Bsc Nursing Semester V Child Health Nursing I Unit III

1. NURSING CARE OF A
NEONATE
UNIT III
Mrs.Rani.G.S., MSc(N)
Assistant professor
Dept of Child Health Nursing

2. SYLLABUS
• Appraisal of Newborn
• Nursing care of a normal newborn/essential newborn care
• Neonatal resuscitation
• Nursing management of low birth weight baby
• Kangaroo mother care
• Nursing management of common neonatal disorder Hyperbilirubinemia ,Hypothermia , Hyperthermia ,
Metabolic disorder, Neonatal infections , Neonatal seizures , Respiratory distress syndrome , Retinopathy of
Prematurity
• Organization of neonatal care unit
• Neonatal equipment

3. • Neonate:- From birth to 4 weeks (28 days) of age, the baby is called neonate or new
born.
• Early neonatal period: From birth to 7 days of life or 168 hours, is early neonatal
period.
• Late neonatal period: From 7th day to 28th days of life is late neonatal period.
• Live birth:- Live birth is defined as complete expulsion or extraction from mother of
product of conception, which after separation shows signs of life for at least 1 hour.

4. • Term baby:- Any neonate born between 37-42 weeks of gestation is known
as term baby.
• Pre term: Any neonate born before 37th week of gestation is called
preterm.
• Post term:- Any neonate born at or after 42 weeks of gestation is known
as post term.
• Perinatal period:-The period extending from 22nd week of gestation to 7
days after birth known as perinatal period.

5. • Low birth weight (LBW) baby - A baby whose birth weight is less
than 2500g, regardless of gestational age.
• Moderately-low-birth-weight (MLBW) baby -A baby whose birth
weight is 1500 to 2500g.
• Very-low-birth weight (VLBW) baby -A baby whose birth weight
is less than 1500g.

6. • Extremely low-birth-weight (ELBW) baby - A baby whose birth weight
is less than 1000g.
• Appropriate-for-gestational-age (AGA) baby - A baby whose birth
weight falls between the 10th and 90th percentiles on intrauterine
growth curves.
• Large-for-gestation-age (LGA) baby - A baby whose birth weight falls
above 90th percentile on intrauterine growth charts.
• Intrauterine growth retardation (IUGR) -Found in babies whose
intrauterine growth is retarded

7. • Small-for-dates (SFD) or small-for-gestational-age (SGA) infant -
An infant whose rate of intrauterine growth was slowed and
whose birth weight falls below the 10th percentile on intrauterine
growth curves.

9. • Premature (Preterm) infant - An infant born before completion of 37
weeks of gestation regardless of birth weight.
• Full-term infant - An infant born between the beginning of 38 weeks
and completion of 42 weeks of gestation, regardless of birth weight.
• Postmature (Post term) infant - An infant born after 42 weeks of
gestational age, regardless of birth weight.

10. APPRAISAL OF NEWBORN
• It is the systematic examination of newborn.
• Assessment of recently born baby at various points.
• The newborn require thorough, skilled observation to ensure a
satisfactory adjustment to extrauterine life

11. Reviews mother’s history
• H/o previous pregnancy
• Health during pregnancy
• Complications during present
pregnancy
• H/o drug intake
• Birth h/o newborn including
gestational age
• Kind & duration of labour
• Colour of amniotic fluid
• Type of delivery
• Use of sedative / anesthesia during
delivery

12. NEWBORN ASSESSMENT
• Physical assessment following delivery can be divided into four
phases
The initial assessment, which includes the APGAR scoring system
Transitional assessment during the periods of reactivity
Assessment of gestational age
Systematic physical examination

13. INITIALASSESSMENT: APGAR SCORING SYSTEM
• Used to assess the newborn’s immediate adjustment to extrauterine life.
• Developed by Virginia Apgar, an anesthesiologist, at Columbia University
in 1952.
• The score is based on observation of heart rate, respiratory effort, muscle
tone, reflex, irritability & colour.
• Each item is given a score of 0,1 or 2
• Evaluations of all five categories are made at 1 & 5 minutes after birth &
repeated until baby’s condition stabilizes.

15. Interpretation of APGAR Scoring
• 0-3 --- severe distress
• 4-6 --- moderate difficulty
• 7-10 --- absence of difficulty in adjusting to extrauterine life

16. Transitional assessment
• Done during the period of reactivity
• Newborn during the first 24 hrs of birth gets various changes in the vital
functions such as heart rate, respiration, motor activity, colour & bowel
activity. These changes occurs in an orderly manner. This period is called as
period of reactivity.
a) First period of reactivity
b) Period of decreased responsiveness (sleep phase)
c) Second period of reactivity

17. a) Assessment during first period of reactivity
• During the first 30 minutes, the
newborn is
o Very alert
o Cries vigorously
o May suck a fist greedily
oAppears very interested in the
environment
oHigh respiratory rate 80brth/mt
oActive bowel sounds
oIncreased mucous secretions
oDecreased temperature

18. b) Period of decreased responsiveness
• At 30-120 mts of age , the newborn enters the 2nd stage of
transitional state of sleep
• Movements are less, jerky & less frequent
• Decreased heart rate & respiratory rate
• Difficult to arouse / interact with newborn
• No interest in sucking

19. c) Second period of reactivity
• Began when the newborn awake from the deep sleep.
• Last about 2-5 hrs
• Alert & responsive
• Increased heart rate & respiratory rate
• Increased gastric & respiratory secretions
• Passage of meconium

20. GESTATIONALAGE ASSESSMENT
• Age & growth patterns appropriate to that age aid in identifying
neonatal risks
• Frequenlty used method of determining gestational age is the
New Ballard Scale (NBS)
• Assess 6 physical & 6 muscular signs
• Each sign has a number score & the cumulative score corelates with a
maturity rating of 20 to 44 weeks of gestation.

22. Posture
• With infant quiet & in a supine position
observe degrees of flexion in arms & legs
• Muscle tone & degree of flexion increase
maturity
• Full flexion of arms & legs – 4

23. Square window
• With thumb supporting back of the arm below
wrist apply gentle pressure with index & third
fingers on dorsum of hand without rotating infant’s
wrist
• Measure angle between base of thumb & forearm
• Full flexion (hand lies flat on ventral surface of fore
arm) - 4

24. Arm recoil
• With infant supine fully flex both
forearms on upper arms hold for
5 seconds pull down on hands to
fully extend and rapidly release
arms .
• Observe rapidity & intensity of
recoil to state of flexion
• A brisk return to full flexion - 4

25. Popliteal angle
• With infant supine & pelvis flat on a firm
surface flex lower leg on thigh & then flex
thigh on abdomen while holding knee with
thumb & index finger extend lower leg with
index finger of other hand.
• Measure degree of angle behind knee
(popliteal angle)
• An angle of <90 degree - 5

26. Scarf sign
• With infant supine, support head in
midline with one hand, use other
hand to pull infant’s arm across the
shoulder so that infant’s hand
touches shoulder .
• Determine location of elbow in
relation to midline
• Elbow does not reach midline - 4

27. Heel to ear
• With infant supine & pelvis flat on a
firm surface , pull foot as far as
possible up toward ear on same side
• Measure distance of foot from ear &
degree of knee flexion
• Knees flexed with a popliteal angle
< 90 degree - 4

28. PHYSICALASSESSMENT OF NEWBORN
Posture:
In full term babies,
• Generalized flexion
• Neck & extremities are flexed
• May lie in frog like structure

29. Activity
• Normal neonates are alert & active
• Baby may be irritable or drowsy if having any neurological problem
Cry
• Cries when hungry or wet
• Weak cry is seen in preterm or LBW
• High pitch cry is seen in babies with raised ICP
Colour
• Entire body & extremities are pink
• Extremities may be blue if the baby is having respiratory distress

30. Vital signs
Pulse
• Normally irregular, due to immaturity of cardio
regulatory centre in medulla
• Rate is rapid, about 120 to 150 bts/mt
• Check brachial or apical pulse for 1 mt
Respiration
• Irregular in depth, rate, rhythm
• Rate 35 to 50 brths/mt
• Count them full 60 seconds
Temperature
• Take from axilla/groin/rectum
• Normal temperature is 36.1 to 37.7 deg cel

31. Anthropometric measurements
Length
• Can be taken in a measuring table/ board with a fixed head piece
on which the infant lies supine with his legs fully extended
• Average length : 47.5 – 53.5cm
Weight
• 2.5 to 3.5 kg

32. Head circumference
• Immediately after birth moulding of skull may give inaccurate
measurement of HC
• So measure after 48 hrs of birth
• Normal HC is 33-37 cm
• Increased HC – hydrocephalus
• Decreased HC - microcephaly

33. CHEST CIRCUMFERENCE
• 31-33cm (2-3 cm < HC)

34. HEAD TO TOE EXAMINATION
SKIN
Colour
• Most term babies have a ruddy complexion because of
othe increased concentration of RBC in the blood vessels &
oa decrease in the amount of subcutaneous fat
• This ruddiness fades slightly over the first month

35. Cyanosis: A newborn’s lips, hands & face are likely to appear blue from immature
peripheral circulation.
• Acrocyanosis are common in first 24 to 48 hrs after birth
• If central cyanosis is present it may be due to inadequate oxygenation.
Jaundice : Hyperbilirubinemia leads to jaundice or yellowing of the skin
Pallor : pallor in newborns is seen as a result of anaemia due to
• Excessive blood loss due to cord cutting
• Inadequate flow of blood from cord into the infant at birth
• Fetal maternal transfusion
• Low iron stores

36. Lanugo :
• Fine slight downy hair that covers the newborn shoulder ,
back & upper arms
Vernix caseosa:
• White, creamy, cheesy like substance that serves as a
lubricant which disappear with in a few days
Erythema toxicum:
• It begins as a papule, increasing in severity to become
erythema by the second day then disappearing on the third
day

37. • Desquamation: peeling of skin takes place few
days after birth
• Milia: tiny white papillae on the nose & chin
• Telangiectatic nevispot: temporary birth marks

38. • Mongolian spot: slate coloured spot (bluish gray coloured ) on the
buttocks or lowered back
• Acrocyanosis: symmetric cyanosis of extremities
• Cutis marmorata : transitory mottling of the skin

39. Harlequin colour changes:
• Discrepancy in colour between two longitudinal halves of the body

40. Birth marks
• Hemangiomas : vascular tumors of the skin.
1. Nevus Flammeus (portwine stain)
• A macular purple or dark red lesion that is present at birth
• Found on the face & thighs
• Also occurs as lighter pink patches at the nape of the neck

41. 2. Strawberry Hemangioma
• Elevated areas formed by immature capillaries & endothelial cells
which appear at 2 weeks after birth
• Occurs because of immaturity of the liver.

42. 3. Cavernous hemangioma
• Dilated vascular spaces
• Usually raised & resemble a strawberry hemangioma in
appearance
• Consist of dilated capillaries
• Continue to enlarge and do not fade with age.

43. Skin turgor
• Elastic when grasped between the thumb & fingers
• Poor turgor is seen in mlanutrirtion or with any metabolic
disorders.

44. HEAD
• FONTANELS:
An anatomical feature of the infant human skull comprising
soft membranous gaps (sutures) between the cranial bones that
make up the calvaria of a fetus or an infant.

46. ANTERIOR FONTANELLE
• Junction of frontal & parietal bones
• Diamond shape called as “bregma”
• Width 2-3 cm , length 3-4cm
• Closes at 12-18 months of life.

47. POSTERIOR FONTANELLE
• Junction between parietal & occipital bones
• Triangular in shape called as “lambda”
• Closes at 1 to 2 months

48. • Size: A newborn’s head appears disproportionately large because it is
one fourth of the total length
• Moulding:
onormal variation
oObserve for appearance,
oshape of head
oMay have elongated appearance in vaginal birth newborns

49. • Caput succedaneum – pitting edema of the scalp at the
presenting part of the head
• Cross suture line
• Gradually absorbed & disappears at about the third day of life.
• Cephalhematoma – accumulation of blood between the
periosteum & a flat skull bone.
• Caused by rupture of a periosteal capillary due to pressure of
birth
• Usually appears after 24 hrs of birth
• Does not cross suture line
• Takes weeks to get absorbed (2-6 weeks)

50. • Craniosynostosis – premature fusion of cranial sutures
• Craniotabes – softening of the skull that usually occurs around the
suture lines & disappears with in days to a few weeks after birth
• It may be secondary to a calcium deficiency & osteogenesis
imperfecta & syphilis

51. EYES
• Newborns usually cry tearlessly, because their lacrimal ducts are immatureuntil 3
months of age
• Assess the colour of sclera (blue), iris (grey/blue)
o An infant’s eyes assume their permanent color between 3 & 12 months of age
• Subconjunctival hemorrhage
o Rupture of conjunctival capillary due to pressure during birth.
o Manifests as red spots as a rod ring around cornea.
o Absorbed with in 2/3 weeks.

53. Blepharophimosis
Brushfield spots
Ectropion
Entropion
Hypertelorism

54. Ears
• Level of top part of external ear should be on a line drawn from
the inner canthus to outer canthus of the eye & back across the
side of head
• Ear tags : benign growth contains skin & sometimes cartilage

55. Nose
• Size & shape
• Note the placement of septum
• Formation of nasal bridge
• Verify patency
• Deviated septum, choanal atresia

56. Mouth
• Epstein pearls: temporary accumulation of
epithelial cells, cyst on each side of hard palate
• Precocious dentition: teeth may be observed in
lower incisors
• Cleft lip & palate: openings or splits in the upper
lips, the roof of the mouth (palate or both)

57. NECK
• Short
• Chubby
• Creased with skin fold
CHEST
• Looks small because the head is large in portion
• Possible breast engorgement with possible secretion of thin watery fluid (witch milk)
• Supernumerary nipples (polythelia)
• Respiratory rate -30-60brths/mt

58. • Retractions
* Drawing in of the chest wall with inspiration is not normal.
* Newborn’s lung alveoli open slowly over the first 24 to 48 hrs &
the baby invariably has mucus in back of the mouth
• Lung sounds – rhonchi (due to increased mucus), grunting (respiratory
distress syndrome), stridor (immature tracheal development)

59. Abdomen
• Looks slightly protruberant
• Scaphoid or sunken appearance may indicate missing abdominal
contents or a diaphragmatic hernia
• Bowel sound should be present with in 1 hr after birth
• Edge of liver is palpable 1 to 2 cm below right costal margin
• Edge of spleen may be palpable 1 to 2 cm below left costal margin

60. • Umbilical cord: white gelatinous structure marked with red & blue streaks of umbilical artery
(2) & umbilical vein (1)
• Child with single umbilical artery should be observed for any abnormalities
• After first hour of life the cord begins to dry 7 shrink
• It begins to brown & then black by 2 – 3 days.
• It breaks free by days 6 to 10 leaving granulating area few centimeters wide
• Base should be dry. Moistness suggests congenital anomalies or infection
• Check for umbilical hernia: <2cm, it gradually closes. > 2cm , it requires surgical correction

61. • Kidney can be assessed by deep palpation of the right & left
abdomen with in first few hours.
• Left kidney is difficult to palpate as the intestine is bulkier in that
part.
• An enlarged kidney may suggest polycystic kidney

63. Anogenital area
• Test the anus for patency by inserting gloved finger
• If the newborn does not pass meconium in first 24 hrs , suspect
imperforate anus or meconium ileus
• An imperforate anus are birth defects in which the rectum is
malformed
• Meconium ileus : a bowel obstruction that occurs when the meconium is
thicker and stickier than normal meconium.

64. Male genitalia
• Scrotum is usually edematous
• Check for the presence of testis in scrotum
• Penis appears small, approximately 2 cm long
• Check for any epispadiasis or hypospadiasis
Female genitalia
Vulva in female newborns is swollen
Check for pseudo menstruation, hymen tag etc

66. BACK
• Spine of a newborn typically appears flat in the lumbar &
sacral areas
• Inspect the base of newborn’s spine to note any opening,
dimpling or sinus track in skin.
• Check for meningocele (with a sac of fluid present
at the gap in the spine) or meningomyelocele (a sac enclosing
the spinal elements, such as meninges, cerebrospinal fluid, and
parts of the spinal cord and nerve roots.)

67. Extremities
• Arms & legs appear short
• Hands pump & clench into fists
• Test the upper extremities for muscle tone by unflexing the arms for 5
seconds
• Short arms suggestive of achondroplastic dwarfism
• Curved fingers & simian creases are associated with Down’s syndrome

68. • Syndactyly / polydactyly
• Check toe nails if it fills immediately after blanching
• Newborn legs are bowed
• Sole of the foot appears flat
• Check for range of motions, club foot, varus deformities, hip
dislocation

70. New born reflexes
• Primitive reflexes are reflex actions originating in the central nervous
system that are exhibited by normal infants

71. NURSING CARE OF NORMAL NEW
BORN
• Aim is to help the newborn to adapt physiologically to extrauterine
environment.
• Physiological adaptation includes:
Initiation of respiration and oxygenation of arterial blood
Temperature regulation.
Initiation of feeding.

72. • To prvent sepsis at birth.,
: Hand hygiene & wear sterile gloves
: Use clean & sterile towel to dry and cover the baby.
: The umbilical cord to be cut with a clean and sterile
blade / scissor
: Clamp cord with a clean sterile clamp or tie
: Nothing to be applied on the cord. Keep it dry.

73. According to WHO immediate care of newborn
baby includes.,
• Immediate care at birth (delayed cord clamping, thorough drying, assessment of breathing, skin-to-skin contact, early initiation of
breastfeeding)
• Thermal care
• Resuscitation when needed
• Support for breast milk feeding
• Nurturing care
• Infection prevention
• Assessment of health problems
• Recognition and response to danger signs
• Timely and safe referral when needed

74. 1.Establish and maintain a patent
airway.
2.Clamp and cut the cord
3.Ensure warmth.
4.Assessment and documentation of
baby's condition.
5.Care of eyes.
6. Care of skin.
7. Administration of vitamin K.
8. Identification of baby.
9.Transfer of the baby according
to level of care required.

75. Establish and maintain a patent airway
• Suction secretions ( mucus & amniotic fluid) of mouth and nose to
clear the airway during crying .
• Typically the newborn’s mouth is first suctioned, then the nose.
• Suction should be done gently using a bulb syringe or mucus trap
to prevent bradycardia, laryngospasm, & cardiac arrhythmias
from vagal stimulation.

77. • If the baby not crying, provide gentle tactile
stimulation.
• The NRP recommends gentle and brief rubbing of a
newborn's back, trunk or extremities using pre-
warmed soft absorbent towels and flicking the soles
of the feet as safe and appropriate methods of
providing tactile stimulation.
• Start CPR, if not cried even after stimulation.

78. Cord clamping
• Clamp at 2-3 cm away from the abdomen using a commercially
available clamp, a clean and autoclaved thread or a sterile rubber
band.
• The stump should be away from the genitals to avoid contamination.
• cord should be inspected every 15-30 minutes during initial few
hours after birth for early detection of any oozing.

80. Ensure warmth
• Loss heat due to evaporation,
radiation, conduction, convection.
• To prevent heat loss
Delivery room temperature -25-28
deg cel
Dry the infant thoroughly soon
after birth using a warm towel.

81. Place the bay under radiant
warmer or
 Over the mother’s chest in
skin to skin contact with her

82. Assessment and documentation of baby's
condition.
• APGAR Scoring at 1 & 5 minute

83. Care of eyes
• Using sterile cotton swabs
dipped in sterile water
• Clean from inner canthus to
outer canthus with separate
swabs for each eye.

84. Skin Care
• Gently wipe off blood, mucus and secretions.
• No recommended to rub off the protective vernix caseosa.
• Prevent hypothermia

85. Vitamin K
• Vit K is required for synthesis of prothrombin by liver.
• Generally bacteria of intestine produce Vit K.
• As newborn intestinal flora don’t produce Vit K for few days,
there is risk for abnormal bleeding.
• Vit K 1 mg IM for term baby
• 0.5 mg for preterm baby.

86. Identification of the baby
• Identification band on baby’s wrist include
 name of mother
 registration number
 date & time of birth
 sex
• Foot impression of baby is also taken for identification.

87. Transfer
• Normal babies are transferred to mother and nursed in postnatal
area (Rooming-in).
• Breast feeding should be started as soon as possible
• Sick or at risk neonates should be transferred to a NICU

88. • Rooming in
• Initiating feeding
• Observation for early signs of diseases
• Prevention of infections
• Care of bowel & bladder
• Maintenance of personal hygiene
• Parental teaching & follow up

89. Observation for early signs of diseases
• Observe for danger signs
Failure to pass meconium within 24 hours of birth.
Failure to pass urine within 48 hours of birth.
Bleeding from any site.
Failure to take feed.
Excessive crying or undue lethargy.

90. • Jaundice within 24 hours of birth (Pathological Jaundice)
• Hypothermia or Hyperthermia
• Seizures
• Persistent vomiting or diarrhea
• Breathing difficulty
• Evidence of superficial infection like oral thrush, conjunctivitis,
umbilical cord infection, pustules on skin etc.

91. Care of bladder & bowel
• Notify the physician if the neonate fails to pass urine and stool within
24 hours of birth.
• The urine output is about 200-300ml by the end of first week of life so
neonate voids about 15-20 times a day.
• Diaper should be changed as soon as wet. The neonate also passes stool
frequently so diaper area should be cleaned with mild soap and water.
• The baby should be kept clean and dry.

92. Personal hygiene
• The personal hygiene of both baby and mother should be
maintained to prevent infections
• The baby should be given sponge bath daily in summers and
every alternate day in winters.
• Care should be taken to prevent chilling and draughts while
giving dip bath to the baby.

93. • Lukewarm water and mild baby scalp should be used for giving baby bath.
• Special attention should be paid to skin creases at axilla, neck, groin and
thighs.
• After giving bath, dry the baby thoroughly and put on soft clothes.
• The umbilical stump should be kept dry and clean.
• Eye care should also be done daily using sterile swabs dipped in sterile water.
• Eyes should be cleaned from inner canthus to outer canthus using separate
swab for each eye.

94. FACILTY BASED NEWBORN CARE (FBNC)
• One of the key initiatives launched by the Government of India
under NRHM & RMNCH+A strategic program to improve the
status of newborn health in the country.
• Under the program efforts are being made to provide different
level of newborn care at the health facilities

96. • Newborn care corners (NBCC) established at all delivery points to provide
essential newborn care, with in the delivery room.
• Facilties provided in NBCC,
Essential care at birth
Resuscitation
Provision of warmth
Early initiation of breastfeeding
Weighing the neonate

97. • Newborn stabilization units (NBSUs) established at Community
Health Centres/ First Referral Units (FRU)
• Management of selected newborn conditions
• Stabilize serious & sick newborns for short periods before referral
to higher centres

98. Special Newborn Care Units (SNCUs)
• Established at district hospital level.
• Established in vicinity of labour room
to provide special care for sick
newborn except assisted ventilations
& major surgeries
Services at SNCUs are:
• Care at birth
• Resuscitation of asphyxiated newborns
• Managing sick newborns
• Kangaroo mother care
• Postnatal care
• Follow up of high risk neonates
• Referral services
• Immunization services