40 terms

Assessment & Nursing Care of Newborn

Week 13
Fetal Circulation
Four unique anatomic features
-Ductus venosus
-Foramen ovale
-Ductus arteriosus
Transitional Circulation
Initiation of first breath is due to the integrated activity of several stimuli:
- Asphyxia
- Cord occlusion
- Thermal stimuli
- Evaluation tool only! Intervention should start prior to 1 minute as needed.
Done at 1 and 5 minutes and 10 mins if APGAR at 5 mins < 7
APGAR Results
- 0 to 3 indicate severe distress
- 4 to 6 indicates moderate difficulty
- 7 to 10 indicates that the newborn is having minimal or no difficulty adjusting to extrauterine life
Thermoregulation - 4 Mechanisms of Heat Loss
- Evaporation - dry
- Radiation - hat, dry linen, warm blanket
- Convection - delay the bath
- Conduction - place skin to skin
Thermoregulation - Normal Axillary Range
> 36.5C (97.7F) to < 38.0C (100.4F)
Skin Color - Normal
-color should be pink tinged
Skin Color - Pale
-pale color may result of decreased concentration of RBCs, poor oxygenation or hypothermia.
Skin Color - Plethoric
-ruddy color results from increased concentration of RBCs (polycythemia) and limited subcutaneous fat deposits.
Skin Color - Acrocyanosis
-common in newborn, localized (blue-gray coloration) of hands and feet
-poor peripheral circulation, resulting in vasomotor instability and capillary stasis.
-most noticeable when newborn is cold.
Skin Color - Mottled
-lacy pattern of dilated blood vessel under the skin.
-result of general circulation fluctuations or when newborn is cold.
-may last several hours or weeks, can come and go periodically.
Normal Heart Rate Range
- 110 to 160 bpm
- Normally the heart has a toc-tic sound.
- 90% of all murmurs are transient and considered normal. Half disappear by age 6 months.
Respirations - Normal Respiratory Rate
> 30 and < 60 bpm

- Respirations are diaphragmatic, with associated rising and falling of abdomen.
- Breath sounds are heard better when the newborn is crying.
Respirations - Normal O2 Saturation Range
- Term >90%
- Preterm >90-95%
Normal Cry Sounds
- Cry-strong, lusty and medium pitched.
- High pitched, shrill cry may indicate neurologic disorders or hypoglycemia
Signs of Respiratory Distress
- Rapid rate
- Nasal flaring
- Grunting
Normal Blood Pressure
- systolic >50
- diastolic >30 (if not >30, recheck later)
Hypoglycemia - Risk Factors
- Less than 37 Weeks gestation
- Gestational Diabetes or Infant of Diabetic Mother
- Five minute APGAR <6
- Unstable transition period
- First detectable on face where skin overlies cartilage and mucous membranes
- Occurs in 50-60% of term newborns
- Blanch tip of nose, forehead or gum line, area appears yellowish immediately after blanching
- Pathologic within 24hrs or persisting for > 7 days
- Physiologic after 24 hrs
Newborn Safety
- Providing a protective environment is key responsibility of nurse
- Prevention of infection, careful identification procedures, transporting via bassinet, protection from abduction
Newborn Feeding Readiness (Hunger Cues)
- Rapid eye movement under lids
- Sucking movements
- Hand to mouth movements
- Body movements
- Small sounds
- Rooting
Feeding and the Newborn's Stomach - Days 1 and 2
- Size of marble or shooter marble (5-15 mL)
Feeding and the Newborn's Stomach - Day 3
- Size of ping-pong ball (22-27 mL)
Feeding and the Newborn's Stomach - Day 10
- Size of chicken egg (60-81 mL)
Best Way to Feed Newborn
More frequent small feedings
When to Initiate Newborn Feeding
- Assess newborn breathing, suck & swallow
- Breastfeeding - immediately after birth within first half hour
- Bottle feeding - when newborn shows cues
- Feed early, especially if newborn at risk for hypoglycemia
>90th % for weight

- Increase risk of birth trauma, hypoglycemia, hypocalcemia, hyperbilirubinemia, meconium aspiration, and polycythemia.
<10th % for weight

- Increase risk of hypoglycemia, asphyxia, respiratory distress syndrome, meconium aspiration, intrauterine infection, and hyperbilirubinemia
Breastfeeding Recommendations
- First six months, up to two years
Advantages of Breast Milk for Baby
Antibodies—Protects against infections
Decreases risk of allergies
Essentials for growth
Protects against obesity
Enhances cognitive development ( 8 IQ pts)
Decreases risk for Diabetes
Decreases risk of Sudden Infant Death Syndrome (SIDS)
Advantages of Breast Milk for Mother
Uterine involution / Delays fertility
Speeds weight loss
Decreases risk of certain cancers
Convenience-perfect temperature, no preparation
Cost savings-no formula, bottles/nipples
Psychological-M-B attachment and an increased feeling of well-being related to release of oxytocin/prolactin
Why Human Milk?
- Optimal growth and development
- Reduced risk of disease - Decreased risk of contamination of formula or from bottles
- Improved health of the mother
- Personal and national economic benefits
- Safety
Breast Milk - Colostrum
- First 2-3 days
- Gold or yellow, Thick
- Colostrum amount matches the size of the newborn's stomach
- High protein content due to increased immunologic content; high levels of antibodies—passive immunity
- Establishes normal GI track flora
- Helps eliminate bilirubin as it has a laxative effect
Breast Milk - Transitional Milk
3-4 days to 2 weeks
Higher concentration of fat, lactose, water-soluble vitamins
Breast Milk - Mature Milk
- After 2 weeks
- 10% solids (carbs, proteins, fats) for energy and growth
- 90% water for hydration
- 20 kcal/oz
Breast Milk - Foremilk
- High in water, vitamins, protein
Breast Milk - Hindmilk
- Higher fat concentration
Factors Inhibiting Let Down of Breastmilk
- Discomfort/pain
- Lack of privacy
- Lack of confidence
- Anxiety
Steps to Latch On
Positioning, pillows, pillows and more pillows
Get mom and baby comfortable
Stimulate rooting reflex
Baby to open mouth WIDE
Baby to latch onto the nipple + areola, not just the nipple

Teach proper breast support (C-hold)
Encourage comfort in handling the breast and moving the baby
Assess for nipple comfort after latch on
Consider offering both breasts - ?
Burp between breasts
Breastfeeding Assessment - LATCH Score
Out of 10
A-Audible swallowing
T-Type of nipple (inverted, flat, everted)
C-Comfort (breast and nipple)
H-Hold (assistance and positioning)