Care of the Newborn By: Ruth V. Tianco, RN Care of the newborn Care of the Normal Newborn Infant • The nurse has a unique opportunity of closely observing and providing care for the newborn infant after delivery. • Because of the newborn infant's helplessness, his needs must be met initially by nursing personnel. • Many nursing assessments and evaluations are conducted for the well-being of the infant. • Nursing care does not stop with the newborn infant. • Interaction with the parents is also important in the development of a family unit. Establishing and Maintaining the Newborn's Airway • The physician suctions the infant before it is completely born with a bulb syringe or a DeLee trap. • A DeLee trap is used if meconium was present in the amniotic fluid. • Once the infant is delivered, his head is held slightly downward to promote drainage of mucus and fluid. • The infant's face is wiped thoroughly clean. • If the infant doesn't breathe spontaneously, he should be stimulated to cry by slapping his heels, lightly tapping the buttocks, and/or rubbing his back gently. • The infant is then positioned with his head slightly down when placed in the radiant warmer. The bulb syringe is used to remove mucus from his mouth and nose. Position the Baby • Keep the baby on its’ back or side, not on its’ stomach • Neither extend nor flex the head. Either may obstruct the airway. • Newborn babies normally make this adjustment themselves. If depressed, however, you may need to position the head to get a good airway. Suction the Airway • Use a bulb syringe • Use it gently • The infant's mouth is suctioned first and then his nose. • May need to help them clear mucous and amniotic fluid from the airway • If bulb syringe is not available, use any suction device. How to use bulb syringe Common characteristics of newborn respirations • (a) Nose breathers. Sleeps with mouth closed, does not have to interrupt feedings to breathe. • (b) Irregular rate. • (c) Usually abdominal or diaphragmatic in character. • (d) Ranges from 40 to 60 breathers per minute. • (e) Breathing is quiet and shallow. • (f) Easily altered by external stimuli. Common characteristics of newborn respirations • (g) Periods of apnea less than 15 seconds is normal. • (h) Acrocyanosis may occur during periods of crying. Acrocyanosis refers to cyanotic look of the baby's hands and feet when he is crying. When the baby stops crying, his hands and feet get pink again. Signs and symptoms of newborn respiratory distress. • (a) Increased rate or difficulty breathing-growing and seesaw breathing. In normal respirations, the infant's chest and abdomen rise. With seesaw respirations, the infant's chest wall retracts and his abdomen rises with inspirations. See fig. 8-3. • (b) Sternal or subcostal retractions. • (c) Nasal flaring. • (d) Excessive mucus, drooling. • (e) Cyanosis. Signs and symptoms of newborn respiratory distress. Identify the Infant After Delivery. (1) The infant must be properly identified before leaving the delivery room. An identification (ID) band is placed on the infant's wrist and leg. An identical band matching the infant's band is placed on the mother's wrist. (2) The infant's footprints or palm prints placed next to the mother's thumb print is rarely done in most facilities. Each facility has its own instant identification method Maintaining Body Temperature. (1) Dry the infant thoroughly immediately after delivery. The infant is extremely vulnerable to heat loss because his body surface area is great in relation to his weight and he has relatively little subcutaneous weight. (2) Place the infant closely to the mother's skin. Skin-to-skin contact with the mother will help prevent heat loss. Oil Bath or Water Bath What equipment is needed for water bathing newborns? • Thick towels or a sponge-type bath cushion. • Soft washcloths. • Basin or clean sink. • Cotton balls. • Baby shampoo and baby soap (non- irritating). • Hooded baby towel. • Clean diaper and clothing. Vernix • Cheesy-white • Normal • Antibacterial properties • Protects the newborn skin Sponge Bath Cont… Bathing of the newborn • Make sure the room is warm, about (75° F). • Check the water temperature by the use of your elbow. • Gather all equipment and supplies in advance. • Add warm water to a clean sink or basin (warm to the inside of your wrist or between 90 and 100° F.). • Place baby on a bath cushion or thick towels on a surface that is waist high. • Keep the baby covered with a towel or blanket. Cont… Bathing of the newborn • NEVER take your hands off the baby, even for a moment. If you have forgotten something, wrap up the baby in a towel and take him or her with you. • Start with the baby's face - use one moistened, clean cotton ball to wipe each eye, starting at the bridge of the nose then wiping out to the corner of the eye. Cont… Bathing of the newborn • Wash the rest of the baby's face with a soft, moist washcloth without soap. • Clean the outside folds of the ears with a soft washcloth. • Wash the baby's head with a shampoo on a washcloth. Rinse, being careful not to let water run over the baby's face. • Holding the baby firmly with your arm under his or her back and your wrist and hand supporting his or her neck, you can use a high faucet to rinse the hair. Cont… Bathing of the newborn • Add a small amount of baby soap to the water or washcloth and gently bathe the rest of the baby from the neck down. • Rinse with a clean washcloth or a small cup of water. • Be sure to avoid getting the umbilical cord wet. • Scrubbing is not necessary, but most babies enjoy their arms and legs being massaged with gentle strokes during a bath. Cont… Bathing of the newborn • Wrap the baby in a hooded bath towel and cuddle your clean baby close. • Follow cord care instructions given by your baby's physician. This may include alcohol or air drying. • Use a soft baby brush to comb out your baby's hair. DO NOT use a hair dryer on hot to dry a baby's hair because of the risk of burns. Anthropometric measurements • Head circumference (33-35 cm)- repeat after molding and caput succedaneum are resolved • Chest circumference (31-33cm)- at the nipple line • Abdominal circumference • Length (F=53, M=54)- from top of head to the heel with the leg fully extended • Weight 2.5- 4 kg Anthropometric measurements Vital signs APGAR SCORING • The Apgar score was devised in 1952 by Dr. Virginia Apgar as a simple and repeatable method to quickly and summarily assess the health of newborn children immediately after childbirth. • Apgar was an anesthesiologist who developed the score in order to ascertain the effects of obstetric anesthesia on babies. APGAR SCORING • The Apgar score is determined by evaluating the newborn baby on five simple criteria on a scale from zero to two, then summing up the five values thus obtained. • The resulting Apgar score ranges from zero to 10. • The five criteria (Appearance, Pulse, Grimace, Activity, Respiration) are used as a mnemonic learning aid. APGAR Color • Most newborns have Pink acrocyanosis (body is centrally pink, but hands and feet are blue • Cyanosis requires Acrocyanosis treatment: – Oxygen – Airway – Ventilation Cyanosis APGAR SCORING • The test is generally done at one and five minutes after birth, and may be repeated later if the score is and remains low. • However, the purpose of the Apgar test is to determine quickly whether a newborn needs immediate medical care; it was not designed to make long-term predictions on a child's health. Component of acronym Score of 0 Score of 1 Score of 2 Appearance blue at extremities Skin color no cyanosis blue all over body pink body and extremities pink (acrocyanosis) Pulse rate Absent < 100 >100 Grimace no response to grimace/feeble cry when sneeze/cough/pulls away Reflex irritability stimulation stimulated when stimulated Activity none some flexion active movement Muscle tone Respiration absent weak or irregular strong Breathing • Scores 3 and below are generally regarded as critically low, 4 to 6 fairly low, and 7 to 10 generally normal. • A low score on the one-minute test may show that the neonate requires medical attention but is not necessarily an indication that there will be long- term problems, particularly if there is an improvement by the stage of the five-minute test. • If the Apgar score remains below 3 at later times such as 10, 15, or 30 minutes, there is a risk that the child will suffer longer-term neurological damage. • There is also a small but significant increase of the risk of cerebral palsy. CORD CARE • Things needed for cordcare: • Sterile gloves • 2 sterile Clamp • 1 sterile scissors • 5 cotton balls • Alcohol • Betadine antiseptic solution • Disposable cord clamp • Sterile kidney basin CORD CARE 1. After the baby is born, leave the umbilical cord alone until the baby is dried, breathing well and starts to pink up. Cont… Cord Care 2. Once the baby is breathing, put two clamps on the umbilical cord, about 5 to 8 inches from the baby's abdomen and to the mother immediately after delivery. Use scissors to cut between the clamps. Cont… Cord Care 3. Milk the cord according to the hospital policy 4. Apply triple dye (refer to local policy). from, 1. base, 2. cord. The dye prevents infection and helps the cord to dry. 5. Put the disposable cord clamp on the umbilical cord, about an inch (3 cm) from the baby's abdomen 6. Cut the cord above the cord clamp using the sterile scissors. Cont… Cord Care 7. Inspect the cord frequently for signs of bleeding immediately after it has been cut. Check for AVA Cont… Cord Care 8. Apply antiseptic solution to the stump of the umbilical cord after checking the AVA. 9. Eventually between 1-3 weeks the cord will become dry and will naturally fall off. 10. During the time the cord is healing it should be kept as clean and as dry as possible. Eye prophylaxis for the newborn This procedure is required by law in all states as prophylaxis against gonorrhea. The medications used are as follows: • 1% silver nitrate • 0.5% erythromycin ointment Eye prophylaxis for the newborn • a. Erythromycin Ophthalmic Ointment. This has become the drug of choice and is received in a sterile syringe from the pharmacy. • It is injected into each eye from the inner to outer canthus immediately after birth. • It does not appear to cause much eye irritation. Administration of erythromycin ophthalmic ointment. Eye prophylaxis for the newborn • b. 1% Silver Nitrate Solution. Two drops are applied in each eye in the conjunctival sac, not the cornea. • The infant eyes may or may not be irrigated after instillation, depending on local policy. • The infant may get profuse discharge and chemical conjunctivitis for a few days with no residual damage. • One percent silver nitrate solution is no longer recommended for use. Administration of Vitamin K • Vitamin K is given as a prophylaxis to prevent hemorrhagic disease. Given few hours after birth it is administered intramuscular (IM) in the vastus lateralis muscle 0.5- 1.0 mg. Clothing of the newborn • Place the infant in a crib with droplight. • Clothed the infant and place a stockinette cap on the infant's head to prevent heat loss through the head. • Wrap the infant snugly in a warm blanket. Neonate Reflexes • This is sometimes referred to as the startle reaction, startle response, startle reflex or embrace reflex. It is more commonly known as the Moro response or Moro reflex after its discoverer, pediatrician Ernst Moro. • The Moro reflex is present at birth, peaks in the first month of life and begins to disappear around 2 months of age. Moro Reflex • It is likely to occur if the infant's head suddenly shifts position, the temperature changes abruptly, or they are startled by a sudden noise. • The legs and head extend while the arms jerk up and out with the palms up and thumbs flexed. Shortly afterward the arms are brought together and the hands clench into fists, and the infant cries loudly. • The reflex normally disappears by three to four months of age, though it may last up to six months. Walking or stepping reflex • The walking or stepping reflex is present at birth; though infants this young can not support their own weight, when the soles of their feet touch a flat surface they will attempt to 'walk' by placing one foot in front of the other. • This reflex disappears at 6weeks as an automatic response and reappears as a voluntary behavior at around eight months to a year old. Rooting Reflex • The rooting reflex is present at birth and assists in breastfeeding, disappearing at around four months of age as it gradually comes under voluntary control. • A newborn infant will turn their head toward anything that strokes their cheek or mouth, searching for the object by moving their head in steadily decreasing arcs until the object is found. Sucking Reflex The sucking reflex is common to all mammals and is present at birth. It is linked with the rooting reflex and breastfeeding, and causes the child to instinctively suck at anything that touches the roof of their mouth and suddenly starts to suck simulating the way they naturally eat. Sucking Reflex There are two stages to the action: • Expression: activated when the nipple is placed between a child's lips and touches their palate. They will instinctively press it between their tongue and palate to draw out the milk. • Milking: The tongue moves from areola to nipple, coaxing milk from the mother to be swallowed by the child. Palmar grasp reflex • The palmar grasp reflex appears at birth and persists until five or six months of age. • When an object is placed in the infant's hand and strokes their palm, the fingers will close and they will grasp it. Palmar grasp reflex • The grip is strong but unpredictable; though it may be able to support the child's weight, they may also release their grip suddenly and without warning. • The reverse motion can be induced by stroking the back or side of the hand. Plantar Reflex • A plantar reflex is a normal reflex that involves plantar flexion of the foot (toes move away from the shin, and curl down. An abnormal plantar reflex (aka Babinski Sign) occurs when upper motor neuron control over the flexion reflex circuit is interrupted. This results in a dorsiflexion of the foot (foot angles towards the shin, big toe curls up). Babinski Reflex • Often confused with the plantar reflex, the Babinski reflex is also present at birth and fades around the first year. • The Babinski reflex appears when the side of the foot is stroked, causing the toes to fan out and the hallux to extend. • The reflex is caused by a lack of myelination in the corticospinal tract in young children. • The Babinski reflex is a sign of neurological abnormality, e.g. upper motor neurone lesion, in adults Galant Reflex • The Galant reflex, also known as Galant’s infantile reflex, is present at birth and fades between the ages of four to six months. • When the skin along the side of an infant's back is stroked, the infant will swing towards the side that was stroked.
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