1. ASSESMENT OF THE NEWBORN

4. Shivering Mechanism is rarely functioning A. Heat is generated immediately by shivering ; infant shivering is characterized by increased muscular activity, restlessness, and crying. B. Infant shivering activity is not apparent as adult shivering activity. C. Metabolism of brown fat (brown adipose tissue). Functions to produce heat under the stress of cooling. Brown fat is located in the intrascapular region, in the posterior triangle on the neck, in the axillae, and behind the sternum. Brown fat is metabolized and utilized within several weeks after birth.

11. OPTHALMIA NEONATORUM

12. Take Anthropometric Measurements Weight – 2, 500g – 4, 000g (2.5 kg. – 8 lbs. & 13 oz) Length – 45-55 cm (18-22in) HC – 33-55 cm (13-14in) 2-3 cm larger than chest CC – 30-33cm (12-13in) AC-29-33 cm Note: A reduction of newborn weight of about 5-10% or less known as physiologic weight loss occurs 1 st 5 days Causes: Infant is no longer under the influence of maternal hormones Voids and defecates Relatively low nutritional intake

16. Nevi – known as stork bites pink or red flat areas of capillary dilatation commonly seen at upper eyelids, nose upper lip, lower occiput bone, nape and the neck. Disappears at 1 st and 2 nd year Erythema Toxicum – also known as Erythema Neonatorum, Newborn Rash transient rash: Characteristics as pink papules with vesicles seen at nape, back and buttocks. Appears at 2 nd day and disappears without treatment. Strawberry Mark – Nevus Vascularis – second most common type of capillary hemangioma. Lesion is elevated, sharply demarcated and bright or dark red, rough surface swelling. Remain until school age or even longer. Portwine Stain or Nevus Flammeus – observed at birth, red to purple color: do not blanch on pressure and do not disappear; commonly found on the face Lanugo – fine downy hair seen at shoulder and upper arm and back; disappears within 2 weeks

17. Mouth – take note of symmetry of lip movements: if assymetrical – cranial nerve VII paralysis *Oral thrush Moniliasis – white cheesy –like substance on cheeks and tongue that bleeds when touched (acquired during passage) caused by Candida ;application of Nystatin If with tooth – possibly due to hypervitaminosis – it is extracted to prevent aspirations Epstein pearl – glistening cystals commonly seen at the palate and gums: due to extra load of maternal calcium. Chest – symmetrically expand retraction indicates respiratory distress. Breast – normally are swollen with appearance of a transparent fluid known as witch milk-these condition are due to effect of maternal hormones

19. Anogenital – note for passage of stool and urine Genitals – externally are edematous or swollen and may pass a mucoid slightly bloody vaginal discharge known as Pseudomenstruation. -Note for Cryptorchidism or undescended testes Phimosis; adhesion of the foreskin usually manage by circumcision -Hydrocele; accumulation of fluid around the testes and is considered normal finding -Note for Epispadia: urinary meatus at the dorsal portion and hypospadias at ventral portion of penis

21. B. Weight. 1. Average birth weight for a term neonate: 3400 gm (' 8oz). 2. Low birth weight: <2500 gm (5 Ib 8 oz). 3. Excessive weight: >4080 gm (9 Ib). 4. Weight loss: between 5% and 10% of birth weight within the first few days of life; infant usually regains weight within 10 to 14 days. C. Head. 1. Molding. a. Head may appear elongated at birth; molding usually disappears within 24 to 48 hours, b. Occurs as a result of abnormal fetal posture in utero and pressure during passage through the birth canal.

25. 4. Head measurement a. Average head circumference of the term neonate: 34.2cm; usual variation ranges from 33-35cm b. Head circumference is approximately 2-3 cm greater than the chest circumference; extremes in size may indicate microcephaly, hydrocephaly or increased intracranial pressure.

26. 5. Fontanels a. Anterior: diamond shape about 5 cm, will increase as molding resolves. b. Posterior: smaller than anterior. c. Palpate for size and tension. d. Increase in tension may indicate tumor, hemorrhage, infection, or congenital anomaly. e. Decrease in tension (sunken fontanel) may indicate dehydration. f. Anterior will close in about 12 to 18 months; pos­terior will close in 2 to 3 months.

27. D. Umbilical cord. 1. Determine number of blood vessels; there should be two arteries and one vein surrounded by Wharton's jelly. 2. Cord atrophies and sloughs off by day 10 to 14. 3. Should be no bleeding or oozing.

30. Specific Body System Clinical Findings: A. Nervous system. 1. Nervous system is relatively immature and characterized by me following: a. Poor nervous control; easily startled. b. Quivering chin. c. Tremors of the lower extremities of short duration. 2. Reflex activity: The presence or absence of certain reflexes is indicative of ongoing normal development. 3. Presence of positive Babinski sign. a. Normal finding until the age of 1 year. b. Dorsiflexion of big toe and fanning of the other toes. 4. Neonatal reflexes

32. NURSING PRIORITY: Monitor the passage of the first meconium stool a. Meconium: sticky, black, odorless, sterile stool that is passed within the first 24 to 48 hours after birth; if no stool is passed, further assessment is needed. b. Stools change according to type and amount of feedings. (1) Transitional stools: occurs during period between second and fourth day; consist of meconium and milk; greenish brown or greenish yellow; loose and often contain mucus. (2) Milk stools: usually occur by the fourth day; stools of formula-fed infant are drier, more formed, and paler. (3) Stools of breast-fed infants are golden yellow, have a pasty consistency, and occur more frequently than stools of formula-fed infants.

33. D. Genitourinary system. NURSING PRIORITY: Most newborns void within the first 24 to 48 hours after birth. 1. Urinary. a. Urinary output is low during the first few days of life or until fluid intake increases. b. Thirty to 60 milliliters is voided per day during the first 2 days of life; followed by 200 ml per day by the end of the first week. c. Frequency of voiding: average of two to six times per day, increasing up to 10 to 15 times per day. 2. Genitalia. a. Female: Labia majora are underdeveloped; small amount of bloody discharge from the vagina may be seen as a result of the presence of maternal hormones. b. Male: Scrotum may be edematous; testes should have descended; assess the urethral opening.

35. 3. Sense of smell is present at birth; infants react to strong odors. 4. Taste. a. Differentiates between pleasant and unpleasant tastes, b. Rejects especially salty, sour, or bitter tastes by grimacing; also stops sucking. 5. Tactile senses . a. Most sensitive area is around the mouth. b. Searches for food when cheek is touched or begins sucking movement when lips are touched.

36. H. Musculoskeletal system. 1. Assumes the position of comfort, which is usually the position assumed in utero. 2. Normal palmar crease is present (simian crease is indicative of Down syndrome). 3. Spine is straight and flat when in prone position. 4. Creases and fat pads are present on the soles of the feet 5. All digits are present on hands and feet; fingernails are present.

37. Nursing Intervention ALERT: Provide physical care for a newborn. Goal: To establish and maintain a patent airway and promote oxygenation.

38. Goal: To establish and maintain a patent airway and promote oxygenation. A. Position infant with head slightly lower than chest; may use postural drainage or side-lying position. B. Suction nostrils and oropharynx with bulb syringe. C. Observe for apnea, cyanosis, and mucus collection and be ready to use oropharyngeal suctioning, stimulation, oxygen administration, or resuscitative procedures, if necessary.

39. NURSING PRIORITY: During first 4 hours after birth, the priority nursing goals are to maintain a clear airway, maintain a neutral thermal environment, and prevent hemorrhage and infection. Bathing will be initiated when infant's temperature is stabilized; feeding may begin immediately if infant is interested. Goal: To protect against heat loss A. Immediately after birth, wrap infant in warm blanket and dry off amniotic fluid. B. Replace wet blanket with warm dry blanket. C. Cover wet hair and head with a blanket or cap. D. Give infant to mother to cuddle; place baby on a warm padded surface, preferably under a radiant heater or in an incubator; or provide for skin-to-skin contact with the mother. E. Avoid any unnecessary procedures until body temperature is stable.

41. B. Obtain an axillary temperature (rectal thermometer may perforate mucosa). C. Monitor vital signs every 15 minutes to 1 hour until infant's temperature stabilizes (usually in about 4 hours). D. Weigh and measure infant. E. Assess for gestational age and intrauterine growth. F. Determine special needs and whether any significant risk factors are present. G. Perform glucose checks for hypoglycemia on infant of diabetic mother or newborn with complications.

43. Goal: To assess periods of reactivity. A. First period of reactivity. 1. Lasts approximately 30 minutes. 2. Newborn is alert, awake, and usually hungry. B. Sleep phase. 1 . First sleep usually occurs an average of 3 to 4 hours after birth and may last from a few minutes to several hours. 2. Newborn is difficult to awaken during this phase. C. Second period of reactivity. 1. Infant is alert and awake. 2. Lasts approximately 4 to 6 hours. NURSING PRIORITY: Periods of reactivity are excellent opportunities for promoting attachment response.

44. Goal: To protect against infection. A. Follow guidelines for proper hand washing before handling infant. B. Prevent ophthalmia neonatorum. 1. Administer prophylactic treatment to eyes soon after birth. 2. Place ophthalmic ointment or solution in the conjunctiva! sac and massage eyelid. C. Avoid exposure to people with possible upper respiratory tract, skin, or GI infections.

45. Goal: To prevent hypofibrinogenemia. A. Administer 0.5 to 1.0 mg of vitamin K, intramuscularly into the upper third of the lateral aspect of the thigh Goal: To properly identify infant. A. Secure identification bands to wrist or ankle of infant and wrist of mother in the delivery room. B. Prints of infant's foot, palms, or fingers may be obtained according to hospital policy; mother's palm prints or fingerprints may also be obtained. C. Advise parents not to release the infant to anyone who does not have proper unit identification.

46. ALERT: Promote newborn and family bonding. Goal: To promote parental attachment to infant immediately after birth. A. Wrap infant snugly in warm blanket and encourage parents to hold infant. Do not allow chilling to occur. B. Encourage touching and holding during periods of reactivity.

49. C. Circumcision care. 1. Keep area clean; change diaper frequently. 2. Observe for bleeding. 3. A sterile gauze dressing with petroleum jelly may be applied to the area during the first 2 to 3 days. 4. If a plastic bell was used, keep area clean; application of petroleum jelly is not necessary; plastic bell will dislodge when area has healed. a whitish-yellow exudate around the glans is granulation tissue and is normal and not indicative of infection. It may be observed for 2 to 3 days and should not be removed.

50. D. Neonate's bath. 1. Bath is delayed until vital signs and temperature stabilize. 2. Warm water is used for the first 4 days; do not immerse infant in water until umbilical cord stump has been released. 3. When bathing neonate, apply principles of clean-to-dirty areas; wash areas in the following order: eyes, face, ears, head, body, genitals, buttocks. 4. Head is an area of significant heat loss; keep it covered.

51. E. Determine weight loss over first 24 hours after birth. F. Assess stools. 1. Meconium stools. 2. Transitional stools. 2. Infant will require more frequent feedings initially; will generally establish a routine of feeding every 3 to 4 hours. B. Breast-feeding . 1. First feeding should occur immediately or within a few hours after birth. 2. Stimulates release of prolactin to initiate milk production. 3. Assess the mother's knowledge of breast-feeding during the first feeding.

52. 4. Assist the mother to hold the infant at the breast with the infant's ear, shoulder, and hips in a straight line. 5. Have the mother touch the infant's lower lip with the nipple to stimulate the latch-on reflex. 6. Most of the areola should be in the infant's mouth 7. Frequent feedings are important initially to establish milk production, often every VA to 2 hours. 8. One of the primary reasons mothers stop breastfeeding is the perception that their milk supply is not sufficient. 9. Encourage mother to not offer the infant a bottle until lactation is well established, generally after about 4 weeks. 10. Engorgement and nipple soreness are the most common problems the mother experiences.

53. C. Bottle-feeding . 1 . It is not necessary to sterilize the water used to reconstitute infant's formula. 2. The infant should be placed in a semi-upright position for feeding. 3. Never prop the bottle, and always hold the infant. 4. Mother should not coax infant to finish all of the bon every time; any unused formula should be discarded 5. Bottles warmed in the microwave should be gem rotated to achieve an even temperature, and temperature of milk should be checked carefully before it :-given to the infant. This warming method is not recommended.