear in the utero. They
recognize their mothers voice
almost immediately, as if they
have heard it in the utero.
Vision Newborn see as soon
as they are born and possibly
have been seeing light and
dark in utero for the last few
months of pregnancy as the
uterus and the abdominal wall
were stretched thin.
Touch The sense of touch is
well developed at birth. They
also react to painful stimuli.
Taste A newborn has the
ability to discriminate taste
because taste buds are
developed and functioning
before birth. A newborn turns
away from a bitter taste such
as salt but readily accepts the
sweet taste of milk or glucose
water.
Smell The sense of smell is
present in newborn as soon as
the nose is clear of mucus and
and amniotic fluid.
Appearance of the Newborn
Posture
Full-term neonate assumes
symmetric posture; face turned
to side; flexed extremities;
hands tightly fisted with thumb
covered by fingers.
Asymmetric posture may be
caused by fractures of clavicle
or humerus or by nerve injuries
commonly of the brachial
plexus.
Infants born in breech position
may keep knees and legs
straightened or in frog position,
depending on the type of
breech birth.
Appearance of a Newborn
Skin
Color
Cyanosis
Hyperbilirubinemia
Pallor
Harlequin sign
Color
-ruddy complexion most
infants
Pale and cyanotic poor central
nervous control
Gray color indicates infection
Cyanosis
generalized mottling of
the skin is common
lips, hands and feet are
likely to appear blue
due to immature
peripheral circulation
(acrocyanosis);
normal in 24-48 hours
after birth
Central cyanosis
cyanosis of the trunk
indicates depressed
oxygenation ; maybe a
result of temporary
respiratory obstruction.
Hyperbilirubinemia leads to
jaundice.
Physiologic jaundice occurs
on the 2nd or 3rd day of life as a
result of the breakdown of fetal
RBC; the high RBC count built
up in uteru is destroyed, heme
and globin are released.
Peak in 1 week; disappear after
2 weeks
Indirect bilirubin has risen to
more than 7 mg/100 ml-
bilirubin permeates the tissue
 outside the circulatory system
and causes the infant to appear
jaundice.
Causes:
Cephalhematoma- a collection
of blood under the periosteum
of the skull bone.
Intestinal obstruction
intestinal flora may break down
bile into its basic components
- early feeding promotes
intestinal movement and excretion
of meconium
20 mg/100ml indirect bilirubin can
interfere with the chemical
synthesis of the brain, resulting a
permanent cell damage
(kernicterus) ( permanent
neurologic damage)
Treatment
Phototherapy To initiate
maturation of liver enzymes
Pallor result of anemia
Causes:
excessive blood loss
when the cord is cut
Inadequate flow of
blood from the cord into
the infant at birth
Fetal-maternal
transfusion
Low iron stores caused
by poor maternal
nutrition during
pregnancy
Blood incompatibility
Harlequin sign because of
immature circulation , a
newborn who has been lying
on his / her side appears red
on the dependent side of the
body and pale on the upper
side.
Meconium staining -
staining of skin,
fingernails, and
umbilical cord indicates
passage of meconium in
utero (possibly caused
by fetal hypoxia in
utero).
Cutis marmorata
-bluish mottling or
marbling of skin in
response to chilling,
stress, or
overstimulation.
Harlequin sign
Mottling
Appearance of a Newborn
Skin
Birthmarks
Hemangiomas
Mongolian spots
Edema - some edema may
occur over buttocks, back, and
occiput if the infant has been
supine; pitting edema may be
caused by erythroblastosis,
heart failure, and electrolyte
imbalance.
Ecchymosis - may appear
over the presenting part in a
difficult delivery; may also
indicate infection or a bleeding
problem.
Petechiae - pinpoint
hemorrhages on skin caused by
increased intravascular
pressure, infection, or
thrombocytopenia; regresses
within 48 hours.
Hemangiomas- vascular tumors
of the skin
Types
Nevus flammeus (port-wine
stain) macular (level with the
skin surface) purple or dark red
lesion present at birth.
- storks beak mark- lighter
, pink patches at the nape of the
neck
b. Strawberry hemangioma
elevated areas formed by
immature capilaries and endothelial
cells; 50 -75 % of this lesions have
disappeared when the child is 7
years old; present at birth / may
appear 2 weeks after
Strawberry hemangioma/
nevus vasculosus
Portwine stain
Nevus flammeus portwine
stain
Storst
Cavernous hemangioma
dilated vascular spaces, do not
disappear with time
Mongolian spots collections
of pigment cells (melanocytes)
that appear as slate-gray
patches across the sacrum or
buttocks and possibly on arms
and legs.
- disappear by school age
Vernix caseosa a white,
creamy, cheese-like substance that
serves as skin lubricant, noticeable
in skinfold on a term newborns
skin
Yellow from bilirubin
Green meconium
-never use harsh rubbing to
wash away vernix
Mongolian spots
Lanugo fine, downy hair that
covers a newborns shoulders,
back, and upper arms,
forehead and ears.
- more lanugo after 37-39
weeks gestation than a newbon
at 40 weeks
Desquamation within 24 hours
after birth; dryness and peeling.
Postmature / intrauterine
malnutrition - extremely dry
skin, leathery appearance and
cracks on skinfold.
Milia due to immature
sebaceous glans ; pinpoint
white papule (plugged or
unopended sebaceous glands )-
cheek/nose
-disappear at 2-4 weeks
Erythema Toxicum (flea bite
rash) appear on first to 4th
day of life up to 2 weeks. It
begins with a papule, increases
in severity to become erythema
by the second day
- caused by newborns
eosinophils reacting to the
environment
Forceps mark - disappears in
1-2 days
Skin turgor
Nails - should reach end of
fingertips and be well
developed in the full-term
infant. There should be no
evidence of pits, ridges,
aplasia, or hypertrophy
Edema - some edema may
occur over buttocks, back, and
occiput if the infant has been
supine; pitting edema may be
caused by erythroblastosis,
heart failure, and electrolyte
imbalance.
Head- appears
disproportionately large
because it is about one fourth
of the total body length
-large and prominent
forehead
-full bodied hair (well
nourished) thin (preterm)
-Examine head and face for
symmetry, paralysis, shape,
swelling, movement.
Measure head circumference
- 13 to 14 inches (33 to 35 cm),
approximately inch (2 cm) larger
than chest. Measure just above the
eyebrows and over the occiput
Fontanelles- area where more
than two skull bones meet;
covered with strong band of
connective tissue; also called the
soft spot.
Enlarged or bulging -
may indicate increased
intracranial pressure
(ICP).
Sunken - commonly
indicates dehydration
anterior fontanelle junction
of the two parietal bones and
the two fused frontal bones
-diamond shaped
-measures 2-3 cm in width
and 3-4 cm in length
- closes at 12-18
months
Posterior fontanelle located
at the junction of the parietal
bones and the occipital bones
-triangular-shaped
measure about 1 cm in
length
Closes by the end of 2nd
month
Sutures the separating
lines of the skull , may
override at birth because of
the extreme pressure
exerted on the head during
passage through the birth
canal.
-overrriding subsides in 24-
48 hours
Wide separation - IICP
(abnormal brain formation/
acumulation of CSF/ subdural
hemorrhage)
Fused - abnormal
Molding the part of infants head
that engages the cervix is molded
to fit the cervix contours
-appears prominent and
asymmetric
Will be restored to normal
shape within few days
Caput succedaneum - edema of
the scalp at the presenting part of
the head. The edema which
crosses the suture lines, is
gradually absorbed and disappears
at about the 3rd day of life.
- needs no treatment
- Usual cause: vacuum assisted
delivery
Cephalhematoma collection of
blood between the periosteum of a
skull bone and the bone itself;
caused by rupture of periosteal
capilllary due to the pressure of
birth.
-swelling does not cross
suture lines
-Appears 24 hours after birth
-Will subside by itself for
weeks
- Will cause jaundice when
greater amount of indirect
bilirubin is released
Craniotabes localized
softening of the cranial bones
that is probably caused by
pressure of the fetal skull
against the mothers pelvic
bone.
- corrects itself without
treatment after few months
Eyes
cry tearlessly until about 3
months
Subconjunctival hemorrhage
resulted from rupture of
conjunctival capillary due to
pressure during birth
Requires no treatment;
completely absorbed with 2-3
weeks
 Edema of the eyelids- remains
for 2-3 days
-red spot on sclerae/ inner
aspect of the eye/ red ring
around cornea
cry tearlessly- lacrimal ducts
are not fully mature until about
3 months of age.
The irises -gray or blue, and
the sclera may be blue due to
its thinness. Infant eyes
assume their permanent color
between 3 and 12 months of
age.
The cornea - round and
proportionate in size to that of
an adult eye.
larger than usual may be the
result of congenital glaucoma.
An irregularly shape pupil or
discolored iris may denote
disease.
The pupil should be dark. A
white pupil suggests congenital
cataract.
Jaundice
Pupils - PERL
Red reflex present
Dolls eye present
Dolls eye
Brushfield's spots -
white or yellow pinpoint
areas on iris that may
indicate trisomy 21 or
even a normal variant.
Abnormal placement of
eyes or small eye
openings can signify a
syndrome or
chromosomal anomaly.
Transient Strabismus
- cross-eyed
appearance that is
common; nystagmus
(constant, rapid,
involuntary movement
of the eye) is also
common and disappears
by age 4 months.
Antibiotic oitnment
(erythromycin) to
protect against
chlamydia and
opthalmia neonatorum
(gonorheal
conjunctivitis)
Eye prophylaxis/ Credes
Prophylaxis
Abnormal
Inflammation or drainage
(chemical/ infectious conjunctivitis)
Constant tearing
Unequal pupils
Failure to follow objects
White areas over pupils
Setting sun sign (hydrocephalus)
Ears
Well formed, complete
pinna should be strong when
bend
Level of the top part of the
external ear should be on line
drawn from the inner canthus
to the outer canthus of the eye
and back across the side of the
head
Trisomy 18 & 13 / kidney
problem low set ears
Test a newborns hearing ring
a bell about 6 inches
Startle response to loud noise
Abnormal
Low set ears
Skin tags
Periauricular sinuses
Dimples (kidney problem)
No response to sound
Nose
 appear large for the face
Obligate nose breathers
Patency
Sense of smell
Septum should be in the
midline; Periodic sneezing
Choanal atresia - (blockage at
the rear of the nose)
Nasal flaring
Discharge
low nasal bridge with broad
base may be associated with
Down syndrome.
Mouth
check cranial nerve injury
Palate - Epsteins pearl -
round, glistening, well
circumscribed cysts as a result
of extra load of calcium ; will
disappear within 1 week ;
intact
Natal teeth / predeciduous
teeth
Size - small mouth found in
trisomy 18 and 21; corners of
mouth turn down (fish mouth)
in fetal alcohol syndrome.
Mucous membranes should be
pink.
Size of tongue/ movement - in
relation to mouth normally
does not extend much past the
margin of gums.
Reflexes
Abnormal
Thrush (candida infection)-
appears on the tongue and
sides of the check as
white/gray patches
Cyanosis
Protruding tongue down
syndrome
Diminished movement of
tongue; drooping mouth
facial nerve paralysis
Unilateral / bilateral cleft palate
Absent or weak reflexes
preterm/ neurologic damage
Excessive drooling
Neck
short and chubby with creased
skinfold.
Mobility
Clavicle
not strong enough to support
the head
Prominent trachea
Enlarged thymus - rapid
glandular growth
Abnormality
Weakness, contractures,
rigidity
Excessive skin folds (webbing
of the neck) may be associated
with congenital abnormalities
such as trisomy 21.
Congenital torticollis - rigidity
of the neck (injury to
sternocleidomastoid at birth)
Meningitis - if ruptured
membrane more than 24 hours
Fractured clavicle
Chest
cylinder shape
The chest is as wide in the
anteroposterior diameter as it
is across and approximately
Prominent xyphoid process
Nipples present and located
properly
at 2 years the chest
measurement exceeds of the
head
 Witchs milk breast of
newborn babies secrete a thin,
watery fluid
Engorgement
Chest is 2 inches smaller than
hc
Straight clavicles
Symmetric chest
Abnormal
Supernumerary nipples
Asymmetry (diagphragmatic
hernia, pneumothorax)
Retraction - drawing in of the
chest wall with inspiration use
of strong force to pull air into
the respiratory tract that s/he
is pulling in the anterior chest
muscle.
Ronchi harsh , innocent
sound of air passing over
mucus.
Grunting RDS ; flaring
Stridor - high crowing sound on
inspiration / immature tracheal
develoment
Rate
Rhythm
Respiratory movement
symmetric, diaphragmatic
Periodic breathing- more
common to preterm
Substernal retractions
Breath sounds bronchial,
rales, expiratory grunting
(RDS)
Cardiovascular System
Rate
Rhythm
Heart sounds - second sound
higher in pitch and sharper
than first; third and fourth
sounds rarely heard; murmurs
common, majority are
transitory and benign.
Pulses- lack of femoral pulses
indicative of inadequate aortic
blood flow.
Cyanosis - Acrocyanosis.
Blood pressure
Abdomen
Contour protuberant,
rounded, soft
Intact skin
Three vessels AVA
Stump of umbilical cord appear
white, gelatenous structure
with red and blue streaks
Second/ 3rd day - black
Day 6-10 - fall off
Should be no bleeding
Signs of infection
Meconium staining
Base should appear dry
Moist and odorous
suggest infection
Meconium passed within 24-48
hours
Urine passed within 24 hours
cylindrical, protrudes slightly,
moves synchronously with
chest in respiration.
Bowel sounds- present 1 hour
after birth
Edge of liver 1-2 cm below
the right costal margin
decrease ability to
conjugate bilirubin
Edge of spleen -1-2 cm
below the left costal
marhin
Liver has decreased
production of
prothrombin and
clotting factors
Abnormal
Distention obstruction,
infection, enlarge organs
 Scaphoid/sunken missing
abdominal contents/
diaphragmatic hernia
Absent bowel sounds
paralytic ileus
Masses kidney tumors
Enlarged liver - infection, heart
failure, hemolytic disease
Abdominal wall defect
omphalocele
No passage of meconium
imperforate anus, obstruction
No urine output kidney
problem/ dehydration
omphalocele
Genitals
Female
Dark labia majora, cover clitoris
and labia minora
Small amount of white mucus
vaginal discharge
Present urinary meatus and
vagina
pseudomenstraution, hymenal
tags
Abnormal
Clitoris and labia minora larger
than labia majora (preterm)
Large clitoris (ambiguous genitalia)
Edematous labia (breech)
Patent anus
Imperforate anus
Male
Testes within scrotal sac
Rugae on scrotum
Prepuce nonretractable
Meatus at the tip of penis
Cremasteric reflex stroking
the inner side of the thigh , as
the skin is stroked, the testes
on that side moves perceptibly
upward. (t8 & T10)
Absent for newborn younger
than 10 days
Abnormal
Testes in inguinal canal / abdomen
(preterm, cryptorchidism)
Cryptorchidism - one or both
testicles are not present
Causes agenesis (absence of
an organ) , ectopic (closed
scrotal sac) and undescended
(short vas deferens / artery)
Lack of rugae on scrotum
(preterm)
Edema on scrotum- pressure
(breech)
Enlarge scrotal sack hydrocele
Small penis/ scrotum preterm,
ambiguous genitalia
Epidpadia urethral opening is
on the dorsal side
Hypospadia ventral side
Phimosis foreskin can not be
retracted
Hydrocele excess fluid;
regresses approx a month
Imperforate anus
Back
Spine - flat in the lumbar and
sacral areas
No openings
Patent anus
Abnormal
Spina bifida - Inspect for pinpoint
opening, dimpling, sinus tract in
skin; failure of the vertebra to
close
Assumes position in the uteru
(back rounded; arms and legs
flexed)
Frank breech - straight legs at the
knee and bring them up to face
Extremities
Arms and legs short
 Test for muscle tone Poor muscle tone - preterm,
Symmetrical movement of neurologic damage ,
arms and legs hypoglycemia, hypoxia
Bowed legs ( normal)
Flat soles of foot
Correct number or fingers and
toes
Flexion and good muscle tone
Creases at foot- covers 2/3 of
the foot
Talipes - clubfoot

Appearance of a Newborn
Skin
Vernix caseosa
Upper extremity Lanugo
Two transverse palm creases Desquamation
Milia
Lower extremities Erythema toxicum
Legs equal in length
Forceps marks
Abduct equally
Appearance of a Newborn
Gluteal and thigh creases and
Head
knee equal
No hip click Fontanelles
Normal position of feet Sutures
Molding
Abnormal Caput succedaneum
Cephalhematoma
Upper extremity Craniotabes
Simian crease (single transverse
palm crease)- down syndrome Appearance of a Newborn
Dimished movement of arm with Eyes
extension and forearm prone ( Erb- Ears
Duchenne Paralysis) Nose
Mouth
Lower extremity
Neck
Resistance in leg abduction
Chest
Unequal thigh or gluteal creases,
hip click, movement of head of
femus, unequal leg length, Appearance of a Newborn
malposition of feet Abdomen
Anogenital area
Abnormal Male genitalia
Achondroplastic dwarfism Female genitalia
unusually short arms Back
Simian crease (single palmar Extremities
crease) - down syndrome
Webbing syndactyly
Extra fingers/ toes Assessment for Well-Being
polydactyly Apgar scoring
Crepitus A - appearance / Color
Redness, lumps, swelling P- Pulses / Heart rate
Dimished or lack of movement Respiratory effort
 Muscle tone Eye care
G Grimace /Reflex Infection precautions
irritability Nursing Care: Newborn and
Family
APGAR SCORING Initial feeding
Bathing
First minute apgar score Sleeping pattern
5 minute apgar score Diaper area care
Apgar Metabolic screening tests
Assessment for Well-Being Nursing Care: Newborn and
Respiratory evaluation Family
Physical examination Hepatitis B vaccination
Height and weight Vitamin K administration
Laboratory studies Circumcision

Assessment for Well-Being Family Readiness

Gestational age Daily home care
Dubowitz Maturity Scale Sleep patterns
Brazelton Neonatal Crying
Behavioral Assessment Parental concerns related to
breathing
Care of a Newborn at Birth Health maintenance
Identification and registration Car safety
Identification band
Birth registration Assignment
Birth record Draw a diagram of fetal
documentation circulation and identify
important structures in fetal
Assessment for Well-Being circulation
Keeping the newborn warm Long bond paper. Be creative as
Promoting adequate breathing u can (use colors to show the
pattern flow of blood)
Record of first cry Long bond paper
Inspection and care of umbilical
cord