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NUR1 233 Lecture Notes - Hypoglycemia, Antiseptic, Postterm Pregnancy

Course Code
NUR1 233
Sonia Elizabeth Semenic

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Chapter 25: Nursing Care of the Newborn
Birth through the first 2 hours
With possibility of transmission of viruses such as hep B and HIV via maternal blood and blood-stained amniotic
fluid, the newborn must be considered a potential contamination source until proved otherwise use gloves always
APGAR score: after 1 minute and 5 minutes
o Heart rate, RR, muscle tone, reflex irritability, skin color (pallid, cyanotic, pink) score out of 2
o Scores 0-3: severe distress, scores 4-6: moderate difficulty, scores 7-10: good
o Don’t predict future neurological outcome but show newborns adjustment to extrauterine environment
Initial physical assessment
o CNS: moves all 4 extremities, flexion, muscle tone good symmetrical features, movement moro, suck,
rooting, and grasp reflexes present, anterior fontanel soft and flat
o Cardiovascular system: heart auscultation, regular rate and rhythm transient acrocyanosis, otherwise pink
in color pulse strong, equal bilaterally capillary refill less than 3 seconds centrally and in peripheral tissues
(not in nail beds)
o Respiratory system: lungs auscultated, clear bilaterally with minimal fine crackles shortly after birth RR <
60 breaths/min respiratory effort nonlabored absence of nasal flaring, grunting, retractions
o Genitouinary system: male urethral opening at tip of penis, testes descended bilaterally female labia
minora and majora intact, hymenal tag may be visible
o Gastrointestinal system: abdomen soft, no visible distention cord attached and clamped anus patent
o Eyes, ears, nose, and throat: eyes clear palates intact nares patent ears in place, correct alignment
o Skin: color (pink or acrocyanotic) skin lesions or abrasions documented birthmarks documented
Gestational age assessment completed within first hours of birth in stable newborn
More comprehensive physical examination completed within 24 hours
Immediately after birth dries infant thoroughly, assesses temp, places ID bracelets on infant, mother and father
o May be wrapped in blanket and to mother or partner or immediate skin-to-skin
o Observations and assessment can be made while baby on mother or when drying baby
Airway maintenance
o Most secretions moved by airway and brought by the cough reflex to the opopharynx to be drained or
swallowed may be placed in side lying position until secretions cleared and then supine
o Excess mucus: suction bulb syringe generally avoided
o Choking on secretions: supported with his/her head on side mouth suctioned centre of mouth avoided so
no gag reflex nasal passages suctioned one nostril at a time always keep bulb in crib
o Listen to respirations and lung sounds to determine whether crackles, rhonchi, or stridor
o Fine crackles: few hours after birth normal
o Catheter insertion and suctioning: 5 seconds or less per catheter insertion help prevent vagal stimulation and
Pressure less than 80mmHg after catheter placed, suction created by placing one’s thumb over the
control as the catheter is carefully rotated and gently withdrawn
o Maintaining O2 supply
Clear airway
Effective establishment of respirations
Adequate circulation, adequate perfusion, and effective cardiac function
Adequate thermoregulation (exposure to cold stress increases O2 and glucose needs)
Body temperature maintenance
o Clod stress increases need for oxygen and may deplete glucose stores can become cyanotic
o Ways to stabilize temp: skin-to-skin on abdomen of mother and cover with blanket, dry and wrap in blanket
after birth, keep head well covered, and keep ambient temp 22-26 degrees celsius
o Vernix caseosa: allowing it to remain on skin has not been associated with decrease in axillary temp in first

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o Use radiant warmer or warm incubator unit if no skin-to-skin for first few hours keep to 36-37
Thermistor probe (automatic sensor): placed on upper quadrant of abdomen below right or left costal
margin (never over a bone) ensure detection of minor temp changes from external environment
before change in core temp
Servocontroller: adjusts warmer temp to maintain infant’s skin temp within preset range
Axillary temp: checked every hour until stabilizes
o Rapid warming: after hypothermia can cause apnea and acidosis warming process progresses slowly
over a period of 2-4 hours
Immediate interventions
o Eye prophylaxis: prophylactic agent necessary as precaution against ophthalmia neonatorum inflammation
of eyes from gonorrheal or chlamydial infection contracted from birth canal
Usual agents: or erythromycin, tetracycline, or sulfonamide
Can be delayed for an hour to allow eye contact and parent-infant attachment and bonding
o Vitamin K prophylaxis: single injection of 0.5-1mg intramuscularly to prevent hemorrhagic disease may
be delayed until after first breastfeeding
Intravenously: only in preterm infants who have no muscle mass give over 10-15 min
Day 8: can produce own vitamin K
o Promoting parent-infant bonding
Oxytocin and prolactin levels rise in mother, and suckling activity activated in infant
Process of developing active immunity begins as infant ingests flora from the mother’s colostrum
From 2 hours after birth until discharge
Physical assessment
o A complete physical examination is performed within 24 hours after the infant’s condition has stabilized
o Observe skin color, tone and condition auscultate lungs, heart, and abdomen perform reflexes last
measure head and length at same time to compare results
Assessment of gestational age
o Ballard scale: assess 6 external physical and 6 neuromuscular signs each sign has number score and
cumulative score correlates with a maturity rating of from 20-44 weeks of gestation
Posture: observe degree of flexion in arms and legs full flexion score 4
Square window: with thumb supporting back of arm below wrist, apply gentle pressure with index
and third fingers on dorsum of hand without rotating infant’s wrist – measure angle between base of
thumb and forearm full flexion score 4
Arm recoil: fully flex both forearms on upper arms and hold for 5 seconds pull down hands to fully
extend and rapidly release arms observe rapidity and intensity of recoil brisk return to full flexion
score 4
Popliteal angle: pelvis flat on firm surface flex lower leg on thigh and then flex thigh on abdomen
while holding knee with thumb and index finger, extend lower leg with index finger of other hand
measure degree of angle behind knee angle less than 90 score 5
Scarf sign: support head midline with one hand use other hand to pull infant’s arm across the
shoulder so the infant’s hand touches shoulder – determine location of elbow in relation to midline
elbow doesn’t reach midline score 4
Heel to ear: pelvis flat on surface pull foot as far as possible upward toward ear on same side
measure distance of foot from ear and degree of knee flexion knee flexed with popliteal angle of
less than 10 score 4
o New simplified Ballard scale used with newborns as young as 20 weeks same physical and neuromuscular
sections but includes -1 scores that reflect signs of extremely preterm infants such as fused eyelids, sticky,
transparent skin, etc.
o <26 weeks: performed at a postnatal age of less than 12 hours
o 26 weeks: performed up to 96 hours after birth recommended within first 48 hours
Classification of newborns by gestational age and birth weight
o AGA: infant whose weight is appropriate for gestational age (between 10th and 90th percentile) can be
presumed to have grown at a normal rate regardless of the length of gestation preterm, term, postterm
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