chapter 18 caring for the normal newborn. maternal-child nursing care optimizing outcomes for...
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Maternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & FamiliesMaternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & Families
Susan WardSusan WardShelton HisleyShelton HisleySusan WardSusan WardShelton HisleyShelton Hisley
The Immediate Neonatal Assessment
Establish airwaySuction
Provide warmthDry the infantPlace on mother’s abdomen; heated blanketsPlace beneath radiant heaterCap
Maternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & FamiliesMaternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & Families
Susan WardSusan WardShelton HisleyShelton HisleySusan WardSusan WardShelton HisleyShelton Hisley
The Immediate Neonatal Assessment
Observe respiratory effort, color, muscle tone
Stimulate neonate to breathe deeply and cry
Assess heart rate, temperatureNote obvious abnormalitiesCheck and record number of umbilical
cord vessels
Maternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & FamiliesMaternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & Families
Susan WardSusan WardShelton HisleyShelton HisleySusan WardSusan WardShelton HisleyShelton Hisley
Apgar Score—1, 5 minutesAssesses immediate adaptationFive categories—each scored 0 to 2
Respiratory effortHeart rateMuscle toneReflex irritabilitySkin color
Maternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & FamiliesMaternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & Families
Susan WardSusan WardShelton HisleyShelton HisleySusan WardSusan WardShelton HisleyShelton Hisley
Immediate Nursing CareMother–infant identification Infection/injury prevention
Eye prophylaxisVitamin K injectionHepatitis B vaccine (parental consent
required)Assess blood glucoseHematocrit and hemoglobin
Maternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & FamiliesMaternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & Families
Susan WardSusan WardShelton HisleyShelton HisleySusan WardSusan WardShelton HisleyShelton Hisley
Question?The nurse administers vitamin K to the newborn for
what reason?
a. Most mothers have a diet deficient in vitamin K, which results in the infant being deficient.
b. Vitamin K prevents the synthesis of prothrombin in the liver and must be given by injection.
c. Bacteria that synthesize vitamin K are not present in the newborn’s intestinal tract.
d. The supply of vitamin K is inadequate for at least 3 to 4 months, and the newborn must be supplemented.
Maternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & FamiliesMaternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & Families
Susan WardSusan WardShelton HisleyShelton HisleySusan WardSusan WardShelton HisleyShelton HisleyThe Later Neonatal
AssessmentBody positioningSkin color Body sizeLevel of reactivityMeasurements and determination of
gestational ageBallard Gestational Age by Maturity Rating
Tool
Maternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & FamiliesMaternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & Families
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Assessment of the Neonate: A Systems Approach
Maternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & FamiliesMaternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & Families
Susan WardSusan WardShelton HisleyShelton HisleySusan WardSusan WardShelton HisleyShelton Hisley
Integumentary SystemInspect skin, scalp, nails, body hair
Color, texture, distribution, disruptions, eruptions, birthmarks
Well-lit roomBirth injuries
Maternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & FamiliesMaternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & Families
Susan WardSusan WardShelton HisleyShelton HisleySusan WardSusan WardShelton HisleyShelton Hisley
Skin AssessmentSmooth and soft
Postterm infants—tough, leathery skinPustular melanosis Milia Erythema toxicumPigmentation—Mongolian spots, café-
au-lait marks
Maternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & FamiliesMaternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & Families
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BirthmarksBrown nevi—brown skin marks Nevus flammeus—“port wine stain” Telangiectatic nevus—“stork bite”Nevus vasculosus—“strawberry mark”
Maternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & FamiliesMaternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & Families
Susan WardSusan WardShelton HisleyShelton HisleySusan WardSusan WardShelton HisleyShelton HisleyAssessment of the Infant’s
Head SymmetryEye shape, size, placement, and
coordinated lid movement, red reflex, gross vision
Ears: shape, size, placement, hearingMovement, color of the lipsChin—appropriate size
Maternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & FamiliesMaternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & Families
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Head—FontanelsEstimate sizeFullness without bulging—normalBulging and tense with large head
circumference—increased intracranial pressure
Sunken—dehydration
Maternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & FamiliesMaternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & Families
Susan WardSusan WardShelton HisleyShelton HisleySusan WardSusan WardShelton HisleyShelton HisleyHead
Caput SuccedaneumDiffuse edema, crosses suture lines,
disappears in few daysCephalhematoma
Subperiosteal hemorrhageDoes not cross suture linesPersists for weeks
Maternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & FamiliesMaternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & Families
Susan WardSusan WardShelton HisleyShelton HisleySusan WardSusan WardShelton HisleyShelton Hisley
AssessmentMouth
Epstein’s pearlsTeethAbility to suckHard and soft palate
NeckTorticollis
Facial features
Maternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & FamiliesMaternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & Families
Susan WardSusan WardShelton HisleyShelton HisleySusan WardSusan WardShelton HisleyShelton HisleyRespiratory System
AssessmentSymmetry in chest movementBreast tissueNasal patencyRespiration rate, pattern, and use of
accessory musclesAuscultate lungs anterior and posterior
Maternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & FamiliesMaternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & Families
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Respiratory AssessmentSkin colorCapillary refillSigns of distress
RetractionsNasal flaringExpiratory grunting
Maternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & FamiliesMaternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & Families
Susan WardSusan WardShelton HisleyShelton HisleySusan WardSusan WardShelton HisleyShelton HisleyCardiovascular System
Assessment Inspection and auscultationPoint of maximum impulseHeart rateCapillary refillPeripheral pulsesAuscultate all areas—murmurs
Maternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & FamiliesMaternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & Families
Susan WardSusan WardShelton HisleyShelton HisleySusan WardSusan WardShelton HisleyShelton HisleyGastrointestinal System
Assessment
Abdominal inspection, including umbilical cord
Auscultate bowel sounds, upper abdomen for gastric bubble, and heart sounds of the abdominal aorta
Palpation
Maternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & FamiliesMaternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & Families
Susan WardSusan WardShelton HisleyShelton HisleySusan WardSusan WardShelton HisleyShelton Hisley
Conditions That Warrant Further Assessment
Abdominal distentionAbsence of bowel soundsDischarge from umbilical cord/siteAbdominal mass
Maternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & FamiliesMaternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & Families
Susan WardSusan WardShelton HisleyShelton HisleySusan WardSusan WardShelton HisleyShelton HisleyGenitourinary System
AssessmentHips abductedPalpate and inspect scrotum, testes, and
penisMale—retract foreskinPalpate and inspect female genitaliaAnus and anal wink reflex
Maternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & FamiliesMaternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & Families
Susan WardSusan WardShelton HisleyShelton HisleySusan WardSusan WardShelton HisleyShelton HisleyCommon Findings—Male
InfantsScrotal swellingSmegmaHypospadiusEpispadius
Maternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & FamiliesMaternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & Families
Susan WardSusan WardShelton HisleyShelton HisleySusan WardSusan WardShelton HisleyShelton HisleyCommon Findings—
Female Infants
Hymenal tags
Vernix caseosa on labia
Pseudomenstruation
Maternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & FamiliesMaternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & Families
Susan WardSusan WardShelton HisleyShelton HisleySusan WardSusan WardShelton HisleyShelton HisleyConditions That
Warrant Further Assessment
Undescended testiclesMicropenisAmbiguous genitaliaImperforate hymen Imperforate anus
Maternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & FamiliesMaternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & Families
Susan WardSusan WardShelton HisleyShelton HisleySusan WardSusan WardShelton HisleyShelton HisleyMusculoskeletal
System AssessmentObserve infant’s movements in cribInspect for differences in extremity
length and sizeAssess muscle tone and symmetryGentle passive ROM to assess joint
rotationAssess head lagSkin folds on thighs
Maternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & FamiliesMaternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & Families
Susan WardSusan WardShelton HisleyShelton HisleySusan WardSusan WardShelton HisleyShelton Hisley
Common FindingsTorticollis Developmental dysplasia of the hip
Asymmetry of hip foldsBarlow maneuverOrtolani maneuverCrepitusUnusual positions of foot
Maternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & FamiliesMaternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & Families
Susan WardSusan WardShelton HisleyShelton HisleySusan WardSusan WardShelton HisleyShelton Hisley
Conditions That May Warrant Further Assessment
Fractured claviclePolydactyly Syndactyly Simian crease
Maternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & FamiliesMaternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & Families
Susan WardSusan WardShelton HisleyShelton HisleySusan WardSusan WardShelton HisleyShelton HisleyNeurological System
AssessmentReflexes
Major—gag, Babinski, Moro, GalantMinor—palmar grasp, plantar grasp, rooting
and sucking, head righting, stepping, tonic neck
Maternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & FamiliesMaternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & Families
Susan WardSusan WardShelton HisleyShelton HisleySusan WardSusan WardShelton HisleyShelton Hisley
Conditions That Warrant Further Assessment
Shoulder dystociaErb’s palsyCerebral palsySpina bifida
Maternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & FamiliesMaternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & Families
Susan WardSusan WardShelton HisleyShelton HisleySusan WardSusan WardShelton HisleyShelton HisleyTeaching About Newborn
Care Temperature assessment BathingNail Care and umbilical cord careClothingDiaperingAttachment
Maternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & FamiliesMaternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & Families
Susan WardSusan WardShelton HisleyShelton HisleySusan WardSusan WardShelton HisleyShelton Hisley
Newborn CareCircumcision Ensuring optimal nutritionDischarge planning for the infant and
family Child care Newborn metabolic screening tests