Nursing Assessment Maternal

history/labor data indicating potential problems with newborn Apgar Scores Findings of brief physical examination performed in the delivery room

1. When the head is delivered birth attendant immediately suction secretions

Wipe mucus from face and mouth and nose Aspirate/suction mouth and nose bulb syringe Keep head slightly lower than the body

2. Assess airway status

A.

Assess for 5 Symptoms of respiratory distress

Retractions Tachypnea (rate: >60 cpm) Dusky color/circumoral cyanosis Expiratory grunt Flaring nares

B. Do not hyperextend neck at anytime (may close glottis)

Place infant in sniff position

Neck slightly extended

as if sniffing air Opens airway

3. Immediately dry infant under a radiant warmer or skin to skin contact with the mother

Keep neonates head covered

Infant temperature should be above 36.4C. Infants lose heat through evaporation, radiation, conduction and convection.

4. Obtain APGAR Scoring at 1 min and 5 min

Apgar test is a scoring system designed by Dr. Virginia Apgar, an anesthesiologist,

a systematic and measurable method to access the newborn in the crucial minutes after birth.

Purposes:
evaluate the conditions of the baby at birth, determine the need for resuscitation, evaluate the effectiveness of resuscitative efforts, identify neonates at risk for morbidity and mortality.

Test

0 Points

1 Point

2 Points

Activity (Muscle Tone) Absent

Arms & legs Active movement extended with flexed arms & legs Below 100 bpm Facial grimace Above 100 bpm Sneeze, cough, pulls away

Pulse (Heart Rate) Grimace (Response Stimulation or Reflex Irritability) Appearance (Skin Color) Respiration (Breathing)

Absent No Response

Blue-gray, pale all over Absent

Pink body and blue extremities Slow, irregular

Normal over entire body Completely pink Good, crying

 If

there are problems with the infant:

an additional score may be

repeated at a 10-minute interval.

For

a Cesarean section:

the baby is additionally

assessed at 15 minutes after delivery.

Scoring
7-9 = free from immediate distress; normal 4-6 = moderately depressed; may require additional resuscitative measures 0-3 = severely depressed; necessitates immediate medical attention

Note: APGAR score

is strictly used to determine the newborns immediate

condition at birth and does not necessarily reflect the future health of your baby.

Scores done at 1 minute to identify who needs immediate intervention. Scores taken again at 5 minutes to assess recovery from depression or a subsequent turn for the worse.
Resuscitation takes precedence over determining score.

5. Do quick Gestational Age Assessment

A.

Sole Creases B. Breast tissue bud C. Skin, vessels, and peeling D. Genitalia E. Resting Posture

 6.

Cord Care
A. Clamp umbilical cord approximately 2.5 cm (1 inch) from abdominal wall w/ cord clamp Examine clamp for closure, no oozing of blood

B. Examine Cord for presence of 3 vessels and document

2

arteries and 1 vein

7. Make sure cord blood is collected for analysis and sent to laboratory for checking of:
RH Blood type Hematocrit Possible cord blood gases

8. Document passage of meconium or urine after delivery For presence of meconium before delivery, mechanical suctioning of naspharynx upon delivery of infant w/ an 8-10 French catheter is done

Recent studies indicate that 2.5% povidoneiodine solution also may be useful in preventing neonatal ophthalmia, but a product for this purpose is not commercially available.
Silver nitrate appears to be the best agent in areas where the incidence of penicillinaseproducing N gonorrhoeae (PPNG) is significant. Neonates born to mothers with active gonococcal infection should receive a single IM injection of aqueous penicillin G.

11.Administer a prophylactic vitamin K Prevent neonatal hemorrhage during first few days of life before infant is able to produce vit. K Recommended route of administration: intramuscular Dose:
1mg (of Konakion MM, 2mg/0.2ml) being given at birth. Preterm infants may receive 0.5mg.

Alternative Route: Oral Dose:

2mg orally at birth;

Repeat dose (2mg) at 3-5 days and at 4-6 weeks of age.

Repeat dose if the infant vomits or regurgitates within 1

hour

13. Footprints are often taken and recorded in the medical record.

Measure weight, length, and head circumference

helps determine if a baby's weight and measurements are normal for the number of weeks of pregnancy. Small or underweight babies, as well as very large babies, may need special attention and care.

Before a baby leaves the delivery area, identification bracelets with identical numbers are placed on the baby and mother. Babies often have two, on the wrist and ankle.